Introduction
Medication administration is a critical nursing responsibility for all hospitalized patients, and accurate drug dosage calculations are integral to patient safety. However, research indicates that many nursing students struggle with medication calculation (Owegi et al. 2021), particularly complex dose calculations (Wennberg‐Capellades et al.
2022). These difficulties translate into measurable harm.
On average, one medication error occurs daily during administration because of miscalculations (Mulac et al. 2022), and the World Health Organization estimates that medication‐related harm affects approximately 1 in 30 patients receiving care worldwide, with the resulting harm being severe or life‐threatening in more than a quarter of the cases (World Health Organization 2023). These errors are most common with the administration of high‐alert medications such as morphine, and are largely attributed to inadequate safety checks, staff stress and bypassed double‐verification protocols (Mulac et al.
2022). Beyond direct patient harm, including prolonged hospital stays, increased fatalities and increased healthcare costs (Bell et al. 2023), such errors also erode patient trust and institutional credibility.
A significant percentage of nursing students and practicing professionals fail to calculate medication dosages (Stake‐Nilsson et al. 2022). This competence is not only a fundamental skill for medication safety but also an essential component of patient safety in healthcare delivery (Elonen et al.
2022). Drug dosage calculations are the mathematical processes or numerical computations used by healthcare professionals to determine the correct amount of medication to be administered to patients. The correct dose of medication ensures safety and therapeutic efficacy (Elonen et al.
2022). The ability to accurately perform these calculations requires cognitive proficiency in mathematics. Confidence in one's ability to succeed is a key factor.
Both aspects are influenced by math anxiety and self‐efficacy (McMullan et al. 2012).
Math anxiety is a phenomenon characterized by feelings of tension and fear that interfere with numerical performance, particularly in high‐stakes scenarios such as medication calculations. Students with high math anxiety tend to avoid situations that require numerical problem solving (Barroso et al. 2021).
This may exacerbate the difficulties associated with drug dosage calculations. An inverse correlation exists between math anxiety and self‐efficacy (Barroso et al. 2021; Khasawneh et al.
2020; Shimizu 2022). Self‐efficacy influences problem‐solving approaches and overall performance. Nursing students experiencing high math anxiety report lower self‐efficacy, which interferes with their drug dosage calculation ability (Sayadi et al.
2021). Self‐efficacy is defined as an individual's belief in their ability to succeed in a particular task. Nursing students with high self‐efficacy are more likely to perform dosage calculations with confidence and accuracy (Abusubhiah et al.
2023). Students with high anxiety and low self‐efficacy are more likely to make medication errors; further, they may doubt their ability to correctly execute the calculations, leading to errors due to second guessing and confusion (Khasawneh et al. 2020).
A meta‐analysis by Barroso et al. (2021) found that students with high math anxiety consistently perform worse on math‐related assessments than their peers with lower anxiety levels.
Nursing education for medication management varies considerably across international contexts, and this variability has direct implications for patient safety. Studies assessing medication calculation competence among nursing students report markedly different outcomes across countries: while poor mathematics skills have been reported in 55%, 52% and 30% of nursing students in the United Kingdom, Turkey and Italy respectively, a study conducted in Saudi Arabia found a pass rate of only 2%, far below the rates reported elsewhere (Hijji 2025). Medication education is also known to vary within Europe itself, and this is a major concern given the increasing mobility of the nursing workforce across the region (Elonen et al.
2022). Taken together, these findings highlight a global need for greater standardization and strengthening of medication management education within nursing curricula.
Several theoretical perspectives, when considered together, help explain the hypothesized relationship between math anxiety and self‐efficacy. Processing efficiency theory holds that anxiety consumes working memory, leaving fewer cognitive resources available for demanding tasks such as drug dosage calculations (Skagerlund et al. 2019).
Attentional control theory extends this by specifying the mechanism: anxiety shifts attentional control away from task‐relevant processing and towards threat‐related stimuli, further impairing focus during calculation tasks. This depletion of cognitive resources is consequential because dosage calculation relies on well‐developed schemas, i.e., structured mental frameworks that allow students to efficiently categorize information and apply the correct mathematical operations (Chen et al. 2024).
When anxiety limits the cognitive resources needed to build or access these schemas, students are likely to struggle with calculations, an experience that, per Bandura's (1977) self‐efficacy theory, undermines self‐efficacy through repeated mastery difficulties, one of the primary sources through which self‐efficacy beliefs are formed. Together, these perspectives suggest a cyclical mechanism: math anxiety depletes the cognitive resources needed for schema‐based problem solving, and the resulting difficulty with calculation tasks erodes self‐efficacy, which may in turn heighten anxiety in future tasks. This integrated framework provided the theoretical basis for examining the association between math anxiety and self‐efficacy in the present study.
Despite the critical implications of medication calculation errors, a significant research gap remains regarding the relationship between math anxiety and self‐efficacy among nursing students. Previous studies have examined these factors independently and, in some cases, linked them to dosage calculation performance and error rates; however, few studies have explored the association between math anxiety and self‐efficacy specifically, rather than their combined association with objectively measured calculation outcomes. Prior work has often relied on general measures of mathematical confidence (Austerberry et al.
2024; Khasawneh et al. 2021; Rozgonjuk et al. 2020), and while nursing‐specific self‐efficacy scales have been used (Belli and Uslu 2025; Bulduk et al.
2024), few studies have modelled nursing‐specific mathematics self‐efficacy alongside socio‐demographic characteristics as competing predictors of anxiety. Additionally, no study has examined this relationship among undergraduate nursing students in Saudi Arabia. Clarifying how these psychological factors relate to one another in this population is an important first step towards informing future interventions aimed at strengthening medication safety education.
Nursing education plays an important role in preparing students for this responsibility; however, Stake‐Nilsson et al. (2022) noted that the curriculum did not sufficiently provide students with these essential skills.
We, therefore, aimed to describe the socio‐demographic characteristics and factors associated with self‐efficacy and math anxiety among undergraduate nursing students in different regions of Saudi Arabia. We investigated socio‐demographics, self‐efficacy and math anxiety among undergraduate nursing students; the relationship between select socio‐demographics, self‐efficacy and math anxiety among undergraduate nursing students; and the variance in math anxiety explained by selected socio‐demographics and self‐efficacy. Understanding how math anxiety is associated with self‐efficacy and medication calculation may provide valuable insights for educators seeking to enhance nursing students' mathematical confidence and accuracy.
Methods
Study Sample and Design
A descriptive cross‐sectional study was conducted to determine the factors associated with self‐efficacy and math anxiety. This study recruited undergraduate nursing students enrolled in bachelor's degree programs in nursing across the 13 administrative regions of Saudi Arabia. A convenience sampling strategy was used to recruit participants for this study.
The inclusion criteria for the participants were as follows: (1) undergraduate student nurses in the second, third, or fourth year or practicum (internship year) who were enrolled in the Bachelor of Science in Nursing (BSN) program at any school of nursing in Saudi Arabia; (2) student nurses who had access to the survey link and voluntarily agreed to participate; and (3) student nurses who could read and write in English. The exclusion criteria were as follows: (1) graduate student nurses; (2) nurses currently practicing in clinical settings; and (3) those who could not read or speak English.
This study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines for reporting cross‐sectional research (von Elm et al. 2007). Using G*Power 3.1.9.6 software, an a priori power analysis was conducted for a linear multiple regression model (fixed model, R2 deviation from zero) with six predictors.
The minimum sample size required for a statistical power of ≥ 90%, medium effect size (Cohen's f2 = 0.15), and significance level of α = 0.05 was calculated to be 123 participants (Faul et al. 2009). Accounting for 10% missing data, the required sample size was 136.
In total, 147 participants were recruited for this study. A total of 147 completed questionnaires were included in the descriptive analyses. Of these, four participants had missing data on one or more variables required for the inferential analyses and were excluded using listwise deletion, resulting in an analytical sample of 143 participants for those analyses.
Data Collection
Institutional review board approval was obtained prior to data collection. Participants were recruited through an online invitation to complete surveys on Qualtrics, a secure, cloud‐based online survey platform commonly used for data collection and management in academic and healthcare research. The questionnaire was distributed directly to undergraduate nursing students through social media platforms, such as WhatsApp and email was utilized to engage a diverse range of participants across 13 regions of Saudi Arabia.
No curricular changes, academic events, or institutional interventions related to mathematics or dosage calculation training were introduced during the 6‐month recruitment period that could have influenced the participants' self‐efficacy or math anxiety levels.
Variables and Instruments
Socio‐Demographics
Socio‐demographic variables, including age, sex, current university, current grade point average (GPA), current academic year and whether the students attended mathematics courses related to drug calculation, were collected from an online survey through the Qualtrics platform.
Nursing Self‐Efficacy for Mathematics (NSE‐Math)
Nursing students' mathematics self‐efficacy was measured using the NSE‐Math scale, a 12‐item self‐report questionnaire used to describe nurses' confidence in performing mathematical and arithmetic tasks related to drug dosage calculations (Andrew et al. 2009). Students' responses were measured on a 10‐point Likert scale with one indicating no confidence at all, and 10 indicating complete confidence in performing the drug dosage calculations.
The item scores were summed to obtain the total score for the instrument. The minimum score for this instrument is 12, and the maximum score is 120. A higher score indicated a higher level of self‐efficacy.
The instrument comprised two main categories. The first category consisted of items aimed at evaluating students' self‐confidence in executing the arithmetic and mathematical skills essential for calculating medication doses (Items 2, 3, 4 and 5). The second category comprised items specifically designed to assess mathematical skills that directly involve the application of mathematics in drug dosage calculations in practice (Items 1, 6, 8, 9 and 11).
The remaining three items (items 7, 10 and 12) were created to enhance the instrument and assess specific medication calculation competencies taught in the nursing practice course (Andrew et al. 2009). This instrument has been widely used in research, with a Cronbach's alpha of 0.88 (Andrew et al.
2009). In this study, Cronbach's alpha was 0.913.
Mathematics Anxiety Scale (MAS)
The MAS, developed by Betz (1978), was intended to measure mathematics anxiety among college students. It consists of 10 items on a 5‐point Likert scale. Responses ranged from 1 (strongly disagree) to 5 (strongly agree).
The first five items were positively worded (items 1–5), whereas the other items were negatively worded (items 6–10). The minimum score for this instrument is 10, and the maximum score is 50. If the positively worded items were reverse‐scored, a higher score indicated greater anxiety.
Furthermore, when the negatively worded items were reverse‐scored, a higher score indicated less math anxiety (Skagerlund et al. 2019). This instrument has been extensively used in research involving students at college and high school levels, with Cronbach's alpha values ranging from 0.72 to 0.92 (Betz 1978).
In this study, Cronbach's alpha was 0.837.
Ethical Considerations
Prior to the commencement of data collection, ethical approval was obtained from the Institutional Review Board at King Saud University [KSU‐HE‐24‐375]. The research was carried out in accordance with the Declaration of Helsinki guidelines. Before completing the questionnaire, participants were provided with information about the purpose of the study and its associated risks and benefits and were informed of their right to withdraw at any point during participation.
Submission of the completed questionnaire indicated consent to participate in the study. To protect participant confidentiality, no identifying information was collected, and all findings were reported only in aggregate form. Data access was limited to the primary investigator.
The data were collected between September 2024 and February 2025.
Data Analysis
Descriptive statistics were used to summarize the study variables, with means and standard deviations reported for continuous measures (age, GPA, self‐efficacy and mathematics anxiety) and frequencies and percentages for categorical measures (sex, academic year and prior mathematics coursework). Pearson's correlation coefficient was used to examine the strength and direction of associations between continuous variables. Independent‐samples t‐tests were conducted to assess group differences in GPA, self‐efficacy and mathematics anxiety by sex and prior mathematics coursework.
A multiple linear regression analysis was performed to explore the predictive relationships between demographic and academic factors, self‐efficacy and mathematics anxiety scores. In the analysis, a two‐sided p‐value < 0.05 was considered statistically significant. All analyses were performed using SPSS v30 (IBM Corp., Armonk, NY).
Results
In total, 147 students were included in the analysis. The mean age of the participants was 21.43 years (SD = 1.40) (Table 1). Most students were male (71.4%), and 28.6% were female.
The mean GPA was 4.06 (SD = 0.60) on a 5‐point scale. Regarding academic standing, 42.72% of the participants were juniors, and 57.28% were seniors. Regarding prior exposure to drug calculation courses, 26.5% had attended a relevant course, whereas 73.5% had not.
The mean NSE‐Math score was 59.14 (SD = 25.11), with subscale scores indicating average confidence levels of 20.27 (SD = 9.66) and 38.87 (SD = 17.88), respectively, in applying mathematical and arithmetic concepts to nursing practice. The mean MAS score was 26.62 (SD = 7.24). Anxiety levels were categorized as low (30.6%), moderate (58.5%), or high (8.2%).
Table 2 presents the Pearson product–moment correlation coefficients among the study variables, including age, GPA, NSE‐Math and MAS. The findings indicated that NSE‐Math was significantly and negatively correlated with MAS (r = −0.386, p < 0.001), suggesting that high self‐efficacy in mathematics is associated with decreased levels of mathematics anxiety. However, no significant correlations were found between age and GPA, NSE‐Math score or MAS score.
Similarly, the GPA did not show significant correlations with the NSE‐Math or MAS scores. Independent‐samples t‐tests showed no statistically significant differences in NSE‐Math scores or MAS scores between the sexes and those who had or had not attended a prior drug calculation course (all p > 0.05; Table 3).
The results of the multiple linear regression analysis demonstrated that the overall model was statistically significant, F (6, 132) = 4.808, p < 0.001, accounting for 17.9% of the variance in mathematics anxiety (R2 = 0.179). Among the predictor variables, NSE‐Math was the only significant predictor of mathematics anxiety (B = −0.115, β = −0.394, t = −4.977, p < 0.001), with a 95% confidence interval (CI) ranging from −0.160 to −0.069 (Table 4). This finding suggests that high self‐efficacy in mathematics is associated with lower levels of mathematics anxiety.
Other predictors, including age, sex, GPA, academic year and prior attendance in a drug calculation course, were not significant predictors of math anxiety. These findings indicate that nursing students' self‐efficacy in mathematics is associated with their experiences of mathematics anxiety, whereas demographic and academic factors do not contribute significantly to the model.
Discussion
This study aimed to describe the socio‐demographic characteristics of undergraduate nursing students in different regions of Saudi Arabia and to examine the factors associated with their self‐efficacy and math anxiety. Specifically, the study investigated the relationships between select socio‐demographic variables, self‐efficacy and math anxiety, and identified the extent to which math anxiety was explained by these variables. The findings revealed a significant and negative correlation between NSE‐Math and math anxiety, indicating that increased mathematical self‐efficacy was associated with lower anxiety levels.
No significant associations were found between age, GPA, sex, academic year, or prior drug calculation coursework and self‐efficacy or math anxiety.
Mathematics self‐efficacy was the only factor associated with math anxiety in this sample, which is consistent with evidence from higher education more broadly. In a cross‐sectional survey of 231 Estonian undergraduates enrolled in compulsory calculus and statistical modelling courses, anxiety and self‐efficacy were inversely related, and the association was stronger than those observed for age, sex, or approaches to learning; once self‐efficacy entered the model, the explained variance in anxiety increased substantially, and it remained the only meaningful predictor among social science students (Rozgonjuk et al. 2020).
A similar relationship appears where the stakes are clinical rather than academic. In a mixed‐methods study of Bachelor of Nursing students at an Australian university that combined a survey of 135 completed responses with eight focus groups, students most often attributed their fear of mathematics to a lack of confidence in their own skills, ahead of fear of making errors or of causing patient harm (Austerberry et al. 2024).
This ordering suggests that anxiety may relate more to how students appraise their ability than to the difficulty of the arithmetic itself, which is relevant in a population where dosage miscalculation can cause clinical harm. The findings that NSE‐Math accounted for a more modest share of variance in our study may reflect construct specificity, since it assesses confidence in nursing‐specific dosage tasks rather than general mathematical confidence. Given the cross‐sectional design, the direction of influence cannot be established, although the association is compatible with reciprocal models in which confidence and anxiety affect one another.
None of the socio‐demographic characteristics examined, including sex, age, academic performance, academic year and prior completion of a drug calculation course, was associated with either anxiety or self‐efficacy. Regarding the sex‐related differences, a scoping review of 10 studies across six countries and several disciplines reported higher anxiety among women, while also noting that the pattern varies by country and discipline (Khasawneh et al. 2021).
Our finding is consistent with those of studies involving allied health cohorts elsewhere; for instance, a mixed‐methods study of 108 s‐ and third‐year paramedic students at an Australian university found moderate anxiety with no difference between men and women (Khasawneh et al. 2020). Where sex differences have been reported, they tended to involve confidence or performance rather than anxiety.
In a descriptive study of 308 s‐, third‐ and fourth‐year nursing students at a state university in eastern Turkey, men reported higher self‐efficacy in paediatric drug preparation, which the authors attributed to stronger mathematical skills, although these aspects were not measured (Bulduk et al. 2024). Among 70 students at a private university in North Cyprus who had completed a basic mathematics course, men scored higher than women on a dosage calculation test, although the same authors note a Turkish study that found no such effect (Fırat Kılıç and Cevheroğlu 2023).
In the Australian paramedic cohort, men achieved higher calculation scores despite comparable anxiety and comparable numerical ability, and sex no longer predicted performance once prior mathematics education was accounted for (Khasawneh et al. 2020). Taken together, these findings suggest that educational background and curricular context may account for the sex differences reported in the literature, although this remains to be tested directly.
Academic year was likewise unrelated to anxiety in our sample. Similarly, a cross‐sectional study of 175 third‐ and fourth‐year nursing students at a Turkish state university reported that anxiety was similar across the 2 years even though third‐year students scored higher on drug preparation and self‐appraised mathematical skill rather than year of study distinguished those who were less anxious (Belli and Uslu 2025). A comparable pattern appeared in the eastern Turkish cohort described above, where third‐year students reported the highest medication self‐efficacy and second‐year students the lowest, which the authors attributed to the third‐year paediatric nursing course and its integrated clinical practice (Bulduk et al.
2024). The Australian paramedic students similarly showed no variation in anxiety by year level (Khasawneh et al. 2020).
Progression through the curriculum may therefore support calculation competence without altering the affective response to mathematics. A similar pattern was observed with regard to age. Anxiety did not differ across age groups in the paramedic cohort (Khasawneh et al.
2020), and in a cross‐sectional study of 163 first‐year baccalaureate nursing students at a Canadian university, baseline arithmetic ability did not predict anxiety, although older students in an accelerated pathway reported lower anxiety, which the authors attributed to accumulated coping strategies rather than to age (Osahor et al. 2019).
Prior completion of a drug calculation course was also unrelated to anxiety or self‐efficacy, echoing the findings of Khasawneh et al. (2020), who examined a paramedic cohort where neither level of mathematics education nor immediacy of university entry made a difference. Intervention research offers some explanation.
In a non‐randomized trial with 80 senior nursing students at an Iranian university, a training program delivered during a 10‐day clinical pharmacology internship led to a substantial increase in calculation scores, while its effect on anxiety was small, emerged only in between‐group comparison, and was not related to the calculation gains (Sayadi et al. 2021). In a comparative descriptive study of 136 nursing students in North Cyprus, a 42‐h basic mathematics course was likewise followed by better dosage calculation performance, though the comparison involved successive curricular cohorts and anxiety was not assessed (Kılıç & Cevheroğlu, 2022).
Instruction appears to build procedural competence more readily than it reduces anxiety, suggesting that the affective dimension may need to be addressed directly rather than treated as a by‐product of skill acquisition.
Academic performance showed a similar independence from anxiety. GPA was essentially unrelated to anxiety scores in our study, although the high mean and narrow range limit what can be inferred, and in another study, prior arithmetic ability did not predict anxiety among the Canadian first‐year students (Osahor et al. 2019).
Academic standing has been related to performance, as evidenced in a study that did not measure anxiety (Kılıç & Cevheroğlu, 2022), where North Cypriot students in higher GPA bands scored progressively better on dosage calculation. Strong academic standing may therefore offer little protection against anxiety about dosage calculation, which has practical implications since high‐achieving students may carry unrecognized apprehension into clinical practice.
Future studies should explore the longitudinal relationship between math anxiety, self‐efficacy and actual performance in drug dosage calculations using objective assessments in addition to self‐reported instruments. Experimental or interventional research is also warranted to evaluate the effectiveness of targeted strategies, such as simulations or cognitive‐behavioural interventions, aimed at reducing math anxiety and enhancing self‐efficacy. Given the significant association between self‐efficacy and math anxiety, clinical educators and preceptors should incorporate supportive learning environments that build student confidence in performing drug dosage calculations.
Mentorship and real‐time feedback in the clinical setting can reinforce mathematical competence and reduce anxiety. Nursing curricula should integrate structured and evidence‐based training modules addressing drug dosage calculations, math anxiety and self‐efficacy. Early and continuous exposure to these concepts across academic levels can enhance student confidence and potentially reduce anxiety.
Faculty development initiatives should also be implemented to prepare instructors to identify and support students who struggle with mathematics‐related anxiety.
This study had some limitations. First, the study relied on self‐reported measures, which may have been influenced by social desirability bias or inaccurate self‐assessment, particularly when evaluating one's own mathematics confidence and anxiety. Second, although the study included participants from various regions of Saudi Arabia, the sample may not fully represent all nursing students across the country.
Therefore, the findings should be generalized cautiously to populations with different demographic, clinical, or healthcare‐system characteristics. Additionally, as the survey was distributed through email invitations and an open social media link, it was not possible to determine the exact number of individuals who viewed the survey without participating; therefore, a traditional response rate could not be calculated. The sex distribution was imbalanced, with a higher proportion of male participants, which may limit the generalizability of the findings to a broader nursing student population, which typically has a higher proportion of female participants.
Finally, this study did not assess actual drug dosage calculation performance, which would have provided a more comprehensive understanding of how math anxiety and self‐efficacy relate to clinical competence.
Conclusion
This study highlighted the relationship between nursing students' mathematics self‐efficacy and their levels of math anxiety, with self‐efficacy being a significant predictor of math anxiety. Although demographic and academic variables did not significantly predict math anxiety, these findings highlight the importance of fostering mathematical confidence in potentially mitigating anxiety and enhancing competence in drug dosage calculation. As medication errors remain a critical threat to patient safety, addressing the psychological and cognitive barriers that may affect students' mathematical performance is essential for preparing safe and competent nurses in the future.
Implications for Research, Education and Policy
This study set the foundation for future experimental research on the impact of dosage calculation workshops and simulations on math anxiety, drug dosage calculation accuracy and self‐efficacy. Additionally, the findings of this research are of paramount importance when informing educational organization leaders and policymakers on how to integrate structured and evidence‐based nursing training modules into nursing curricula. Accordingly, our data can help prepare future nurses with the ability to provide high‐quality care to patients while maintaining their safety.
In clinical practice, healthcare institutions should implement structured mentorship and preceptorship programs to support newly graduated nurses during medication administration, particularly during the transition from academic to clinical settings. Institutional safeguards, such as double‐checking protocols for high‐alert medications, may further reduce errors potentially associated with math anxiety or low self‐efficacy. Policymakers should also consider standardized national guidelines for dosage calculation competency training, including periodic reassessment throughout nursing programs.
Author Contributions
Essa Hakamy: conceptualization, methodology, software, data curation, supervision, resources, project administration, formal analysis, validation, visualization, writing – review and editing, writing – original draft, funding acquisition, investigation. Hamza Moafa: conceptualization, investigation, writing – original draft, methodology, validation, visualization, writing – review and editing, project administration, formal analysis, software, data curation, supervision, resources. Ahmed Nahari: conceptualization, methodology, software, formal analysis, data curation, writing – original draft, writing – review and editing.
Monir Almotairy: conceptualization, methodology, formal analysis, data curation, writing – original draft, writing – review and editing.
Funding
This work was supported by the Ongoing Research Funding Program (ORF‐2026‐1655) of King Saud University, Riyadh, Saudi Arabia. The funder had no role in the study design; data collection, analysis or interpretation; preparation of the manuscript; or the decision to submit the manuscript for publication.
Ethics Statement
Institutional review board approval was obtained prior to conducting this study by the Ethics Committee of King Saud University with approval reference number (KSU‐HE‐24‐375).
Consent
Informed consent was obtained from all participants. This study was conducted in accordance with the principles of the Declaration of Helsinki. Informed consent was obtained, including a statement describing the purpose of the study, the inclusion and exclusion criteria, and the benefits and risks.
In addition, the participants were informed that completing the questionnaire was voluntary and that they had the right to withdraw from the study without any consequences. All data were kept confidential and protected by using a password‐protected computer. All data were destroyed once the study was concluded.
Finally, access to the data was restricted to the primary investigator.
Conflicts of Interest
The authors declare no conflicts of interest.