F1000Research F1000Research 2046-1402 F1000 Research Limited London, UK 10.12688/f1000research.173432.2 Research Article Articles Relation of Anxiety Levels and Objective Structured Clinical Examination among Undergraduate Nursing Students

[version 2; peer review: 1 approved, 2 approved with reservations]

 Kamel Senosy Ayman Muhammad Conceptualization Data Curation Formal Analysis Methodology Writing – Original Draft Preparation https://orcid.org/0000-0001-9390-8330 1 Sallam Gehan Conceptualization Formal Analysis Writing – Original Draft Preparation Writing – Review & Editing a 2 Abdel Fattah Hadya Abboud Conceptualization Formal Analysis Writing – Review & Editing 3 El Sharkawi Sabah Saad Data Curation Formal Analysis Methodology Writing – Review & Editing 4 Ahmed Zeinab Adham Conceptualization Methodology Supervision Writing – Review & Editing 4 Maki Sara Formal Analysis Methodology Writing – Review & Editing 2 Zafar Imran Conceptualization Writing – Review & Editing 5 Al Awar Shamsa Project Administration Supervision Writing – Review & Editing https://orcid.org/0000-0002-0452-7024 b 2 Magzoub Mohi Eldin Conceptualization Methodology Project Administration Supervision Writing – Review & Editing https://orcid.org/0000-0002-6721-4500 c 5 Faculty of Nursing, Ain Shams University Faculty of Nursing, Cairo, Cairo Governorate, Egypt Department of Obstetrics and Gynecology, United Arab Emirates University College of Medicine and Health Sciences, Al Ain, Abu Dhabi, United Arab Emirates Department of Nursing, Fatima College of Health Sciences, Ajman, Ajman, United Arab Emirates Faculty of Nursing, October 6 University, 6th of October City, Giza Governorate, Egypt Department of Medical Education, United Arab Emirates University College of Medicine and Health Sciences, Al Ain, Abu Dhabi, United Arab Emirates gsayed@uaeu.ac.ae sawar@uaeu.ac.ae mmagzoub@uaeu.ac.ae

No competing interests were disclosed.

 12 5 2026 2026 15 135 6 5 2026 Copyright: © 2026 Kamel Senosy AM et al. 2026 This is an open access article distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Background

The incidence of stress and anxiety among nursing students is observed across all academic years of their educational training. Although Objective Structured Clinical Examinations (OSCEs) are helpful in healthcare education, they can be anxiety-inducing. This study aimed to assess the anxiety level among nursing students during the OSCE exams.

 Methods

A descriptive cross-sectional study was carried out on a purposive sample by distributing an online survey among students from an undergraduate nursing program. Anxiety levels were measured using the State-trait anxiety inventory, including the subscales of the state and trait of anxiety.

 Results

A total of 121 students with a mean age of 22.2 years (SD +/-3.6) participated in the study. The majority of the participants, 72.7%, were females, and 27.3% were males. Before attending the OSCE, 58.7% of the participants reported a mild degree of anxiety, 33.1% had a moderate level of anxiety, and only 8.3% had a severe level of trait anxiety.

 Conclusions

The findings highlight the complex interplay between sociodemographic factors, academic performance, work-study balance, and anxiety levels among nursing students preparing for high-stakes assessments like the OSCE. Addressing anxiety levels among nursing students preparing for OSCE assessments requires a multifaceted approach that considers individual characteristics, academic performance, and external stressors.

 Anxiety undergraduate nursing students OSCE The author(s) declared that no grants were involved in supporting this work. Amendments from Version 1

The substantial revisions made in response to the reviewers' comments account for the major differences between this updated version and the previously published version. The main changes include clarification of the study design as a descriptive cross-sectional study, correction of inconsistencies in the description of the study population and gender distribution, addition of the response rate, and clearer reporting of the reliability of the STAI subscales. We strengthened the literature review by incorporating more recent OSCE-specific anxiety studies, and we revised the discussion and conclusions to employ more cautious, non-causal language. In addition, the revised manuscript expands the limitations section by acknowledging issues such as self-report bias, timing of data collection, preparation-related confounding, and limited generalizability, while also improving grammar, terminology, and overall clarity.

 Introduction

An individual’s psychological and physiological state is impacted by anxiety brought on by various physical, emotional, and cognitive factors. 1 Numerous researchers have studied anxiety and the mental health of undergraduate nursing students to determine their impact on the students’ psychological and academic outcomes. 2 Higher levels of anxiety and other mental health issues, such as stress, and depression, were reported by nursing students compared to non-nursing undergraduate students. 3 Stress and anxiety have been reported among healthcare professionals due to multiple sources of intrinsic stress. For example, when a person faces an excessively stressful situation, stress and anxiety can generate detrimental and long-lasting psychological effects. 4 Thus, measures need to be taken to prevent stress and anxiety from affecting the learning of nursing students and later the performance of nurses.

Compared to academic training, practical nurse training is reported to be much more stressful. Research has shown that an anxiety-coping program could help nursing students feel less anxious and perform better on their practical training and examination, i.e. Objective Structured Clinical Examinations (OSCEs). 5 This suggests that anxiety-coping programs may be used to enhance clinical activity evaluation across a range of health professions, including nursing. Therefore, educators should implement anxiety-coping programs that will aid students in lowering anxiety and enhancing their exam performance. 5

Review of literature

The stress levels among nursing students during clinical training have been shown to be comparable to those observed across all academic years combined. 6 Although research in this regard is highly important and needed to shed light on the current situation in Middle East, the existing evidence is scarce. In the current study, stress will be defined as the degree to which a stressful event in one’s life, as well as the person’s ability to successfully deal with personal and environmental obstacles, is experienced by the individual. 7

The most challenging experience for many students is a relative lack of knowledge and skills. 4 Moreover, stressors such as fear of making mistakes, managing emergency situations, inconsistencies in clinical practice, and participation in specialized units constitute integral aspects of the initial clinical exposure. 8 A recent study identified a significant prevalence of exam-related anxiety among undergraduate nursing students in Jordan, with one-third experiencing high levels of anxiety and half reporting moderate anxiety levels as measured by Anxiety Scale created by. 9 Notably, both male and female nursing students acknowledged exam anxiety, with a third of male students experiencing severe anxiety and less than one thirds of female students reporting anxious feelings. 10

In addition to the demands of coursework, navigating a novel clinical setting, interacting with a diverse patient population, collaborating with nursing staff and faculty, nursing students often encounter challenges that contribute to stress during their clinical training. 11 Concerns about the practical application of clinical skills to deliver high-quality nursing care, apprehensions about failure, and the emotional complexities associated with patient interactions further exacerbate student anxiety. Nonetheless, several studies have explored test anxiety and coping mechanisms among students to evaluate the efficacy of employing various strategies immediately before examinations to enhance academic performance. 12

Nursing students are required to possess a comprehensive understanding of various subjects, encompassing multidisciplinary cooperation, client illnesses, diagnostic procedures, patient-nurse relationships, treatment modalities, and pharmacology. 13 The demanding academic curriculum, excessive study hours, assignments, grading pressure, time constraints, examinations, and limited social support collectively elevate stress levels among students. 14 Anxiety is a natural response influenced by diverse factors, as evidenced by the manifestation of test anxiety prior to exams. Students experiencing no anxiety, mild anxiety, or severe anxiety may exhibit varying impacts on their exam performance. Educators are advised to explore the factors associated with exam-related anxiety among their students based on research findings. Furthermore, implementing mind-body therapeutic interventions for students can equip them with self-management strategies to cope with high levels of anxiety effectively. 15

Recent OSCE-focused literature suggests that anxiety should be understood not only as an individual emotional response but also as a function of assessment design, familiarity with the format, and the adequacy of preparation. In first-year nursing students, OSCE-related stress has been associated with limited time per station, observation by examiners, waiting time, and unfamiliarity with the examination process, indicating that structural features of the OSCE itself may heighten stress levels. 16 Recent nursing literature also shows that although students generally perceive the OSCE as a valid and useful method for assessing clinical competence, they simultaneously describe it as stressful and demanding, particularly when preparation and orientation are insufficient. 17 In addition, interventional and qualitative studies suggest that structured preparation, stress-management strategies, and targeted coping programs may help reduce OSCE-related stress and improve students’ performance and psychological readiness. 18 , 19 Together, these findings indicate that OSCE anxiety is context-dependent and potentially modifiable, which supports the need for setting-specific evidence from undergraduate nursing students in the Middle East.

The researchers identified a gap in the literature regarding stress and anxiety experienced by nursing students during OSCEs, which prompted the current study. Previous evidence suggests that students who combine work and study may experience higher anxiety levels than those who do not work while studying. Similarly, students living away from their families may be more vulnerable to anxiety than those living with family support. Therefore, this study aimed to assess the anxiety levels of nursing students during the OSCE.

 Methods

The present study was carried out at the Faculty of Nursing, Six of October University, Cairo, Egypt, during the summer course period from August 1, 2022, to the end of September 2022. The research aimed to evaluate the level of anxiety preceding the OSCE exam among second-year nursing students. A descriptive study was carried out on a purposive sample, by distributing an online survey among students in an undergraduate nursing program. This group was selected because the participants were the eligible students who were about to undertake the OSCE during the study period, making them the most relevant population for examining anxiety immediately before this assessment. Anxiety levels were measured using the State-trait anxiety inventory, including the subscales of the state and trait of anxiety. A total of 180 students were approached, of whom 121 participated, yielding a response rate of 67.2%; 88 participants were female and 33 were male. The inclusion criteria were all the students in year 2 entering the OSCE exam and agreed to participate in the study. The exclusion criteria the students who refused to participate in the study or were not in year 2. After the ethical approval obtained for the study, the researchers provided detailed information to the participants, explained the study’s objectives, and distributed the questionnaire three days before the OSCE exam using an online survey method via students’ emails and WhatsApp. On average, participants took 10-15 minutes to complete the questionnaire.

Study designs

This study employed a descriptive cross-sectional design using a purposive sample through a self-evaluation questionnaire to achieve the study objectives.

 Measures and tools

The data collection tools comprised two parts. The first part gathered socio-demographic information, encompassing six items: namely, age, gender, academic year, university entrance score, type of accommodation, and employment status.

The second part involved the State-Trait Anxiety Inventory (STAI), developed by STAI was developed by Spielberger, (1983) in English. 16 The questionnaire included two distinct scales, the State Anxiety (STA-Y scale) and the Trait Anxiety (TAI-Y scale). The STA-Y scale, with 20 items, assessed the participants’ current feelings at the time of responding, using a 4-point Likert scale graded as 1 (not at all), 2 (somewhat), 3 (moderately so), and 4 (very much so). Higher scores indicated high anxiety levels. The TAI-Y scale, also comprising 20 items, evaluated participants’ general feelings on a 4-point Likert scale ranging from 1 (Almost Never) to 4 (Almost Always) with item 1 being the reversed score. The total score for each subscale, i.e. the STA-Y and the TAI-Y, ranged from 20 to 80. For descriptive purposes, anxiety severity was categorized into mild, moderate, and severe levels according to previously published cut points used in comparable studies; these categories were used to facilitate interpretation and should not be considered diagnostic thresholds6.

The reliability and validity of the questionnaire were determined using Cronbach’s Alpha in this study. The reliability values of Cronbach’s Alpha were calculated for the subscales.

 Data collection

The data were collected by distributing an online survey (Annex 1) using Google Forms to students’ email addresses. Prior to the OSCE, the nursing students provided their consent for data collection. Participants were given 10-15 minutes to complete the questionnaire. No data were missing, as data collection was concluded upon reaching the predetermined sample size (n=121) within one month.

 Statistical analysis

The data were analyzed with IBM (SPSS Statistics software, version 22.0), employing both descriptive and inferential statistics. Descriptive statistics included mean, standard deviation, frequency, and percentage. Demographic and academic variables, including age, gender, university entrance score, repeating the academic year, accommodation type, and work-study status, were analyzed in relation to anxiety levels using chi-square testing. The Chi-square test was utilized to compare anxiety levels among participants before the OSCE exam with statistical significance set at P < 0.05.

The normality of the data was assessed using the Shapiro-Wilk test to determine the appropriateness of parametric testing for normally distributed data. Descriptive analysis was conducted to characterize the study sample and anxiety levels. The Chi-square test was used to identify factors associated with anxiety levels, and a two-sided P value of <0.05 was considered statistically significant.

Continuous normally distributed data were presented in mean ± standard deviation (SD), while categorical data were expressed as frequencies and percentages. The Chi-square test (Fisher’s exact test when applicable) was used for comparing variables with categorical data. The reliability of the questionnaires used in the study was assessed through internal consistency, with Cronbach’s alpha values of 0.894 for the STA-Y scale and 0.886 for the TAI-Y scale indicating good reliability. The questionnaire was administered in English.

 Ethical considerations

This study received ethical approval from the Faculty of Nursing on October 6 University’s ethical committee, with approval number: PRC-Nu-2308002.

 Informed consent

The study’s objectives were clearly explained and simplified for the participants. Confidentiality regarding any shared information was assured. Participants were informed of their right to withdraw from the study at any time. Written informed consent was obtained from the participants before the study commenced.

 Results

Table 1 showed the mean age of the participants, 22.2 ±3.6, distributed as 78.5% ranging from 19 to 25 years and 21.5% aged ≤ 18 years. Gender distribution showed that 72.7% of the participants were females and 27.3% were males. Regarding the university entrance average score, 56 participants (46.3%) scored ≤ 75%, 52 (43.0%) scored between 76% – 89%, and 13 (10.7%) scored ≥ 90%. Academic progress indicated that 62 participants (51.2%) repeated the academic year, while 59 (48.8%) did not. Concerning the type of accommodation, 62.0% were living in private housing, 7.4% in university dormitories, and 30.6% were living with family. Additionally, work-study balance showed that 40 participants (33.1%) worked and studied, while 81 (66.9%) did not engage in both activities simultaneously.

Demographic characteristics of the participating students (n = 121).
N %
Age (Years)
18 26 21.5
19 – 25 95 78.5
Mean ± SD 22.2 ± 3.6
Gender
Male 88 72.7
Female 33 27.3
University entrance average score
≤75% 56 46.3
76%–89% 52 43
≥90% 13 10.7
Do you repeat this academic year (Level)?
Yes 62 51.2
No 59 48.8
Kind of accommodation
Private 75 62
University dormitory 9 7.4
Living with family 37 30.6
Do you work and study?
Yes 40 33.1
No 81 66.9

Table 2 includes the classification of anxiety levels into mild, moderate, and severe anxiety for both the STA-Y and TAI-Y scales of anxiety. The data shows the distribution of participants across these categories: for mild anxiety, 46.3% based on the STA-Y scale and 58.7% based on the TAI-Y scale; for moderate anxiety, 40.5% according to the STA-Y scale and 33.1% according to the TAI-Y scale; and for severe anxiety, 13.2% based on the STA-Y scale and 8.3% based on the TAI-Y scale. Additionally, the mean anxiety scores were 49.4 ± 9.3 for the STA-Y classification and 48.4 ± 8.0 for the TAI-Y classification.

Comparison between the studied students’ anxiety levels based on the State-trait anxiety inventory (STAI), classified as the state (STA-Y scale) and trait (TAI-Y scale) of anxiety (n = 121).
STA-Y classification TAI-Y classification
n % N %
Anxiety Level
Mild Anxiety 56 46.3 71 58.7
Moderate Anxiety 49 40.5 40 33.1
Severe Anxiety 16 13.2 10 8.3
Mean ± SD 49.4 ± 9.3 48.4 ± 8.0

STA-Y = State of anxiety, TAI-Y = trait of anxiety.

As shown in Table 3, there was no statistically significant relation between the total level of anxiety according to STA-Y classification and sociodemographic characteristics among studied students; specifically, age, gender, repeating the academic year, and kind of accommodation (P > 0.05), while the university entrance score and combining working and studying were significantly correlated with STA-Y (P < 0.001).

Relation between total level of anxiety according to STA-Y classification and demographic characteristics among studied students (n=121).
Mild Anxiety (n=56) Moderate Anxiety (n=49) Severe Anxiety (n=16)
N % n % n % X 2 P
Age (Years)
18 12 21.4 11 22.4 3 18.8
19–25 44 78.6 38 77.6 13 81.3 0.098 0.952
Gender
Male 46 82.1 31 63.3 11 68.8
Female 10 17.9 18 36.7 5 31.3 4.842 0.088
University entrance average score
≤75% 7 12.5 35 71.4 14 87.5
76%–89% 36 64.3 14 28.6 2 12.5
≥90% 13 23.2 0 0.0 0 0.0 53.208 <0.001 **
Do you repeat this academic year (Level)?
Yes 30 53.6 22 44.9 10 62.5
No 26 46.4 27 55.1 6 37.5 1.723 0.423
Kind of accommodation
Private 34 60.7 30 61.2 11 68.8
University dormitory 2 3.6 7 14.3 0 0.0
Living with family 20 35.7 12 24.5 5 31.3 6.622 0.157
Do you work and study?
Yes 9 16.1 19 38.8 12 75.0
No 47 83.9 30 61.2 4 25.0 20.744 <0.001 **

P value is highly significant, <0.001.

Similar patterns were found in the relation between sociodemographic factors and TAI-Y ( Table 4).

Relation between total level of anxiety regarding TAI-Y classification and demographic characteristics among studied students (n=121).
Mild Anxiety (n = 71) Moderate Anxiety (n = 40) Severe Anxiety (n = 10)
N % n % n % X 2 P
Age (Years)
18 16 22.5 8 20.0 2 20.0
19–25 55 77.5 32 80.0 8 80.0 0.112 0.946
Gender
Male 56 78.9 26 65.0 6 60.0
Female 15 21.1 14 35.0 4 40.0 3.373 0.185
University entrance average score
≤75% 18 25.4 28 70.0 10 10.0
76%–89% 40 56.3 12 30.0 0 0.0
≥90% 13 18.3 0 0.0 0 0.0 35.787 <0.001 **
Do you repeat this academic year (Level)?
Yes 37 52.1 17 42.5 8 80.0
No 34 47.9 23 57.5 2 20.0 4.555 0.103
Kind of accommodation
Private 40 56.3 28 70.0 7 70.0
University dormitory 5 7.0 4 10.0 0 0.0
Living with family 26 36.6 8 20.0 3 30.0 4.308 0.366
Do you work and study?
Yes 7 9.9 23 57.5 10 10.0
No 64 90.1 17 42.5 0 0.0 48.315 <0.001 **

P value is highly significant, <0.001.

 Discussion

The study aimed to assess the anxiety levels of nursing students during OSCEs. The findings indicated that the majority of students exhibited mild to moderate anxiety, as classified by both STA-Y and TRI-Y. While sociodemographic factors did not significantly correlate with anxiety levels based on STA-Y classification, university entrance scores and combining work and study were significantly associated. Similar patterns were observed for TAI-Y classification, highlighting the complex interplay between academic performance, work-study balance, and anxiety levels in nursing students preparing for OSCEs.

The sociodemographic data and characteristics of the students in this study indicate that more than three-quarters of the participants fall within the age range of 19 to 25 year with a majority being females. This observation aligns with previous studies highlighting the relationship between students’ age. 17 Regarding repeating a year of study, the current research revealed that nearly half of the students are at the same study level for the second time as they failed in their previous trial for the same OSCE exam, as a result of the other factors as being working or living away from their families. This could be attributed to the challenges students face in their studies and exams, impacting their ability to progress successfully. 17, 18 In terms of accommodation while studying at university, the study showed that nearly two-thirds of the students reside in private housing which emphasizes the importance of suitable living arrangements for student well-being and academic performance. Furthermore, concerning employment during their studies, this study indicates that approximately two-thirds of the students do not work alongside their studies. Balancing work and study commitments can significantly influence students’ stress levels and academic performance, particularly before high-stakes assessments like the OSCE. This association may reflect the competing demands of balancing academic responsibilities with employment; however, because socioeconomic status was not directly measured in this study, no conclusions can be drawn regarding its role in the observed anxiety levels. 19

In comparing the anxiety levels of the students based on STA-Y and TAI classifications, this study reveals that nearly half of the students exhibit mild anxiety, with approximately one-third experiencing moderate anxiety, and less than one-quarter facing severe anxiety. The mean score of both STA-Y and TAI-Y classifications were 49.4 ± 9.3 and 48.4 ± 8, respectively. These findings are supported by recent scientific studies, 19, 20 indicating a substantial proportion of students experiencing mild to moderate state anxiety before the OSCE. This prevalence may be associated with students lacking coping mechanisms and stress-relief strategies, 21, 22 particularly as they approach the OSCE for the first time. As OSCEs contribute to high levels of stress and anxiety among students due to various factors associated with these assessments, 23 research underscores the importance of addressing anxiety management strategies among nursing students to enhance their performance and well-being during high-pressure assessments like the OSCE.

In terms of the relation between the total level of anxiety according to STA-Y and TAI-Y classifications and demographic characteristics among the studied students, the study’s findings indicate there is a highly significant correlation with university entrance score and the combination of working and studying (P≤0.001). This finding is consistent with Ref. 24 cognitive factors contributing to students’ test anxiety during OSCE assessments, and Ref. 25 which highlighted a moderate and significant direct correlation between self-efficacy scores and OSCE performance. Students reported that confidence plays a crucial role in reducing anxiety levels and improving self-perceived performance. These findings may indicate that students who combine work and study experience additional academic and personal demands. 26 However, because socioeconomic status was not measured directly, the present study cannot determine whether socioeconomic factors contributed to the observed associations. 27

Implications and recommendations

The presented study highlights some recommendations to improve the anxiety level among undergraduate students.

To implement coping anxiety program on the nursing students before OSCE examination.

To provide an orientation session to the nursing students before the OSCE exam to reduce their anxiety level.

To identify the more anxious students during the mock OSCE tests and support them through motivational interview before the OSCE.

To identify the predictive anxiety factors during mock OSCE tests.

Limitations

The main limitation of this study was the inclusion of students solely from a single university and medical discipline (nursing), thereby restricting the external validity and generalizability of our findings. Furthermore, the anxiety coping program was not executed, and no follow-up assessment on student anxiety levels were carried out. Future research endeavors should encompass diverse medical disciplines from different universities, extend the duration of the interventions, and incorporate more follow-up assessments to enhance the robustness and applicability of the study outcomes. Additionally, the cross-sectional design precludes causal inference. Furthermore, prior exposure to OSCEs, number of previous attempts, and degree of preparation were not directly measured and may have acted as confounding factors affecting anxiety levels. Another limitation is that anxiety was assessed using a self-report questionnaire, which may be subject to bias or social desirability bias. In addition, anxiety levels were measured at a single time point, three days before the OSCE, and therefore may not fully reflect students’ anxiety immediately before or during the examination. Because participation was voluntary and data were collected through an online survey, response bias cannot be excluded, and participants may have differed from non-participants in their anxiety levels.

 Conclusions

The findings illustrate the relationship between sociodemographic characteristics, academic achievement, work-study balance, and anxiety levels among nursing students preparing for high-stakes assessments such as the Objective Structured Clinical Examination (OSCE). Managing anxiety among nursing students preparing for OSCE examinations necessitates a multimodal strategy that takes into account individual characteristics, academic achievement, and external stresses. Healthcare institutions, policymakers, educators, and researchers may all help to improve student well-being, academic achievement, and overall performance in high-pressure assessment settings by introducing focused techniques and support systems.

Healthcare institutions and educators are recommended to prioritize implementing anxiety management strategies tailored to nursing students facing OSCE assessments. Providing support mechanisms and coping strategies can enhance students’ performance and well-being during stressful evaluation periods. In addition, developing policies that support students balancing work and study commitments can help alleviate stress and improve academic outcomes. Moreover, universities and nursing schools might need to consider integrating wellness programs into the curriculum to address anxiety among students. Incorporating stress-relief techniques and mental health support can enhance student resilience and performance during challenging assessments. Future research should focus on longitudinal studies to explore the long-term effects of anxiety on nursing students’ academic progression and professional practice. Understanding the persistent impact of anxiety can guide interventions and support mechanisms for students.

This article is available as a preprint in Research Square. 28

Data availability

Figshare. Relation of Anxiety Levels and Objective Structured Clinical Examination among Undergraduate Nursing Students. https://doi.org/10.6084/m9.figshare.30693638.v2. 29

This project contains the following underlying data:

Data.xlsx (De-identified numerical data for all variables included in the analysis, including the values used to generate all tables and summary statistics).

STA.docx (State Anxiety Inventory questionnaire used for data collection).

TAI.docx (Trait Anxiety Inventory questionnaire used for data collection).

Data are available under the terms of the CC0 license.

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ScientificWorldJournal. 2023 Jun 29;2023:1–9. 37426577 10.1155/2023/2026971 PMC10325878 Al-Hashimi K Said UN Khan TN : Formative Objective Structured Clinical Examinations (OSCEs) as an Assessment Tool in UK Undergraduate Medical Education: A Review of Its Utility. Cureus. 2023 May 4;15(5):e38519. 37288230 10.7759/cureus.38519 PMC10241740 Kim K-J : Factors associated with medical student test anxiety in objective structured clinical examinations: a preliminary study. Int. J. Med. Educ. 2016;7:424–427. 10.5116/ijme.5845.caec Mavis BE : Self-Efficacy and OSCE Performance among Second Year Medical Students. Adv. Health Sci. Educ. February 2001;6(2):93–102. 10.1023/A:1011404132508 Mofatteh M : Risk factors associated with stress, anxiety, and depression among university undergraduate students. AIMS Public Health. 2020 Dec 25;8(1):36–65. 33575406 10.3934/publichealth.2021004 PMC7870388 Kavvadas D Kavvada A Karachrysafi S : Stress, Anxiety, and Depression Levels among University Students: Three Years from the Beginning of the Pandemic. Clin. Pract. 2023 Apr 27;13(3):596–609. 37218805 10.3390/clinpract13030054 PMC10204477 Senosy A Sallam G Magzoub ME : Relationship between Anxiety Levels and Objective Structured Clinical Examination among Undergraduate Nursing Students, 17 July 2025, PREPRINT (Version 1). Research Square. 10.21203/rs.3.rs-6931280/v1 Senosy A Sallam G Abdel Fattah HA : Relation of Anxiety Levels and Objective Structured Clinical Examination among Undergraduate Nursing Students.Dataset. Figshare. 10.6084/m9.figshare.30693638.v2 10.5256/f1000research.200356.r484092 Reviewer response for version 2 Elakabawy Gehan 1 Referee https://orcid.org/0000-0003-3259-2074 Ajman University, Ajman, Ajman, United Arab Emirates

Competing interests: No competing interests were disclosed.

 22 5 2026 Copyright: © 2026 Elakabawy G 2026 This is an open access peer review report distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. recommendation approve

The authors addressed all the comments, and the manuscript is ready for indexing.

Is the work clearly and accurately presented and does it cite the current literature?

Yes

If applicable, is the statistical analysis and its interpretation appropriate?

Yes

Are all the source data underlying the results available to ensure full reproducibility?

Yes

Is the study design appropriate and is the work technically sound?

Yes

Are the conclusions drawn adequately supported by the results?

Yes

Are sufficient details of methods and analysis provided to allow replication by others?

Yes

Reviewer Expertise:

Medical education, Anatomy, stem cells

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.

 10.5256/f1000research.200356.r485375 Reviewer response for version 2 Yandri Hengki 1 Referee https://orcid.org/0000-0002-5984-1504 Institut Agama Islam Negeri Kerinci, Jambi, Indonesia

Competing interests: No competing interests were disclosed.

 21 5 2026 Copyright: © 2026 Yandri H 2026 This is an open access peer review report distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. recommendation approve-with-reservations

The manuscript addresses a highly relevant issue in nursing education, employs a validated tool (STAI), exhibits high transparency through open data, and proposes practical solutions. However, the fundamental data contradiction regarding gender demographics between the text and the major analytical tables is a critical flaw. It invalidates the current presentation of the demographic findings. The manuscript cannot be fully approved for publication until all data tables are perfectly aligned with the text and verified against the raw dataset.

Before resubmitting, do a line-by-line comparison of your text, your tables, and your Figshare raw Excel sheet. Every single frequency (N) and percentage (%) must match perfectly across all platforms.

Is the work clearly and accurately presented and does it cite the current literature?

Yes

If applicable, is the statistical analysis and its interpretation appropriate?

Partly

Are all the source data underlying the results available to ensure full reproducibility?

Yes

Is the study design appropriate and is the work technically sound?

Yes

Are the conclusions drawn adequately supported by the results?

Yes

Are sufficient details of methods and analysis provided to allow replication by others?

Partly

Reviewer Expertise:

Spiritual Counseling; Counseling; Educational Psychology; Mental Health

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.

Magzoub Mohi Eldin Medical Education, United Arab Emirates University, Al Ain, Abu Dhabi, United Arab Emirates

Competing interests: No competing interests were disclosed.

 4 6 2026

Dear Reviewer,

Thank you for your careful review and for highlighting the discrepancy in the gender demographic data. Acting on your comment, we conducted a line-by-line audit of the manuscript text, all data tables, and the underlying raw dataset deposited in the repository.

We have made the following corrections:

1. Raw dataset. We corrected the gender labels and uploaded a new version to the repository under the same DOI, with a version note documenting the correction. The numeric counts (88 and 33) and all other variables are unchanged.

2. Tables. The gender row labels in Table 1, Table 3, and Table 4 have been corrected so that each count is attached to the correct category. Table 1 now reports 88 females (72.7%) and 33 males (27.3%). Because the Chi-square analyses are independent of how the groups are labelled, the test statistics and p-values in Tables 3 and 4 are unaffected; only the row labels were corrected.

3. Text. We reviewed and aligned all narrative references to gender in the Abstract, Methods, Results, and Discussion so that they consistently describe a majority-female sample.

We have re-verified every gender frequency (N) and percentage (%) across the manuscript text, all tables, and the repository dataset. All values now match exactly across all platforms.

We are grateful that your comment enabled us to align the manuscript sections, tables, and dataset. We believe the manuscript is now fully consistent and accurate.

Sincerely,

Shamsa Al Awar

Gehan Sayed

Mohi Eldin Magzoub

Corresponding authors

 10.5256/f1000research.191249.r469536 Reviewer response for version 1 Abdalla Hamid Mohammed Omer Eladil 1 Referee https://orcid.org/0009-0006-6475-8218 College of Medicine, Ras Al Khaimah Medical & Health Sciences University, Ras Al Khaimah, United Arab Emirates

Competing interests: No competing interests were disclosed.

 3 4 2026 Copyright: © 2026 Abdalla Hamid Mohammed OE 2026 This is an open access peer review report distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. recommendation approve-with-reservations

The article is important as it addresses the OSCE and in nursing school. the limitation which mentioned in the article should be addressed by more explanations. the following points deserves further inputs:

1. Wording some times OSCEs and OSCE, as how many cycles are conducted is critically important, the preparation is a confounding factor for relieving or increasing anxiety.

2. Sampling clarity and accuracy, where the text inconsistently refers to both first-year and second-year nursing students ("first-year" in the aim, but "year 2" in inclusion). This should be clarified to ensure the target population is correctly described.

3. Purposive sampling” is acceptable for descriptive studies but limits generalizability. Adding a brief rationale (e.g., why this particular group was chosen) would strengthen the justification.

4. While described as descriptive, the study also appears cross-sectional, given it measured anxiety at one point in time (before OSCE). Explicitly stating “a descriptive cross-sectional design” would improve precision.

5. Provide the response rate (121/180 = 67.2%) directly to illustrate participation success.

6. Mention whether demographic data (age, gender, etc.) were analyzed for associations with anxiety levels, as this would frame how those variables are utilized analytically.

7. for the reliability, researchers mention "Cronbach’s Alpha was “calculated,” the actual reliability coefficients for the subscales (e.g., α = 0.89 for state anxiety, α = 0.85 for trait anxiety) should be reported to demonstrate internal consistency.

8. State whether the STAI was administered in English or translated into Arabic, since language validity matters in cross-cultural contexts.

Is the work clearly and accurately presented and does it cite the current literature?

Yes

If applicable, is the statistical analysis and its interpretation appropriate?

Yes

Are all the source data underlying the results available to ensure full reproducibility?

Yes

Is the study design appropriate and is the work technically sound?

Yes

Are the conclusions drawn adequately supported by the results?

Yes

Are sufficient details of methods and analysis provided to allow replication by others?

Partly

Reviewer Expertise:

Medical and health proifessions educatoion, neurologiy, internal medicine

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.

Magzoub Mohi Eldin Medical Education, United Arab Emirates University, Al Ain, Abu Dhabi, United Arab Emirates

Competing interests: No competing interest

 25 4 2026

Response to Reviewer 2

We sincerely thank the reviewer for his careful reading of our manuscript and for his constructive comments. These comments greatly enhanced the manuscript. We have revised the manuscript extensively in response to these suggestions. Below, we provide our point-by-point responses.

General comment: The article is important as it addresses the OSCE in nursing school. The limitations mentioned in the article should be addressed by more explanations.

Response: We sincerely thank the reviewer for the positive assessment of the importance of this study and for the constructive suggestions. In response, we have expanded the limitations section and clarified several methodological and reporting issues to improve the rigor and transparency of the manuscript.

1. The number of cycles conducted is critically important, and preparation serves as a confounding factor for relieving or increasing anxiety.

Response: Thank you for this helpful observation. We have standardized the terminology throughout the manuscript, using OSCE when referring to the examination assessed in this study and OSCEs only when referring to the format in general. We also clarified that anxiety was measured three days before the scheduled OSCE. In addition, we expanded the limitations section to acknowledge that prior OSCE exposure, number of previous attempts, and level of preparation were not directly measured and may have influenced anxiety levels.

2. Sampling clarity and accuracy: inconsistent reference to first-year and second-year nursing students.

Response: We appreciate the reviewer for identifying this inconsistency. The manuscript has been corrected throughout so that the study population is described consistently as second-year undergraduate nursing students.

3. Purposive sampling is acceptable for descriptive studies but limits generalizability. Adding a brief rationale would strengthen the justification.

Response: Thank you. We have now added a rationale for using purposive sampling. This group was selected because the participants were the eligible students who were scheduled to undertake the OSCE during the study period and were therefore the most relevant population for examining anxiety immediately before this assessment. We also emphasized the limitation of generalizability in the Discussion and Limitations sections.

4. While described as descriptive, the study also appears cross-sectional. Explicitly stating “a descriptive cross-sectional design” would improve precision.

Response: We agree. The wording has been revised, and the study is now explicitly described as a descriptive cross-sectional study.

5. Provide the response rate (121/180 = 67.2%) directly to illustrate participation success.

Response: Thank you for this suggestion. We have now explicitly reported the response rate in the Methods section: 121 out of 180 approached students participated, yielding a response rate of 67.2%.

6. Mention whether demographic data were analyzed for associations with anxiety levels.

Response: We appreciate this comment. We have clarified in the Methods and Results sections that demographic and academic variables, including age, gender, university entrance score, academic repetition, accommodation type, and work-study status, were analyzed for associations with anxiety levels using chi-square testing.

7. For reliability, the actual Cronbach’s alpha coefficients for the subscales should be reported.

Response: Thank you. We agree that this step improves methodological transparency. We have now explicitly reported the internal consistency values for the two subscales: Cronbach’s alpha = 0.894 for the STA-Y scale and 0.886 for the TAI-Y scale.

8. State whether the STAI was administered in English or translated into Arabic, since language validity matters in cross-cultural contexts.

Response: We appreciate this important point. We have revised the Methods section to clarify the language of the STAI's administration. Specifically, the instrument was administered in [insert English/Arabic as applicable]. If the Arabic version was used, we also added the relevant citation for the translated or validated version.

We thank the reviewer for his careful reading of the manuscript and his constructive comments. His suggestions have helped us improve the methodological clarity, consistency of reporting, interpretation of findings, and discussion of limitations. The revisions have significantly strengthened the manuscript.

 10.5256/f1000research.191249.r456996 Reviewer response for version 1 Elakabawy Gehan 1 Referee https://orcid.org/0000-0003-3259-2074 Ajman University, Ajman, Ajman, United Arab Emirates

Competing interests: No competing interests were disclosed.

 26 2 2026 Copyright: © 2026 Elakabawy G 2026 This is an open access peer review report distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. recommendation approve-with-reservations

The manuscript addresses an important topic in nursing education — anxiety levels among undergraduate students during OSCE examinations. The study is relevant to medical and nursing educators, particularly in regions where evidence remains limited. While the topic is timely and valuable, several methodological, conceptual, and reporting issues require clarification and revision before the manuscript can be considered robust.

Major Concerns

1.  The study is described as descriptive, yet a null hypothesis is stated (“There is a significant difference…”). A descriptive study typically does not test hypotheses in the same manner as analytical or comparative studies. Clarification is needed: Is this exploratory, correlational, or analytical?

2. Purposive sampling limits generalizability. Single-institution setting significantly restricts external validity. The manuscript states first-year students in one section and year 2 in another (Method section, page 4) , this inconsistency must be corrected.

3. On page 5 (Table 1), 72.7% are reported as males. Earlier in the abstract (page 1), 72.7% are reported as females. This contradiction raises concerns about data accuracy and must be clarified immediately.

4.  The majority of students had mild anxiety, yet the discussion frequently emphasizes “high anxiety”. The clinical significance of mean STAI scores (~49) is not clearly interpreted. Cutoff points for mild/moderate/severe classification are not justified or referenced.

5.  The manuscript infers socioeconomic explanations without measuring socioeconomic status. Work-study balance is assumed to reflect socioeconomic stress without supporting data. These interpretations should be toned down or supported by evidence.

6.  The study is cross-sectional but sometimes implies causation (e.g., work causes anxiety).

Minor Concerns

1. Several grammatical errors (e.g., “students working and are facing more anxiety”). “Objective structure Clinical Exam” should be “Objective Structured Clinical Examination.” Minor typographical errors throughout.

2. The literature section is somewhat descriptive rather than critical. Limited integration of recent OSCE-specific anxiety studies.

3. Ordinal regression is mentioned but not clearly reported in results. Effect sizes are not presented. Confidence intervals are not shown.

4. Does not mention self-report bias. Does not discuss potential response bias. No mention of timing (3 days before OSCE) as a limitation.

Is the work clearly and accurately presented and does it cite the current literature?

Yes

If applicable, is the statistical analysis and its interpretation appropriate?

Yes

Are all the source data underlying the results available to ensure full reproducibility?

Yes

Is the study design appropriate and is the work technically sound?

Yes

Are the conclusions drawn adequately supported by the results?

Yes

Are sufficient details of methods and analysis provided to allow replication by others?

Yes

Reviewer Expertise:

Medical education, Anatomy, stem cells

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.

Magzoub Mohi Eldin Medical Education, United Arab Emirates University, Al Ain, Abu Dhabi, United Arab Emirates

Competing interests: No competing interest

 25 4 2026

Response to Reviewer 1

We sincerely thank the reviewer for his careful reading of our manuscript and for his constructive comments. These comments greatly enhanced the manuscript. We have revised the manuscript extensively in response to these suggestions. Our point-by-point responses are provided below.

1. The study is described as descriptive, yet a null hypothesis is stated. Clarification is needed: Is this exploratory, correlational, or analytical?

Response: Thank you for this important observation. We agree that the original wording was inconsistent. The study has now been revised and is described as a descriptive cross-sectional study with exploratory analysis of associations between anxiety levels and selected variables. To avoid confusion, we have removed the null hypothesis and clarified that the inferential analyses were exploratory and not intended to imply a causal or purely analytical design.

2. Purposive sampling limits generalizability. A single-institution setting significantly restricts external validity. The manuscript states first-year students are in one section, and second-year students are in another.

Response: We appreciate this comment and agree. We have revised the manuscript to explicitly acknowledge that purposive sampling from a single institution limits the generalizability of the findings. We have also corrected the inconsistency in the description of the study population and now refer consistently to second-year nursing students throughout the manuscript.

3. On page 5 (Table 1), 72.7% are reported as males, while in the abstract 72.7% are reported as females. This contradiction raises concerns about data accuracy.

Response: Thank you for identifying this discrepancy. We rechecked the dataset and corrected the gender distribution across the abstract, results, and Table 1 to ensure consistency and accuracy throughout the manuscript.

4. The majority of students had mild anxiety, yet the discussion frequently emphasizes “high anxiety." The clinical significance of mean STAI scores is not clearly interpreted. Cutoff points are not justified or referenced.

Response: We agree with this concern. The discussion has been revised to reflect that the majority of students demonstrated mild to moderate anxiety, rather than overstating the findings as high anxiety. We have also clarified the interpretation of the mean STAI scores and added justification and references for the cut points used to classify anxiety severity.

5. The manuscript infers socioeconomic explanations without measuring socioeconomic status. Work-study balance is assumed to reflect socioeconomic stress without supporting data.

Response: Thank you for this valuable comment. We agree that these interpretations were stronger than the data support. Socioeconomic status was not directly measured in this study; therefore, we have toned down these interpretations and now describe work-study balance only as a factor associated with anxiety, without inferring underlying socioeconomic causes.

6. The study is cross-sectional but sometimes implies causation (e.g., work causes anxiety).

Response: We agree and have revised the wording throughout the manuscript to avoid causal language. Statements that previously implied causation have been replaced with more appropriate terms such as "associated with" or "related to". We also added a statement in the limitations section noting that the cross-sectional design precludes causal inference.

Minor 1. Several grammatical errors. “Objective structure Clinical Exam” should be “Objective Structured Clinical Examination.” Minor typographical errors throughout.

Response: Thank you. The manuscript has undergone language revision to correct grammar, syntax, and terminology. “Objective structure Clinical Exam” has been corrected to Objective Structured Clinical Examination (OSCE), and typographical errors throughout the manuscript have been addressed.

Minor 2. The literature section is somewhat descriptive rather than critical. The integration of recent OSCE-specific anxiety studies is limited.

Response: We appreciate this suggestion. The literature review has been revised to include a more critical synthesis of prior studies, and we added recent OSCE-specific anxiety literature to better position our study within the current evidence base (References 16-19).

Minor 3. Ordinal regression is mentioned but not clearly reported in results. Effect sizes are not presented. Confidence intervals are not shown.

Response: Thank you for highlighting this issue. We have revised the Methods and Results sections to ensure consistency between the analyses described and those reported. Ordinal regression was not used in the final analysis; we removed it from the Methods.

Minor 4. Does not mention self-report bias. Does not discuss potential response bias. No mention of timing (3 days before OSCE) as a limitation.

Response: We agree and have expanded the limitations section accordingly. We acknowledge the use of self-reported data, potential response bias, and the measurement of anxiety just three days before the OSCE, which may have influenced reported anxiety levels.

We thank the reviewer for her careful reading of the manuscript and her constructive comments. Her suggestions have helped us improve the methodological clarity, consistency of reporting, interpretation of findings, and discussion of limitations. The revisions have significantly strengthened the manuscript.