Received: 8 November 2021 Revised: 2 March 2022
DOI: 10.1111/medu.14799
REVIEW ARTICLE
Student engagement in undergraduate medical education: A
scoping review
Salah Eldin Kassab1,2
1
Department of Physiology, Faculty of
Medicine, Suez Canal University, Ismailia,
Egypt
2
Gulf Medical University, Ajman,
United Arab Emirates
3
College of Dentistry, Gulf Medical University,
Ajman, United Arab Emirates
4
Department of Oral Biology, Faculty of
Dentistry, Suez Canal University, Ismailia,
Egypt
Correspondence
Salah Eldin Kassab, MD, PhD, MHPE,
Department Physiology, Faculty of Medicine,
Suez Canal University, Ismailia, Egypt.
Email: kassabse@gmail.com;
drkassabe@med.suez.edu.eg
© 2022 Association for the Study of Medical Education and John Wiley & Sons Ltd.
Med Educ. 2022;1–13.
Accepted: 6 March 2022
| Walid El-Sayed3,4 | Hossam Hamdy2
Abstract
Introduction: Student engagement is defined as behavioural, cognitive and emotional
aspects of students' academic experience in teaching, learning and research through
interacting with other students, faculty and community. Despite the growing interest
in the field of student engagement, medical education research in this area is still
fragmented. This scoping review aims to contribute to the understanding of
measurements, drivers and outcomes of medical student engagement.
Methods: The authors searched MEDLINE, PubMed, ProQuest, SCOPUS, ERIC,
Science Direct and EBESCO for English articles published from 1990 until October
2021. In addition, we hand-searched key medical education journals and references
in recently published articles. Using specific selection criteria, two authors indepen-
dently reviewed the articles for eligibility, followed by data extraction using both
quantitative and qualitative analysis.
Results: Of the 2136 retrieved articles, 51 studies were selected for the review, and
94% of them were published in the past 8 years. The prevailing measures of student
engagement failed to cover the multidimensionality of the construct with more focus
on the behavioural dimension. Quantitative methods represented two thirds of the
studies with a higher frequency of cross-sectional designs and using self-reports. The
identified drivers of medical students' engagement are directed mainly to modifying
the context of the learning environment. These factors increased student engage-
ment by fostering relevance of learning, positive student relationships with peers and
faculty, and enhancing student agency, and sense of competence. Cognitive
engagement appears to be a positive predictor of academic achievement, but the
relationship with other dimensions of engagement is controversial.
Conclusions: Student engagement in undergraduate medical education is an
important, yet under-researched construct. The research that does exist suggests
engagement to be malleable, something that can be modified by different types of
interventions taking into consideration the context of education and practice. Further
research is required, however, to address the gaps identified in this review.
wileyonlinelibrary.com/journal/medu 1
2 KASSAB ET AL.
1 | I N T RO DU CT I O N
Studies have demonstrated that student engagement is one of the
most robust predictors of academic achievement,1 increased student
2
perseverance and retention, and correlates with desirable mental
health outcomes such as low rates of depression3 and higher life
4
satisfaction. In addition, student engagement facilitates the teaching
process and is intrinsically rewarding for teachers,5 although student
disengagement is a major factor for teacher burnout.6 Furthermore,
student engagement is recognised as an important component of
educational practice. For example, it is identified by the Association
for Medical Education in Europe's ASPIRE initiative as a basis on
which to recognise/reward medical training programmes for
excellence.7
Student engagement is a complex meta-construct that has been
conceptualised into different dimensions. The most ubiquitous
conceptual model consists of three distinct but interrelated
dimensions of engagement: cognitive, behavioural and emotional/
8–10
affective. Other researchers added a fourth dimension such as
social engagement,11 academic engagement12 or agentic engage-
ment.13 Recently, an overarching definition of student engagement
considers student engagement as two conceptually different but
interrelated constructs: learning engagement and school engage-
14
ment. For defining the student engagement construct, this review
adopted Groccia's multidimensional conceptual model. In this model,
student engagement is defined as the aspects of student academic
experience in teaching, learning and research through interacting with
other students, faculty and community at the cognitive (thinking),
affective (feeling) and behavioural (doing) levels.10
The cognitive dimension of student engagement represents the
mental resources invested by the students in their learning. This
includes the use of deep learning strategies, deep concentration,
thinking about learning activities, perceived value of academic tasks
and use of high-order skills. Emotional engagement refers to the
emotions a student experiences in response to the teacher, peers and
the learning environment. These emotions include positive and
negative feelings such as happiness, anxiety, enjoyment, boredom,
enthusiasm and pride.15 In addition, emotionally engaged students
experience the feeling of bonding and attachment to their peers,
teachers and school.16 Behavioural engagement refers to the
observable academic performance and participation in school
activities. This involves attendance, participation in class activities,
effort, persistence, participation in extracurricular activities and atten-
tiveness to educational activities.14
To enhance the conceptual clarity of student engagement, it is
important to distinguish its relationship with other related constructs
such as motivation and self-regulated learning. Motivation constitutes
the cognitive and affective factors that drive students' behaviour to
engage in an activity, while engagement represents how the students
feel, behave and think during the activity itself.14 Therefore,
motivation is considered as a facilitator (outside the construct) rather
than an indicator (feature within the construct) of engagement.17,18
Self-regulated learning involves students' volitional planning,
monitoring and control of their motivation, behaviour, cognition and
context to achieve specific goals.19 On the other hand, learning
engagement is concerned with students' direct experience with the
learning activities.14 The relationships between student engagement,
motivation and self-regulated learning can be illustrated using the
following example. Alex is a medical student who developed an
interest and desire to understand acid–base balance because he
perceived the value of the topic due to its utility and relevance to his
medical career (motivation). Driven by this will, he started to read the
topic in a textbook with full concentration and using deep learning
strategies (cognitive engagement). He also set the goals for understand-
ing the topic, selected the appropriate learning strategies, for example,
solving clinical problems in acid–base balance, monitored his
understanding, for example, by taking self-tests, and used self-
reflection to modify the goals or strategies for improving his future
learning (self-regulated learning). Therefore, despite its direct relation-
ship with self-regulated learning and motivation, student engagement
is considered as a unique construct that should be studied and under-
stood in its own.
There are numerous published instruments for measuring student
engagement at the pre-college level. However, the literature on
student engagement is curtailed by the inadequate attention to the
theoretical basis underpinning the measurement of this construct.20
Furthermore, because student engagement is context-specific, the
validity of these instruments needs to be established for measure-
ments in medical education. Despite the great interest in student
engagement in medical education, the construct is still nebulous and
fragmented. Accordingly, scoping reviews are suitable when the
collection of literature has not been comprehensively reviewed and
when the body of knowledge is diversified,21,22 The aim of this
scoping review is to explore and analyse published studies on
medical student engagement in order to identify the gaps in
medical education literature and propose a research agenda to cover
this gap.
2 | METHODS
This review is guided by the framework published by Arksey and
O'Malley.21 In addition, we used the Preferred Reporting Items for
Systematic reviews and Meta-Analyses extension for Scoping Reviews
(PRISMA-ScR) as a guide for reporting the review findings.23
2.1 | Identifying the research questions
This scoping review is designed to address the following research
questions:
1. What are the methods used for measuring student engagement in
undergraduate medical education?
2. What are the driving factors of student engagement in undergrad-
uate medical education?
KASSAB ET AL.
3. What are the outcomes of student engagement in undergraduate
medical education?
2.2 | Identifying relevant studies
We conducted an online search using the following databases:
MEDLINE, PubMed, ProQuest, SCOPUS, Education Resources
Information Centre (ERIC), Science Direct and EBESCO. The search
strategy was conducted with the help of an academic librarian
through an iterative process using both keywords and Medical Subject
Headings (MeSH) terms. We settled on a search by title and abstract
using the search terms: [‘student engagement’ OR ‘engagement’ OR
‘learner engagement’] AND [‘medical’]. We added additional
filters using the following search terms anywhere in the text
[‘undergraduate’] AND [‘qualitative research/quantitative research/
mixed methods’]. We managed the matched articles using EndNote
(version 7, Clarivate Analytics, Philadelphia, United States). Following
the database search, we searched the references list in key articles
addressing the subject of student engagement. That step was
followed by hand-searching of 14 key journals that were previously
identified as key titles in medical education (Appendix S1).24,25 We
restricted the search to studies published from 1 January 1990, until
15 October 15 2021.
2.3 | Study selection: Inclusion and exclusion
criteria
We applied the following eligibility criteria: (1) published in English,
(2) the focus of research is on measuring student engagement, factors
affecting engagement or outcomes of engagement, (3) the main
subjects are undergraduate medical students and (4) peer-reviewed
articles with clear data collection including quantitative, qualitative or
mixed methods. The following studies are excluded: (1) non-English
articles, (2) related to hospital-physician engagement or physicians on
additional training after graduation such as residency, fellowship or
continuing medical education, (3) student engagement in other health-
related professions, and (4) books, chapters of books, commentaries,
editorials, letters, conference papers, conference abstracts, white
papers, dissertations or theses. In the first round, the first two authors
(SK and WE) independently screened all the titles and abstracts of the
studies for eligibility. In the second run, SK and WE independently
examined all full-text articles. Inconsistencies between the first two
authors were discussed, and a final decision was reached after discus-
sion with the third author (HH).
2.4 | Charting the data
We used Microsoft Excel (Microsoft Corp., Redmond, WA, USA) with
the following data charting template: title, author, name of journal,
publication year, country, study population, study methodology, study
3
design, engagement measure, dimensions of engagement, data collec-
tion methods, outcome measures, main findings and conclusions. The
charting template was agreed upon by the research team. The data
from the included articles were extracted through an iterative process
and the charting template was continuously shared and updated
through input from all the authors.
2.5 | Collating and analysing the data
We used a descriptive-analytical approach for summarising the infor-
mation from the included studies using the charting template. Quanti-
tative data included a descriptive numerical summary of the study
characteristics. Qualitative data were thematically analysed by the
first two authors (SK and WE) who read the articles and collated the
common themes identified by the original authors of the various
qualitative articles. Themes were colour-coded in an excel sheet, and
frequently reported themes were independently analysed by both
authors. Repeated discussion between the two authors resulted in a
final list of themes. The third author addressed any inconsistencies to
reach a consensus.
3 | RE SU LT S
3.1 | Study selection process
Figure 1 illustrates the flow of information in the different phases of
the study selection process. Searching the online databases revealed
1222 research articles, although another 914 articles were identified
through other sources (references and hand-searching of medical
education journals). After the deduplication process, 1052 records
were identified, and 939 were excluded through screening by
abstracts and titles. Out of the eligible 113 full-text articles, 62 were
excluded because they did not fulfil the selection criteria ending up
with the final list of 51 articles to be included in the review.
3.2 | Study characteristics
As shown in Figure 2 (upper panel), most of the articles (94.1%,
n = 48) are published in the last 8 years. The lower panel of Figure 2
shows that 47.1% (n = 24) of the studies are conducted in the United
States,26–49 9.8% (n = 5) in the United Kingdom,50–54 9.8% (n = 5) in
Australia,55–59 4% (n = 2) in Germany,60,61 4% (n = 2) in the
Netherlands,62,63 2% (n = 1) in Canada,64 2% (n = 1) in Norway,65 2%
(n = 1) in Ireland,66 5.8% (n = 3) in China,67–69 4% (n = 2) in
Turkey,70,71 2% (n = 1) in Pakistan,72 2% (n = 1) in Malaysia,73 2%
(n = 1) in Korea,74 2% (n = 1) in India75 and 2% (n = 1) in Brazil.76 The
methodology in the included studies were quantitative in 66.7%
(n = 34), qualitative in 11.8% (n = 6) and mixed methods in 21.6%
(n = 11). The quantitative study designs included cross sectional in
39% (n = 20),26,28–31,33,37–39,42,43,45,53,63,64,67,69,70,74,75 experimental
4 KASSAB ET AL.

F I G U R E 1 Flowchart of the process of study

identification, screening and selection process in
the scoping review of student engagement in
undergraduate medical education. The chart is
constructed in line with the Preferred Reporting
Items for Systematic reviews and Meta-Analyses
extension for Scoping Reviews (PRISMA-ScR)

in 12% (n = 6),27,32,34,51,66,76 quasi-experimental in 8% used for measuring medical student engagement. Two self-reports
(n = 4) 41,46,73,77
and longitudinal in 8% (n = 4). 50,62,65,71
are measuring the cognitive engagement dimension,62,73 and two
self-reports are measuring behavioural engagement.45,65,74 Other
self-reports that measure three dimensions include the Utrecht Work
3.3 | Methods used for measuring student
Engagement Scale (UWES),26,63,67,69 survey of student engagement
engagement
(SSE) instrument37–39 and technology-enhanced learning (TEL)
From the selected studies, 43 studies have used one or more than engagement scale.53 Finally, there is one self-report measure that
one instrument for measuring student engagement. The most covers four engagement dimensions.75
frequently used instrument is the self-report in 51.0% (n = 22) of the
studies,26–28,32,34,37–39,43,53,57,59,62–67,69,73–75 although real-time
3.3.2 | Observational measures
measures were used in 19.0% (n = 8),29,31,33,36,40,46,47,76 multiple
methods represented 16.0% (n = 7),41,44,45,50,51,56,60 direct As described in Table 1, we have identified two observation
observation represented 7.0% (n = 3)42,70,71 and interviews used in instruments based on the same concept: the STROBE42,45 and a
7.0% (n = 3) of the studies. 55,58,68
For the level of measuring student modification of STROBE called in-class engagement measure
engagement, 42% (n = 18) studies are measuring at the activity (IEM).70,71 Both instruments are used for measuring behavioural
29,32–34,41,42,44,45,56,59,60,62,65,66,70,71,73,76
level, 37% (n = 16) at the engagement during classroom learning activities. Categories of
course level27,31,36–40,46,47,50,51,53,55,57,58,68 and 21% (n = 9) at the student behaviours on the STROBE include talking, listening, reading,
26,28,43,63,64,67,69,74,75
medical school level. organising, writing and others.42,45

3.3.1 | Self-report measures 3.3.3 | Real-time measures

There were large variations in the structure of the self-reports ranging We identified several diverse real-time measures as indicators for
from one item,27,28,57,66 three to nine items,34,45,62,65,69,73 to a full student engagement that focus mainly on the behavioural dimension.
scale of 14–22 items.26,37–39,53,59,74,75 Table 1 shows 10 self-reports Examples of these methods include (1) students participation in
KASSAB ET AL. 5

examined student engagement in a simulation-based learning environ-

ment and demonstrated three dimensions of engagement: reflective
engagement, performance engagement and interactive engagement.68
The third study demonstrated that the 3-D anatomical models
enhanced both behavioural engagement of medical students.58

3.3.5 | Multiple methods

Using more than one method for measuring medical student engage-
ment was either for validation of one of the primary instruments
used45 or for triangulation of evidence41,44 to get a more comprehen-
sive assessment of engagement levels. One of the two studies that
used triangulation in engagement assessment was applied in virtual
patient simulations and used direct observation, work sample analysis,
teacher rating and student self-report.44 The second study evaluated
the use of technology in small group learning and used attendance,
completed assignments, response/feedback, quality of student
discourse and faculty satisfaction with student engagement.41

3.4 | Driving factors for student engagement in

medical education

We identified 36 studies that addressed the driving factors of medical

student engagement in learning. One study examined the personal
factors and demonstrated that learners' self-efficacy and intrinsic

F I G U R E 2 Bar charts illustrating a summary of the publications motivation are positive predictors of learning engagement.69 Another
(n = 51) used in this review about student engagement in two studies examined the role of basic psychological needs
undergraduate medical education. Upper graph illustrates the percent (autonomy, competence and relatedness) as predictors of
number of publications from 2002 until 2021, and lower graph engagement.64,74 Twelve studies examined the role of active learning
illustrates the country from which the study is conducted
methods in enhancing medical student engagement. These methods
included problem-based learning,42,45,70 team-based
38,42,62,65,71
learning, case-based teaching,70 pair work in large
multiple-choice question (MCQs) delivered via an online teaching classrooms,33 reflective practice68,76 and interprofessional
platform,36 (2) number and quality of question asking and time spent education.43,68 Another study demonstrated enhanced medical
on interactive activities,31,47 (3) number of clicks on social media student engagement when moving from grading to pass/fail along
pages designed for medical education (page view, page preview, post with enhanced regular feedback.49
46
likes, post shares), (4) time students spent online on the study mate- An additional 17 studies examined the role of the TEL environ-
rial76 and (5) attendance and number of posted discussion board ment in facilitating the medical student engagement. The use of tech-
responses to a clinical scenrio.41 There is one instrument called the nology in these studies includes simulation-based learning,29,44,56,68
online engagement metric for virtual patients that has multiple microblogs,47 social media,46,52,75 adaptive tutorials,59 videoconfer-
indicators of behavioural engagement and had good psychometric ence sessions,31,41 digital games,55 three-dimensional printed
properties.29 The only identified real-time indirect measure of the models,58 virtual reality using 360 videos,32,57,66 learning dash-
cognitive dimension includes heart rate assessment by wristwatch- boards60 and audience response systems.51 Furthermore, there are
33
style monitors during the learning sessions. five studies that examined the factors which facilitate students' state
of connection with the school community (school engagement). These
studies included volunteering programmes30,43 and empowering stu-
3.3.4 | Interviews and focus groups dents by taking leadership roles in the college programme.28,35,61

This review identified three studies that used interviews for qualita-
3.5 | Outcomes of student engagement in medical
tive data collection. The first study examined medical student engage-
education
ment with a team-based digital game in anatomy and histology and
yielded three engagement dimensions: enjoyment, collaborative social Out of the 12 studies included in this review for measuring the
interaction and challenge, improved knowledge.55 The second study engagement outcomes, four studies demonstrated a positive

TABLE 1 Instruments used for measuring student engagement in undergraduate medical education
Name of the instrument
Student self-report measures
Situational cognitive engagement
questionnaire
Student Self-Report of
Engagement (SSRE).
Student engagement scale
Survey of student engagement
(SSE) instrument
Utrecht Work Engagement Scale
(UWES)
Dimension(s) and conceptualization of
engagement
Cognitive
• Effort
• Persistence
• Absorption
Behavioural
• Attention
• Class discussion
Behavioural
• Instructional preparation
• Performing instructional activities
• Expressing oneself
• Extending instruction
• Instructional enthusiasm
Three dimensions
• Cognitive development
• Cooperative learning
• Personal skill development
Three dimensions
• Cognitive (dedication)
• Emotional (vigour)
• Behavioural (absorption)
6
Operationalization of engagement Evidence of validity and reliability Measurement setting Reference
62
Four items for measuring cognitive Coefficient H = 0.81 Face to face
engagement. The items are scored Confirmatory factor analysis and path
on a 5-point Likert scale: 1 (not true analysis.87
et al for me) and 5 (very true for me).
45,65
The instrument consists of 9 items Good internal consistency (Cronbach's Face to face
using a five-point Likert scale alpha of 0.84) and
(1 = strongly disagree, 5 = strongly unidimensionality.89
agree).
74
The scale includes 16 items on a Cronbach's alpha = 0.90. Face to face
5-point Likert scale ranging from 1 For the five subscales,
(strongly disagree) to 5 (strongly Cronbach α coefficients were 0.83,
agree). 0.80, 0.85, 0.80 and 0.78,
respectively.
37–39
Consists of 14 items with a 4-point Cronbach's alpha coefficient is 0.84, Face to face
Likert scale (1 = never to 4 = very and higher engagement score with
often). increased PBL activities.90
• Cognitive development (5 items)
• Cooperative learning (4 items)
• Personal skill development (5 items)
The total engagement score is the sum
of the scores in the three
dimensions.
3,26,63,69
The scale consists of 14 items3 or 15 Cronbach's alpha: Face to face
items.26 Shorter versions that • UWES-15: 0.93
consist of 3 items69 and 9 items63 • UWES-S: 0.87
are also used. Rated on a 7-point • UWES-S-9: 0.90
Likert Scale (from 0 to 6 points). • UWES-S-3: 0.86
Item scores are summed and then
divided by the number of items to
represent total engagement score.
KASSAB ET AL.

TABLE 1 (Continued)
Name of the instrument
Four dimensions with agentic
engagement questionnaire
User Engagement Scale-20
(UES-20)
TEL engagement scale
User Experience Questionnaire
(UX questionnaire)
Learners' Engagement and
Motivation
Questionnaire
Dimension(s) and conceptualization of
engagement
Four dimensions
• Cognitive (elaboration-based
learning strategies, metacognitive
learning strategies)
• Emotional (enjoyment, interest,
curiosity, fun)
• Behavioural (on-task attention,
lesson involvement, effort)
• Agentic (constructive contribution
into the flow of the instruction)
Two dimensions
• Cognitive (focused attention)
• Emotional (aesthetic appeal,
perceived usability, novelty, felt
involvement and endurability)
Three dimensions
• Emotional (satisfaction)
• Cognitive (goal setting and
planning)
• Social/behavioural (physical
interaction)
Two dimensions
• Cognitive (concentration/
absorption)
• Emotional (enjoyment, excitement)
Cognitive
• Attention focus
• Intrinsic interest
• Curiosity
KASSAB ET AL.
Operationalization of engagement Evidence of validity and reliability Measurement setting Reference
75
The questionnaire consists of 22 items Confirmatory factor analysis supports E-learning (social media)
on a 5-point Likert scale ranging the four-factor structure with
from 1 (strongly disagree) to 5 acceptable fitness indices.
(strongly agree) and represented by
four dimensions:
Agentic: 5 items
Behavioural: 5 items
Cognitive: 8 items
Emotional: 4 items
59
The scale consists of 20 items (6 Factor analysis indicated that a four- E-learning (Adaptive
subscales) with a 5-point Likert scale factor model was appropriate to eLearning Platform)
(1 = strongly disagree and explain the variance in responses.
5 = strongly agree) to evaluate their
engagement with the learning
resource to which they were
exposed.
53
The scale consists of 19 items with Cronbach's alpha = 0.86. Exploratory E-learning (TEL
5-point Likert scale (1 = strongly factor analysis supports the three- resources)
disagree and 5 = strongly agree). factor structure.
Satisfaction is 8 items, goal setting
and planning is 7 items, and physical
interaction is 5 items.
32
The scale consists of 8 items on a scale The survey was adapted from a pre- E-learning (360 and 2-D
of 0–100, asking the student to validated questionnaire that has videos)
indicate how much you agree with been used in gaming literature.91
each statement. Cognitive
dimensions are 4 items and
emotional dimension is 4 items.
73
Consists of 6 items on a Likert scale A pre-validated scale with Cronbach Blended learning
measured on a 7-point semantic alpha = 0.93–0.95 and exploratory
scale ranging from not at all true to factor analysis demonstrates a
very true. unidimensional factor structure.92
1) Attention focus (2 items)
2) Intrinsic interest (2 items)
3) Curiosity (2 items)
(Continues)
7

TABLE 1 (Continued)
Name of the instrument
Real-time measures
Online engagement metric for
virtual patients (VPs)
Observational measures
STROBE
In-class engagement measure
(IEM)
Abbreviations: PBL, problem-based learning; TEL, technology-enhanced learning.
Dimension(s) and conceptualization of
engagement
Behavioural (student interactions with
VP)
• Time on page
• Multiple-choice question (MCQ)
answer accuracy
• Use of a clinical reasoning tool
• Scoring of students' written
summary statements based on the
VP encounter
Behavioural
• Learner-to-learner engagement:
speaking, listening or both.
• Learner-to-instructor engagement:
speaking, listening or both.
• Self-engagement: learner reading
and writing.
Behavioural
• Student behaviour scale
• Instructor behaviour scale
Operationalization of engagement
The engagement metric score is
calculated as follows:
1. Time in seconds spent on each
page (0 = <20 sec, 1= > 20 sec)
2. Score of MCQs embedded in the
case (0 to 100%).
3. Clinical reasoning score (0 to
100%), computed by the VP
software.
4. Written summary statements
scored by a machine learning
software (binary score 0 to 1).
The final engagement score represents
the mean of the four components.
Consists of 5-min observational cycles
repeated continuously throughout
the learning session. An ‘observed
learner engagement behaviour’ is
defined as the single response
coded on the STROBE by a trained
observer after having observed a
learner continuously over a period
of 10–20 s.
Consists of 5 items on a Likert scale
1–5 (1–2 is non-participating and 3–
5 is gradually increasing
participation). The instrument is a
revised form of STROBE, used for
recording behaviours of an
instructor and four randomly
selected students as snapshots for
5-min cycles.
8
Evidence of validity and reliability Measurement setting Reference
29
1. Content review by education E-learning
experts.
2. Confirmatory factor analysis
(acceptable fit to a one-factor
model).
3. Correlations of the engagement
score with self-report measures.
4. Excellent raters' agreement with
the content and scoring cut-points
(0.98).
42,45
1. Good to excellent inter-observer Face to face
agreement.
2. Student-to-student interactions are
greater in PBL compared with
traditional lectures.
3. Concordance of scores with the
student self-report of engagement
(SSRE)
70,71
1. Content-related: review from Face to face
experts
2. Criterion-related: differences in
scores in active learning vs.
traditional classes). There is also
excellent inter-observer agreement
in scores.
KASSAB ET AL.
KASSAB ET AL.
relationship between cognitive engagement and academic
achievement in knowledge-based assessments,59,62,73,75 In addition,
student engagement, measured by UWES-3, significantly mediates
the relations between intrinsic/extrinsic motivation and academic per-
formance.69 Similarly, there was a significant relationship between
participation (as a measure of engagement in class activities) and
36,50
knowledge assessment scores although the effect size is small.
On the other hand, studies that used instruments for the assessment
of multiple dimensions of engagement yielded no significant
relationships between learning assessment scores and student
38,39,53
engagement. The same finding was observed when using stu-
dent attendance as a behavioural engagement indicator.40 However,
qualitative interviews with students demonstrated other outcome
benefits of student engagement in voluntary or leadership roles in
college activities. These benefits included fostering relationships
between students and their peers and faculty, empowering the
students, feedback tools for the curriculum and learning new
skills.30,48
4 | DISCUSSION
The growing interest in research about student engagement in
medical education emanated from the demonstrated evidence of its
positive effects on students, teachers and the overall quality of the
college programme. However, the novelty and multidimensionality of
the student engagement construct were associated with many
challenges in its conceptualization and measurement that led to diffi-
culties in comparing studies and inconsistent outcomes of student
engagement.
4.1 | Methods used for measuring student
engagement
Most of the identified student engagement instruments in this review
contain items that measure a small scope of the engagement con-
struct. Around two thirds of the selected studies measured one or
two dimensions of student engagement and therefore do not reflect
the multidimensionality and complexity of this construct. There was a
heavy emphasis on measuring the behavioural dimension, with a small
representation of the cognitive and emotional dimensions. Even the
studies that measured three dimensions were not consistent in
conceptualising the dimensions of engagement.
Each of the instruments for measuring medical student engage-
ment has its strengths and limitations that need to be considered.
Despite the known problems with self-reported data, research on
student engagement suggests that self-reports are more suitable for
measuring unobservable indicators of engagement, mainly in the cog-
nitive and emotional dimensions.78 On the other hand, direct observa-
tion can provide a comprehensive image on the contextual factors
related to student engagement.78 However, studies raise a concern
about the ability of direct observers to measure the reality, especially
9
without proper training.79 Moreover, direct observation studies can
have limited generalizability because it usually includes a small number
of students.80 Notwithstanding the advantage of real-time measures
in sampling a large amount of information in a short period of time,
they require a well-structured setup for measurement81 and can be
distractive for students and teachers.82 In addition to the above mea-
sures, interviews and focus groups can get an in-depth information
about students experience in engagement. Nevertheless, they can be
difficult to analyse and require training of interviewers.78,83 Therefore,
triangulation of evidence by combining multiple methods can achieve
a more comprehensive image of the student engagement construct in
medical education. However, the challenge remains on how to inte-
grate the findings from the multiple methods of measuring student
engagement.82
4.2 | Driving factors for student engagement
Student engagement has been characterised as a rich and malleable
construct that responds to the changes that are targeted by school
interventions.84,85 These interventions appear to be more effective
when they target the context, rather than the learner characteristics
that are difficult to be altered.84 This scoping review identified multi-
ple interventions that can enhance medical student engagement.
These instructional methods could increase engagement of medical
students by targeting one or more of the following drivers: (1) positive
student-peer relationships, (2) positive student-faculty relationships,
(3) enhanced sense of competence, (4) sense of agency and empower-
ment by the students and (5) perceived relevance through meaningful
learning activities.84,85 The first four drivers are based on the self-
determination theory where fulfilment of the students' basic psycho-
logical needs of autonomy, relatedness and competence in the school
could enhance their intrinsic motivation86 and lead to increased
engagement.17 The main limitation of the studies on drivers of
medical students' engagement is that they are mostly survey-based
and only few studies have used experimental designs. Two survey-
based studies in this review demonstrated that students perceived
the need for competence as the strongest predictor of engage-
ment.64,74 However, there was no specific measure in the remaining
studies for the relative contribution of each driver on different
engagement dimensions.
4.3 | Outcomes of student engagement
Studies in this review demonstrated that cognitive engagement of
medical students correlated with knowledge-based achieve-
ment.59,62,73,75 Similar relationships between cognitive engagement
and academic achievement have been also established in college
students87 as well as in high school students.88 On the other hand,
the relationships between academic achievement and other dimen-
sions of engagement are fuzzy. For example, the correlation between
the behavioural engagement of medical students and academic
10
achievement has been reported as positive36,50 or not existing.40,75
Likewise, the role of ‘agency’ as a predictor of academic achievement
75
was not confirmed in medical education. However, previous studies
in high schools demonstrated that agentic engagement independently
predicted academic achievement in high school students.13 Research
studies demonstrated that the relationship between student engage-
ment and academic achievement was not significant when using
instruments for the assessment of multiple dimensions of engage-
ment.38,39,53 The lack of consistency in the relationship between
medical student engagement and academic achievement could be
explained by the use of different indicators for operationalising
engagement, which makes it difficult to compare the findings between
studies. For example, behavioural engagement has been oper-
ationalised into attendance,40 participation36,50 or on-task attention,
75
lesson involvement, and effort. Furthermore, engagement dimen-
sions are not discrete, but interrelated, and therefore the outcome of
one dimension could be partly explained by other dimensions.
4.4 | Limitations
Despite the comprehensive approach used in this scoping review with
the help of an expert librarian, there is a possibility of missing relevant
articles published in other databases. Because our search was focused
on English language studies, we may have inadvertently excluded
pertinent articles published in other languages. Furthermore, we could
have missed additional sources of evidence because we did not
contact any researchers or experts. Finally, taking into consideration
the growing interest in student engagement, relevant articles are likely
to have been published after the date of our data collection.
4.5 | Future research agenda
With the current fuzziness in conceptualization and operationalization
of the student engagement construct in the medical education litera-
ture, a plan for a comprehensive research agenda should be in action
to address these problems. There is a paucity of research that
addresses the psychometric properties of instruments used for mea-
suring the multiple dimensions of the student engagement construct
in medical education. In addition, many researchers consider engage-
ment and disengagement as two conceptually and methodologically
different constructs which do not lie bipolarly on the same contin-
uum.77 However, there is a dearth of research on the methods of
measuring medical student disengagement, as well as the driving fac-
tors and outcomes of student disengagement. Most of the identified
interventions are designed with the main goal of increasing the
engagement of all medical students. However, there is a lack of
research on interventions that target students who demonstrate signs
of cognitive, behavioural and emotional disengagement. In addition,
there is a lack of longitudinal studies for the follow-up of student
engagement following the changes in contextual factors in the
medical school. Furthermore, research examining the outcomes of
KASSAB ET AL.
interventions that target enhancing the engagement of medical
students with academic or behavioural problems should be a high
priority. Because most of the outcome-based studies of medical
student engagement have used cognitive tests as outcome measures,
other outcome measures such as psychomotor skills, student reten-
tion, student satisfaction and career readiness are still to be explored.
Finally, more qualitative research is required to provide comprehen-
sive understanding of the process by which engagement can lead to
certain outcomes.
ACKNOWLEDG MENTS
The authors would like to thank Mr. Daies Idiculla, librarian at Gulf
Medical University, and Ms. Aji Gopakumar, research analyst of qual-
ity assurance & institutional effectiveness and lecturer of statistics at
Gulf Medical University, for their great help in the process of litera-
ture search and providing the full-text articles for this scoping review.
FUNDING
None.
CONFLIC T OF INT ER E ST
None.
AUTHOR CONTRIBU TIONS
SEK initiated the study idea and research design. He helped in the
literature search, selection of articles, data charting and analysis. He
also drafted the first version of the manuscript. WE helped in the
literature search process, selection of articles, data entry and analysis.
HH contributed to the study design and selection of the included
articles. All authors contributed to the interpretation of data, drafting
and critical revision of the manuscript. All authors read and approved
the final manuscript. All authors agreed to be accountable for all
aspects related to the manuscript.
ET HICAL APPROVAL
NA.
OR CID
Salah Eldin Kassab https://orcid.org/0000-0003-1482-1996
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How to cite this article: Kassab SE, El-Sayed W, Hamdy H.
Student engagement in undergraduate medical education: A
scoping review. Med Educ. 2022;1-13. doi:10.1111/medu.
14799