Analysis of licensure examination anxiety and its influencing factors among undergraduate nursing students

Doreen Asantewa ABEASI,Frank Bediako AGYEI

Department of Nursing and Midwifery,Presbyterian University College,Asante-Akyem,Ghana

ABSTRACT Background:Examination anxiety is a concern for educational policymakers because of the impact it can have on the overall outcome of the performance of the candidates who partake in such examinations.Aim:The aim of this study is to determine the examination anxiety level of students of Nursing and Midwifery College,Agogo,and Presbyterian University College and to evaluate the factors affecting them.Materials and Methods:A total of 160 undergraduate nursing students comprising 80 degree and 80 diploma students were conveniently sampled for the study.The study was conducted in September 2019 using a descriptive cross-sectional design.The Westside Test Anxiety Scale was used to measure examination anxiety among the participants.A researcher-designed questionnaire in which participants responded to a three-point Likert scale was used to assess factors influencing examination anxiety.Results:The findings of the study showed that test anxiety was higher among the diploma candidates (M=3.60) than the degree candidates (M=2.95) and the difference was statistically significant (P=0.024).Demographic characteristics such as age (P=0.009),sex (P=0.003),study hours per day (P=0.001) were found to be significantly associated with test anxiety.The factors found to influence examination anxiety among students were volume of materials to study (P=0.044),level of preparation (P=0.005) perceived difficulty of the questions (P=0.033) and myth about examinations (P=0.000).The perceived importance of the examination (P=0.057) and schedule of the exams (P=0.68) did not influence examination anxiety.Conclusion:Candidates for the licensure examination organized by the Nursing and Midwifery Council of Ghana should be assessed for test anxiety and offered the necessary psychological support where necessary.

Keywords:Education,Ghana,licensure,nursing,test anxiety,undergraduate

INTRODUCTION

Summative assessment typically includes the evaluation of individuals after which their progress is summarized at a specific time within a course or program through feedback and a grade.[1]Usually,it emphasizes on the outcome of a task and seeks to monitor educational outcomes.In higher education,the most frequently used summative assessment methods are examinations and written tests.[2,3]Examinations are regarded as useful academic exercise,[4]with varying purposes.They include;making judgments with regards to the skills or knowledge acquired by an individual,evaluating improvement over a specific period,examining strong and weak points,or classifying students whether they should be included or excluded.[5]In nursing and midwifery education,student nurses are challenged with the sine qua non of successfully finishing various forms of assessment of which includes examinations if they are to achieve their goals personally and professionally.[5]

In Ghana,the Nursing and Midwifery Council (NMC),has the mission to ensure the highest standards of not only training but also the practice of nursing and midwifery.The mandate of the NMC is from the Health Professions Regulatory Bodies Act (Act 857).[6]As part of their mission,the NMC thus organizes licensure examinations for student nurses at the end of their training.The assessment procedure is most at times regarded as one of the crucial aspects of a student nurse’s course as it measures students’ competency to practise.[5]This implies that the practice of an individual who has completed the training of nursing would be deemed illegal if the person has not satisfied all the requirements of the NMC.[1]Thus,such a person may face the full rigor of the law.Success in the licensure examination is therefore the only legal requirement to practice as a nurse in Ghana.[7]It is,therefore,not surprising that most students after their stipulated period of training attach so much importance to the licensure examinations.[7]However,a report by the NMC has revealed that a large number of students who sit for the exams fail in their first attempt[7,8]which is attributed to a myriad of factors.One of the main factors that have been linked to such unfortunate outcomes is examination anxiety.[9-13]Examination anxiety is also referred to as test anxiety.

It is normal to have some form of anxiety during examinations as such anxiety may not be entirely bad.Some studies have reported positive impact of moderate anxiety during examinations.[14,15]Kumari and Jain[15]reported that anxiety can compel the student to focus on a given task.On the other hand,too much stress and anxiety during the examination can be distressing to the student and may affect him/her in multifaceted ways including physically,emotionally,socially,and cognitively.[16]Some studies have reported that high test anxiety is likely to lead to poor performance.[10,17]This makes it necessary to identify the factors behind such anxiety to offer the needed guidelines for students when preparing for or writing such examinations.Some factors that have been associated with examination anxiety are fear of failure,[18]inappropriate style of learning,[19]negative and irrational thinking about exams,[18]inadequate rest,examination schedule,[20]excessive course load,[18]gender,[20]previous exams experience,[21]and lack of preparation.[22]

A review of the literature reveals most studies have reported high prevalence of test anxiety among undergraduate students[17,19,23]and high school students,[21,24,25]but those examinations were internal examinations organized by the institutions.Few studies have looked at test anxiety among nursing students.[26,27]Some studies have also examined academic anxiety but not necessarily test anxiety.[28]A study that compared two groups,looked at undergraduate and postgraduate students’ levels of test anxiety.[22]Few studies have reported on examination anxiety of nursing students in Ghana.[27]This study,therefore,seeks to take another look at the determinants of examination anxiety among nursing students in Ghana.If anxiety is a key factor behind the failure of the candidates in Ghana,[8]it may have effect on the health care system of the country since there would be the inadequate number of practicing nurses in the country.[7]Thus,the higher the pass rate,the better would it be for the country.Consequently,identifying the sources of such anxiety is critical for Ghana.

The current study makes three key contributions to literature.It is the first study to evaluate examination anxiety among candidates preparing to write their licensure examinations in Ghana.In addition to the above,the study tries to examine the prevalence of examination anxiety of two groups of undergraduate students,such evidence which is missing in the Ghanaian context.Such comparison is necessary to find out if the duration of the training program has any effect on the candidates’ examination anxiety.Finally,the current study seeks to assess factors influencing examination anxiety among nursing students sitting for an external examination as most studies in literature have focused on examination anxiety among nursing students sitting for internal examinations and not external examinations.The study,therefore,seeks to examine the level of examination anxiety and its influencing factors among degree students of Presbyterian University College,Ghana (PUCG) and diploma students of the Nursing and Midwifery Training College (NMTC),Agogo.

MATERIALS AND METHODS

Study design and setting

To examine the prevalence of examination anxiety among undergraduate and diploma nursing students as well as the influencing factors,a cross-sectional design was used for the study.The study was conducted at the PUCG and the NMTC,Agogo.The former has a department of nursing which trains nursing students for 4 years for the award of Degree while the later trains for 3 years for the award of a Diploma.

Sampling technique and sample size

The convenience sampling method was used to select participants of the study.The population consisted of 274 candidates preparing to write their licensure examination.Using the Krejcie and Morgan sample size estimation formula,[29]a sample size of 159 was arrived at.A total of 160 licensure candidates comprising 80 each from the two the institutions were recruited for the study.

Inclusion criteria

The inclusion criteria were as follows:(1) The student should be in the final year preparing for the licensure examination;(2) The student should be a registered candidate for the Registered General Nursing examinations;(3) The student should provide consent to take part in the study.

Exclusion criteria

The exclusion criteria were students who were not in their final year and refused to wilfully participate or offer consent.

Data collection and instrument

The participants responded to a questionnaire divided into three sections.The first section examined the demographic information of the participants.The second section assessed examination anxiety using the Westside Test Anxiety Scale (WTAS) and the last,factors likely to influence examination anxiety.

Demographic questionnaire

The questionnaire included items on the demographic and social variables of the participants including their age,gender,academic institution,Cumulative Grade Point Average (CGPA).

Westside Test Anxiety Scale

WTAS is a 10-item self-reporting instrument used to measure test anxiety among students.The scale is brief and takes about 8-10 min to administer.It consists of a five-point scale response ranging from always true to never true.The highest score is 50 and the least being 10.The higher the score,the higher the level of test anxiety and vice versa.To determine the level of test anxiety,the score is divided by 10.The score ranges and interpretations are as follows:1.0-1.9 (comfortably low),2.0-2.4 (normal),2.5-2.9 (high normal),3.0-3.4 (moderately high),3.5-3.9 (high),and 4.0-5.0 (extremely high).[30,31]It is a reliable and valid instrument for the measure of anxiety impairment.A Cronbach's alpha coefficient of 0.78 and split-half reliability of 0.77 as well as concurrent validity of 0.51 have been reported.[32]

Predictors of examination anxiety questionnaire

The participants were required to respond to a three-point Likert scale with the options as agree,neutral,and disagree.

Statistical analysis

IBM SPSS Statistics for Windows,version 24.0 (Arrmonk,NY:IBM) was used to analyze data.Descriptive statistics were used to describe the basic features of the data in the study including the age and sex of participants. One-way analysis of variance (ANOVA) was used to determine differences between Degree and Diploma students on test anxiety.Regression analysis was done to identify factors which could predict test anxiety.AP-value was considered to be statistically significant if it was less than 0.05.

Ethical considerations

The participants were informed of the research objectives and were given the opportunity to ask questions for clarification.They were assured of the confidentiality of the collected information and also of anonymity.They were informed of the freedom to withdraw from the study whenever they wanted without facing any negative consequences.Informed consent was obtained from all the subjects by signing the consent form.

RESULTS

Demographic data of respondents

The results from Table 1 showed that majority of the candidates were between 20 and 25 years for both NMTC (diploma) and PUCG (degree) students.Females comprised the majority of respondents in both groups.Majority of respondents had CGPA between 3.0 and 3.59.Most of the candidates studied between 2 and 4 hours in both groups.A combination of personal studies and group discussion was the preferred mode of study in both groups.

Table 1:Demographic data of respondents

Test anxiety among diploma and degree students

The results from Table 2 showed that majority of the Diploma students (58.75%) reported high test anxiety scoring between 3.0 and 5.0 on the test anxiety scale.Only a few,11 (13.75%),16 (20.00%),and 6 (7.50%) reported low,normal,or high normal test anxiety respectively.On the other hand,only 30 (37.5%) of the Degree students reported moderate to extremely high test anxiety with majority (62.5%) reporting low,normal,or high normal test anxiety.

Further analysis was done to find out if the differences between the two groups on test anxiety will be significant using one-way ANOVA [Table 3].The findings showed that participants who offered diploma scored higher mean (M=3.60) for test anxiety than those who offered degree (M=2.95).The difference was significant (P=0.024).

Association between selected demographic variables and test anxiety

Using a univariate analysis,results showed that females had a higher mean score (M=4.03) to high test anxiety than males (M=3.34),thus females experience high test anxiety than males (P=0.009).Furthermore,respondents with older ages recorded lower mean score (M=3.33) for test anxiety than those with younger ages,20-25 years (M=3.86) and 26-30 years (M=3.50).The difference observed among the age groups was statistically significant (0.003).On CGPA,respondents with higher CGPA recorded lower mean score for test anxiety than those with lower CGPA even though this was not significant (P=0.075).Furthermore,respondents with longer or more than 10-hour study recorded lower mean score (M=2.60) than those with 5-7 (M=3.53),8-10 (M=3.53) and 2-4 (M=3.85) respectively.Thus,respondents with longer study hours experience lower or less test anxiety than those with shorter study hours (P=0.001) [Table 4].

Factors influencing licensure examination anxiety

The myth about the licensure examination (P=0.000),inadequate preparation (P=0.005),volume of materials to study (P=0.044),and perceived difficulty of questions (P=0.033) were found to predict test anxiety as shown in Table 5.The perceived importance of the examination (P=0.057) and the schedule of the exams (P=0.680) did not predict test anxiety.

Table 3:Examination anxiety difference among diploma and degree students

Table 4:Association between demographic variables and examination anxiety for both degree and diploma candidates (n=160)

Table 5:Factors predicting examination anxiety

DISCUSSION

The findings of the current study revealed that examination anxiety was significantly high among diploma students than degree students.The above differences could be due to several factors.First and foremost,degree students of PUCGgo through 4 years of nursing education whilst diploma students of NMTC use 3 years.This means that the degree students have an extra year as an added advantage to cover extensively the curriculum.Also,because a Bachelor’s degree is awarded at the end of the 4 years of training,it appears most of the students do not feel pressured as several opportunities exist for them in other sectors apart from the clinical environment.

The finding is consistent with a study conducted by Liet al.[33]who examined anxiety and influencing factors of nursing students in different levels before the National Council Licensure Examination for Registered Nurses (NCLEX-RN).Their study reported that among the 1527 nursing students,154 had mild anxiety,688 with moderate anxiety,and 685 with severe anxiety.The same study also reported that anxiety levels were severe among the lower educational levels as compared to higher educational levels.The percentage of severe anxiety for the various levels was 46.80%,44.83%,and 27.59% for the diploma,advanced diploma,and baccalaureate degree,respectively.Atindanbilaet al.[27]also found that students pursuing Health Assistant Clinical which is a certificate program reported more test anxiety than those pursuing diploma,though their study was not in relation to licensure examination.The current finding is worrying because high test anxiety scores have been linked to low academic performance on the test.[11,12]Considering this reported impact of high test anxiety,then it means high test anxiety can negatively affect the performance of the candidates in the licensure examination.

The study sought to find out demographic factors which influenced test anxiety among licensure candidates.The current study found that gender influenced test anxiety.Females reported high test anxiety than males.Females have been found to be more uncomfortable and self-conscious in testing situations than males.From the cultural point of view,males are socialized not to overtly express how they feel as that is seen as a sign of weakness.Again,males may feel they have a huge social responsibility of making it thus no need to entertain any form of anxiety.In consistent with the current study,other studies have reported that females had high test anxiety than males.[34]On the contrary,Bashiret al.[21]mentioned in their study that females were less likely to develop test anxiety as compared to males.In that study,males had 2.501 times higher odds of having test anxiety.Other studies did not find a significant relationship between test anxiety and gender.[27,35]

The researcher did not find any significant relationship between test anxiety and students’ CGPA.Candidates in the current study may view CGPA as a cumulative record of internal examinations which may not have direct bearing on an external examination like the licensure examinations.Similarly,Dawoodet al.[13]did not find any significant relationship between the test anxiety and GPA.On the contrary,Bashiret al.[21]and Onyeizugbo[32]found that those with high grades were less likely to have high test anxiety.

In the current study,age was found to influence test anxiety which is consistent with other studies.[14]Similarly,a study reported that younger people are more likely to develop anxiety that older people.[36]Several studies did not find any significant relationship between age and test anxiety.[21,35,37,38]The results also showed that students who studied for few hours presented with high levels of test anxiety.The number of study hours is somewhat directly related to the level of preparation.Adequate preparation is likely to boost a student’s self-esteem and self-confidence in taking an examination.Thus,regardless of the likely questions and level of difficulty the candidate can be rest assured that he/she will not be clueless.The finding is consistent with other studies which have cited inadequate preparation as a contributing factor to higher test anxiety.[21,22]It is,therefore,not surprising that the schedule of the exams did not predict test anxiety.If a student is adequately prepared,the student may not be so much worried about the schedule of the exams.

The findings indicated that the myth surrounding the examination is a factor influencing licensure examination anxiety.The licensure examination is surrounded by a lot of myths.Some of these myths come from candidates who have gone through the exams previously.The fact that the examination is being organized by an external body creates a certain impression in the minds of the students.There is a myth that yearly,the NMC has a quota in terms of the number of students they expect to pass the licensure examinations.These myths are usually accepted by the students which affect them psychologically and lead to examination anxiety.Although the NMC has a requirement where examiners meet candidates a day before the examinations,these meetings may not have a significant impact on the candidates for several reasons.First,the examination anxiety may have developed already.Second,the focus of such meetings is to provide the candidates’ information on the dos and don’ts and not necessarily aimed at demystifying the negative perceptions on the licensure examinations.The study by Johnson[39]corroborates the current findings as he also found that myths about NCLEX exams led to anxiety.

The volume of materials to study for the examination was identified to affect anxiety.The end-of-semester examinations in the various institutions usually cover the content that was studied for that particular semester.However,with regards to the licensure examinations,they cover everything that was learnt throughout training.This appears quite burdensome for the students.The perceived burdensomeness of the volume of materials to study might also be due to the fact that students are not prepared adequately and may wait when the examinations is so close before they start to learn.Other studies have reported that too much course load was a factor influencing test anxiety.[40]Regardless of the volume of materials to study,adequate preparation can mitigate its impact on test anxiety.

In addition,the perceived difficulty of the licensure examination was identified as a factor contributing to examination anxiety.This is consistent with the findings by von der Embseet al.[41]When students perceive that the examination is difficult it means they anticipate there are a lot of expectations from them.These expectations may create stress on these students and lead to anxiety.The perceived importance of the examination and the schedule of the exams were not identified as predictors of examination anxiety.Possibly participants in the current study did not consider the examination to be a to do-or-die affair as the NMC gives opportunity to candidates who are referred in the first attempt to re-sit.Furthermore,students were not anxious about writing a paper every day for 3 days.This means that other factors might be contributing to examination anxiety than the perceived level of importance and the schedule of examination.

CONCLUSION

Anxiety has a significant impact on the performance in an examination,hence,the current study sought to examine the level of examination anxiety among two undergraduate nursing student groups and also to find out factors influencing it.The study found that examination anxiety was high among diploma nursing students as compared to degree nursing students.Age,gender,number of study hours were demographic factors found to influence test anxiety.Based on the findings,the following recommendations are made:(1) The NMC of Ghana should collaborate with the training institutions,to hold seminars for students concerning the licensure examinations.This should not be done only before the exams but can begin when the students enter their final year.(2) Candidates should be assessed by psychologists before the licensure examinations.Students who are found with high levels of anxiety should be offered psychological support before they begin the exams.(3) The various health training institutions should teach candidates how to prepare adequately for examinations with more emphasis on deep learning as compared to surface learning since the later does not emphasize on synthesis and application of information which is crucial for success in the licensure examination.(4) Future studies should explore the role of psychological factors like self-esteem in examination anxiety.

Acknowledgement

The researchers would like to express their profound appreciation to licensure candidates of NMTC,Agogo,and PUCG who wholeheartedly and willingly participated in the study.Dr.Paul Adjei Kwakwa is also acknowledged for his time in reading through the manuscript and offering meaningful as well as constructive criticisms.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.