Relation of Anxiety Levels and Objective Structured Clinical Examination among Undergraduate Nursing Students

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

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.

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.

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.

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).

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

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

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