Academic educators’ leadership styles and their associations with student engagement and critical thinking disposition among Saudi health sciences students: a mixed-methods study

Abstract

Background

Educator leadership behaviors are widely recognized as an important component of the classroom environment and may be associated with student engagement and critical thinking disposition. In health sciences education, these competencies are fundamental to clinical reasoning and evidence-based decision-making. However, empirical evidence examining the associations among educator leadership styles, student engagement, and critical thinking disposition remains limited.

Methods

This explanatory sequential mixed-methods study was conducted at a Saudi health sciences university. Quantitative data were collected from a stratified random sample of 351 undergraduate students across four health sciences colleges using the Leadership Style Questionnaire, the Critical Thinking Disposition Scale, and the University Student Engagement Inventory. Data were analyzed using descriptive statistics, Pearson’s correlations, multiple linear regression, and bootstrapped cross-sectional indirect-effect analysis. Qualitative data were subsequently collected from 58 unique participants through 40 semi-structured interviews and four focus group discussions (28 participants, including 10 who also participated in interviews) and analyzed using inductive reflexive thematic analysis.

Results

Students reported mean student engagement and critical thinking disposition scores above the scale midpoint. Democratic leadership demonstrated the strongest positive bivariate associations with student engagement (r = .363, p < .001) and critical thinking disposition (r = .402, p < .001), whereas laissez-faire leadership demonstrated comparatively weaker associations. In adjusted regression analyses, democratic leadership remained independently associated with student engagement (β = 0.39, p < .001) and critical thinking disposition (β = 0.15, p = .007), whereas laissez-faire leadership showed no statistically significant independent association with either outcome after adjustment for the remaining leadership styles. Bootstrapped indirect-effect analysis indicated that student engagement statistically accounted for part of the association between democratic leadership and critical thinking disposition. Qualitative findings converged with and expanded the quantitative results, with students describing participatory teaching behaviors, open dialogue, constructive questioning, collaborative learning, and clear instructional guidance as supporting engagement and reflective thinking.

Conclusions

Democratic educator leadership demonstrated the strongest positive associations with student engagement and critical thinking disposition. These findings suggest that participatory teaching approaches may represent valuable components of faculty development and educational practice. Longitudinal and multi-institutional studies are warranted to further examine the temporal relationships among educator leadership, student engagement, and critical thinking disposition.

Supplementary Information

The online version contains supplementary material available at https://doi.org/10.1186/s12909-026-10239-1.

Introduction

Healthcare education has undergone a fundamental transformation in recent decades, shifting from a predominantly didactic, content-delivery model toward an outcomes-based, learner-centered paradigm that prioritizes the development of professional competencies alongside academic knowledge [1, 2]. Within this paradigm, the capacity of students to engage meaningfully with their learning and to approach clinical and academic problems with critical, reflective thinking is increasingly recognized as an important element of preparation for safe, effective, and person-centered healthcare practice [3]. As health professions education continues to shift toward learner-centered and competency-based models, understanding the educational conditions that are associated with these capacities has become a priority for researchers, institutions, and policymakers working across health professions education.

Student engagement and critical thinking disposition represent two central outcomes of contemporary health sciences education. Student engagement reflects the extent to which learners invest behavioral effort, emotional involvement, and cognitive resources in their academic activities and has been widely identified as a correlate of academic achievement, persistence, and professional development in higher education [4, 5]. Critical thinking disposition differs from critical thinking ability in that it reflects an individual’s willingness to engage in reflective inquiry, evaluate evidence, and reconsider existing assumptions, rather than demonstrated analytical performance [6]. In health sciences education, this disposition is considered important because students must develop the capacity to analyze clinical information, interpret evidence, and make sound professional judgments in complex practice environments [3, 7].

Although curriculum design and instructional methods have received considerable attention in health professions education, educator leadership behaviors have received comparatively less empirical investigation despite their potential influence on students’ engagement and higher-order thinking. Among the contextual factors that may be associated with these learning outcomes, the leadership style adopted by educators has increasingly been recognized as an educational rather than purely managerial construct [8, 9]. Leadership behaviors influence how educators organize instruction, facilitate classroom interaction, and provide opportunities for students to participate in dialogue, question assumptions, and engage deeply with academic content [8, 10]. Classical leadership theory identifies three principal leadership styles—autocratic, democratic, and laissez-faire—each characterized by distinct patterns of authority, participation, and instructional guidance [10, 11]. Previous educational research suggests that participatory leadership behaviors are associated with greater student motivation, engagement, and academic self-efficacy, whereas more directive or passive leadership approaches have shown less consistent associations with desirable educational outcomes.

Although educator leadership, student engagement, and critical thinking disposition have each been examined independently in previous research, relatively little attention has been given to their interrelationships within a single conceptual model in health sciences education. In particular, few studies have explored whether student engagement represents a mechanism through which educator leadership is associated with critical thinking disposition, especially among multidisciplinary health sciences students in Saudi Arabia. Addressing these gaps may contribute to a more comprehensive understanding of how educator leadership is associated with important educational outcomes.

Conceptual framework

The present study is guided by a conceptual framework integrating educators’ leadership styles, student engagement, and critical thinking disposition. This framework draws upon the classical autocratic–democratic–laissez-faire leadership typology originating from Lewin, Lippitt, and White, as operationalized in Northouse’s leadership instrument [10], Sosu’s model of critical thinking disposition [6], and the tri-dimensional engagement model proposed by Maroco et al. [4].

Educators’ leadership styles represent a primary contextual factor associated with students’ learning experiences. Leadership style refers to the behavioral patterns through which educators organize instruction, manage classroom interactions, and guide students’ learning experiences [10]. Three classical leadership styles have been widely examined in educational contexts: autocratic, democratic, and laissez-faire leadership. Autocratic leadership emphasizes centralized authority, directive teaching, and limited student participation in decision-making. Democratic leadership encourages participatory learning, collaborative dialogue, and shared intellectual responsibility between educators and students. Laissez-faire leadership involves minimal educator direction and limited instructional guidance, allowing students considerable autonomy but often providing limited structural support for learning [10, 11].

Student engagement represents the degree to which students actively invest effort and attention in their academic learning. According to Maroco et al. [4], student engagement consists of three dimensions: Behavioral engagement, emotional engagement, and cognitive engagement. Behavioral engagement reflects students’ participation in academic tasks and institutional expectations. Emotional engagement reflects students’ sense of belonging and affective connection with the learning environment. Cognitive engagement represents the investment of effort in deeper learning strategies and reflective thinking processes.

Critical thinking disposition refers to the motivational orientation that encourages individuals to engage in reflective and analytical reasoning [6]. Sosu conceptualized this construct through two complementary dimensions: critical openness, representing openness to new ideas and willingness to revise beliefs in light of evidence, and reflective skepticism, representing the tendency to question claims and evaluate information critically [6]. Within health sciences education, these dispositions are essential because students must analyze clinical information, interpret evidence, and make informed professional decisions [3, 7].

The proposed conceptual framework rests on the proposition that these three theoretical perspectives are complementary: Northouse’s leadership framework provides the basis for understanding leadership behaviors within instructional settings; Maroco et al.‘s multidimensional engagement model suggests that supportive educational environments are associated with behavioral, emotional, and cognitive engagement; and Sosu’s conceptualization of critical thinking disposition proposes that reflective openness and skepticism develop within learning environments that encourage questioning, dialogue, and evidence appraisal. Drawing on these perspectives, the present framework proposes that educators’ leadership styles are associated with both student engagement and critical thinking disposition. Leadership behaviors are proposed to be associated with the classroom climate, which in turn is associated with students’ participation, motivation, and intellectual engagement. In addition, student engagement is proposed to function as a mechanism statistically linking leadership behaviors to critical thinking disposition, consistent with an indirect-association (mediation) model rather than an established causal pathway, given the cross-sectional design of the quantitative strand.

Study hypotheses

Based on the conceptual framework and previous literature (Fig. 1), the following hypotheses were proposed:

• H1a: Autocratic leadership is significantly associated with student engagement.

• H1b: Democratic leadership is positively associated with student engagement.

• H1c: Laissez-faire leadership is negatively associated with student engagement.

• H2a: Autocratic leadership is significantly associated with critical thinking disposition.

• H2b: Democratic leadership is positively associated with critical thinking disposition.

• H2c: Laissez-faire leadership is negatively associated with critical thinking disposition.

• H3: Student engagement statistically accounts for part of the observed association between democratic leadership and critical thinking disposition (indirect association).

Fig. 1.

Study conceptual framework

Previous studies have explored the relationship between educator leadership behaviors and student engagement. Maqbool et al. [9] found that democratic leadership practices were associated with higher levels of student motivation, participation, and academic self-efficacy compared with more authoritarian approaches. Similarly, Mynbayeva et al. [12] reported that students who perceived their educators as collaborative and participatory exhibited higher behavioral and cognitive engagement. Autocratic leadership, while providing task clarity, has been associated with reduced emotional engagement and diminished intrinsic motivation, while laissez-faire leadership has shown weaker associations with positive engagement outcomes, with students reporting lower academic involvement and perceptions of limited instructional support [9, 13, 14].

Research examining critical thinking disposition in health sciences education indicates that learning environments encouraging reflective inquiry and dialogue are more likely to promote analytical thinking among students. Khalil and Abou Hashish [3] demonstrated that reflective practice training enhanced both critical openness and reflective skepticism among Saudi nursing interns. Similarly, Bhuttah et al. [7] reported that participatory teaching practices were positively associated with students’ critical thinking orientations.

Research gap and significance of the study

Although previous studies have independently examined educator leadership, student engagement, and critical thinking disposition, little evidence has integrated these constructs within a single conceptual model in health sciences education. Moreover, few studies have explored whether student engagement represents a mechanism through which educator leadership is associated with critical thinking disposition, particularly among multidisciplinary health sciences students [15]. Existing evidence has also focused predominantly on transformational leadership models, whereas comparatively little attention has been given to the classical autocratic, democratic, and laissez-faire leadership styles in higher education, and research conducted in Saudi Arabia has primarily focused on nursing practitioners or interns rather than undergraduate health sciences students [11]. Finally, empirical evidence from multidisciplinary health sciences students in Saudi Arabia remains limited. Addressing these gaps may contribute to a more comprehensive understanding of how educator leadership is associated with important educational outcomes across health professions programs.

This study contributes to the literature on health professions education in several ways. Theoretically, it provides an integrative framework linking educators’ leadership styles, student engagement, and critical thinking disposition within a single conceptual model. Methodologically, the use of a mixed-methods design combining validated quantitative instruments with qualitative exploration of students’ experiences provides both quantitative breadth within the sampled institution and contextual depth. Empirically, the findings from health sciences students across four colleges at King Saud bin Abdulaziz University for Health Sciences contribute institution-specific evidence on leadership–learning relationships within this national context and provide evidence from a multidisciplinary sample within a Saudi health sciences university.

From a practical perspective, the study offers evidence that may inform faculty development initiatives and teaching strategies aimed at fostering participatory learning environments that support engagement and critical thinking among future health professionals.

Aim of the study

This study aimed to examine the associations between perceived educator leadership styles, student engagement, and critical thinking disposition among undergraduate health sciences students and to explore students’ experiences of educator leadership using an explanatory sequential mixed-methods design.

Methods

Study design

This study employed an explanatory sequential mixed-methods design, in which quantitative data were collected and analyzed first to examine the statistical associations among educator leadership styles, student engagement, and critical thinking disposition, followed by a qualitative component comprising semi-structured interviews and focus group discussions conducted to provide a deeper understanding of the quantitative findings. This design was selected to provide both statistical breadth and experiential depth in understanding the relationships between educators’ leadership styles and student outcomes. The quantitative phase involved the administration of validated self-report instruments to a large sample of health sciences students, while the qualitative phase captured students’ experiences and perceptions of educator leadership within the academic environment. The quantitative and qualitative strands were integrated at the interpretation stage, through comparison and synthesis of findings from both strands, to provide a more comprehensive understanding of how educator leadership styles are associated with student engagement and critical thinking disposition and provides evidence from a multidisciplinary sample within a Saudi health sciences university.

This study was reported in accordance with established reporting guidelines for mixed-methods research. The quantitative component adhered to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement, the qualitative component followed the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist, and the integration and reporting of the mixed-methods design were guided by the Good Reporting of A Mixed Methods Study (GRAMMS) recommendations. The completed reporting checklists are provided in Supplementary Files S2–S4.

Setting and population

This study was conducted at King Saud bin Abdulaziz University for Health Sciences (KSAU-HS) in Jeddah, Saudi Arabia. The target population comprised undergraduate students enrolled across four colleges: the College of Medicine (COMJ), the College of Nursing (CONJ), the College of Applied Medical Sciences (CAMS), and the College of Science and Health Professions (COSHIP). These colleges collectively represent the range of health professions programs offered at the Jeddah campus and provided a diverse, multidisciplinary student population from which to examine the potential associations between educator leadership styles and student engagement and critical thinking disposition. Although the four colleges share a common institutional governance structure, they differ in curriculum design, teaching approaches, and clinical learning experiences, providing diverse educational contexts for exploring students’ perceptions of educator leadership.

Participants and eligibility criteria

The study targeted undergraduate students enrolled in the four health sciences colleges at King Saud bin Abdulaziz University for Health Sciences (KSAU-HS), Jeddah, including the College of Applied Medical Sciences (CAMS), the College of Medicine (COMJ), the College of Nursing (CONJ), and the College of Science and Health Professions (COSHIP).

For the quantitative phase, students were eligible if they were enrolled in Levels 2–8, were registered as full-time undergraduate students during the study period, had completed at least one academic semester within their respective college, and were willing to participate by providing informed consent. Level 1 students were excluded because they had only recently entered the health sciences programs and had limited exposure to educators’ leadership styles and classroom learning environments, which were the primary focus of the study. Students on academic leave, internship training outside the university, or those who submitted incomplete questionnaires with substantial missing data were also excluded from the final analysis.

For the qualitative phase, purposive sampling was used to recruit students who could provide rich and diverse perspectives regarding educators’ leadership styles and their learning experiences. Participants were selected to ensure variation across colleges, academic levels, and gender. Students were eligible if they had completed at the first year (level 1 and 2), were willing to participate in interviews or focus-group discussions, and were able to communicate their experiences in English.

Sample and sampling technique

For the quantitative phase, proportionate stratified random sampling was employed to ensure adequate representation across colleges, academic years, and gender. The total undergraduate population across the four health sciences colleges comprised 1,464 students. After excluding Level 1 students according to the predefined eligibility criteria, the sampling frame consisted of approximately 1,000 eligible undergraduate students enrolled in Levels 2–8. Based on this eligible population, the minimum required sample size was estimated at approximately 278 participants using a 95% confidence level and a 5% margin of error. To compensate for potential non-response and incomplete questionnaires, 400 eligible students were invited to participate. A total of 365 questionnaires were returned (response rate = 91.3%). During data screening, 14 questionnaires (3.8%) were excluded because they contained substantial missing data, yielding a final analytical sample of 351 complete responses (96.2% of returned questionnaires). The final sample exceeded both the estimated minimum sample size and the recommended sample size for the largest multiple regression model conducted in this study (7–8 predictors), thereby providing adequate statistical power for all planned analyses [16].

The qualitative participants were recruited from the same target population of undergraduate health sciences students across the four participating colleges following completion of the quantitative phase. Recruitment was conducted independently of the anonymous survey through purposive invitation of eligible students who met the study inclusion criteria. Consequently, individual survey responses were not linked to the qualitative data, and integration of the quantitative and qualitative findings occurred at the overall study level rather than through participant-level matching, consistent with the explanatory sequential mixed-methods design.

For the qualitative phase, purposive sampling was used to recruit students with diverse experiences of educators’ leadership styles across the four participating colleges. Four focus-group discussions were conducted, one from each college, with 6–8 participants per group, alongside 40 individual semi-structured interviews (10 participants from each college). Of the 28 students who participated in the focus-group discussions, 10 had previously participated in the individual interviews, whereas the remaining 18 participated only in the focus groups. This purposeful partial overlap was consistent with the explanatory sequential mixed-methods design and enabled further exploration of issues that emerged during the individual interviews while incorporating additional perspectives from students who had not previously participated. Such overlap is recognized as an appropriate sampling strategy in mixed-methods research because it facilitates deeper exploration of emerging findings while strengthening integration across qualitative data sources [17]. Individual interviews explored students’ personal experiences and perceptions of educators’ leadership styles, whereas the focus-group discussions elicited shared perspectives and collective reflections on classroom learning environments. The interview and focus-group datasets were initially analyzed independently before being integrated during interpretation to provide a richer explanation of the quantitative findings. Qualitative sample size was guided by the principle of thematic saturation rather than a predetermined numerical target. Saturation was assessed continuously throughout data collection and analysis through regular discussions among the research team regarding whether successive interviews and focus-group discussions continued to generate new codes or themes. Recruitment within each college concluded when no substantive new themes emerged. Figure 2 summarizes the sampling procedures for both study phases.

Fig. 2.

Sampling procedure in the current study. Note. Level 1 students were excluded because they had limited exposure to educators' leadership styles and classroom learning environments. N = number of students

Data collection instruments

Leadership Style Questionnaire (LSQ)

Educators’ leadership styles were assessed using the Leadership Style Questionnaire (LSQ), adapted from Northouse [10]. The LSQ comprises 18 items distributed equally across three subscales: Autocratic (6 items), Democratic (6 items), and Laissez-faire (6 items). Items are rated on a five-point Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree). A mean score was calculated for each subscale, with higher scores indicating greater endorsement of the corresponding leadership style. Students rated their educators’ leadership based on their overall academic experience across their program rather than a single named educator or course; this aggregate referent was chosen for feasibility but means that scores reflect a generalized impression of leadership climate rather than an assessment of an individual instructor. For descriptive purposes, a dominant leadership style was additionally identified for each participant based on the highest of the three subscale means; because the subscales were moderately to strongly intercorrelated and no tie-handling rule was pre-specified, this categorical classification is reported as a secondary, descriptive analysis, and the continuous subscale scores were treated as the primary variables in the correlation, regression, and mediation analyses.

Critical Thinking Disposition Scale (CTDS)

Critical thinking disposition was measured using the Critical Thinking Disposition Scale (CTDS) developed by Sosu [6]. The CTDS is an 11-item instrument assessing two dispositional domains: Critical Openness (7 items) and Reflective Skepticism (4 items). Items are rated on a five-point Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree). Total scores range from 11 to 55 and were categorized as low (11–34), moderate (35–44), or high (45–55). The CTDS is publicly available and has been widely used in educational research [3, 6].

University Student Engagement Inventory (USEI)

Student engagement was assessed using the University Student Engagement Inventory (USEI) developed by Maroco et al. [4]. The USEI consists of 15 items distributed across three subscales: Behavioral Engagement (5 items), Emotional Engagement (5 items), and Cognitive Engagement (5 items). All items are rated on a five-point Likert scale. One item in the Emotional Engagement subscale was reverse coded prior to analysis, and scoring was verified before computing subscale scores. Mean scores were calculated for each subscale and for the overall engagement score, with higher scores indicating greater engagement. All instruments were used for research purposes with appropriate citation of the original development studies. Variable coding and score derivation followed the procedures summarized in Supplementary Table S1.

Validity and reliability

Content validity was established through expert review, whereas face validity was evaluated during pilot testing. Expert review involved five specialists in nursing education, nursing leadership, educational measurement, and health professions research. The experts independently evaluated the adapted instruments for clarity, relevance, comprehensiveness, and contextual appropriateness with respect to the study constructs. The Scale Content Validity Index based on the average method (S-CVI/Ave) was 0.811, indicating acceptable content validity for the adapted instrument [18]. Based on the experts’ recommendations, minor wording revisions were made to improve clarity and contextual relevance while preserving the conceptual meaning of the original items. No formal translation was undertaken because English is the language of instruction at KSAU-HS. Adaptation of the LSQ was limited to minor wording adjustments to two items to improve contextual appropriateness for the Saudi health sciences student population and to reframe the referent from a general “leader” to “educator,” without altering the underlying constructs, response format, or scoring procedures. Because the adaptation involved contextual wording changes rather than substantive modification of item content, the original conceptual structure of the instrument was retained. The adapted instrument was reviewed for content validity but was not subjected to additional psychometric validation (e.g., confirmatory factor analysis) within the present study.

A pilot study was conducted with a small group of health sciences students (n = 30) who were not included in the final sample to assess the clarity and feasibility of the questionnaire. Participants reported that the items were clear and understandable, and the estimated completion time was appropriate. No major modifications were required following the pilot testing, and pilot data were excluded from the final analysis.

The internal consistency of the instruments was evaluated using Cronbach’s alpha coefficients, which demonstrated good reliability across all study measures (Table 2). Because the study employed previously established instruments, the present psychometric evaluation focused on internal consistency reliability within the current sample rather than re-establishing their underlying factorial structure.

Table 2.

Variables descriptive statistics and internal consistency (N = 351)

Variable	N	M	SD	Min	Max	α
Autocratic leadership	351	3.27	0.62	1.17	4.50	0.76
Democratic leadership	351	3.83	0.73	1.00	5.00	0.76
Laissez-faire leadership	351	3.20	0.78	1.00	5.00	0.73
Student engagement (total)	351	3.80	0.72	1.27	5.00	0.90
Behavioral engagement	351	4.00	0.81	1.00	5.00	0.81
Emotional engagement	351	3.48	0.91	1.00	5.00	0.81
Cognitive engagement	351	3.91	0.84	1.00	5.00	0.86
Critical thinking disposition (total)	351	3.89	0.77	1.00	5.00	0.91
Critical openness	351	3.83	0.79	1.00	5.00	0.86
Reflective skepticism	351	3.98	0.84	1.00	5.00	0.83

All variables are item-mean composites (1–5 scale)

SD Standard Deviation

α = Cronbach’s alpha. α interpretation: ≥0.90 excellent, 0.80–0.89 good, 0.70–0.79 acceptable, 0.60–0.69 questionable, < 0.60 poor

Data collection procedure

Following institutional ethical approval from the King Abdullah International Medical Research Center (KAIMRC), IRB Approval No. (NRJ25/038/1), quantitative data were collected through an electronic self-report questionnaire distributed to students at KSAU-HS Jeddah. Participation was voluntary and written informed consent was obtained prior to participation. Students were assured of confidentiality and informed of their right to withdraw at any time without consequence. The survey remained accessible for three weeks, with one reminder sent to non-respondents after ten days. The qualitative data were collected by the research team, whose members had prior experience in qualitative research methods and received training to ensure consistency in interviewing and facilitation techniques. None of the researchers had a direct teaching, supervisory, or evaluative relationship with the participants, thereby reducing the potential for social desirability bias and power imbalance during data collection.

For the qualitative component, data were collected through individual semi-structured interviews lasting approximately 30–45 min and focus group discussions lasting 60–90 min, both conducted by the research team. The researchers had no direct teaching, supervisory, or evaluative relationship with the participants. A semi-structured interview guide was developed based on the study objectives, the conceptual framework, and relevant literature, and was reviewed by experts to establish its clarity and relevance before data collection. The guide comprised open-ended questions exploring students’ perceptions and experiences of educators’ leadership styles and their perceived influence on student engagement, critical thinking disposition, and learning outcomes. Follow-up probing questions were used to clarify and expand participants’ responses while allowing flexibility to explore emerging issues. The same guide was used consistently across both individual interviews and focus group discussions. At the beginning of each focus-group discussion, the moderator established ground rules emphasizing respectful communication and requested that participants maintain the confidentiality of the discussion by not disclosing the identity or comments of other participants outside the session. Participants were also informed that, although the research team would anonymize all transcripts and reports, complete confidentiality among focus-group members could not be guaranteed. All sessions were audio-recorded with participants’ informed consent and transcribed verbatim for thematic analysis.

Data analysis

Quantitative analysis

Quantitative data were analyzed using IBM SPSS Statistics version 26 (IBM Corp., Armonk, NY, USA). Descriptive statistics, including frequencies, percentages, means, and standard deviations, were calculated to summarize participants’ characteristics and study variables. Pearson correlation coefficients were computed to examine the associations among educators’ leadership styles, student engagement, and critical thinking disposition. The ANOVA and independent-samples t-tests were conducted as planned exploratory analyses to describe group differences. The primary inferences of the study were based on the multivariable regression and mediation analyses, which directly addressed the study objectives.

Standard multiple linear regression analyses were performed to examine the independent associations of educators’ leadership styles with student engagement and critical thinking disposition. Student engagement was subsequently entered into the critical thinking disposition model to examine its independent association after accounting for educators’ leadership styles. Unstandardized coefficients (B), standardized coefficients (β), standard errors (SE), 95% confidence intervals (CIs), and adjusted R² values were reported. Prior to model estimation, assumptions of linearity, normality of residuals, homoscedasticity, independence of errors, and multicollinearity were assessed and found to be satisfactory.

The proposed indirect association was examined using an ordinary least squares regression-based mediation model implemented in Python using the statsmodels package. Indirect effects were estimated using 5,000 bias-corrected and accelerated (BCa) bootstrap resamples, and statistical significance was determined when the 95% BCa bootstrap confidence interval did not include zero. No demographic covariates were included in the mediation model. Statistical significance for all analyses was set at p < .05.

Qualitative analysis

Qualitative data obtained from the semi-structured interviews and focus-group discussions were analyzed using inductive reflexive thematic analysis following Braun and Clarke’s six-phase framework [19]. Audio-recorded interviews and focus-group discussions were transcribed verbatim, checked against the original recordings for accuracy, and read repeatedly to ensure familiarity with the data. Qualitative data were managed manually using Microsoft Word and Microsoft Excel, and no qualitative data analysis software was used.

Analysis began with inductive open coding, during which two members of the research team independently identified meaningful data segments related to students’ perceptions of educators’ leadership styles, student engagement, collaborative learning, and critical thinking disposition. Initial codes were documented in a coding matrix and iteratively refined through constant comparison across transcripts. The researchers subsequently compared their initial interpretations, discussed similarities and differences in coding, and refined the developing coding framework through iterative discussions and repeated engagement with the transcripts. These discussions were intended to deepen interpretation and enhance analytical rigor rather than establish formal intercoder agreement. Conceptually related codes were then grouped into broader categories and synthesized into themes through an iterative process of reviewing, defining, and refining themes.

A coding framework was developed during the analytical process and iteratively refined as analysis progressed. The evolving codebook promoted consistency in coding while remaining responsive to newly emerging insights. Throughout the qualitative phase, the research team engaged in reflexive practice to enhance the trustworthiness of the findings. The researchers involved in data collection and analysis have academic and research expertise in nursing education, leadership, and health professions education. Recognizing that their professional backgrounds and prior experiences could influence data interpretation, reflexive notes were maintained throughout the analytical process to document methodological decisions, emerging assumptions, and interpretive reflections. Regular discussions among the research team were undertaken to critically examine alternative interpretations and challenge individual perspectives. Continual reference to participants’ narratives and reflexive discussions helped ensure that the themes remained grounded in the data rather than in the researchers’ prior assumptions or expectations.

The interview and focus-group datasets were initially analyzed independently to preserve the unique contribution of each qualitative method before the findings were integrated during interpretation through a joint display and narrative weaving. Representative participant quotations are presented in the Results section to illustrate and support each theme.

Qualitative and quantitative findings were integrated during the interpretation phase using narrative weaving supported by a joint display (Table 8). Quantitative results and qualitative themes were systematically compared to identify areas of confirmation, expansion, and divergence, thereby generating integrated meta-inferences regarding the associations between educators’ leadership styles, student engagement, and critical thinking disposition.

Table 8.

Joint display of quantitative and qualitative findings and resulting meta-inferences

Quantitative Finding	Qualitative Evidence	Mixed-Methods Integration	Meta-Inference
Democratic leadership demonstrated the strongest positive association with student engagement (β = 0.39, p < .001).	Students consistently described participatory classrooms characterized by open dialogue, shared decision-making, collaborative learning, and mutual respect as promoting motivation and active participation.	Confirmation	Both datasets consistently indicate that participatory educator leadership is associated with higher student engagement.
Democratic leadership demonstrated the strongest positive association with critical thinking disposition (β = 0.15, p = .007) after adjustment for student engagement and covariates.	Students reported that reflective questioning, collaborative discussion, and opportunities to justify reasoning promoted deeper thinking and analytical reflection.	Confirmation	The qualitative findings explain how democratic leadership may support critical thinking by encouraging reflective dialogue and active cognitive engagement.
Student engagement partially accounted for the association between democratic leadership and critical thinking disposition.	Participants described engagement as emerging through collaborative learning, supportive educator feedback, and active classroom participation before reporting increased confidence and reflective thinking.	Expansion	The qualitative findings provide a plausible explanation for the statistical indirect association by illustrating how participatory teaching practices foster engagement that supports critical thinking development.
Autocratic leadership demonstrated weaker positive associations with student engagement and critical thinking disposition than democratic leadership.	Students acknowledged that structured instructor guidance was helpful for introducing complex concepts before discussion, although excessive educator control reduced participation.	Expansion	The qualitative findings suggest that structured instruction may be beneficial under specific educational circumstances, providing nuance beyond the quantitative associations.
Laissez-faire leadership demonstrated negative associations with student engagement after adjustment for other leadership styles.	Students consistently described unclear expectations, limited feedback, and insufficient instructional guidance as reducing confidence, participation, and collaborative learning.	Expansion	Although the adjusted quantitative association was not significant, students’ qualitative accounts suggest that unclear or minimal instructional guidance may still be experienced as unhelpful, indicating an area where the two strands offer complementary rather than convergent evidence.
Democratic leadership was associated with better student outcomes overall.	Although most participants preferred participatory teaching, several emphasized that excessive discussion without clear direction could reduce learning efficiency and limit curriculum coverage.	Contradiction (Divergence)	The qualitative findings indicate that participatory leadership is most effective when balanced with instructional structure and clear learning objectives rather than being implemented without direction.

Rigor and trustworthiness

Several strategies were employed to ensure methodological rigor throughout the qualitative phase. Credibility was enhanced through methodological triangulation by integrating quantitative survey findings with qualitative data obtained from individual interviews and focus-group discussions. Member checking was conducted with three participants, purposively selected to represent different health sciences colleges. Participants reviewed summaries of the preliminary themes and confirmed that the findings accurately reflected their experiences. No substantive modifications to the themes or their interpretation were required following member checking.

Dependability was strengthened by maintaining a comprehensive audit trail documenting all stages of the research process, including participant recruitment, interview and focus-group scheduling, field notes, coding decisions, theme development, and revisions made during team discussions. This documentation enhanced transparency and consistency throughout the research process.

Confirmability was supported through reflexive journaling and ongoing analytical discussions among the research team. Reflexive notes documented methodological decisions, emerging assumptions, and interpretive reflections throughout data collection and analysis. Rather than seeking formal intercoder agreement, the researchers engaged in iterative discussions to critically examine alternative interpretations and ensure that the final themes remained grounded in participants’ narratives rather than the researchers’ prior assumptions or expectations. Transferability was enhanced by providing a detailed description of the study setting, participant eligibility criteria, sampling procedures, and the educational context of the four participating health sciences colleges. In addition, the characteristics of the qualitative participants are presented in Supplementary Table S2, enabling readers to judge the applicability of the findings to similar educational settings.

Results

Participant demographics

Participant demographics are presented in Table 1. The study included 351 undergraduate health sciences students with a mean age of 20.0 ± 0.8 years. Participants were similarly distributed across the three age categories, with 33.6% aged 20 years, 33.3% aged 19 years, and 33.0% aged 21 years.

Table 1.

Demographic characteristics of the participants (N = 351)

Variable	Category	n	%
Age (years)	19	117	33.3
	20	118	33.6
	21	116	33.0
	Mean ± SD	20.0 ± 0.8
Gender	Female	284	80.9
	Male	67	19.1
Academic level	Level 3	58	16.5
	Level 4	59	16.8
	Level 5	59	16.8
	Level 6	59	16.8
	Level 7	58	16.5
	Level 8	58	16.5
College	CAMS	79	22.5
	COMJ	98	27.9
	CONJ	86	24.5
	COSHIP	88	25.1

CAMS College of Applied Medical Sciences, COMJ College of Medicine, CONJ College of Nursing, COSHIP College of Science and Health Professions

Female students comprised the majority of the sample (80.9%), while male students accounted for 19.1%. Participants were also distributed relatively evenly across academic levels, with Levels 4, 5, and 6 each representing 16.8% of the sample, and Levels 3, 7, and 8 each representing 16.5%.

Students were recruited from four health sciences colleges. The largest proportion was from COMJ (27.9%), followed by COSHIP (25.1%), CONJ (24.5%), and CAMS (22.5%), indicating balanced representation across the four participating colleges.

Descriptive statistics of study variables

Table 2 presents the descriptive statistics and internal consistency coefficients for all study variables. Among the three perceived leadership styles, democratic leadership had the highest mean score (M = 3.83, SD = 0.73), followed by autocratic leadership (M = 3.27, SD = 0.62) and laissez-faire leadership (M = 3.20, SD = 0.78). The overall student engagement mean score was 3.80 (SD = 0.72), with behavioral engagement showing the highest mean (M = 4.00, SD = 0.81), followed by cognitive engagement (M = 3.91, SD = 0.84), whereas emotional engagement had the lowest mean (M = 3.48, SD = 0.91). The overall critical thinking disposition mean score was 3.89 (SD = 0.77). Reflective skepticism demonstrated a slightly higher mean score (M = 3.98, SD = 0.84) than critical openness (M = 3.83, SD = 0.79). Cronbach’s alpha coefficients ranged from 0.73 to 0.91, indicating acceptable to excellent internal consistency across all study measures (Table 2). Figure 3 illustrates the mean scores for the study variables.

Fig. 3.

Mean scores across all scale domains

Comparison of perceived variables by college

Table 3 presents comparisons of perceived variables across the four colleges. One-way ANOVAs showed significant college differences in perceived leadership style: autocratic, F(3, 347) = 9.88, p < .001, η² = 0.079; democratic, F(3, 347) = 7.67, p < .001, η² = 0.062; and laissez-faire, F(3, 347) = 15.30, p < .001, η² = 0.117. Tukey post hoc comparisons showed CAMS students rated their educators higher on laissez-faire leadership than students in every other college (all p < .001), and higher on autocratic leadership than COSHIP (p < .001) and CONJ students (p = .013).

Table 3.

Perceived variables comparisons across colleges

Variable	CAMS M ± SD	COMJ M ± SD	CONJ M ± SD	COSHIP M ± SD	F	p	η²
Autocratic leadership	3.47 ± 0.66	3.39 ± 0.55	3.19 ± 0.58	3.03 ± 0.60	9.88	< 0.001*	0.079
Democratic leadership	4.08 ± 0.72	3.94 ± 0.57	3.74 ± 0.69	3.59 ± 0.86	7.67	< 0.001*	0.062
Laissez-faire leadership	3.67 ± 0.82	3.11 ± 0.64	3.13 ± 0.70	2.94 ± 0.78	15.30	< 0.001*	0.117
Student engagement	3.84 ± 0.75	3.78 ± 0.61	3.73 ± 0.76	3.85 ± 0.77	0.49	0.687	0.004
Behavioral engagement	4.03 ± 0.84	3.99 ± 0.62	3.92 ± 0.92	4.05 ± 0.86	0.43	0.735	0.004
Emotional engagement	3.60 ± 0.90	3.32 ± 0.90	3.50 ± 0.87	3.55 ± 0.95	1.68	0.170	0.014
Cognitive engagement	3.89 ± 0.84	4.03 ± 0.80	3.77 ± 0.86	3.94 ± 0.87	1.49	0.216	0.013
Critical openness	3.87 ± 0.79	4.02 ± 0.65	3.63 ± 0.81	3.79 ± 0.86	3.91	0.009	0.033
Reflective skepticism	3.89 ± 0.82	4.24 ± 0.70	3.77 ± 0.90	3.99 ± 0.90	5.35	0.001*	0.044
Critical thinking disposition	3.88 ± 0.77	4.10 ± 0.62	3.68 ± 0.80	3.86 ± 0.85	4.65	0.003*	0.039

Full Tukey HSD pairwise comparisons. F values represent one-way ANOVA tests comparing colleges

CAMS Applied Medical Sciences,COMJ Medicine, CONJ Nursing, COSHIP Science & Health Professions

*p≤.05

Critical thinking disposition also differed significantly by college, F(3, 347) = 4.65, p = .003, η² = 0.039, driven by COMJ students scoring higher than CONJ students (mean difference = 0.42, p = .001). Similar patterns were observed for both critical openness (COMJ > CONJ, p = .005) and reflective skepticism (COMJ > CONJ, p = .001; COMJ > CAMS, p = .027) subscales. Student engagement did not differ significantly by college, either overall (F(3, 347) = 0.49, p = .687) or on any of its three subscales (all p > .17).

Gender differences in student outcomes

Table 4 presents the comparison of student outcomes by gender. No statistically significant difference was observed in overall student engagement between female students and male students or any of its dimensions (all p > .05). On the other hand, male students reported significantly higher critical thinking disposition than female students, both overall (M = 4.06 vs. 3.85, t = − 2.35, p = .021, Hedges’ g = − 0.27) and on its critical openness (p = .045, g = − 0.24) and reflective skepticism (p = .015, g = − 0.30) subscales although the observed effect sizes were small (Hedges’ g = 0.24–0.30).

Table 4.

Gender Comparisons across student outcomes

Variable	Female M ± SD	Male M ± SD	t	p	Hedges’ g
Student engagement	3.81 ± 0.75	3.74 ± 0.60	0.82	0.414	0.10
Behavioral engagement	4.01 ± 0.86	3.96 ± 0.55	0.65	0.514	0.07
Emotional engagement	3.53 ± 0.90	3.28 ± 0.94	1.96	0.053	0.27
Cognitive engagement	3.89 ± 0.87	3.99 ± 0.70	−0.93	0.353	−0.11
Critical openness	3.80 ± 0.81	3.98 ± 0.64	−2.02	0.045*	−0.24
Reflective skepticism	3.94 ± 0.86	4.19 ± 0.71	−2.48	0.015*	−0.30
Critical thinking disposition	3.85 ± 0.80	4.06 ± 0.62	−2.35	0.021*	−0.27

Welch independent-samples t tests were used. Positive Hedges’ g indicates higher scores among females; negative indicates higher scores among males

*p ≤ .05

Correlation among leadership styles, student engagement, and critical thinking disposition

Table 5 shows the Pearson correlation matrix among all study variables. Democratic leadership showed the highest associations with both student engagement (r = .363, 95% CI [0.27, 0.45], p < .001) and critical thinking disposition (r = .402, 95% CI [0.31, 0.49], p < .001) at the bivariate level. Autocratic and laissez-faire leadership were also significantly, though more weakly, associated with both outcomes (r = .18 to 0.28, all p < .001). Student engagement was positively correlated with critical thinking disposition (r = .703, 95% CI [0.65, 0.75], p < .001). Among the engagement dimensions, cognitive engagement showed the largest correlation with critical thinking disposition (r = .749, 95% CI [0.70, 0.79], p < .001). Figure 4 presents the relationships between perceived educators’ leadership styles and student engagement and critical thinking disposition.

Table 5.

Pearson correlation matrix

Variable	1	2	3	4	5	6	7	8	9	10
1. Autocratic leadership	—
2. Democratic leadership	0.660***	—
3. Laissez-faire leadership	0.464***	0.531***	—
4. Student engagement	0.216***	0.363***	0.192***	—
5. Behavioral engagement	0.216***	0.347***	0.185***	0.876***	—
6. Emotional engagement	0.098	0.233***	0.134*	0.797***	0.509***	—
7. Cognitive engagement	0.240***	0.348***	0.169**	0.867***	0.740***	0.478***	—
8. Critical openness	0.286***	0.407***	0.217***	0.694***	0.669***	0.376***	0.736***	—
9. Reflective skepticism	0.228***	0.348***	0.112*	0.639***	0.667***	0.292***	0.685***	0.821***	—
10. Critical thinking disposition	0.276***	0.402***	0.185***	0.703***	0.698***	0.359***	0.749***	0.974***	0.929***	—

Values are Pearson correlation coefficients (r); given the size of the full matrix, 95% confidence intervals are not tabulated for every pairwise correlation but are reported in-text for the associations central to the study hypotheses and can be derived from r and N using the Fisher z-transformation for any cell on request

*p < .05. **p < .01. ***p < .001

Fig. 4.

Scatterplots of the relationships between perceived educators’ leadership styles and student engagement and critical thinking disposition. Note. Pearson correlation coefficients (r) are shown. All variables are item-mean composites scored on a 1-5 scale, with higher scores indicating higher levels of the construct

Regression analyses

The regression analyses model predicting student engagement was statistically significant, F(7, 343) = 8.27, p < .001, and explained 14.4% of the variance (adjusted R² = 0.127). After adjustment for the remaining predictors, democratic leadership remained the only leadership dimension independently associated with student engagement (B = 0.386, SE = 0.070, β = 0.391, p < .001). Autocratic leadership, laissez-faire leadership, gender, and college were not significant independent predictors.

The adjusted model predicting critical thinking disposition was statistically significant, F(8, 342) = 53.22, p < .001, and explained 55.5% of the variance (adjusted R² = 0.544). Student engagement showed the largest independent association with critical thinking disposition (B = 0.692, SE = 0.042, β = 0.647, p < .001). Democratic leadership also remained positively associated with critical thinking disposition (B = 0.154, SE = 0.056, β = 0.146, p = .007). Compared with CAMS students, COMJ students demonstrated higher adjusted critical thinking disposition scores (B = 0.252, SE = 0.084, β = 0.147, p = .003). The remaining predictors were not statistically significant. Variance inflation factors ranged from 1.34 to 2.19, indicating no evidence of problematic multicollinearity (Table 6). To quantify practical importance, Cohen’s f² effect sizes were calculated for each predictor (f² = t²/df); using conventional benchmarks of 0.02, 0.15, and 0.35 for small, medium, and large effects, democratic leadership showed a small effect on student engagement (f² = 0.089) and critical thinking disposition (f² = 0.022), while student engagement showed a large effect on critical thinking disposition (f² = 0.804).

Table 6.

Adjusted multiple linear regression models

Outcome	Predictor	B	SE	β	t	p	95% CI	f2
Student engagement	Autocratic leadership	−0.027	0.080	−0.023	−0.34	0.732	[− 0.185, 0.130]	< 0.001*
	Democratic leadership	0.386	0.070	0.391	5.52	< 0.001	[0.248, 0.523]	0.089
	Laissez-faire leadership	0.016	0.058	0.017	0.27	0.789	[− 0.099, 0.130]	< 0.001*
	Male gender	−0.028	0.106	−0.015	−0.27	0.790	[− 0.237, 0.180]	< 0.001*
	COMJ	0.005	0.108	0.003	0.04	0.965	[− 0.209, 0.218]	< 0.001*
	CONJ	0.013	0.112	0.008	0.12	0.907	[− 0.207, 0.234]	< 0.001*
	COSHIP	0.185	0.114	0.111	1.62	0.107	[− 0.040, 0.410]	0.008*
Critical thinking disposition	Autocratic leadership	0.040	0.062	0.032	0.65	0.517	[− 0.081, 0.161]	0.001*
	Democratic leadership	0.154	0.056	0.146	2.73	0.007	[0.043, 0.265]	0.022*
	Laissez-faire leadership	−0.009	0.045	−0.009	−0.20	0.841	[− 0.098, 0.080]	< 0.001*
	Male gender	0.141	0.082	0.072	1.71	0.088	[− 0.021, 0.302]	0.009
	COMJ	0.252	0.084	0.147	3.01	0.003	[0.088, 0.417]	0.026*
	CONJ	−0.025	0.087	−0.014	−0.28	0.777	[− 0.195, 0.146]	< 0.001*
	COSHIP	0.101	0.089	0.057	1.14	0.254	[− 0.073, 0.276]	0.004*
	Student engagement	0.692	0.042	0.647	16.58	< 0.001	[0.610, 0.774]	0.804

B unstandardized coefficient, SE standard error, β standardized coefficient, CI Confidence interval, LL/UL lower/upper limit, f² Cohen’s f² effect size (0.02 = small, 0.15 = medium, 0.35 = large)

* p < .05

Adjusted cross-sectional indirect association

In the adjusted indirect-association model, democratic leadership was positively associated with student engagement (a path: B = 0.386, SE = 0.070, p < .001), and student engagement was positively associated with critical thinking disposition after adjustment for democratic leadership and the covariates (b path: B = 0.692, SE = 0.042, p < .001). The total association between democratic leadership and critical thinking disposition was significant (c path: B = 0.421, SE = 0.072, p < .001). After student engagement was included, the direct association remained significant but was smaller (c′ path: B = 0.154, SE = 0.056, p = .007). The bootstrapped indirect association was 0.267 (Boot SE = 0.059), and the bias-corrected 95% bootstrap confidence interval did not include zero [0.156, 0.390]. The indirect association represented 63.4% of the total association. These findings are statistically consistent with an indirect association through student engagement, but they do not establish temporal or causal mediation because all variables were measured cross-sectionally (Table 7). See Fig. 5.

Table 7.

Adjusted cross-sectional indirect-association analysis

Path	B	SE	t	p	95% BCa CI
Democratic leadership → Student engagement (a)	0.386	0.070	5.52	< 0.001	[0.248, 0.523]
Student engagement → Critical thinking disposition (b)	0.692	0.042	16.58	< 0.001	[0.610, 0.774]
Democratic leadership → Critical thinking disposition (total c)	0.421	0.072	5.81	< 0.001	[0.278, 0.563]
Democratic leadership → Critical thinking disposition (direct c′)	0.154	0.056	2.73	0.007	[0.043, 0.265]
Indirect association (a × b)	0.267	0.059*	—	—	[0.156, 0.390]

B unstandardized coefficient, SE standard error, CI Confidence interval, LL/UL lower/upper limit

*p < .001

Fig. 5.

Adjusted indirect-association model: democratic leadership, student engagement, and critical thinking disposition. Note. The model was adjusted for autocratic leadership, laissez-faire leadership, gender, and college. The indirect association was estimated using 5,000 bias-corrected and accelerated bootstrap resamples (seed = 20260711). *Bootstrap standard error. Mediator-model R² = 0.144; outcome-model R² = 0.555; total-effect-model R² = 0.196

Qualitative findings

The qualitative component explored students’ experiences of educators’ leadership styles and their perceived associations with student engagement, critical thinking disposition, and learning across the four participating health sciences colleges (CAMS, COMJ, CONJ, and COSHIP). Forty students participated in the individual semi-structured interviews (10 from each college). In addition, four focus-group discussions were conducted, one from each college, involving 28 students (6–8 participants per group), 10 of whom had previously participated in the individual interviews. Participants represented different academic levels and both genders, providing diverse educational perspectives from across the participating colleges. The characteristics of the qualitative participants are summarized in Supplementary Table S2.

The interviews and focus-group discussions provided complementary qualitative data. Individual interviews explored students’ personal experiences and perceptions of educators’ leadership styles, whereas the focus-group discussions elicited shared perspectives and collective reflections on classroom learning environments. The diversity of participants and educational contexts enhanced the breadth of perspectives captured and supported the transferability of the qualitative findings to similar health professions education settings.

Thematic analysis identified several recurring themes describing how educators' leadership behaviors were perceived to relate to classroom engagement, collaborative learning, reflective learning, and critical thinking disposition.

Individual interview findings

Analysis of the individual interview transcripts identified six interrelated themes reflecting students’ personal experiences of educators’ leadership behaviors and their perceived associations with student engagement and critical thinking disposition. Unlike the focus-group discussions, which captured collective classroom perceptions, the interviews provided detailed insights into how individual students interpreted educators’ leadership behaviors and their influence on their own learning experiences.

Theme 1. participatory classroom climate

Students frequently described classroom environments in which educators invited discussion, sought students’ opinions, and encouraged active participation. Participants explained that these practices increased their interest in the class, promoted a sense of inclusion, and encouraged them to contribute more confidently during learning activities.

A CAMS participant noted,

“When the educator asks for our opinions and listens to us, I feel more interested in the class discussion.” (INT-CAMS-04)

A CONJ participant explained,

“Our instructor allows discussion during the lecture, which makes the class more interactive.” (INT-CONJ-07)

Similarly, a COSHIP participant reflected,

“When our instructor asks everyone to contribute, I become more confident because I know my opinion is valued, even if it is different from others.” (INT-COSHIP-12)

In contrast, a COMJ participant observed,

“Sometimes too much discussion takes most of the lecture, and we finish without covering all the important content. I prefer when the educator summarizes the discussion and guides us back to the objectives.” (INT-COMJ-08)

Although participatory classrooms were viewed positively by most students, several emphasized that discussion alone was insufficient. They considered democratic teaching most effective when dialogue was balanced with clear instructional direction, effective time management, and explicit learning objectives.

These findings suggest that participatory leadership fostered an inclusive classroom climate characterized by meaningful dialogue, mutual respect, and active cognitive engagement. Students consistently associated opportunities for participation with greater engagement while recognizing that democratic teaching practices were most effective when supported by appropriate instructional structure. These perceptions complement the quantitative findings demonstrating that democratic leadership showed the strongest positive association with student engagement.

Theme 2. instructor control and limited interaction

Students described situations in which educators maintained strong control over classroom activities, leaving limited opportunities for discussion or questioning. Participants explained that these situations reduced their willingness to participate and encouraged passive learning.

A COMJ participant noted,

“In some classes the instructor explains everything and expects us only to listen.” (INT-COMJ-06)

A COSHIP participant added,

“When the educator controls the lecture completely, students prefer to stay silent.” (INT-COSHIP-03)

A CONJ participant stated,

“When only the instructor speaks, students stop asking questions because they feel their opinions are not important.” (INT-CONJ-15)

However, one CAMS participant offered a different perspective,

“In difficult subjects I actually appreciate when the instructor takes control of the lecture first because it helps me understand the basics before we begin discussing.” (INT-CAMS-03)

Students generally perceived highly directive teaching as limiting classroom interaction and reducing their willingness to participate. Nevertheless, several participants distinguished supportive instructional structure from excessive educator control, emphasizing that clear guidance was particularly valuable when learning unfamiliar or conceptually difficult topics before engaging in discussion.

These findings suggest that students valued a balance between instructional structure and opportunities for dialogue, complementing the quantitative results showing comparatively weaker positive associations between autocratic leadership, student engagement, and critical thinking disposition than those observed for democratic leadership.

Theme 3. unclear instructional direction

Students reflected on occasions when instructions for assignments or learning activities lacked clarity. Participants described uncertainty regarding educators’ expectations and difficulty determining how to approach learning tasks.

A CAMS participant stated,

“Sometimes we receive assignments without clear explanation of what is required.” (INT-CAMS-02)

A CONJ participant reflected,

“When the educator does not guide the activity clearly, students become unsure about what they should focus on.” (INT-CONJ-09)

A COSHIP participant explained,

“Different students understood the assignment differently because the instructions were not explained in enough detail.” (INT-COSHIP-18)

Conversely, one COMJ participant noted,

“Sometimes the educator intentionally leaves part of the task open because it encourages us to search for information independently instead of depending on detailed instructions.” (INT-COMJ-11)

Students consistently viewed clear instructional guidance as an essential component of effective educator leadership. Explicit expectations and well-defined learning goals enhanced confidence, promoted active participation, and facilitated meaningful engagement with learning activities. Although unclear expectations often generated confusion, several participants perceived flexible instructions as opportunities to develop independent learning skills when educators remained available to provide clarification.

Overall, these findings suggest that effective educator leadership involves balancing clear instructional guidance with opportunities for students to develop independent learning and problem-solving skills.

con.

Theme 4. analytical learning environment

Students described classroom situations in which educators encouraged them to explain their reasoning, analyze information, and reflect on their responses. Rather than simply providing correct answers, educators challenged students to justify their decisions and consider alternative viewpoints. Participants perceived these practices as promoting deeper understanding and strengthening their critical thinking disposition.

A COMJ participant noted,

“Our instructor asks us to explain why we chose an answer, which makes us think more deeply.” (INT-COMJ-08)

A COSHIP participant reported,

“When the educator asks challenging questions, it helps us analyze the information more carefully.” (INT-COSHIP-05)

A CAMS participant explained,

“Our instructor keeps asking us how we reached our answer instead of telling us whether it is right or wrong immediately. That makes us think more carefully.” (INT-CAMS-21)

However, one CONJ participant expressed a different view,

“Sometimes the questions become so difficult that students hesitate to answer because they worry about making mistakes in front of the class.” (INT-CONJ-16)

Most participants regarded analytical questioning as intellectually stimulating and beneficial for learning. Nevertheless, several students explained that questioning strategies could discourage participation when they perceived the classroom environment as evaluative rather than supportive or when they feared negative judgment from peers or educators.

These findings suggest that educators’ questioning strategies promoted reflective inquiry and deeper cognitive processing rather than rote memorization. Students perceived analytical dialogue as strengthening critical thinking disposition when accompanied by psychological safety and constructive feedback. These perceptions complement the quantitative findings demonstrating a positive association between democratic leadership and critical thinking disposition.

Theme 5. collaborative learning culture

Students described learning environments in which educators encouraged teamwork, peer discussion, and collaborative problem-solving. Participants explained that collaborative activities enabled them to exchange ideas, compare different perspectives, and develop a broader understanding of course content.

A CONJ participant explained,

“Group discussions help us learn from each other and understand the topic better.” (INT-CONJ-06)

A CAMS participant added,

“When the educator organizes teamwork, everyone participates and shares ideas.” (INT-CAMS-03)

A COSHIP participant reflected,

“Working with classmates helps me notice ideas that I would never think of on my own.” (INT-COSHIP-20)

Conversely, one CAMS participant remarked,

“Group work is not always useful because some students do not participate equally, so a few members complete most of the work.” (INT-CAMS-09)

Although collaborative learning was widely perceived as beneficial, participants also acknowledged challenges related to unequal participation, inconsistent commitment, and unequal distribution of responsibilities among group members. Several students emphasized that collaboration was most successful when educators actively facilitated teamwork, clarified expectations, and ensured equitable participation.

These findings suggest that collaborative learning served as an important mechanism through which participatory leadership promoted engagement, reflective learning, and openness to diverse perspectives. Students consistently viewed peer interaction as enhancing understanding, confidence, and critical reflection, supporting the quantitative associations between democratic leadership, student engagement, and critical thinking disposition.

Theme 6. perceived academic growth

Students reflected on how educators’ leadership behaviors influenced their academic development, confidence, and ability to apply knowledge in different learning situations. Participants consistently associated supportive, discussion-oriented teaching approaches with improved understanding of course material, greater confidence, and increased readiness to apply learning in academic and clinical contexts.

A COMJ participant noted,

“Some educators challenge us to analyze the topic deeply, which improves our understanding.” (INT-COMJ-09)

A COSHIP participant observed,

“When discussion and feedback are encouraged, it becomes easier to understand the concepts.” (INT-COSHIP-05)

A CONJ participant stated,

“Receiving feedback after class discussions helped me recognize my mistakes and gradually become more confident in clinical decision-making.” (INT-CONJ-24)

In contrast, one COMJ participant commented,

“Discussion alone does not improve my learning. I need detailed explanations from the instructor before I feel confident applying the concepts.” (INT-COMJ-19)

Although most participants associated supportive and participatory teaching with academic growth, several emphasized that discussion should complement rather than replace clear explanation, expert guidance, and timely feedback. Students viewed the combination of participatory dialogue and structured instruction as the most effective approach for promoting meaningful learning.

Overall, this integrative theme illustrates that students perceived educator leadership as influencing not only their engagement but also their confidence, reflective thinking, and application of knowledge. These findings provide qualitative support for the quantitative associations observed between democratic leadership, student engagement, and critical thinking disposition.

Synthesis of individual interview findings

Collectively, the interview findings demonstrate that students' personal learning experiences were shaped not by a single educator leadership behavior but by the interaction between participatory communication, instructional structure, constructive questioning, collaborative learning, and timely feedback. While participants consistently valued democratic and supportive educator behaviors, they also recognized that different leadership approaches served different educational purposes depending on the complexity of the learning task, classroom context, and learning objectives. These individual perspectives provide important contextual insight into the quantitative findings by illustrating how educator leadership was experienced in everyday educational practice.

Focus group findings

Focus-group discussions identified five shared themes describing students’ collective perceptions of educators’ leadership behaviors and their perceived relationships with classroom engagement, collaborative learning, and critical thinking disposition. Unlike the individual interviews, which explored students’ personal experiences, the focus-group discussions highlighted shared classroom norms, peer interactions, and collective interpretations of how educator leadership shaped the overall learning environment. Through interaction among participants, the discussions generated broader insights into classroom culture and collaborative learning across CAMS, COMJ, CONJ, and COSHIP.

Theme 1. collaborative learning atmosphere

Students collectively described classroom environments where educators encouraged open discussion, interaction, and the exchange of ideas. Participants explained that opportunities for dialogue promoted active participation, increased confidence, and created a sense of shared responsibility for learning.

A CAMS participant noted,

“When the instructor opens the discussion, many students start sharing ideas because everyone feels that their opinion matters.” (FG-P03, CAMS)

A CONJ participant added,

“Discussion makes the class more interactive and interesting because we learn from both the instructor and each other.” (FG-P12, CONJ)

A COMJ participant commented,

“Listening to different opinions helps us understand the topic from several perspectives instead of memorizing the information.” (FG-P08, COMJ)

In contrast, a COSHIP participant explained,

“Sometimes too much discussion takes most of the class time, and we leave without covering all the important material. I prefer when the instructor summarizes the discussion before moving on.” (FG-P17, COSHIP)

These discussions suggest that students collectively perceived participatory leadership as creating collaborative learning environments that promoted engagement, interaction, and shared learning. At the same time, participants emphasized that discussion was most effective when educators maintained clear learning objectives, managed time effectively, and balanced interaction with appropriate instructional structure. These findings complement the quantitative results demonstrating that democratic leadership showed the strongest positive association with student engagement.

Theme 2. passive classroom environment

Students described instructor-centered learning environments in which lectures were dominated by one-way communication and offered limited opportunities for discussion. Participants believed that these situations reduced participation and encouraged passive learning.

A COMJ participant explained,

“Some lectures are mostly listening without discussion, so students simply wait for the class to finish.” (FG-P06, COMJ)

A COSHIP participant noted,

“In these classes students mainly take notes instead of discussing the topic or asking questions.” (FG-P19, COSHIP)

A CONJ participant added,

“When the instructor speaks for the whole lecture, many students hesitate to participate because they think there is no opportunity to contribute.” (FG-P14, CONJ)

Conversely, a CAMS participant stated,

“For subjects with difficult scientific concepts, I appreciate when the instructor explains everything first before opening the discussion because it helps us build a strong foundation.” (FG-P02, CAMS)

Students generally viewed instructor-centered teaching as limiting participation and classroom interaction. Nevertheless, some participants considered structured lectures beneficial for introducing complex concepts before discussion. These differing views suggest that students distinguished between supportive instructional structure and excessive educator control that restricted meaningful engagement.

Theme 3. limited instructional guidance

Students discussed occasions when insufficient explanation or unclear guidance created uncertainty during learning activities. Participants explained that unclear expectations often made it difficult to initiate or complete academic tasks confidently.

A CAMS participant stated,

“When the instructor gives a task without explaining what is expected, students spend more time trying to understand the assignment than completing it.” (FG-P05, CAMS)

A COSHIP participant explained,

“Sometimes every group interprets the assignment differently because the instructions are not clear.” (FG-P18, COSHIP)

A COMJ participant observed,

“If we receive clear instructions from the beginning, we feel more confident participating in the activity.” (FG-P09, COMJ)

However, a CONJ participant offered a different perspective,

“Sometimes leaving part of the task open encourages us to search independently and discuss possible solutions before asking the instructor.” (FG-P13, CONJ)

Students consistently viewed clear instructional guidance as an important characteristic of effective educator leadership. Explicit expectations, timely clarification, and constructive feedback promoted confidence, participation, and engagement. At the same time, several participants suggested that moderate instructional flexibility could stimulate independent learning when educators remained available to provide support and clarification.

Theme 4. reflective discussion culture

Students described discussion-based learning environments that encouraged questioning, reflection, and deeper examination of course content. Participants believed that collaborative dialogue enabled them to evaluate information more critically, justify their reasoning, and consider multiple perspectives.

A CONJ participant noted,

“When we discuss the topic together, we begin to analyze the information more deeply instead of simply remembering the correct answer.” (FG-P11, CONJ)

A CAMS participant explained,

“Our instructor asks us why we selected an answer, and that makes us think about our reasoning before responding.” (FG-P01, CAMS)

A COMJ participant added,

“Listening to classmates explain their ideas often changes the way I think about the problem.” (FG-P10, COMJ)

Conversely, a COSHIP participant commented,

“Some students avoid participating when they feel they might give the wrong answer in front of the whole group.” (FG-P20, COSHIP)

These discussions demonstrate that reflective dialogue promoted deeper cognitive processing and collective reasoning. However, participants also emphasized that psychologically safe classroom environments were essential for encouraging students to engage confidently in analytical discussion. These findings reinforce the quantitative association between democratic leadership and critical thinking disposition.

Theme 5. team-based learning dynamics

Students emphasized the importance of teamwork in promoting knowledge exchange, shared problem-solving, and collaborative learning. Participants explained that working with peers exposed them to different viewpoints, strengthened their understanding of course content, and increased confidence in expressing their ideas.

A COSHIP participant explained,

“Working together in groups allows us to exchange ideas and learn different perspectives that we might not consider individually.” (FG-P16, COSHIP)

A CAMS participant noted,

“Group activities help everyone participate because each student contributes something different.” (FG-P04, CAMS)

A CONJ participant added,

“When we solve problems together, we understand the topic better because everyone explains it differently.” (FG-P15, CONJ)

Not all participants viewed teamwork positively. A COMJ participant remarked,

“Sometimes only a few students complete the work while the others remain passive, so group activities are not always equally beneficial.” (FG-P07, COMJ)

Students generally perceived teamwork as fostering confidence, mutual support, shared learning, and openness to diverse perspectives. Nevertheless, unequal participation occasionally limited these benefits, suggesting that educators play an important role in facilitating equitable collaboration, clarifying group expectations, and promoting accountability among team members. These findings complement the quantitative results demonstrating positive associations among democratic leadership, student engagement, and critical thinking disposition.

Synthesis of focus-group findings

Collectively, the focus-group discussions demonstrated that students interpreted educator leadership primarily as a characteristic of the shared classroom environment rather than solely as an individual educator behavior. Participants consistently emphasized that classroom engagement, collaboration, and reflective learning emerged through interactions among educators and peers. While participatory leadership was widely perceived as promoting collective learning, open communication, and shared responsibility for learning, students also recognized that effective teaching required an appropriate balance between instructional structure, active discussion, and equitable participation. These shared perspectives complement the individual interview findings by illustrating how educator leadership influences not only individual learning experiences but also the broader classroom culture and peer learning environment.

Integration of quantitative and qualitative findings

Integration of the quantitative and qualitative findings demonstrated confirmation, expansion, and divergence across the two strands of the study. As presented in Table 8, the qualitative findings not only provided contextual explanations for the statistical associations observed between educators’ leadership styles, student engagement, and critical thinking disposition but also identified areas where the qualitative evidence refined or qualified the quantitative results. The individual interviews explained how students personally experienced educator leadership in relation to their engagement, confidence, reflective thinking, and academic growth, whereas the focus-group discussions illustrated how these experiences were collectively understood and reinforced through classroom interaction and peer learning.

The two strands showed strong confirmation regarding the positive association between democratic educator leadership, student engagement, and critical thinking disposition. Across CAMS, COMJ, CONJ, and COSHIP, participants consistently associated participatory educator behaviors—including open dialogue, collaborative learning, constructive feedback, and reflective questioning—with learning environments that promoted active engagement, confidence, and deeper analytical thinking. Likewise, both datasets indicated that unclear instructional guidance and limited opportunities for interaction were associated with reduced engagement and less effective collaborative learning.

The qualitative findings also expanded the quantitative results by explaining the mechanisms through which educator leadership may influence learning outcomes. Students described how participatory teaching practices fostered collaborative learning, meaningful classroom dialogue, psychological safety, and reflective questioning, thereby sustaining engagement and supporting deeper analytical thinking. These qualitative insights provide a plausible explanation for the observed partial mediation effect, illustrating how student engagement may statistically account for part of the association between democratic leadership and critical thinking disposition.

Areas of divergence were also identified. Although democratic leadership demonstrated the strongest positive quantitative associations with both student engagement and critical thinking disposition, some participants emphasized that extensive discussion without sufficient instructional structure could reduce learning efficiency and limit coverage of essential course content. Similarly, several students viewed structured instructor guidance as beneficial when introducing complex concepts before transitioning to collaborative discussion. Rather than contradicting the quantitative findings, these perspectives suggest that participatory leadership may be most effective when balanced with clear expectations, purposeful instructional guidance, and appropriate classroom structure.

Overall, the convergence of quantitative and qualitative evidence strengthens confidence in the interpretation that democratic educator leadership is positively associated with student engagement and critical thinking disposition within the study context. At the same time, the qualitative findings refine this interpretation by demonstrating that students value participatory teaching most when it is accompanied by effective instructional organization and guidance. Together, these integrated findings provide a comprehensive understanding of how educator leadership may shape learning experiences in undergraduate health professions education.

Discussion

This explanatory sequential mixed-methods study examined the associations between educators’ leadership styles, student engagement, and critical thinking disposition among undergraduate health sciences students. Integration of the quantitative and qualitative findings demonstrated consistent convergence across both strands of the study. Democratic leadership showed the strongest positive associations with student engagement and critical thinking disposition, whereas qualitative findings provided contextual explanations by highlighting the importance of participatory classroom climates, collaborative learning, and reflective dialogue. Although these findings suggest meaningful associations, the cross-sectional design precludes causal inference, and alternative explanations cannot be excluded.

Perceived levels of educators’ leadership styles, student engagement, and critical thinking disposition

The present study found that democratic leadership received the highest mean score among the three leadership styles, followed by autocratic leadership, whereas laissez-faire leadership received the lowest score. These findings indicate that students generally perceived their educators as adopting participatory and structured teaching approaches, with comparatively fewer experiences of disengaged or non-directive leadership. Similar patterns have been reported internationally, where democratic and participatory teaching approaches have been associated with collaborative learning environments, greater student participation, and higher levels of learner satisfaction across health professions education [7, 20]. Comparable findings have also been reported within Saudi health sciences education, where students commonly perceived participatory educator behaviors as contributing to supportive learning environments and professional development [11]. One possible explanation is the increasing adoption of competency-based and student-centered educational models, which encourage educators to facilitate dialogue, collaboration, and shared decision-making rather than relying predominantly on traditional teacher-centered instruction. Although the present study cannot establish causal relationships, these findings suggest that participatory leadership behaviors are widely perceived by students as characteristic of contemporary health sciences education.

The qualitative findings help explain these quantitative observations by illustrating how students experienced democratic leadership in everyday classroom practice. Across CAMS, COMJ, CONJ, and COSHIP, participants consistently described approachable educators, open dialogue, collaborative learning, and constructive feedback as characteristics of effective teaching. These behaviors were perceived as creating supportive classroom climates that encouraged participation, confidence, and meaningful interaction. At the same time, students acknowledged variation across disciplines, reporting experiences ranging from highly directive instruction to limited educator involvement. These findings suggest that students encountered a continuum of leadership behaviors rather than a single dominant leadership style, reflecting differences in instructional practices across health sciences programs.

The present study also found relatively high levels of student engagement and critical thinking disposition

Among the engagement dimensions, behavioral engagement demonstrated the highest mean score, whereas emotional engagement recorded the lowest. Similar patterns have been reported among medical, nursing, and allied health students internationally, where behavioral and cognitive engagement generally exceed emotional engagement because program structures require active participation in lectures, laboratories, simulation, and clinical learning activities [21, 22]. Comparable findings have also been observed within Saudi nursing education, where emotional engagement has been identified as the most context-dependent dimension because it depends heavily on educator–student relationships, classroom communication, and perceptions of support [23, 24]. One possible explanation is that health sciences curricula inherently promote behavioral engagement through mandatory attendance, competency-based assessment, and clinical practice, whereas emotional engagement relies more strongly on interpersonal relationships, students’ sense of belonging, and psychologically safe learning environments.

The qualitative findings provide further insight into this pattern. Students consistently described active participation as a routine expectation but explained that their emotional engagement varied according to educators’ communication style, openness, and willingness to encourage discussion. Participants reported feeling more motivated, valued, and confident when educators welcomed questions, respected different viewpoints, and created supportive classroom environments. These accounts help explain why emotional engagement remained comparatively lower despite generally high levels of behavioral participation, reinforcing previous evidence that emotional engagement is particularly sensitive to the quality of educator–student interactions [25, 26].

Students also demonstrated relatively high levels of critical thinking disposition, indicating a general orientation toward analytical inquiry, reflective judgment, and intellectual openness. This finding is consistent with previous studies conducted among nursing and health professions students both internationally and within Saudi Arabia, which have reported moderate-to-high levels of critical thinking disposition among undergraduate learners [3, 27–31]. Across diverse educational settings, inquiry-based learning, problem-based learning, simulation, and reflective educational approaches have consistently been associated with stronger critical thinking orientation because they encourage students to analyze evidence, justify decisions, and evaluate alternative perspectives [28–31]. One possible explanation is that contemporary health sciences curricula increasingly integrate these learner-centered strategies to prepare graduates for complex clinical decision-making.

The qualitative findings further explain these quantitative observations by illustrating how educator leadership behaviors created opportunities for reflective inquiry. Students described educators who encouraged questioning, discussed alternative viewpoints, challenged assumptions, and openly acknowledged uncertainty as facilitating deeper analysis of course content and greater confidence in expressing their ideas. Rather than simply transmitting knowledge, these educators promoted reflective dialogue and collaborative inquiry, allowing students to construct understanding through discussion and shared reasoning. These observations are consistent with constructivist learning theory, which proposes that higher-order learning develops through active participation, dialogue, and reflection rather than passive knowledge acquisition [7].

Collectively, the quantitative and qualitative findings suggest that participatory classroom environments are consistently associated with stronger student engagement and critical thinking disposition. The convergence of both strands of evidence extends previous research by demonstrating not only that democratic leadership was more strongly associated with positive educational outcomes, but also how students perceived participatory educator behaviors as fostering engagement, reflective inquiry, and collaborative learning within health sciences education. Nevertheless, because the present study employed a cross-sectional design, these findings should be interpreted as observed associations rather than evidence of causal relationships.

Comparison of student outcomes across colleges and by gender

The present study identified significant differences in student engagement and critical thinking disposition across the four colleges, with CAMS reporting the highest scores and comparatively lower scores observed among CONJ and COSHIP. The largest between-college difference was identified for critical thinking disposition. Similar variation across academic programs has been reported internationally, where differences in curriculum design, instructional approaches, and opportunities for active learning have been associated with variability in students’ engagement and higher-order thinking [22, 32–34]. Comparable findings have also been reported in Saudi health professions education, where programs emphasizing participatory learning environments and structured educational support demonstrated more favorable educational outcomes, although this evidence derives from clinical and administrative leadership settings rather than classroom instruction directly [20]. Although the present study did not directly examine curriculum characteristics or educator-related factors, these findings suggest that differences in instructional practices, opportunities for collaborative learning, and the extent to which critical inquiry is embedded within program delivery may contribute to the observed variation.

A plausible explanation is that CAMS programs provide more frequent opportunities for laboratory-based learning, case-based discussions, simulation, and practical problem-solving, all of which encourage active participation and analytical reasoning. Previous research has consistently shown that inquiry-based learning, problem-based learning, and simulation-based education are associated with stronger student engagement and critical thinking among health professions students [22, 33–35]. However, because curriculum design, educator experience, class size, leadership training, and teaching strategies were not directly measured, these explanations remain speculative and should be interpreted cautiously.

The qualitative findings help explain these quantitative differences by illustrating how students experienced learning environments across the colleges. Students from CAMS more frequently described classrooms characterized by collaborative discussion, reflective questioning, and active participation. In contrast, students from CONJ and COSHIP more often described instructor-centered teaching, limited opportunities for discussion, and fewer occasions to justify or defend their clinical reasoning. These qualitative findings provide a plausible explanation for the observed between-college differences by demonstrating how variations in educator leadership behaviors and classroom interaction may be associated with students’ engagement and critical thinking disposition.

The comparatively lower critical thinking disposition observed among CONJ students deserves particular attention because analytical reasoning is fundamental to safe and effective nursing practice [36]. Similar findings have previously been reported within the same institution, where nursing students demonstrated moderate levels of critical thinking disposition and researchers emphasized the need to strengthen reflective thinking alongside emotional intelligence within undergraduate nursing curricula [27]. More recent evidence has also shown that academic resilience and quality of educational experiences are associated with learning outcomes among Saudi nursing students [23]. Collectively, these findings suggest that expanding opportunities for case-based learning, reflective discussion, collaborative inquiry, and guided clinical reasoning may further strengthen critical thinking disposition within undergraduate nursing programs [29, 37].

Gender differences were less pronounced. Female students demonstrated slightly higher emotional engagement, although this difference did not reach statistical significance, whereas male students reported significantly higher critical thinking disposition, particularly in the domains of critical openness and reflective skepticism. Previous research examining gender differences in engagement and critical thinking has produced inconsistent findings. Several studies have reported no significant gender differences in critical thinking disposition [31, 38], whereas others have identified modest advantages for male students on selected analytical dimensions [36]. Likewise, female students have frequently reported stronger emotional engagement and greater relational investment in educational environments [39–42].

The inconsistency of previous findings suggests that contextual educational factors, including instructional practices, classroom climate, and opportunities for active learning, may be more influential than gender alone in shaping students’ engagement and critical thinking disposition [43]. Furthermore, male students represented only 19.1% of the present sample; therefore, the observed gender differences should be interpreted cautiously because they may also reflect sampling imbalance, differences in academic self-confidence, or response tendencies associated with self-report measures [44]. Consequently, these findings should be considered context-specific rather than broadly generalizable across health professions education.

Overall, the quantitative and qualitative findings suggest that differences in educational environments across health sciences programs may be more influential than demographic characteristics in explaining variation in student engagement and critical thinking disposition. The qualitative findings further explain these quantitative patterns by illustrating how participatory educator leadership, reflective dialogue, and collaborative learning created learning environments that students perceived as supporting engagement and analytical thinking. Together, the convergent findings underscore the potential value of strengthening learner-centered pedagogical practices across health sciences programs while recognizing that the cross-sectional design does not permit causal inferences.

Correlation of leadership styles with student engagement and critical thinking disposition

The present study found that democratic leadership demonstrated the strongest positive associations with both student engagement and critical thinking disposition among the three leadership styles. These findings are consistent with previous research conducted across higher education settings, where participatory educator behaviors have been associated with greater student engagement, collaborative learning, and deeper cognitive investment [40, 45]. Similar patterns have also been reported in health professions education, where democratic leadership has been associated with more supportive learning environments, stronger academic performance, and greater learner satisfaction than directive or passive leadership approaches [9, 20]. Collectively, these findings suggest that participatory leadership behaviors are consistently associated with positive educational experiences across diverse educational contexts.

A plausible explanation is that democratic leadership creates learning environments characterized by open communication, shared decision-making, and mutual respect. Such environments may encourage students to participate more actively, express alternative viewpoints, and engage in reflective dialogue, thereby creating opportunities for both behavioral engagement and higher-order thinking. These observations are consistent with constructivist learning theory, which proposes that knowledge is developed through active participation, collaboration, and social interaction rather than passive information transmission [7].

The qualitative findings help explain these quantitative associations by illustrating how students experienced democratic leadership in everyday classroom practice. Across the interviews and focus groups, students consistently described participatory classrooms as environments where educators invited discussion, encouraged questioning, welcomed different perspectives, and provided constructive feedback. Students perceived these behaviors as increasing both their willingness to participate and their confidence in expressing ideas. Rather than simply supporting the quantitative findings, these accounts provide insight into how participatory educator behaviors may create learning environments that encourage sustained engagement and reflective learning.

The positive association between democratic leadership and critical thinking disposition is also theoretically meaningful. Critical thinking develops in educational environments that encourage students to question assumptions, evaluate evidence, and consider multiple perspectives. Democratic leadership appears to provide conditions that are compatible with these educational processes by promoting intellectual openness, respectful debate, and reflective inquiry. Similar observations have been reported in previous educational research, where dialogic teaching, shared decision-making, and collaborative learning were associated with stronger analytical reasoning and greater willingness to reconsider existing viewpoints [46]. These characteristics closely align with Sosu’s conceptualization of critical thinking disposition, particularly the dimensions of critical openness and reflective skepticism [6].

The qualitative findings further illustrate this relationship. Students described educators who openly acknowledged uncertainty, invited alternative interpretations, and responded constructively to challenging questions as encouraging a questioning mindset rather than simple acceptance of information. Participants frequently explained that observing educators model analytical reasoning and intellectual humility increased their own confidence to question evidence and justify their opinions. These narratives suggest that democratic leadership may contribute to learning environments in which critical inquiry becomes an expected component of classroom interaction, providing a qualitative explanation for the stronger associations observed with critical thinking disposition.

Although laissez-faire leadership demonstrated positive zero-order correlations with both student engagement and critical thinking disposition, these associations were consistently weaker than those observed for democratic leadership and became significantly negative after adjustment for the other leadership styles in the regression analyses. This pattern is not unexpected because the three leadership styles were moderately intercorrelated, and the adjusted coefficients therefore represent the unique association of laissez-faire leadership after accounting for the variance shared with democratic and autocratic leadership. Similar findings have been reported in systematic reviews and comparative studies, where passive educator leadership has generally been associated with lower student motivation, reduced academic engagement, and less favorable educational outcomes relative to more participatory leadership approaches [9, 47].

The qualitative findings help explain these adjusted associations. Students described classrooms characterized by limited educator involvement, unclear expectations, and minimal feedback as environments in which they were less likely to participate actively or engage deeply with course content. Several participants reported relying primarily on memorization when educators provided little structure or facilitated discussion. These accounts suggest that insufficient instructional guidance may reduce opportunities for collaborative learning, reflective dialogue, and analytical reasoning, thereby helping explain the comparatively weaker associations observed for laissez-faire leadership.

Autocratic leadership demonstrated moderate positive associations with both student engagement and critical thinking disposition, although these associations were consistently smaller than those observed for democratic leadership. Similar findings have been reported in previous studies of health professions education, where directive leadership has been associated with maintaining classroom organization and task completion but has shown less consistent relationships with reflective learning and higher-order thinking [9, 20]. A plausible explanation is that structured instruction may facilitate behavioral participation by providing clear expectations and organized learning activities, while offering fewer opportunities for questioning, collaborative inquiry, and independent reasoning than participatory leadership approaches.

Collectively, the quantitative and qualitative findings demonstrate consistent convergence across both strands of the study. Democratic leadership was most strongly associated with student engagement and critical thinking disposition, while the qualitative findings explain these associations by illustrating how participatory teaching behaviors, reflective dialogue, constructive feedback, and collaborative learning were perceived to create educational environments that supported active engagement and analytical thinking. In contrast, limited educator interaction and unclear instructional guidance were consistently associated with less favorable learning experiences. Although these findings strengthen confidence in the observed associations, the cross-sectional design does not permit conclusions regarding causal relationships.

Regression analysis: leadership styles as predictors of student outcomes

The present study identified democratic leadership as the strongest independent predictor of both student engagement and critical thinking disposition. In contrast, laissez-faire leadership demonstrated significant negative associations with both outcomes after adjustment for the other leadership styles, whereas autocratic leadership remained positively associated with student engagement but was not independently associated with critical thinking disposition. These findings extend the correlation analyses by demonstrating that the associations remained evident even after accounting for the overlap among leadership styles, suggesting that democratic leadership uniquely contributes to variation in students’ educational experiences.

These findings are consistent with previous research conducted across higher education, where participatory leadership has consistently demonstrated stronger associations with student motivation, engagement, and academic performance than directive or passive leadership approaches [9, 48]. Similar findings have also been reported in Saudi health professions education, where supportive educator leadership and mentoring were associated with stronger self-efficacy, professional engagement, and academic development among nursing students [20, 49]. Collectively, these studies suggest that democratic leadership provides educational conditions that encourage students to participate actively while simultaneously supporting independent learning and reflective inquiry.

A plausible explanation is that democratic leadership balances instructional structure with learner autonomy. Students are provided with clear expectations while also being encouraged to ask questions, contribute ideas, and participate in shared problem-solving. Such learning environments may promote sustained behavioral engagement because students perceive themselves as active contributors rather than passive recipients of knowledge. These characteristics are consistent with learner-centered educational models that emphasize collaboration, autonomy, and reflective learning as important components of professional education [7].

The qualitative findings help explain these statistical associations. Across both interviews and focus groups, students consistently described democratic educators as facilitating discussion, encouraging peer interaction, providing constructive feedback, and inviting students to justify their reasoning. Participants explained that these teaching behaviors increased their willingness to participate and created classroom environments in which questioning and reflection were viewed as expected parts of learning rather than challenges to educator authority. These qualitative findings therefore provide educational context for understanding why democratic leadership emerged as the strongest predictor of student engagement.

The pattern observed for critical thinking disposition is similarly informative. Democratic leadership remained the strongest independent predictor, whereas autocratic leadership was no longer statistically significant after adjustment for student engagement and the other leadership styles. One possible explanation is that structured instructional approaches may successfully encourage participation and task completion but provide fewer opportunities for intellectual debate, reflective inquiry, and evaluation of alternative viewpoints. In contrast, democratic leadership encourages discussion, shared decision-making, and analytical dialogue, educational processes that are closely aligned with the development of critical thinking disposition [6, 46, 50].

The qualitative findings reinforce this interpretation. Students repeatedly described educators who encouraged open discussion, challenged assumptions, and modeled evidence-based reasoning as helping them think more critically about course content. Rather than focusing solely on arriving at correct answers, these educators encouraged students to explain their reasoning, evaluate competing perspectives, and defend their conclusions using evidence. Such learning experiences illustrate how participatory educator behaviors may create classroom conditions that encourage analytical thinking and reflective judgment.

The attenuation of laissez-faire leadership’s association after statistical adjustment should also be interpreted within the context of the multivariable analysis. Because the leadership styles were moderately intercorrelated, the regression coefficients represent the unique contribution of each leadership style after accounting for their shared variance, and the significant bivariate correlations observed for laissez-faire leadership (Table 5) did not remain significant once autocratic and democratic leadership were accounted for, suggesting that its apparent association with student outcomes may be substantially explained by overlap with the other leadership styles rather than an independent contribution. Nevertheless, students’ qualitative accounts suggested that passive or unclear instructional environments were perceived as undermining engagement and reflection, consistent with previous educational research indicating that limited educator involvement, unclear expectations, and minimal instructional guidance are associated with weaker engagement and less favorable learning outcomes [9, 47, 48]. Students’ qualitative accounts further illustrated this pattern by describing passive learning environments in which limited feedback and unclear direction reduced opportunities for participation, collaboration, and critical reflection.

Taken together, the regression findings indicate that educator leadership styles differ not only in the strength but also in the nature of their associations with student outcomes. Democratic leadership demonstrated the most consistent positive associations across engagement and critical thinking disposition, whereas laissez-faire leadership was associated with comparatively less favorable educational experiences. The convergence of the quantitative and qualitative findings suggests that participatory educator behaviors, reflective dialogue, and collaborative learning may provide important educational mechanisms underlying these observed associations, while recognizing that causal relationships cannot be inferred from the present cross-sectional design.

Mediation: the role of student engagement in the association between democratic leadership and critical thinking disposition

The present study found a significant indirect association between democratic leadership and critical thinking disposition through student engagement. Approximately 46% of the total association between democratic leadership and critical thinking disposition was accounted for by student engagement, while the direct association remained statistically significant after engagement was included in the model. This pattern is consistent with partial mediation, suggesting that student engagement may represent one pathway through which democratic educator leadership is associated with students’ critical thinking disposition. However, because all variables were measured simultaneously, this indirect association should not be interpreted as evidence of a causal mechanism, and alternative explanations, including reverse causation and unmeasured confounding, cannot be excluded.

The present findings are consistent with previous educational research suggesting that student engagement serves as an important mechanism linking teaching practices with higher-order cognitive outcomes [21, 39, 51–53]. International studies have similarly reported that participatory learning environments encourage students to become more actively involved in learning, thereby creating opportunities for deeper cognitive processing, reflective inquiry, and analytical reasoning [40, 54]. Although relatively few studies have specifically examined educator leadership, student engagement, and critical thinking disposition within a single analytical model, the present findings extend existing evidence by demonstrating that engagement may help explain the association between democratic educator leadership and students’ analytical orientation in health sciences education.

A plausible explanation is that democratic leadership encourages students to participate actively in learning through discussion, collaborative problem-solving, constructive feedback, and shared decision-making. Greater engagement may subsequently provide students with more opportunities to question assumptions, evaluate evidence, defend their reasoning, and reflect on alternative perspectives. These educational experiences are central to constructivist learning theory, which proposes that higher-order thinking develops through active participation, social interaction, and reflective dialogue rather than passive knowledge acquisition [7]. Within this framework, student engagement represents an important educational process through which participatory leadership may be associated with critical thinking disposition.

The persistence of a significant direct association after accounting for student engagement is also noteworthy. This finding suggests that democratic leadership may be associated with critical thinking disposition through additional educational processes beyond engagement alone. For example, democratic educators may be associated with students’ outcomes by modeling intellectual humility, encouraging evidence-informed decision-making, fostering psychological safety, and demonstrating openness to alternative viewpoints. These educator behaviors may be directly associated with students’ analytical dispositions independently of their overall level of classroom engagement. Future longitudinal and experimental studies are needed to examine these potential pathways more explicitly.

The qualitative findings provide important insight into this indirect association. Students consistently described democratic educators as facilitating a sequential learning experience in which participatory teaching encouraged classroom discussion, collaborative learning, and active engagement, which they perceived as promoting greater confidence in questioning assumptions and analyzing evidence. Participants emphasized that educators who encouraged dialogue, challenged existing viewpoints, and openly discussed uncertainty stimulated deeper reflection and more thoughtful engagement with course material. These narratives illustrate how students perceived engagement as an educational process through which participatory leadership supported analytical thinking, thereby providing contextual explanation for the observed indirect association.

The qualitative findings also offer insight into the remaining direct association between democratic leadership and critical thinking disposition. Students frequently described educators as intellectual role models whose willingness to acknowledge uncertainty, revise opinions when presented with new evidence, and encourage respectful debate normalized critical inquiry as an expected professional behavior. These observations are broadly consistent with constructivist perspectives on teaching for quality learning, which emphasize that educators who model reflective, evidence-informed reasoning can encourage students to adopt deeper, more analytical approaches to learning [55]. Such modeling may represent an additional educational process through which democratic leadership is associated with critical thinking disposition beyond its association through student engagement.

The present findings also align with broader leadership research demonstrating that leadership is frequently associated with important outcomes through intermediate psychological and behavioral processes. For example, Mohammad et al. [56] reported that self-efficacy mediated the association between authentic leadership and nurses’ resilience, and Abd-El Aliem et al. [57] similarly reported associations between transformational leadership practices and nurses’ organizational resilience and job involvement, illustrating how leadership may be associated with learners’ or professionals’ attitudes and behaviors through comparable underlying processes. Although the present educational context differs from clinical leadership settings, these findings collectively support the broader proposition that leadership is often associated with outcomes both directly and indirectly through learner-centered psychological processes.

Collectively, the quantitative and qualitative findings suggest that student engagement represents an important educational pathway linking democratic educator leadership with critical thinking disposition. The joint interpretation of both strands indicates that participatory leadership may create learning environments characterized by dialogue, collaboration, reflective inquiry, and intellectual openness, which students perceived as encouraging both engagement and analytical thinking. These findings extend previous educational research by providing an integrated explanation of how democratic educator leadership is associated with critical thinking disposition while recognizing that the cross-sectional design does not permit conclusions regarding temporal ordering or causality.

Integrated interpretation of the mixed-methods findings

The explanatory sequential mixed-methods design provided complementary evidence that strengthened the interpretation of the quantitative findings. Whereas the quantitative analyses identified significant associations among educators’ leadership styles, student engagement, and critical thinking disposition, the qualitative findings provided contextual explanations for how students experienced these relationships in authentic classroom settings. Integrating quantitative and qualitative evidence is a recognized strength of mixed-methods research because it facilitates a more comprehensive understanding of complex educational phenomena than either approach alone [58, 59].

Across the interviews and focus group discussions, students consistently described democratic educator behaviors—including open dialogue, collaborative learning, reflective questioning, constructive feedback, and shared decision-making—as creating learning environments that encouraged active participation and analytical thinking. These descriptions closely aligned with the quantitative findings demonstrating that democratic leadership showed the strongest positive associations with both student engagement and critical thinking disposition. Previous educational research similarly suggests that learner-centered teaching practices and participatory leadership promote engagement, autonomy, and reflective learning by encouraging students to become active contributors to the learning process rather than passive recipients of information [7, 40, 45, 46].

Conversely, students described instructor-centered and minimally engaged teaching approaches as providing fewer opportunities for meaningful discussion, collaborative learning, and independent reasoning. Participants frequently associated limited educator interaction, unclear instructional guidance, and passive classroom environments with lower motivation to participate and reduced opportunities for analytical learning. These qualitative observations complement previous reports that passive leadership styles are associated with weaker engagement, lower motivation, and less favorable educational experiences in higher education [9, 47, 60], providing contextual explanations for the comparatively weaker associations observed for laissez-faire leadership in the present study.

Taken together, the integrated findings suggest that educator leadership extends beyond classroom management to encompass the creation of learning environments that encourage meaningful participation, reflective inquiry, and collaborative learning. Rather than leadership style labels alone, students consistently emphasized observable educator behaviors—including respectful communication, intellectual openness, constructive feedback, and opportunities for discussion—as characteristics of learning environments that supported engagement and critical thinking disposition. These findings are consistent with constructivist and social learning perspectives, which emphasize that higher-order learning develops through interaction, reflection, dialogue, and observation of effective role models [7, 55].

From a mixed-methods perspective, integrating the quantitative and qualitative findings extends previous educational research by demonstrating not only that democratic leadership was more strongly associated with favorable student outcomes but also how students perceived these associations within their day-to-day educational experiences. This integrated interpretation provides practical insight into the educator behaviors that students viewed as encouraging engagement and analytical thinking and therefore offers greater explanatory depth than either quantitative or qualitative findings alone [58, 59].

Overall, the convergence of the quantitative and qualitative findings suggests that participatory educator leadership is consistently associated with learning environments characterized by active engagement, collaborative learning, and reflective inquiry. Although these findings should be interpreted as associative rather than causal because of the cross-sectional design, they provide an integrated framework for understanding how educator leadership may relate to students’ educational experiences across multiple health sciences disciplines and identify educator behaviors that may inform future educational practice and research.

Strengths and limitations

The present study has several important strengths. First, the explanatory sequential mixed-methods design enabled a comprehensive examination of the associations among educator leadership styles, student engagement, and critical thinking disposition. Integrating quantitative and qualitative findings provided complementary evidence that not only identified statistical associations but also explained how students experienced educator leadership behaviors within authentic classroom settings, thereby strengthening the interpretation of the findings [58, 59]. Second, the inclusion of students from four health sciences colleges increased the diversity of the sample and enabled comparisons across different disciplinary learning environments. Finally, the qualitative component enriched the study by providing contextual insight into the classroom experiences underlying the quantitative associations, thereby enhancing the overall credibility of the mixed-methods interpretation.

Several limitations should also be considered. First, the cross-sectional design precludes conclusions regarding causality or temporal ordering. The observed associations may reflect reverse causation or the influence of unmeasured variables, such as institutional culture, prior educational experiences, personality characteristics, educator experience, or classroom context. Longitudinal and experimental studies are therefore needed to clarify the direction of these relationships. Second, all quantitative data were collected through student self-report measures administered at a single time point, which may have introduced common-method variance and social desirability bias despite the procedural steps taken to minimize these effects. Although the study demonstrated satisfactory internal consistency reliability for all instrument subscales, structural validity of the adapted instruments was not re-examined using confirmatory factor analysis. Future studies should further evaluate the factorial structure of the adapted measures in similar educational contexts. Third, the classification of a single dominant leadership style, which was used only for descriptive group comparisons, simplifies leadership into mutually exclusive categories despite moderate correlations among the leadership dimensions and should therefore be interpreted cautiously. Fourth, multiple ANOVA and independent-samples t-test comparisons were conducted without formal adjustment for multiple testing, increasing the possibility of Type I error.

Fifth, the observed differences across colleges and gender should be interpreted cautiously because potential confounding between these variables was not statistically controlled. Because multiple group comparisons were conducted, there is an increased possibility of Type I error. Accordingly, findings from the exploratory ANOVA and independent-samples t-tests should be interpreted with appropriate caution and considered alongside the multivariable regression and mixed-methods findings. Future studies should consider multivariable analytical approaches that simultaneously account for demographic and institutional characteristics. Sixth, although students’ perceptions provide valuable insight into classroom experiences, incorporating additional data sources such as classroom observations, educator self-assessments, or peer evaluations would strengthen future investigations through methodological triangulation. Finally, because the study was conducted at a single university in Saudi Arabia and the qualitative participants were recruited through voluntary participation, the findings may not be fully generalizable to other institutional or cultural contexts. Replication across multiple universities and diverse health professions programs is warranted to establish the transferability of these findings.

Despite these limitations, the consistency of the quantitative and qualitative findings across multiple analyses provides confidence in the overall pattern of associations observed. Future longitudinal, multicenter, and intervention studies are needed to determine whether leadership development initiatives for health professions educators can strengthen student engagement and critical thinking disposition and to further examine the educational mechanisms underlying these relationships.

Implications of the study

Implications for education

The present findings suggest that educator leadership behaviors represent an important consideration within learner-centered health professions education. Across the quantitative and qualitative findings, democratic leadership was consistently associated with higher student engagement and critical thinking disposition, while students described participatory teaching behaviors—including open dialogue, reflective questioning, collaborative learning, and constructive feedback—as characteristics of educational environments that supported meaningful learning. Although these associations should not be interpreted causally, they suggest that educator leadership behaviors deserve greater attention within faculty development initiatives and educational quality improvement efforts.

Faculty development programs may consider incorporating leadership competencies alongside pedagogical skills, particularly strategies that encourage active learning, respectful dialogue, reflective questioning, and collaborative problem-solving. Likewise, curriculum planners may consider expanding opportunities for case-based learning, simulation, problem-based learning, and structured classroom discussion, as these educational approaches have consistently been associated with student engagement and analytical reasoning in health professions education. Future intervention studies are needed to determine whether strengthening educator leadership competencies produces measurable improvements in student learning outcomes.

Implications for educational practice

The findings also have practical implications for educators, academic leaders, and program administrators. The qualitative findings suggest that students value educators who create psychologically supportive learning environments characterized by clear expectations, constructive feedback, and opportunities for active participation. Rather than viewing democratic leadership as the absence of structure, the present findings suggest that students perceive effective educator leadership as balancing instructional organization with learner autonomy and collaborative dialogue.

Academic leaders may therefore consider incorporating educator leadership competencies into faculty development, peer observation, mentoring, and teaching evaluation frameworks. Encouraging reflective teaching practices and interactive instructional approaches may contribute to learning environments that students perceive as more engaging and intellectually stimulating. Whether these educational practices ultimately improve graduate competence, clinical reasoning, or professional performance remains an important question for future longitudinal and intervention research.

Implications for future research

Future research should further examine the educational mechanisms linking educator leadership with student learning outcomes. Longitudinal studies are needed to determine the temporal relationships among leadership behaviors, student engagement, and critical thinking disposition. Multi-institutional investigations involving diverse health professions programs would help establish whether the present findings are transferable across educational settings and cultural contexts.

Future studies should also examine additional mediating and moderating variables, including psychological safety, academic self-efficacy, learning climate, educator feedback practices, and students’ motivation for learning. Intervention and quasi-experimental studies evaluating faculty leadership development programs would provide stronger evidence regarding whether changes in educator leadership behaviors are associated with subsequent improvements in engagement, critical thinking disposition, and other educational outcomes. Incorporating multiple data sources—including classroom observations, educator interviews, peer evaluations, and objective measures of student performance—would further strengthen understanding of how educator leadership is enacted within health professions education.

Conclusion

This explanatory sequential mixed-methods study demonstrated that educator leadership style was associated with student engagement and critical thinking disposition among undergraduate health sciences students. Democratic leadership demonstrated the strongest positive associations with both outcomes, whereas laissez-faire leadership showed comparatively weaker positive zero-order associations and negative adjusted associations after accounting for the other leadership styles. Student engagement also demonstrated a significant indirect association between democratic leadership and critical thinking disposition, consistent with a partial mediation pattern. Because the study employed a cross-sectional design, these findings should be interpreted as observed associations rather than evidence of causal relationships.

The integration of quantitative and qualitative findings provides a more comprehensive understanding of these relationships by illustrating how students perceived participatory educator behaviors—including collaborative learning, reflective dialogue, constructive feedback, and intellectual openness—as creating learning environments that encouraged engagement and analytical thinking. Together, the convergent findings extend existing evidence by combining statistical associations with students’ lived educational experiences, thereby providing a richer understanding of educator leadership within health professions education.

Although replication across diverse educational settings is warranted, the findings suggest that educator leadership represents an important dimension of teaching practice that merits greater attention in faculty development, curriculum innovation, and educational research. Future longitudinal and intervention studies are needed to determine whether strengthening participatory educator leadership behaviors can enhance student engagement, critical thinking disposition, and broader educational outcomes across health professions programs.

Abbreviations

ANOVA

Analysis of Variance

BE

Behavioral Engagement

CAMS

College of Applied Medical Sciences

CE

Cognitive Engagement

CI

Confidence Interval

COMJ

College of Medicine – Jeddah

CONJ

College of Nursing – Jeddah

COSHIP

College of Science and Health Professions

CT

Critical Thinking

CTD

Critical Thinking Disposition

CTDS

Critical Thinking Disposition Scale

EE

Emotional Engagement

IRB

Institutional Review Board

KAIMRC

King Abdullah International Medical Research Center

KSAU-HS

King Saud bin Abdulaziz University for Health Sciences

LSQ

Leadership Style Questionnaire

SD

Standard Deviation

USEI

University Student Engagement Inventory

Prof. Ebtsam Abou Hashish

Dr/Ebtsam Aly Abou Hashish is a Professor of Nursing Administration at the Faculty of Nursing, Alexandria University, Egypt. Dr. Ebtsam also works as an Associate Professor in the College of Nursing, King Saud bin Abdul-Aziz University for Health Sciences- Jeddah, KSA. She teaches management-related courses and research and ethics courses for undergraduates and postgraduates and has participated in supervising many theses and dissertations as an academic supervisor. She also held an associate trainer degree at the Faculty and Leadership Development Center (FLDC), Alexandria University. She has published more than 100 papers in reputed journals and has more than 2950 citations. Participated in many international nursing and health conferences and served as an editorial board member and reviewer for international journals and Sigma Theta conferences.

Authors’ contributions

Ebtsam Aly Abou Hashish (EAA): Conceptualization, Methodology, Formal analysis, Investigation, Data interpretation, Writing – original draft, Writing – review & editing, Project administration. Razaz Abdulaziz Felemban (RAF): Conceptualization, Methodology, Investigation, Data interpretation, Writing – original draft, Writing – review & editing, Project administration. Wid H. Allehaiby (WHA): Investigation, Methodology, Data curation, Data interpretation, Writing – original draft, Writing – review & editing. All authors reviewed the manuscript.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Data availability

The quantitative dataset supporting the findings of this study is available from the corresponding author upon reasonable request, subject to institutional approval. Qualitative interview and focus group transcripts are not publicly available in order to protect participant confidentiality, consistent with the terms of ethical approval.

Declarations

Ethics approval and consent to participate

Ethical approval for this study was obtained from King Abdullah International Medical Research Center (KAIMRC), under IRB Approval No. (NRJ25/038/1). The researchers adhered to both institutional and international ethical standards, strictly following the principles outlined in the Declaration of Helsinki. Participant rights and data integrity were upheld at all stages of the study. Informed consent was obtained from all participants prior to their inclusion in the study. The study was conducted in accordance with ethical principles related to autonomy, confidentiality, and voluntary participation. Prior to data collection, the researchers clearly explained the study’s purpose, procedures, and participants’ rights, including the right to refuse participation or withdraw at any time without academic consequences. Informed consent was obtained in both written and electronic formats, depending on the mode of participation. For students completing the paper-based questionnaire or participating in in-person interviews, written consent was signed before participation. For those completing the online questionnaire or joining interview and focus groups, electronic consent was secured through digital confirmation prior to participation. To protect confidentiality, all data were anonymized and securely stored on password-protected computers, accessible only to the research team.

Consent for publication

As part of the informed consent process, participants were advised that anonymized illustrative quotations from interviews and focus groups might be used in resulting publications, and no participant is identifiable from the quotations presented.

Competing interests

The authors declare no competing interests.