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A Conceptual View of Test Anxiety Heather A. Gibson, PhD, RN Heather A. Gibson, PhD, RN, is Associate Professor, York College, City University of New York (CUNY), Jamaica, NY and a recent PhD Nursing graduate, Graduate Center, City University of New York (CUNY), Jamaica, NY. Keywords Concept analysis, education, nursing, student, test anxiety Correspondence Heather A. Gibson, PhD, RN, York College, City University of New York (CUNY), Jamaica, NY 11451 E-mail: [email protected]; [email protected]

PURPOSE. The purpose of this study is to clarify the term test anxiety with a focus on nursing education. CONCLUSION. Walker and Avant’s concept analysis technique was used to examine the term test anxiety. The attributes of the concept of test anxiety include administration of a test, negative subjective feelings, behavioral aspects, physical signs, and cognitive aspects. PRACTICE IMPLICATIONS. Understanding test anxiety in the nursing student can help develop research-based interventions. Assessing test anxiety in nursing students is important for nurse educators to better understand the challenges that face these upcoming nursing professionals. Nursing research that further explores test anxiety is needed.

Gibson

It has been estimated that 25–40% of the U.S. population suffers from test anxiety (Cassady, 2010; Cizek & Burg, 2006; Huberty, 2009). Test taking begins in early childhood and extends to late adulthood, and most individuals who take tests will experience test anxiety at some point in their lifetime (Cizek & Burg, 2006). The concept of test anxiety has broad implications for various populations, and at all levels of education, across disciplines. In nursing education, and the professional development of future nurses, the concept of test anxiety is critical. Test anxiety has a negative impact on learning and is a major cause for underachievement and prevents some students from reaching their academic potential (Rana & Mahmood, 2010). Most individuals are tested at some point during their formal education and professional careers. For many individuals, managing test anxiety presents real challenges. A student’s test-taking skills are affected by test anxiety, and poor test results can negatively impact overall academic performance (Cizek & Burg, 2006). The concept of test anxiety requires further

clarification, especially as new modes of testing administration are continually developed. Test anxiety is an important concept in nursing academia, where the attrition rate due to test failure is of significant concern for nursing faculty (Gatto, 2010; Higgins, 2005). High stakes testing with strict progression policies can be overwhelming for nursing students (Spurlock, 2013). Test anxiety usually emerges from the highly structured processes of assessment and testing of student performance across the entire nursing school curriculum. Ultimately, test anxiety can occur when the nursing student is taking the national licensure exam and can lead to failure of the exam (Thomas & Baker, 2011). The aim of this paper is to examine the concept of test anxiety, using the Walker and Avant (2011) concept analysis method, to explicate the full significance of the term, and to increase knowledge through the use of attributes and antecedents. The Walker and Avant method examines the structure and function of a concept, and how a concept can change over time. 267

© 2014 Wiley Periodicals, Inc. Nursing Forum Volume 49, No. 4, October-December 2014

Test Anxiety

H. A. Gibson

Using the Walker and Avant method to analyze the nature of test anxiety is appropriate given the diversity of examinations that have evolved over time to evaluate students’ levels of proficiency. Tests have changed both in form and structure, including written essay exams, multiple choice paper exams, standardized exams, computerized or computer-based standardized exams, and high stakes testing. As the assessment and testing of students has evolved, so have the levels of test anxiety. Methods to combat test anxiety and decrease its negative impact on student learning requires attention and reevaluation. The focus of the paper is on the concept of test anxiety in the context of nursing education, and other disciplines will be included to illustrate the multidisciplinary relevance of the concept. The literature on the subject of test anxiety is extensive (Alpert & Haber, 1960; Hastings, 1944; Hembree, 1988; Liebert & Morris, 1967; Mandler & Sarason, 1952; Meichenbaum & Butler, 1980; Sarason, 1980; Sarason & Mandler, 1952; Spielberger, 1980; Zeidner, 1998; Zuriff, 1997). However, very little of the literature published within the past 5 years analyzes the concept of test anxiety and nursing students. The term test anxiety has been employed in the academic lexicon and vernacularly for some time, but requires clarification for the nursing profession. If the concept of test anxiety is better understood in this dynamic testing society, then research regarding the construct and necessary interventions may increase. Method The Walker and Avant method (Walker & Avant, 2011) was used to evaluate the concept of test anxiety and its application for nursing students. This method is appropriate because it provides a framework for examining the basic elements and structure of the concept of test anxiety, and recognizes that the concept can change over time. Furthermore, it recognizes that the concept can change over time as a result of the influences of social or contextual factors (Walker & Avant, 2011). Since the concept of test anxiety has been in use since the 1950s, the Walker and Avant method is a suitable choice for a concept analysis. The process of concept analysis is dynamic as terms are clarified for future use. The Walker and Avant framework is a modification of Wilson’s (1963) method of concept analysis; it is an iterative process as shown in Table 1. Although the steps are numbered, during concept analysis, it is common to revisit and 268 © 2014 Wiley Periodicals, Inc. Nursing Forum Volume 49, No. 4, October-December 2014

Table 1. Concept Analysis Processes (Walker & Avant, 2011) 1. 2. 3. 4. 5. 6.

Select a concept. Determine the aims or purposes of analysis. Identify all uses of the concept that you can discover. Determine the defining attributes. Identify a model case. Identify borderline, related, contrary, invented, and illegitimate cases. 7. Identify antecedents and consequences. 8. Define empirical referents.

revise another step when additional information is obtained (Walker & Avant, 2011). The processes of selecting a concept and the objectives of the analysis have been addressed previously. To begin, the method of article selection will be explained, followed by explanations of the processes used to identify the contexts in which the concept is used; determine the defining attributes; identify a model case; identify additional cases (borderline, related, and contrary); identify antecedents and consequences; and define empirical referents (Walker & Avant, 2011). Initially, article selection was conducted using the Cumulative Index to Nursing and Allied Health Literature (CINAHL) database, and searching the keywords “test anxiety.” The search produced 370 journal articles related to test anxiety. The sample yielded data from 1952–2012. The abstracts were reviewed and articles were excluded that involved animals, nonEnglish language, duplicate articles, or no relevance to test anxiety. These exclusions were applied to all databases. After the reduction, 10 articles were reviewed for content. The reference sections of the selected articles provided additional books, websites, and articles for consideration. The sources yielded research from various disciplines, including nursing, education, psychology, and sociology. PubMed, CINAHL, Scopus, and Education Resources Information Center (ERIC) databases were searched using the keywords “test anxiety in nursing students.” The search produced between 120 and 150 articles from each database, excluding the ERIC database, which yielded 32 articles. After removing duplicate, unrelated, and non-English language articles, the result was 8 articles, published within the past 5 years that focused on test anxiety in nursing. An abbreviated summary of the research and attributes from these data sources are noted in Table 2.

© 2014 Wiley Periodicals, Inc. Nursing Forum Volume 49, No. 4, October-December 2014

Hembree (1988)

Spielberger (1980)

Boutin and Tosi (1983)

Charlesworth (1981)

Meichenbaum and Butler (1980)

Dawley and Wenrich (1973)

Wine (1971) Sarason (1980)

Liebert and Morris (1967)

The deficits model asserts that test-anxious students with poor performance is due to lower ability and ineffective study skills.

• The cognitive-attentional model of test anxiety • Lower performance of highly anxious individuals is mainly due to the difference in the attention focus during task performance. Nursing students with test anxiety participated in group desensitization sessions that included relaxation instruction and visualization. The students obtained lower scores on the Test Anxiety scale after the intervention. There are four variables for test anxiety which includes 1. Internal dialogue 2. Behavioral acts 3. Behavioral outcomes 4. Cognitive structures Dual Deficit Models also a include a lack of study skills. Nursing students decreased their test anxiety with progressive relaxation, deep muscle relaxation, autogenic training, visual imagery, and modified systematic desensitization. An improvement was shown in nursing students who were treated with hypnotherapy to decrease irrational ideas during test anxiety. • Spielberger defined two anxiety constructs: state anxiety and trait anxiety. • State anxiety (S-anxiety)—emotional factors at a specific time. Consists of subjective feelings of tension, apprehension, nervousness, and worry, and activation or arousal of the autonomic nervous system.

Evaluated tension in examination settings Motivational Drive Model • Examined anxiety and learning • The first study to differentiate test anxiety from the general concept of anxiety • Differentiated between facilitating (mild anxiety) and debilitating test anxiety (includes negative thought) • Interference model of test anxiety Two main components of test anxiety were introduced which included worry and emotionality.

Hastings (1944) Mandler and Sarason (1952)

Alpert and Haber (1960)

Research/definition

Year

• Trait anxiety (T-anxiety) as relatively stable individual differences in anxiety proneness, that is, differences between people in the tendency to perceive stressful situations as dangerous or threatening, and in the disposition to respond to such situations with more or less intense elevations in S-anxiety • If the person has trait anxiety, then they are more likely to have state anxiety at a higher level.

• State Trait Anxiety Scale (Spielberger, 1980) • Test Anxiety Scale

1. Internal dialogue is talking negatively with oneself. 2. Behavioral acts are observed behaviors—study habits and test-taking ability. 3. Behavioral outcomes are results, grades, or feedback. 4. Cognitive structure is the motivation or direction for the student behavior. State Trait Anxiety Scale (Spielberger, 1980)

Test anxiety is focused on task demands of retrieving previously learned information and producing negative self-preoccupation or task irrelevancy. • Worry is a cognitive component that is formed from negative beliefs such as doubt. • Emotionality is the affective and physiological component. Cognitive Activities • Task irrelevant • Task relevant

Test Anxiety Questionnaire—Adults

Attributes

Table 2. History of Test Anxiety and Test Anxiety in Nursing Education—Abbreviated List

H. A. Gibson Test Anxiety

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Markman et al. (2011)

Beggs et al. (2011)

Eum and Rice (2011)

Kutlu et al. (2008)

Lai et al. (2008)

Edelman and Ficorelli (2005)

Sharif and Armitage (2004)

Studied the effect of slow music on examination anxiety on nursing students enrolled in English for Nursing Terminology class Examinations in education are used for measurement and appraisal which can increase the student’s stress and produce anxiety. Nursing and health students were provided lavender aromatherapy as an intervention. Test anxiety includes worry as the primary component (Liebert & Morris, 1967). Additionally, test anxiety has a relationship with goal orientation and perfectionism. A cause of test anxiety is lack of self-confidence which can be addressed by guided reflection. The cognitive and emotional aspects may be alleviated with the use of guided imagery in nursing students. Examined the relationship between nursing students’ health beliefs about test anxiety and willingness to seek professional help.

Tested the effect of 60 beats per minute music on the test anxiety for junior baccalaureate nursing students Three components of test anxiety were identified by as 1. Subjective distress 2. Physical symptoms 3. Cognitive effects Test anxiety has three facets: 1. Cognitive preoccupation 2. Affective (tension, bodily) 3. Behavioral Used counseling intervention program to decrease anxiety in nursing students. The topics included anxiety control, breathing relaxation, worrying thoughts, rational and irrational beliefs, and study skills. Examined the lived experience of nursing students with test anxiety

Summers et al. (1990) Zuriff (1997)

Zeidner (1998)

Research/definition

Year

Table 2. Continued

Used Bandes and Friedman (1997) Test Anxiety Questionnaire: • Fear of social condemnation—failure • Disorderly functioning and thinking • Excitement and tension

1. Cognitive 2. Emotional 3. Physical

1. Goal orientation 2. Perfectionism

Themes developed: 1. Reality of the anxiety episode: feelings, awareness, and uniqueness 2. Academic implications of test anxiety 3. Effective measures for coping State Trait Anxiety Inventory & Test Anxiety Inventory (Spielberger, 1980)

State Trait Anxiety Scale & Test Anxiety Inventory (Spielberger, 1980) 1. Subjective distress (fear, apprehension, tension) 2. Physical symptoms (trembling, sweating, and voice tremor) 3. Cognitive effects (difficulty concentrating) 1. Cognitive preoccupation (worry, irrelevant thinking) 2. Affective (tension, bodily reactions) 3. Behavioral (deficient study skills/test taking skills and procrastination/avoidance)

Attributes

Test Anxiety H. A. Gibson

H. A. Gibson Use of the Concept Walker and Avant (2011) suggested that a review of all aspects and applications of the concept, across multiple disciplines, is necessary in the course of a concept analysis, including available literature used by various disciplines and dictionary definitions which may evolve over time. A concept formed in one context may be made use of in a completely different context. Although the focus of this article is the examination of the concept test anxiety in the context of nursing education, the concept of test anxiety will be reviewed in relation to other disciplines. The concept of test anxiety is usually referred to with student examinations of content material such as elementary school students, nursing students, students with learning disabilities, and college students (Lai et al., 2008; Putwain, 2009; Whitaker Sena, Lowe, & Lee, 2007). The experience of test anxiety is not bound by international or cultural perspectives (Bodas & Ollendick, 2005; Neuderth, Burkhard, & Schmidtke, 2009). In addition, test anxiety is relevant to the patient anticipating a scheduled medical procedure who becomes anxious about the procedure and/or the outcome. The concept is used in reference to other evaluative circumstances, such as performances, interviews, and public speaking events. During a musical performance test, the students who exhibited high anxiety received below capacity performance in the test (Kivimaki, 1995). This body of research demonstrates how the concept of test anxiety may be used in other disciplines. The concept of test anxiety is transposed with various other terms within the literature, across various disciplines. The same concept may be articulated using a different word (Rodgers, 2000). This alternative word is referred to as a surrogate term, suggesting that there are at least two or more terms that are used interchangeably for one another (Rodgers, 2000). There were a few surrogate terms for test anxiety gleaned from the literature. The surrogate terms identified include examination anxiety; test and study worry and emotionality; and performance anxiety. The surrogate term “examination anxiety” was utilized in at least two of the articles. In one study, researchers studied examination anxiety within nursing students in Taiwan, and the other study evaluated examination anxiety in secondary school students in Great Britain (Gregor, 2005; Lai et al., 2008). The term examination was noted as an interchange-

Test Anxiety able term for test in both studies. “Test and study worry and emotionality” is a surrogate term identifying the context in which the test and studying for the test yields two major components of anxiety which are worry and emotionality (Kieffer & Reese, 2009). “Performance anxiety” is another surrogate term and is applied to the entertainment domain referring to a performance before an audience. An example of performance anxiety is musicians being tested and graded in their music classes. An individual experiences performance anxiety when participating in any activity where the quality of the performance is important or is being evaluated by more competent individuals (Yondem, 2007). Therefore, performance anxiety can occur in a range of anxiety-provoking situations, including test taking, mathematics performance, public speaking, sports, arts performances, and sexual performances (Yondem, 2007). Use of the Concept in Nursing Education Nursing students tend to be more test anxious when compared with other students (Evans, Ramsey, & Driscoll, 2010; Sharif & Armitage, 2004). In historical studies, test-anxious nursing students benefited from desensitization techniques such as relaxation; visualization, and autogenic training (Charlesworth, 1981; Dawley & Wenrich, 1973). In another study, Boutin and Tosi (1983) used hypnotherapy with nursing students; this resulted in a decrease of their irrational ideas during test taking. According to Edelman and Ficorelli (2005), nursing students described three major themes when they encountered test anxiety. The themes were (a) reality of the anxiety episode; (b) academic implications of test anxiety; and (c) effective measures for coping. More recently, in a study conducted by Evans et al. (2010), first year nursing students were screened and treated for test anxiety which led to a significant improvement in test scores. Beggs, Shields, and Goodin (2011) recommend the use of guided reflection between nursing students and nursing professors as a treatment option for test anxiety. Furthermore, the use of aromatherapy such as lavender (Kutlu, Yilmaz, & Cecen, 2008; McCaffrey, Thomas, & Kinzelman, 2009) and rosemary (McCaffrey et al., 2009) resulted in a decrease of test anxiety in nursing students and improved examination outcomes. Markman, Balik, Braunstein-Bercovitz, and Ehrenfeld (2011) evaluated test anxiety in nursing students as it related to health beliefs and willingness to seek 271

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Test Anxiety treatment. However, the findings noted that accessibility to treatment for test anxiety may be the biggest deterrent to nursing students. Markman et al. (2011) believe that test anxiety is common in the academic setting and more widely available treatment could overcome the problem in nursing students. Definition of Test The concept of test can refer to the verb or a noun. For the purpose of this study, the concept of test, the noun, will be described. A test is a basis for evaluation (Test, 2012). A test can also be considered “a series of questions, problems, or physical responses designed to determine knowledge, intelligence, or ability” (Test, 2012). Definition of Anxiety The term test anxiety originated from the concept of anxiety; therefore, it is imperative to provide a fundamental definition of anxiety. Anxiety is defined as “an abnormal and overwhelming sense of apprehension and fear often marked by physiological signs (as sweating, tension, and increased pulse), by doubt concerning the reality and nature of the threat, and by self-doubt about one’s capacity to cope with it” (Anxiety, 2012). Additionally, nursing professionals define anxiety as a “vague uneasy feeling of discomfort or dread accompanied by an autonomic response (the source often nonspecific or unknown to the individual); a feeling of apprehension caused by anticipation of danger (Herdman, 2012). It is an alerting signal that warns of impending danger and enables the individual to take measures to deal with the threat” (Herdman, 2012). Definition of Test Anxiety Test anxiety is defined as “an unpleasant feeling or emotional state that has both physiological and behavioral components and that is experienced in formal testing or other evaluative situations” (Dusek, 1980). A recurrent theme in the definitions of test anxiety is an unpleasant feeling with two components: the physical and the psychological/behavioral during testing (Zeidner, 1998; Zuriff, 1997). The physical aspect includes sweating, palpitations, restlessness, dyspnea, tremors, and other symptoms (Zeidner, 1998; Zuriff, 1997). The psychological/behavioral 272 © 2014 Wiley Periodicals, Inc. Nursing Forum Volume 49, No. 4, October-December 2014

H. A. Gibson aspects include forgetfulness, fear, doubt, and negative thoughts (LeBeau et al., 2010; Zeidner, 1998; Zuriff, 1997). The integral or central cause of the anxiety is the test or examination. Spielberger (1980) defined test anxiety as stemming from state and trait anxiety. Spielberger and Vagg (1987) suggested that test anxiety is a situationspecific anxiety trait. State anxiety is the current level of anxiety and is situation specific (Spielberger & Vagg, 1987). Trait anxiety is the predisposed anxiety of a person in relation to their personality (Spielberger & Vagg, 1987). Therefore, test anxiety is both situational and dispositional. Students with high test anxiety feel more threatened in testing situations and are more likely to portray a higher level of state anxiety (Spielberger & Vagg, 1987). On the other hand, Zeidner (1998) attests that test anxiety is a specific form of anxiety that falls under a specific phobia of being evaluated. A specific phobia is categorized as a “marked and persistent fear that is excessive or unreasonable, cued by the presence or anticipation of a specific object or situation (e.g., flying, heights, animals, receiving an injection, seeing blood)” (American Psychiatric Association, 2010, DSM-IV 300.29). This definition presents a problem for the nursing student who has a fear of failing nursing exams, and the concern is valid since most nursing programs will only allow the student to fail one nursing course (Beggs et al., 2011). The importance of test anxiety is being recognized as a current problem that is still relevant in this decade and is underresearched. Test anxiety is currently not recognized as a diagnosis in the DSM-IV-TR (2000). Research suggests that test anxiety should be considered as a specific phobia to facilitate its diagnosis and treatment (LeBeau et al., 2010). Hence, for the medical profession, the criteria, categorization, and definition of test anxiety may be changing in the near future. If this change occurs, research of test anxiety in nursing students may increase. Defining Attributes The defining attributes represent the true meaning of a concept (Walker & Avant, 2011). The defining attributes are the core characteristics of the concept; the attributes can be likened to the ingredients of a culinary creation. For instance, particular ingredients are integral components of the end product for a particular dish. This analogy is also true for a concept. The defining attributes are needed to recognize a specific

Test Anxiety

H. A. Gibson concept. The term such as test anxiety is merely the language used to represent the concept; there are necessary aspects that constitute the concept. Therefore, the concept of test anxiety and the defining attributes were examined. The defining attributes of test anxiety are as follows: (a) there is a test or examination to be administered, which is the source; (b) there is a negative subjective feeling of fear or worry (Cassady & Johnson, 2001; Driscoll, 2007; Sarason, 1984); (c) there are behavioral aspects such as study habits and test-taking abilities (Meichenbaum & Butler, 1980); (d) there are physical signs such as palpitations, trembling, fidgeting, nausea, jitters, or headaches (Zeidner, 1998; Zuriff, 1997); (e) there are cognitive aspects such as forgetfulness, disorganization, or irrelevant thinking (LeBeau et al., 2010; Zeidner, 1998; Zuriff, 1997). A person experiencing the concept of test anxiety has these criteria in common. Antecedents Antecedents are the events or incidents that usually occur right before the instance of the concept (Walker & Avant, 2011). What is the leading situation that precedes test anxiety? Knowledge of the exam is an antecedent of test anxiety. An exam must exist, and the person must know that they are having an evaluation. For example, a student may perform well on a homework assignment that is not being graded and test anxiety would not occur. However, if the student knew they were being evaluated for the same homework assignment, knowledge of the evaluation would precede the test anxiety. Another antecedent of the concept of test anxiety is the perception of failing or fear of failure (Anxiety & Depression Association of America [ADAA], 2012). If a person believes that there is a situation or evaluation where they may fail, then the test anxiety may begin. A student’s self-worth may be linked to the outcome of the exam (ADAA, 2012), such as the nursing student who is the first to graduate college and become a nurse in their family. The pressure of the test outcome can be a motivator for some students, but it can also lead to a fear of failure that is overwhelming for other students to handle. Research conducted revealed that an individual’s self-concept of academic ability is an important factor in correlation of test anxiety (Howell & Hanson, 1989). Students who believed they would perform poorly or fail the exam would then experience test anxiety (Howell & Hanson, 1989).

Consequences The consequences of test anxiety are the reactions observed after the institution of the concept. Essentially, the consequences follow an occurrence of the concept (Walker & Avant, 2011). For the concept of test anxiety, the consequences are the outcomes associated with it. Some of the outcomes specifically in the context of nursing education are poor test results, poor self-esteem, failure of nursing exams or school subjects, having to repeat a class, and failure to complete a program or enter into the nursing profession. Contemplation of suicide is one severe consequence of test anxiety (Wang, 2005). Cases Cases are used to illustrate what the concept is and what it is not (Walker & Avant, 2011). Several types of cases are examined and include a model case, a contrary case, a borderline case, and a related case. Once the defining attributes of a concept are identified, then the model cases are constructed to test the clarity of the cases. Walker and Avant (2011) define a model case as one that clearly illuminates all of the defining attributes of test anxiety. The contrary case is an example of a case that definitely does not represent test anxiety. The borderline case has some of the attributes of test anxiety present, but the case lacks all the defining attributes to classify it as a model case. A related case may appear to embody the attributes of test anxiety, but with closer inspection, those attributes were determined to have been made in error. Examples of each of the four cases are provided. The names and cases are all fictitious. Model Case John, a male student in his 40s, is scheduled to have a nursing exam on the following day and is afraid because he failed the last examination. He is worried because he knows that if he fails this exam, he will most likely fail the course and could be dismissed from the program. During the exam, he fidgets, begins to sweat, and experiences his heart racing. He takes a long time to finish the exam. He later tells the instructor that his mind went blank during the exam, and all that he could think about was the importance of the exam and its necessity for his success in the program. He stated that he had been reading and studying for 1 week. 273

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Test Anxiety

H. A. Gibson

In this model case presented, the student was exposed to the antecedents of test anxiety which include the knowledge of a test and the perception of failure due to previously failed exams. Once at the exam, the student experiences negative thoughts, physical symptoms, and cognitive problems of forgetfulness. Consequently, the student fails the exam and the course.

This case is an example of a borderline case because it has many of the attributes of test anxiety. However, it does not portray all of the attributes. The student is aware of the exam, and there are behavioral aspects such as procrastination with studying. The student is worried about taking the test and is concerned about a possible low test grade. However, there are no physical symptoms and no cognitive impairment.

Contrary Case

Related Case

Janice is scheduled to have a nursing test on labor and delivery in 2 weeks. She feels comfortable about the exam since she has been studying for the past 4 weeks, and she attended study groups with her peers and a tutor. At the exam, she takes her assigned seat and reads the directions on the test. She says a selfprayer before answering the first question. Janice is calm, breathing normally, and sitting quietly in her seat. She is moving just enough to turn the pages of the exam, and circle the correct answers. When she reads the test questions, she feels that she remembers the material and is able to eliminate the incorrect options. After completing the exam, Janice is confident that she has earned a good grade and is not worried about the test score. In the contrary case, the student did not exhibit any of the test anxiety attributes except having knowledge of the test. The student did not have any physical signs of test anxiety such as fidgeting or heart palpitations because she was calm. Additionally, she did not experience any cognitive deficits such as forgetfulness; she clearly remembered the material. During and after the test, the student experienced positive thoughts. She was not worried or fearful of the testing process. She was well-prepared for the exam, and she participated in test preparation activities.

Karen has three nursing tests scheduled for the last 2 weeks of school. She has been aware of the exam schedules since the first day of classes. She developed a studying routine for all three classes where she studies 4 hr per day. She is tired from the lack of sleep and states that she is stressed. She takes the first two exams without incident, and she is certain that she has performed well. On the day of her third exam, she was worried about her sick friend. During the exam, she experienced fatigue and a headache; however, she completes the exam in a timely fashion. She remembered the information without difficulty, and after the exam, she calls her friend before going to work. This related case is an example of stress. The student has many exams scheduled within a short time frame, and she is not sleeping. Furthermore, she is now concerned about the welfare of her friend. This is not an example of test anxiety. The student experienced similar physical attributes as seen in test anxiety. However, with further examination, it is apparent the attributes represent the case of stress. The student does not have the cognitive attributes for test anxiety.

Borderline Case

Empirical referents are categories of the phenomena and are the method of measuring or recognizing the defining attributes (Walker & Avant, 2011). Several scales have been developed to measure test anxiety such as the Test Anxiety Inventory (Spielberger, 1980), the Reactions to Tests Scale (Sarason, 1984), Cognitive Test Anxiety Scale (Cassady & Johnson, 2001), and the Westside Test Anxiety Scale (Driscoll, 2007). Within these scales, measurements or empirical referents for the concept of test anxiety are provided. For the concept of test anxiety, worry and emotionality are empirical referents. Worry is the cognitive

Tomorrow, Lionel is having a test on fluid and electrolytes. He has studied for 1 week in preparation for the exam. He is worried that he has studied for only 1 week, although he attended a study session with a tutor. During the exam, he has difficulty answering some of the questions but is able to guess the answers. He can remember a lot of the material, as well as test taking tips that his tutor provided. He is relaxed as he progresses through the exam at a steady pace. Once the test is over, he wants to know when the grades will be available since he is concerned. 274 © 2014 Wiley Periodicals, Inc. Nursing Forum Volume 49, No. 4, October-December 2014

Empirical Referents

Test Anxiety

H. A. Gibson reaction of test anxiety such as preoccupations or concerns. Emotionality is the physiological arousal such as the rapid heartbeat or nausea (Sarason, 1984; Spielberger, 1980). For example, test anxiety measurement instruments may include questions regarding the experience of worrying at different stages of the exam, encountering a racing heartbeat, sweaty palms, headaches, jitters, or nausea during an exam (Sarason, 1984). As the literature on test anxiety has evolved, the term worry has been equated with cognitive impairment, or cognitive test anxiety, which refers to cognitive reactions or internal dialogue in regard to evaluative situations (Cassady & Johnson, 2001). Other empirical referents for test anxiety include cognitive impairment which measures concentration, focus, fear of failure, lack of confidence in skills, feeling unprepared for tests, forgetfulness or test-irrelevant thinking (Cassady & Johnson, 2001; Driscoll, 2007; Sarason, 1984). These empirical referents help to measure the phenomena of test anxiety and provide a clear picture of the concept in nursing students.

results based on the consequences of their test scores (Rana & Mahmood, 2010). Hence, test anxiety is a reality and can have extreme detrimental effects where excessive amounts of anxiety during an evaluative assessment inhibit responses and may produce poor outcomes (Simpson et al., 1995). Nursing educators should develop and provide more research interventions to combat test anxiety, such as guided imagery, guided reflection (Beggs et al., 2011), music (Lai et al., 2008; Summers, Hoffman, Neff, Hanson, & Pierce, 1990), aromatherapy (Kutlu et al., 2008), and relaxation breathing (Christiaens, 2004). Additionally, ways to cope with the irrelevant thinking and negative inner conversation (Christiaens, 2004) should be discussed in focus or study groups. Additionally, nursing educators should offer study skills groups to assist with the knowledge deficit or lack of study skills that is frequently associated with test-anxious students. Test anxiety exists in many nursing students; only with awareness, knowledge, and intervention can educators continue to tackle this problem.

Implications

Conclusion

As nursing education evolves and students are confronted with more exams, and the National Council Licensure Examination (NCLEX) is in a computerized format, the concept of test anxiety will continue to have importance. Test anxiety is considered to be important because of its high correlation with poor test performance (Cassady & Johnson, 2001). The quality of student learning outcomes will increase when test anxiety is properly defined and recognized, and appropriate interventions are applied. When test anxiety is present, learning and performance is challenged, and more interventions should be developed to decrease this problem. Yet, recent studies examining test anxiety in the nursing profession are limited. Simpson, Parker, and Harrison (1995) assert that a minimal amount of anxiety can mobilize human beings to respond rapidly and efficiently, such as in mild anxiety. On the one hand, mild anxiety can be productive for students and can contribute to positive successful outcomes on an exam (Rana & Mahmood, 2010). Mild anxiety can sharpen a student’s mind and channel energy to increase focus for test preparation and test taking (Beck, 2007). On the other hand, when the anxiety builds and accumulates into a negative force, the student enters into a downward cycle that is filled with unproductive contemplations of

The purpose of this concept analysis was to provide a clear definition of test anxiety across many disciplines with a focus on the nursing education perspective as a foundation for the recognition of test anxiety, and a direction for future research. The concept of test anxiety is multidimensional involving physical, psychological/behavioural, and cognitive aspects. By reviewing the various attributes for test anxiety through a 50-year span, the most essential attributes were noted for nursing educators. Cases were developed using the Walker and Avant (2011) concept analysis method that clearly demonstrated test anxiety in the nursing student. The concept of test anxiety can be used by nurse educators to promote programs that could decrease this detrimental problem that affects student outcomes. Acknowledgments. The author gratefully acknowledges the Jonas Nurse Leaders Scholar Program and Donna Nickitas, PhD, RN, NEA-BC, CNE, FAAN. References Alpert, R., & Haber, R. (1960). Anxiety in academic achievement situations. Journal of Abnormal and Social Psychology, 61(2), 207–215. doi:10.1037/h0045464 275

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A conceptual view of test anxiety.

The purpose of this study is to clarify the term test anxiety with a focus on nursing education...
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