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Year : 2022  |  Volume : 19  |  Issue : 1  |  Page : 9-15

Exam Anxiety and Factors Influencing Exam Preparation: A Mixed Method Study

Department of Psychiatric Nursing, St. Thomas College of Nursing, Kottayam, Kerala, India

Date of Submission15-Jul-2021
Date of Decision24-Sep-2021
Date of Acceptance25-Sep-2021
Date of Web Publication05-Jul-2022

Correspondence Address:
L Manoj Kumar
MSc (N), MA, Department of Psychiatric Nursing, St. Thomas College of Nursing, Changanassery, Kerala- 680 104
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/iopn.iopn_69_21

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Background: The time of examination is a stressful period for students. However, an optimum level of stress can help in motivating the students, this stress can be from test anxiety which arises from stimuli of being tested or judged academically. Nursing students experience a higher level of exam anxiety comparing to students from other disciplines. Aims and objectives: This study aimed to assess the level of exam anxiety perceived by nursing students in selected setting. Along with exam anxiety; this research explored factors influencing exam preparation among nursing students. Material and methods: A mixed-method research study was conducted to assess test anxiety and to explore factors influencing their exam preparations. Total enumeration sampling technique was used to recruit 272 BSc nursing students from a nursing college attached to a tertiary care hospital in South India. Data were collected using a sociodemographic pro forma, a test anxiety scale to assess test anxiety, and a focus group discussion (FGD) was conducted using an FGD guide to explore factors influencing exam preparations of nursing students. Demographic data and test anxiety scores were analyzed using frequency and percentage. Qualitative data recorded were transcribed and identified repeated concepts, then coding was done to develop themes. Results: The study revealed that more than half of subjects 53.3% (145) having high exam anxiety, followed by 39.7% (108) subjects who had medium exam anxiety and 7.0% (19) had low exam anxiety. On comparison of mean test anxiety scores, the mean test anxiety score of first-year BSc nursing students (21.88 ± 5.384) remained higher than the second year (20.06 ± 4.403), third-year (19.17 ± 4.529), and fourth-year (20.84 ± 4.857) nursing. From FGD, three themes emerged as nursing students described their experiences and feelings toward factors influencing exam preparation. (1) Materialistic and environmental factors for exam preparation. (2) Motivational determinants that promote exam preparation. (3) Perceived barriers or distractions in preparing for an exam. Conclusion: This study concludes that faculty who are in close association with students can improve student outcomes by early identification of test anxiety, intervening if necessary, and sometimes by referring to a psychiatrist for ruling out further mental health issues that may arise from exam anxiety.

Keywords: Exam technique, mixed method study,qualitative, test anxiety

How to cite this article:
Kumar L M. Exam Anxiety and Factors Influencing Exam Preparation: A Mixed Method Study. Indian J Psy Nsg 2022;19:9-15

How to cite this URL:
Kumar L M. Exam Anxiety and Factors Influencing Exam Preparation: A Mixed Method Study. Indian J Psy Nsg [serial online] 2022 [cited 2023 May 28];19:9-15. Available from: https://www.ijpn.in/text.asp?2022/19/1/9/349892

  Introduction Top

Every person may experience tension and worry at some points in their lifetime. Situations that cause such events can vary from person to person and from time to time, some may experience difficulty in facing the public, anticipating an exam, or beginning conversation with a stranger. Excessive tension and worry can contribute to anxiety-related symptoms. When symptoms of anxiety affect day-to-day activities and quality of life, it can take shape of a mental disorder or mental health issue.[1]

An uncomfortable psychological reaction to a stimuli that are often associated with an individual's experience of getting tested, judged academically or in an evaluating situation can be viewed as test anxiety. This reaction is undesirable and considered to be one among the dreaded fears of student population globally.[1]

Level of test anxiety is varying in nature depending upon type of discipline they are in, practical exams, or OSCE and so on. Nursing bachelors is considered to be one among the toughest professional courses as it demands tests and examinations on theory and practical skills. The need of performing at satisfactory level is considered as having a key role for academic achievements. Many challenges leashes students from such achievements as they desire for, and exam anxiety is one of the prevailing challenges for the same. Multiple studies quoted about negative impact of examination anxiety on academic performance in various settings and academic population globally.[2],[3]

Almost all college students are susceptible and prone to test anxiety. Many studies portrayed that nursing students are experiencing higher level of test anxiety as compared to students of other discipline. This may be due to stressful academic sessions, vast syllabus that inculcating theory and practical classes with demonstrations in very short period. Nursing students often have to attend practical exam sessions on real patients instead of dummies or mannequins.[4]

Around 30% of nursing students had test anxiety as reported by a systematic review conducted in the United States of America which shows gravity of the problem.[5] Many European studies[4] reported more or less same figures about the exam anxiety level of nursing students, quoted with attributes such as higher magnitude of curriculum and academic complexity. Studies published recently in the Indian context correlates the performance of nursing students and test anxiety. Nursing students academic performance can be directly affected by the presence of test anxiety, they also sum up as test anxiety is one of the pertinent issues among average and below-average nursing students.[6]

Test anxiety has detrimental effects on academic performance and student success. Nurse educators who are in close association with students can play a vital role in student outcomes by early identification of test anxiety, intervening, and if needed implementing effective, supportive strategies, sometimes by referring to a psychiatrist for ruling out further.[5]

Test anxiety frequently causes students to experience distraction in exams and problems in preparing for exams. Consequence of exam anxiety can be undue usage of time for studies, leaving colleges, aversion towards studies, failures in exams, as well as physical and psychological disturbances.[7] Various determinants can lead to exam anxiety; one among them can be faulty preparation for exams.[8],[9],[10] Signs and symptoms of exam anxiety can be projected out in any of the three domains say physical, emotional, and cognitive; any of these symptoms can definitely hurdle the lucid performance of a student.[9]

There has been no single study to the best of researcher's knowledge assessing test anxiety among nursing students and exploring factors affecting exam preparation using the help of qualitative research approach. The present study was undertaken with the aim of assessing the level of test anxiety in nursing students in a medical college environment in Southern India. The study also aimed to explore the factors influencing exam preparation which probably connected with exam anxiety.

  Materials and Methods Top

A mixed-method research approach using sequential exploratory research design was adopted to find out the level of exam anxiety and factors influencing exam preparation among nursing students. The quantitative part of the study is given more weightage than the qualitative domain; however, study process and data collection allotted utmost care in both aspects. As the study had two approaches, sample size also varied for each approach.

Study subjects

For assessing test anxiety using quantitative approach, sample size was 272 by adopting a total enumeration sampling technique. This sampling technique is a type of nonprobability sampling in which the whole population of interest in the study setting is recruited for the study. For finding out factors influencing exam preparation using qualitative approach, sample size was not calculated at the outset. A pilot study was conducted upon 10 participants, and a few number of participants are interviewed using an interview schedule. On that interview, data saturation was attained after seven participant's data collection, hence a sample size of 7 was found to be optimum. Study inclusion criteria were those who are studying in selected nursing college, who are willing to participate and those who are not having any comorbidities or in treatment for anxiety disorders.

Tools and techniques

Test anxiety scale

This is a standardized tool developed by Sarason, with a reliability of 0.83 was adapted from Sarason, I. G. (1980), Test Anxiety: Theory, Research, and Applications. This scale is a reliable and validated tool, which used in multiple studies conducted in Indian context after translating and retranslated state in different settings. A score of 12–20 ranks in the medium range, and any score above 20 signifies high-test anxiety. Scoring 15 or greater is a good indication that subjects experience considerable discomfort about taking tests and exams. After the pilot study, it was found feasible to use in the main study as no study subjects faced any comprehension issues.

Focus group discussion guide for assessing factors influencing exam preparation

After the pilot study, rather than interview method focus group discussion (FGD) method was found to be more appropriate for qualitative approach. Factors influencing exam preparation were assessed using a FGD guide prepared by the researcher. The FGD guide was validated by submitting to experts in the field of nursing, psychology, education, and psychiatry.

This guide included four open-ended questions as follows;

Nowadays, there is a trend of progressively downhill results under nursing stream exams. You can present your view points for the following questions sincerely.

  1. What are the thoughts that come to your mind when you think about exams?
  2. What will be your exam preparation strategies once you get exam notification?
  3. What are the factors that influence your exam preparation plan; factors that can enhance the preparation; and factors that can distract preparation for exams?
  4. Does the usual planning for exams is adequate enough for reducing anxiety related to exams? If not; what are the factors you think that may foster your exam preparation?

Ethical considerations

Institutional Ethics Committee (IEC) approval of Sree Gokulam Medical College and Research Foundation, Trivandrum, was obtained to carry out the study. The study protocol was approved by the IEC vide letter no. SGMC-IEC-No: 34/446/04/2020. Written informed consent form was obtained from all the participants. It was clearly mentioned to study participants that the audio record collected during data collection will be used for data analysis purpose only, and it will be kept confidential. Formal permission was obtained from the head of the institution of the study setting.

Qualitative data analysis

Qualitative data were analyzed by adhering to general steps of qualitative data analysis as documented by Creswell, 2007. The data were transcribed through verbatim from the audio record. The transcription of FGD audio recording was read to portray a general impression of the experiences of our participants. A final list of significant statements was developed, and from this list, the authors grouped them into larger units of information. From this pertinent information, researcher identified common themes. Themes and related subthemes were extracted from the statements of study participants. The authors identified frequently repeated and consensus statements as those which should be considered as most significant. Conflicting and ambiguity in opinions on the contents of a theme were discussed and resolved by a research group. This group was composed of experts with master of nursing degree and a consultant from psychiatry department. Representative participant verbatim was identified, quoted to support the narrative, and derived themes.

The data were collected over a period of 4 weeks. Researchers personally contacted the subjects who met the inclusion criteria; they are given with a brief introduction about study objectives and purpose of the study. The test anxiety scale was administered on subjects in the presence of researchers to rule out any bias. FGD was conducted in a calm and private environment.

  Results Top

Socio-demographic data of subjects

Majority of subjects (57%) belongs to the age group 17–20 years and 43% belongs to 21–24 years. Regarding gender majority subjects 92.3% (251) were females and 7.7% (21) were males. Regarding the education background of mothers of subjects, 14.7% (40) have professional degree, 14.3% (39) are graduates, 22.1% (60) are having diploma or intermediate education, 46.3% (126) studied up to high school, 1.8% (5) studied up to middle school, and 0.7% (2) studied up to primary school.

Regarding the education background of fathers of subjects, 6.6% (18) have professional degree, 12.1% (33) are graduates, 19.5% (53) are having diploma/intermediate education, and 57% (155) studied up to high school, 3.3% (9) up to middle school, and 1.5% (4) primary school. On analyzing occupation of mother of subjects, 9.2% (25) have professional job, 4% (11) have semi-professional job, 5.1% (14) are having clerical job or shop owner, 8.8% (24) are skilled worker, 7.4% (20) semi-skilled worker, 1.8% (5) unskilled worker, and 63.6% (173) are unemployed.

The majority of subjects 94.1% (256) does not consume any medications, 5.9% (16) subjects consume medications. Regarding the area of residence, majority of subjects 72.4% (197) reside at rural area and 27.6% (75) subjects at urban area. Regarding family type, majority subjects 90.1% (245) belong to nuclear family and 9.9% (27) subjects living in joint family. Regarding place of stay, majority subjects 55.1% (150) are residing in hostel and 44.9% (122) subjects are living at home. Regarding the students' current academic year; 26.5% (72) was from first year, 25.7% (70) from second year, 24.3% (66) from third year, and 23.5% (64) from fourth year, respectively. On analyzing majority of subjects, 34.6% (94) of studies 2–3 h, 27.6% (75) studies 1–2 h, 21% (57) studies up to 1 h, 16.5% (45) studies above 4 h, and 0.4% (1) do not spend time for daily studying.

Distribution of subjects based on level of exam anxiety

Findings revealed that more than half subjects 53.3% (145) had high exam anxiety, followed by 39.7% (108) subject had medium exam anxiety, and 7.0% (19) subjects were having low exam anxiety.

[Figure 1] reveals the mean test anxiety scores of each academic year students; mean test anxiety score of first-year BSc nursing students (21.88 ± 5.384) remained higher than second year (20.06 ± 4.403), third year (19.17 ± 4.529), and fourth year (20.84 ± 4.857) nursing
Figure 1: Line graph showing mean test anxiety scores across academic years

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Comparison of anxiety score across academic year

Kruskal–Wallis ANOVA test was performed to analyze differences in test anxiety scores of students across different academic years. Collected data were not normally distributed (Shapiro Wilk, P < 0.05), and this study used a nominal scale of measurement. Hence, using a non-parametric test was found to be appropriate.

From [Table 1], it's evident that there is statistically significant difference (P > 0.05) across exam anxiety score in different batches of nursing students. Mean ranks also portray exam anxiety as comparatively high among first-year students, followed by fourth-year students. Hence, the null hypothesis of no difference between exam anxiety scores across groups was be rejected.
Table 1: Kruskall–Wallis score, degrees of freedom, and P value (n=272)

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Factors influencing exam preparation

Study participants included for the qualitative part of the study were having more or less same demographic profile as of study subjects in quantitative section. All participants were from first-year BSc nursing students.

Factors influencing exam preparation were analyzed using FGD data. This portion of analysis followed a phenomenological approach to facilitate understanding of the experiences of nursing students while they anticipate exams and prepare for the same. As the name implies, phenomenology is the “exploration of a phenomenon” with several participants who all have a common experience. Seven first-year BSc nursing female students were selected purposefully to join the FGD, as data saturation was attained by six interviews during pilot study [Table 2].
Table 2: Themes identified through interviews with nursing students

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Theme 1: Materialistic and environmental factors related to exam preparation

Nursing students, when getting notification for exams, they start thinking about it seriously in most normal scenarios. Their usual way of planning roams around preparation of time table. Students used to correlate the content of notes they had with syllabus, if anything missing from what they seen in syllabus, they will try to gather notes in accordance with syllabus. While they think about optimum situation to study a calm, quiet, and sole environment was the choice majorly among students for preparation.

Theme 2: Motivational determinants that enhance exam preparation

Participants projected various motivational factors that help to enhance exam preparation. According to participants, positive and negative sorts of reinforcements enhance their exam preparation drive. Teachers concern about students and simple pieces of advice are valued a lot in starting up for exam preparation. Participants said that repeated bits of advice from parents for studying well matters a lot. When parents start comparing with siblings, exam preparation and study habits also affect. Some anxiety-provoking situations also work as motivational factors as participants described; when comparing self with peer's cause's anxiety which further drives to start reading.

Theme 3: Perceived barriers or distractions that hinders in preparing for exams

Distraction from the preparation plan by purposeless engagement with friends was reported by study participants. Deviating from academic topics during the combined study was pointed as a factor that negatively influences preparation time. Significant loss of time is associated with the use of social media applications such as Facebook, wats app, Instagram, and YouTube. While planning for preparation to face exams, main hindering factor as reported by students was the procrastination behavior. Sleep pattern disturbances associated with exam anticipation were described as excessive sleep, loss of sleep because of worrying thoughts. Psychological distress was also verbalized by students. Reasons for such distress were quoted as unknown worrying and tension when thinking about exams. These thoughts usually aggravate when days are getting close to exam date and preparation is not going well.

  Discussion Top

This study revealed that more than half subjects are having high exam anxiety and some proportion of subjects have medium exam anxiety, and very little proportion of subjects have low exam anxiety. On comparison of mean test anxiety scores of each academic year students, mean test anxiety score of first-year BSc nursing students remained higher than second year, third year, and fourth year nursing. This variation in mean anxiety score may be due to the exam experience of each batch students. Students who have already experienced writing university level exams are attributed with low level of anxiety, respectively.

Anticipation-related worries can also arise when waiting for an exam due date. The gradual progression of students from a school level curriculum to a college level graduation program also gives students an apprehension. Newbie graduate students have a long adaptation period to embrace the new college environment; in terms of curriculum and physical infrastructure. Their exam-related apprehension is easy to get accumulated to the end of the exam due date, so there is widespread anxiety in the exam phase as revealed by results. This apprehension can also impact the mindset of students negatively. Association with experience and anxiety was not able to portray statistically; however, it is transparently portrayed with mean anxiety scores distributed across different batches of students. Research conducted on different streams of medical and paramedical fields also portrayed more or less same results;[10] they also revealed that exam anxiety is more prevalent among first-year students.

These results differ slightly with the results of Onyekuru and Ibeghunam, who found that 28.57% of participants had low test anxiety, 18.13% of them had high test anxiety, and more than half of the students (53.3%) had reasonable test anxiety. The difference may be related to the difference in cultural background, diversity of geographical location, and the environment of college.[11] The pertinent construct in this study exam anxiety has been discussed globally in cross-cultural studies. Significance of cultural variation in exam anxiety can be attributed clearly that developing countries provide gravity to student-oriented curriculum which makes them be actively engage in self-directed learning styles. However, developing country like India is still in a gradual progression toward such kind of change in educational system and evaluation protocols. When analyzing the demographic profile of study subjects, the area of residence also matters to some extent. This is visible in the form that students hailing from urban areas are less prone to have exam anxiety. Similar results were reported by a study was conducted by Avinash D (2016) at B J Nursing College, which is located in a rural area. As per the study, nursing students do project out higher level of test anxiety; hence, the probability of anxiety level variations with regard to geographical arena can be noted.[8]

The nature of the course, vast syllabus, saturated clinical posting, presence of high quality evaluation, and direct evaluation of patient care leads students to face higher levels of anxiety compared to other students.[12] Nursing syllabus and the pattern of exams are considered to be one among the toughest professional courses available nationwide. Along with theory, a gross amount of hours has to be experienced by the students to graduate from nursing college. Nursing curriculum is planned in such a way that theory and practical experience are made availed in a mixed form. This mode of delivery of education is newbie for first-year students. For these concerns, it is of great concern to strengthen the current identification and assessment of nursing students' anxiety. If identifying any of the mental health issues associated with exam anxiety, then to implement relevant programs and interventions to alleviate their anxieties.

Very few studies[13],[14] have attempted qualitatively to rule out factors that affect students while preparing for exams; once the factors are identified the student training schedules can be tailored accordingly. This study was able to analyze in-depth about factors embraced within exam preparation among nursing students. This is not yet attempted in any Indian studies published so far. Total enumeration sampling, which was adopted for this, enabled grab entire data from the population of interest. However, certain limitations are also leashed in the form of nonprobability sampling, limited within an institution that restrained from comparison with other college students. Regarding methodological challenges, integrating study findings from qualitative and quantitative approaches remained a hurdle that needs to be addressed in future. Certain limitations of the present study such as using a cross-sectional design and using self-reported measures to collect data are evident though. However, the findings of this study add new evidence concerning exam anxiety among nursing students in the Indian context.

Implications of the study

Study implications demand the factors that impact exam anxiety should be looked at with cardinal importance. Methods for reduction of test anxiety can be tailored to the student, and implemented by psychologists, school health nurse, and other stakeholders. If the education system pays due attention in reducing exam anxiety, and ultimately, it will improve students' performance in multi-disciplinary areas. The nursing educators can pave important ways to help students during exam preparation period to stay in continuous contact with them if facing severe anxiety related to exams and to deal with the challenges of education, preparation for exams and so.

Recommendation from the study

Further studies have to be conducted across cross-culture and wide geographical backgrounds to rule out the anxiety that restraint's the caliber and academic motives of college students. It was thus counseled that students ought to begin getting ready for taking an examination from the day a semester resumes instead of procrastinating studies till a test is at hand. By this, students can thus avoid cramming, and therefore the anxiety associated as well. The students should notice that onerous work is the key to success; however, it is of utmost importance to overcome challenges arising in the form of anxiety, stress, and so on. Practice of relaxation techniques will help to control psychological distress to some extent.

  Conclusion Top

The current study portrays that it is important to comprehend the fact that test anxiety is likely among students. However, this may be present in varying in degree. For some students, it may be beneficial; for others, it may lead to poor performance and may cause negative effect on their health. The current literature study recommends that academicians and educationalists in the universities should have awareness about negative and positive aspects of this exam anxiety and its impact on academic population as well. Care should also be taken to prevent any psychosocial morbidity to be associated with this morbid anxiety of students.

Declaration of conflicting interests

The author declares no potential conflicts of interest with respect to the research, authorship, and/or publication of this articl.


Authors would like to thank students of Post Basic Nursing 2017 batch of Sree Gokulam Nursing College, Trivandrum, for collecting data from subjects and other arrangements of study setting.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

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Driscoll R, Evans G, Ramsey G, Wheeler S. High Test Anxiety among Nursing Students. Online Submission; 2009. Available from: https://eric.ed.gov/?id=ED506526. [Last accessed on 2021 Mar 29].  Back to cited text no. 4
Shapiro AL. Test anxiety among nursing students: A systematic review. Teach Learn Nurs 2014;9:193-202.  Back to cited text no. 5
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Carveth JA, Gesse T, Moss N. Survival strategies for nurse-midwifery students. J Nurse Midwifery 1996;41:50-4.  Back to cited text no. 11
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  [Figure 1]

  [Table 1], [Table 2]


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