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Concept Analysis of Test Anxiety in Nursing Students

Molly Gleason

Methodist College
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Concept Analysis of Test Anxiety in Nursing Students

Test anxiety is a common barrier to success for students. Though test anxiety is prevalent

in several different educational programs, research has found that nursing students have a higher

incidence of test anxiety when compared to other student bodies due to the higher academic

requirements in their courses (Yang, Lu, Chung, & Chang, 2014). Nursing school curriculum

combines education of both theory and practice. This phenomenon of practice, including skills

and clinical practice, must be formally evaluated in addition to theory testing (Yang et al., 2014).

This combination of testing strategies causes a high degree of anxiety while being evaluated,

whether it be for an in-seat testing situation or a hands-on skill performance. The concept of test

anxiety needs to be further explained in order to better understand the relationship between the

concept and nursing students’ academic performance and success. The term “test anxiety” is a

relatively new term, but the concept itself has been demonstrated in student attitudes, test scores,

and academic performance for years. In a study by Mandler and Sarason in 1952, tension in

testing settings in adults was evaluated (Gibson, 2014). Since Mandler and Sarason, there have

been multiple other studies and questionnaires conducted which will be discussed. In an

intellectually strong individual, their full academic capacity may not be displayed due to poor

scores and evaluations. This concept must be defined, understood, and then solutions presented

in order to help these individuals reach their full potential. A literature review was conducted

using the Cumulative Index to Nursing and Allied Health Literature database, or CINAHL. First,

the keywords “test anxiety” were used, which produced 7,907 results. It was then limited to full

text articles, which yielded 2,353 results. The articles ranged from 1953-2016.

Method
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The method that will be used to analyze the concept of test anxiety in nursing students is

the Walker and Avant method. The Walker and Avant method has been used for concept analysis

since 1986, when they first reevaluated John Wilson’s method for concept analysis in nurses

(McEwen & Wills, 2014). The purpose was to further define and explain items for nurses’ better

understanding in either theory development, practice, or research (McEwen & Wills, 2014). The

steps to Walker and Avant’s concept analysis are as follows: Select a concept, determine the

aims or purpose of analysis, identify all the uses of the concept possible, determine the defining

attributes, identify a model case, identify borderline, related, contrary, invented, and illegitimate

cases, identify antecedents and consequences, and define empirical referents (McEwen & Wills,

2014).

Identify the Uses of the Concept of Test Anxiety

First, the concept of test anxiety must be defined and like-ideas must be explored through

a search for definitions and synonyms. Test anxiety must be presented in the field of nursing

education, as well as the fields of general education and psychology.

Definitions of Test Anxiety

The word test in this particular concept will be the noun version of test anxiety. The

definition of test is “A critical examination, observation, or evaluation” (Merriam-Webster,

2016). The definition of anxiety is “Fear or nervousness about what might happen” (Merriam-

Webster, 2016). One definition of test anxiety is “A fear of failing that you feel before or while

taking an important examination that prevents you from performing as well as you otherwise

could on the exam” (Your Dictionary, 2016). Another definition is “A state of uneasiness and

distress before and during a test that often lowers performance (VCU Medical Center, 2016).

Yang et al., define test anxiety as a “Temporary emotional responses produced during
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psychologically stressful situations involving tests” (Yang et al., 2014).

Synonyms from Thesaurus

Other words for test anxiety include exam anxiety and performance anxiety. Other words

for test include examination, exam, quiz, experiment, inspection, audition, final, review,

interrogation, midterm, and boards (Merriam-Webster, 2016). Other words for anxiety include

agitation, nervousness, apprehension, worry, unease, dread, fear, panic, and foreboding

(Merriam-Webster, 2016).

Use of the Concept of Text Anxiety in Nursing Education

The dimension of nursing education uses this concept with skill competencies during

nursing school, the NCLEX, and continuing education after achieving Registered Nurse (RN)

status. Test anxiety is a critical problem in nursing schools because of the rigid progression

through the curriculum (Gibson, 2014). Nursing school evaluations are not limited to written

exams but include hands-on skills performances as well. Some studies show that test anxiety

affects students more so when being evaluated on a skill rather than an in-seat exam (Yang et al.,

2014). These evaluations carry a high weight due to the fact that if a student is found

unsatisfactory, they will not only fail the competency, but could fail the class, and their whole

course progression towards graduation would be altered. After nursing school is complete, the

student must then sit for the ultimate high stakes test: the National Council Licensure

Examination for Registered Nurses, or NCLEX. Failing the NCLEX results in the inability to

gain nursing licensure and practice as an RN. Continuing education requirements in Illinois

include twenty hours of continuing education every two years (Nursing Continuing Education,

2013). This could include online exams, and if the RN is unable to pass, it could result in a loss

of state licensure.
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Conditions that must be present for test anxiety to occur are the internal feeling that they

have not prepared adequately for the competency, comparison or competition with their peers, or

a previous failure of a competency (Yang et al., 2014). Outcomes of this concept would be

performing poorly on competencies during nursing school, failing nursing classes, therefore

being unable to complete the nursing program. If the student is able to successfully complete the

program, they could still fail the NCLEX. Failing to adequately complete continuing education

requirements for the RN license due to poor performance could also be an outcome. Ultimate

outcomes of poor performance on skill competencies are inadequate delivery of patient care due

to skills being performed inaccurately and poor patient outcomes.

Use of the Concept of Test Anxiety in General Education

General education uses this concept with testing or evaluation of students in any

educational program. Objective written test and essays will be the focus of the concept in this

discipline. Conditions that must be present are consistent with those in the nursing dimension,

which include anxiety before, during, and after an evaluation. Outcomes of this concept in this

dimension would be failing tests and exams as a student. Educators have the responsibility to

reduce anxiety in their students before the test takes place as well as place referrals to appropriate

tutoring and learning centers (Yang et al., 2014). One study concluded that the majority of

students that suffered from test anxiety identified the single element that caused the most anxiety

was the attitude of the teacher (Yang et al., 2014). It was found that the students were concerned

that the teacher’s communication, both verbal and nonverbal, and attitudes would affect their

performance and thus their success (Yang et al., 2014). When students are in a highly anxious

state, they might misinterpret the meaning of these attitudes, which would then lead to more

anxiety (Yang et al., 2014). The same study concluded that another element that caused anxiety
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was the unfamiliarity and strictness of the testing atmosphere. Therefore, the educator must work

to promote a calm, level environment in order to allow the students to perform to the best of their

ability (Yang et al., 2014). Educators should make it a main focus to achieve a positive

atmosphere for learning to allow the students to achieve their optimal performance. This is true

in all realms of education, from elementary education to higher education.

Use of the Concept of Test Anxiety in Psychology

The dimension of psychology uses this concept as a diagnosis of an anxiety disorder or

even a phobia (Gibson, 2014). Anxiety is the most common form of mental illness, with more

than 20 million diagnoses in the world (Young, 2015). Test anxiety falls under the realm of an

anxiety diagnosis, as the student perceives the test as the threat which causes the anxious reaction

(Fernandez-Castillo & Caurcel, 2014). One study that analyzed data regarding test anxiety found

that a specific type of anxiety occurs when students take tests that is different from generalized

anxiety disorder, and that each individual with test anxiety may experience different symptoms

and emotions (Gerwing, T., Rash, Gerwing, A., Bramble, & Landine, 2015). Psychology has

aimed to define antecedents for test anxiety, including a serotonin deficiency (Liu & Lu, 2013).

Newer research has proposed that a polymorphism of the monoamine oxidase A gene is a risk

factor for test anxiety as well (Liu & Lu, 2013). One study showed that 35% of students at the

collegiate level experience some level of test anxiety, and the realm of psychology has strived to

reduce this emotional response for students (Fernandez-Castillo & Caurcel, 2014). Psychology

has used test anxiety to conduct research regarding the link between anxiety and other emotional

and behavioral problems (Fernandez-Castillo & Caurcel, 2014). Psychology has also researched

the concept of attention when related to test anxiety and has found that being in an anxious state

decreases attention span (Fernandez-Castillo & Caurcel, 2014). According to new theories,
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attention no longer encompasses the three elements of alert, oriented, and under voluntary

control, but rather considers selective attention and concentration capacity as the two central

elements of attention (Fernandez-Castillo & Caurcel, 2014). Selective attention refers to the

ability to choose one or two relevant stimuli to focus on while essentially ignoring the others,

and concentration capacity refers to the ability to keep focus on one item for an extended time

(Fernandez-Castillo & Caurcel, 2014). These elements are important when analyzing the concept

because when present, test anxiety results in overstimulation of alertness and orientation, leading

to a decrease in attention, which leads to cognitive dysfunction and errors (Fernandez-Castillo &

Caurcel, 2014).

Conditions that must be present for test anxiety to occur include those that are

encompassed by the diagnosis of anxiety, the cognitive, somatic, and motor symptoms, as well as

a decrease in attention, orientation, and executive control (Fernandez-Castillo & Caurcel, 2014).

Cognitive symptoms would include a lack of confidence, somatic symptoms would include those

physical symptoms felt and displayed by the student, and the motor symptoms would include a

lack of time management, and a lack of information processing (Young, 2015). The outcome of

test anxiety in the discipline of psychology would be living with an anxiety disorder.

Use of the Concept of Test Anxiety in My Own Experience

The concept of test anxiety is relative to my own experience as an RN in my current

career as a Clinical Skills Educator. I work closely with students during the clinical evaluation

process, and witness firsthand evaluation anxiety that impedes their performance and outcomes.

This is evidenced by student verbal admittance of suffering from test anxiety, as well as repeated

academic failures. I must consult the research in order to find ways to promote optimal learning

experiences and positive learning environments for the students while performing their skills.
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Nursing students must have the ability to perform skills accurately in order to first pass the

evaluation, then pass the course, and then most importantly, to provide safe and effective care to

patients. Through this concept analysis I will identify the antecedents and consequences and

study the literature in order to better help the students in their success, both in my current role

and upon completing the Masters of Science in Nursing, Nurse Educator program at Methodist

College, Peoria, Illinois. According to Gerwing et al. 2015, there are many different ways

educators can help relieve test anxiety in their students which include providing clear

expectations of the students for each exam, promote effective note taking and study habits, allow

for accommodations when needed such as extra time or a separate testing space, always practice

under the Family Educational Rights and Privacy Act (FERPA) laws and provide confidentiality

regarding feedback and grades, raise awareness regarding test anxiety to lessen the stigma of

negativity around test anxiety or other emotional disorders, and to allow the students to feel

comfortable coming forth and admitting their feelings (Gerwing et al., 2015). The students also

must have a role in lessening their own test anxiety and emotional disturbances. One study states

that the student must put forth the personal effort and make time to study, do not procrastinate,

ask for the help they need, and practice reducing anxiety symptoms and negative internal self-

talk in order to be successful (Gerwing et al., 2015). Studies have indicated that there are several

methods to lessen the anxious state nursing students enter when being evaluated, which include

relaxation and guided imagery, aromatherapy, and personal reflection (Gibson, 2014). When

hypnotherapy is used, it may help students lessen their irrational thoughts of failure (Gibson,

2014). These methods need to be considered by students, nursing educators, and evaluators in

order to support the student in gaining optimal performance.

Antecedents
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Walker & Avant describe antecedents as the events that happen before the concept

existed (McEwen & Wills, 2014). First, the student must be aware that they must take an exam in

the future, and understand that they will be evaluated (Gibson, 2014). Another antecedent of test

anxiety is previously failing an exam, which conditions the student to believe that they will

perform inadequately again (Gibson, 2014). This causes the student to enter a cycle of a “self-

fulfilled prophecy” of believing they are going to fail, which in turn causes them to fail. Another

element could be the pressure placed on the student to perform well, whether it be internally,

from their family, peers, or teachers, though research has shown that the factor that is most

correlated with the development of test anxiety is the internal negative self-concept of their

performance (Gibson, 2014). Other antecedents include a previous emotional diagnosis including

anxiety, attention deficit disorder, or obsessive compulsive disorder, unrealistically high

expectations for themselves, a type-A or perfectionist personality, a low self-esteem or lack of

confidence or motivation, past failures at tests and evaluations, poor test taking skills or bad

study habits, or high pressure or competition (Young, 2015).

Critical Attributes

According to Walker & Avant, critical attributes provide the main characteristics of the

concept (McEwen & Wills, 2014). Critical attributes of test anxiety are the awareness that an

evaluation will take place, a feeling of dread or fear, and feelings leading to physical symptoms

such as tachycardia, shaking, or gastrointestinal upset, the feelings leading to cognitive

symptoms such as decreased attention and focus, and predisposing factors such as a previously

diagnosed emotional disorder or a lack of effective studying or preparation (Gibson, 2014).

According to a study conducted by Yang et al., six critical attributes of test anxiety exist: 1.

Uncertainty of the passing standards, 2. Worry that there are insufficient channels for feedback
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or consultation after the test, 3. Worry about the effectiveness of their practice and study habits,

4. Worry about the attitude of the teachers monitoring the test, 5. Worry about the atmosphere

during the test, and 6. Anxiety about the test itself (Yang et al, 2014). Other critical attributes

include an increased urge to urinate, dry mouth, a self-perception of failing the exam, and fatigue

(Young, 2015). It is important to keep in mind that the critical attributes of test anxiety can vary

from student to student, some being general, and some being specific to the situation.

Consequences

According to Walker & Avant, a consequence is what happens due to the concept

occurring (McEwen & Wills, 2014). A consequence of having test anxiety is failing the test due

to the overwhelming anxious state during the exam or evaluation. Grades or results, whether they

be low of below passing, can cause the student to fail the course. The student’s self-esteem will

suffer, and the student will either have to repeat the course, or fail the program and not become

an RN. This happening could lead to many other life altering consequences such as further

anxiety, depression, or even suicide (Gibson, 2014). Prolonged anxiety symptoms can have

physical alterations as well such as an increase in blood pressure and fatigue.

Defining Personal Critical Attributes

The two personal critical attributes found from my literature search are a feeling of fear

and decrease in focus. These were the two most common attributes of the concept discussed, and

will therefore be considered the most critical. Yang’s six critical attributes will be excluded due

to inadequate support from other literature. Physical symptoms will be excluded because they

can vary greatly from student to student.

Personal Antecedents
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Personal antecedents are events that happen before the concept existed. According to my

literature review, the most common antecedent found was a previous failure of an evaluation.

The personal antecedent of test anxiety therefore is previously failing an exam, which conditions

the student to believe that they will perform inadequately again (Gibson, 2014). The specific

physical symptoms were excluded because each student with test anxiety may experience a

different range of symptoms and emotions.

Personal Consequences

A consequence is what happens due to the concept occurring. The personal consequence

of test anxiety is failing the test due to the overwhelming anxious state during the exam or

evaluation. Long term effects were excluded because some cases of test anxiety are limited to the

academic program that the student is participating in.

Constructing a Model Case

Analysis

In a scenario, a student (Sarah) participated in a skill competency on IV insertion. She

had failed her previous skill competency on injections in this same course, and if she knew that if

she failed the IV insertion competency, she would not pass the course. She had prepared

adequately through practice hours, studying theory, meeting with her instructor, reading her

book, and watching tutorial videos. During the competency, she has feelings of fear, dread, and

apprehension. She also was unable to focus her attention on the skill. She was given negative

comments in her feedback and a failing score. In this model case, Sarah had the antecedent of

previously failing a skill competency. She experienced the critical attributes of feeling of fear or

dread, and also a decrease in focus. The consequence was failing the competency, and then

ultimately, the course.

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Constructing Additional Cases

Contrary Case

In another scenario, a student (William) participated in a skill competency on adult

physical assessment. He had prepared adequately through practice hours, studying theory,

meeting with his instructor, reading his book, and watching tutorial videos. During the

competency, he felt calm and confident, and was able to focus adequately and perform his

assessment completely and accurately. Stan did not have any of the antecedents and the critical

attributes were not present.

Borderline Case

In another scenario, a student (Ashley) participated in a skill competency on nasogastric

tube insertion. She had prepared adequately through practice hours, studying theory, meeting

with her instructor, reading her book, and watching tutorial videos. During the competency, she

experienced a feeling of fear, but was able to maintain her focus and calm her thoughts as she

progressed through the skill. This is a borderline case because she did demonstrate one critical

attribute of a feeling of fear, but did not lose her focus. She also did not have the antecedent of a

previous failure.

Defining Empirical Referents

Walker & Avant refer to empirical referents as the way we measure the critical attributes

(McEwen & Wills, 2014). Test anxiety needs to be evaluated and measured by looking at the

students’ symptoms and predisposing factors. Several studies have been conducted to find a

standardized questionnaire or screening process for test anxiety in students such as the Test

Anxiety Inventory, the Reactions to Tests Scale, the Westside Test Anxiety Scale (Gibson,
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2014). Empirical referents for test anxiety include measuring the symptoms and the reaction. The

symptoms include physical symptoms such as tachycardia and nausea (Gibson, 2014). The

reaction is the worry, preoccupation, and negative thoughts which lead to the cognitive

impairment, and then the ultimately failing the test (Gibson, 2014).

Implications for Nursing

The implications of test anxiety for nursing are the frequent testing and evaluations

during the nursing program and ultimately the NCLEX. As discussed earlier, high stakes testing

situations have an impact on the amount of anxiety noted. A small degree of anxiety can enhance

a student’s focus and performance outcomes, but when the anxiety becomes overwhelming, it

creates a negative situation with a negative impact on the consequence (Gibson, 2014). The

implications of test anxiety specific to my nursing practice is the need to better define test

anxiety’s antecedents and consequences, and to bring awareness to educational institutions. The

negative stigma of anxiety, specifically test anxiety, must be lifted, so that students can ask for

and accept the help they need. Educators must become aware of this phenomenon and implement

screenings for students, be an active listener, and provide self-evaluation to make sure they are

not personally contributing to the anxious state. As educators, we wish to see our students

succeed and to witness their greatest potential. All of our students have the ability to reach their

optimum potential, and if we can work together to recognize and overcome test anxiety, this

would allow our students a better chance at having excellent outcomes and achieving their goals.

Conclusion

The purpose of defining and analyzing test anxiety as a concept allows for the correlation

between test anxiety and negative outcomes. This concept is evident in multiple disciplines, as

discussed in nursing, education, and psychology. There are many attributes for test anxiety that
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are general but vary from situation to situation. The method used was Walker & Avant, and

through these steps, the concept was demonstrated. Educators, specifically in nursing, can use

this concept to better understand the student’s perspective and to create positive learning

environments which will have a positive impact on student outcomes.

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Gerwing, T. G., Rash, J. A., Gerwing, A. M., Bramble, B., & Landine, J. (2015). Perceptions and
incidence of test anxiety. Canadian Journal for the Scholarship of Teaching and
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