test anxiety research thesis

Test anxiety : theory, measurement and intervention

Campus location, principal supervisor, additional supervisor 1, year of award, department, school or centre, degree type, usage metrics.

SYSTEMATIC REVIEW article

Effects of mindfulness on test anxiety: a meta-analysis.

• 1 Department of Psychology, Beykoz University, Istanbul, Türkiye
• 2 Department of Psychology, Yildiz Technical University, Istanbul, Türkiye

Objective: This meta-analysis evaluated the effectiveness of mindfulness-based interventions (MBIs) on test anxiety across diverse age groups and intervention modalities.

Methods: Rigorous inclusion criteria were applied to select studies focusing on MBIs as the independent variable, with test anxiety as the outcome. A comprehensive search across multiple databases yielded 18 primary studies, contributing 20 comparisons. Data were extracted on study characteristics, sample sizes, and intervention details, and were analyzed using a random-effects model.

Results: The analyses incorporated 1,275 participants, with MBIs demonstrating a moderate to large negative effect on test anxiety (effect size = −0.716; 95% CI: −1.383 to −0.049). Moderation analysis indicated that mean age, number of sessions, and intervention delivery mode did not significantly influence effect sizes. Publication bias assessment suggested the presence of bias via Egger’s regression ( p  = 0.025), though Begg and Mazumdar’s test and Duval and Tweedie’s trim and fill method indicated no missing studies.

Conclusion: MBIs are effective in reducing test anxiety, though results should be interpreted with caution due to potential publication bias and unexplained heterogeneity. The impact of MBIs did not vary significantly with participant age, number of sessions, or delivery mode.

Introduction

Exams, which are difficult for students of all ages, cause performance anxiety. It is an important problem in many countries that can affect students’ achievement and academic performance ( D’Agostino et al., 2022 ). Intense test anxiety causes students to feel emotionally and cognitively challenged and helpless and ultimately negatively affects test success. Test anxiety has become a serious problem as it causes many different negative consequences such as low self-esteem, dropping out of school, lack of social skills, performance anxiety, academic failure and the emergence of various psychological problems ( Hughes, 2005 ). On average, one in two students in Organization for Economic Cooperation and Development (OECD) countries worry about the difficulty of exams and feel very anxious even if they are well prepared for the exam, and school-related anxiety is negatively associated with school performance and life satisfaction ( OECD, 2017 ).

Test anxiety has been defined as the emotional, physiological, and behavioral reactions surrounding the possible consequences of negative evaluation in an upcoming test or exam ( Zeidner, 1998 ). Test anxiety has two main sources: anxiety and affectivity. While the anxiety dimension mostly includes cognitive concerns related to one’s performance, affectivity is mostly autonomous reactions to the test situation ( Hembree, 1988 ). Von der Embse et al. (2018) conducted a meta-analysis study on test anxiety for more than 30 years and found that standardized tests, university entrance exams, grade point average, perceived test difficulty, avoidant coping behaviors, achievement goals, age, gender, self-esteem and self-efficacy were related to test anxiety ( Von der Embse et al., 2018 ).

It is generally assumed that the presence of evaluation stress increases state anxiety, especially in individuals with high trait anxiety. People with high trait anxiety are said to be more sensitive to evaluation anxiety. People with high trait anxiety are characterized by their predisposition to perceive threats. According to Eysenck’s Attentional Control Theory, anxiety disrupts the effective functioning of the goal-directed attention system, especially the two executive functions (inhibition and shifting). When anxious thoughts utilize the limited resources of working memory, fewer resources may remain for targeted tasks ( Eysenck et al., 2007 ). As individuals become more aware of where their attention is, they begin to notice the sensations, thoughts and feelings that arise within them. When we realize that we have been distracted or given full attention to a thought, we can slowly return awareness back to the original object of focus and then watch where the mind goes next. Mindfulness can be defined as “noticing the present experience with acceptance” ( Linehan, 1993 ).

Mindfulness is an awareness of thoughts, feelings and bodily sensations. Mindfulness requires directing and accepting attention to what is happening in the present moment without judgment ( Bishop et al., 2004 ). Although its positive effects are known in many psychological problems, it contributes to the success of individuals by reducing their test anxiety to a tolerable level. Many scientific studies have been conducted on Mindfulness based interventions (MBI) ( Kabat-Zinn, 2003 ; Rapgay and Bystrisky, 2009 ; Malinowski, 2013 ). Mindfulness-based programs aim for individuals to learn this approach and use it in their daily lives. Mindfulness-based interventions help individuals to direct their attention to the here and now and learn to approach thoughts differently by realizing that thoughts are just thoughts ( Bishop et al., 2004 ). Mindfulness interventions teach individuals mindfulness-based skills to use more functional strategies by accepting negative thoughts and emotions as they come to mind without judgment ( Segal et al., 2012 ) Individuals increase their awareness through various exercises and practices and learn not to be captive to the negative thoughts that come to their minds. Through mindfulness practices, some cognitive processes such as cognitive flexibility and attention improve ( Kuyken et al., 2010 ).

When we are consciously aware, we experience the world directly, not just through the lens of thought. Thoughts are not reality itself but just symbols and representations that symbolize reality. Mindfulness is in many ways a simple skill, because it only requires using the five senses to become aware of what is happening in the moment ( Cardaciotto et al., 2008 ). While it is easy to be consciously aware for a minute or two, it is difficult to maintain this state of mind. This is against other natural tendencies of the brain. The brain uses its free time to focus on possible problems that need to be solved. This is evolutionarily useful, as it allows us to anticipate threats to our survival. But it is a dysfunctional way to live. Mindfulness is the resource that gives people the security they need, to meet challenging experiences with less resistance. Stress is part of everyday life. In the event of stress, thoughts, emotions and the body are affected and reflected in behavior. Stress distracts attention and concentration, increases anxiety and weakens social skills ( Bartlett et al., 2021 ). Thus, when problems arise, people can act calmly, predictably and get more efficient results. Attention is an important mental power. Through mindfulness techniques the mind trains its attention, can pay more attention to what it wants to achieve and increase performance, it can give more constructive solutions instead of stress and anxiety ( Maran et al., 2021 ).

By training the mind people can bring their attention to daily movements and to the “now” and the activities they are working on. All mindfulness practices draw attention to the present moment. The breath or any other object of focus for mindfulness is always in the present moment. Everything happens in the present moment. When attention is hijacked by a strong sensation or emotion, people lose the present moment. This does not mean that the present moment is really lost; it means that the experience of the present moment is lost. When attention is strong, people can do what they do moment by moment ( Purser and Loy, 2013 ).

Studies have shown that mindfulness approach is effective in regulating students’ anxiety states. Studies have revealed that it affects the density of gray matter in the brain, increases the activation of the prefrontal cortex and reduces the activation of the amygdala, which is activated in situations such as fear and anxiety. Mindfulness interventions leads to permanent and positive changes in anxiety-related areas of the brain ( Lutz et al., 2008a ; Chiesa and Serretti, 2010 ; Goldin and Gross, 2010 ; Hölzel et al., 2011 ; Taren et al., 2013 ; Hernández-Saca, 2016 ). It has been revealed that the amygdala is less activated when individuals add mindfulness practices to their daily practices ( Lutz et al., 2008b ; Goldin and Gross, 2010 ). Researchers believe that “the act of deliberately activating the relaxation response inhibits the activation of the sympathetic nervous system in favor of the parasympathetic nervous system” ( Edenfield and Saeed, 2012 ). During mindfulness meditation, the parasympathetic nervous system is activated ( Edenfield and Saeed, 2012 ). And researchers stated that the anxiety response and the relaxation response cannot coexist at the same time. In summary, when the severity of test anxiety increases and its duration is prolonged, deterioration in the performance and disfunctionality in individual’s lives occurs ( Linsay, 2002 ). One of the methods that can be applied to reduce test anxiety to the desired level is mindfulness intervention techniques. If children and adolescents start to benefit from mindfulness practices, they will be more competent in situations such as life stress, academic evaluation, performance anxiety and exam anxiety that they will face in the future. Mindfulness is called an approach that is a mixture of perception and acceptance of what is perceived; mindfulness is to perceive the present moment with a conscious mind and an open, loving and compassionate heart ( Kiken et al., 2017 ).

In previous studies, there are meta-analysis studies showing that mindfulness interventions are effective in reducing anxiety levels ( Bamber and Morpeth, 2019 ; Breedvelt et al., 2019 ). These meta-analysis studies examined the effect on general anxiety levels. In meta-analysis studies examining the effect of previous test anxiety interventions, they emphasized that the results of techniques including behavioral therapy, cognitive-behavioral therapy and mixed approaches were positive ( Ergene, 2003 ; Von der Embse et al., 2013 ). However, it is seen that mindfulness-based interventions are quite limited in these studies. It is thought that this study will provide guidance for future research and contribute to the comparison of different interventions. Therefore, the aim of the study is to examine the effect of mindfulness-based interventions on test anxiety. It was also examined whether the effects of mindfulness-based interventions varied depending on age, number of sessions, session frequency and intervention delivery format (online or face-to-face).

Inclusion/exclusion criteria

Inclusion criteria.

In line with the aim of the research, the researches obtained from the literature review were evaluated within the framework of the following criteria:

a. Being a research written in English language.

b. Being a research conducted using an experimental design.

c. Conducting the study with students at all levels of education.

d. The intervention to the level of test anxiety in the study is based on mindfulness-based approach.

e. One of the dependent variables of the study is the test anxiety levels of individuals.

f. Including the arithmetic mean and standard deviation values of individuals’ test anxiety levels and the number of participants.

According to the criteria given in the research, firstly, non-English studies were eliminated. Then, non-experimental studies, studies in which the study group was not students, studies conducted with other theoretical orientations, studies that did not include a control group or studies with different dependent variables other than test anxiety were also excluded. As a result of this elimination process, two articles were excluded from the study due to the lack of standard deviation values in two articles and also the control group was not included in the other four studies. For this reason, it was decided to use articles and thesis that met these criteria in the study and 18 studies that met the criteria were identified.

Data selection

In this meta-analysis, we wanted to combine the results of studies that examined the exam anxiety of mindfulness studies in a nonclinical population.

We searched for publications in the major psychological databases Proquest, Science Direct, Springer link, Taylor & Francis, Web of science, Wiley with the descriptors, “mindfulness,” mindfulness studies, exam- test anxiety, mindful breathing, mindful drawing, brief mindful intervention” In addition, we scanned the references and citations of articles, reviews, and meta-analyses. When we found references of dissertations, we additionally checked if they had been published in the meantime. We included all studies that had been published by 2007–2022.

To be included, primary study researchers must have used mindfulness-based interventions with students and measured specifically test anxiety as an outcome. Both undergraduate, graduate, secondary school, college students were included. We included studies of non-clinical student samples (investigator measured). To be included, studies had to be written in English.

We included primary studies with two-group comparisons (MBI vs. control) as well as studies with pre-test/post-test analysis of MBI (one-group MBI). For the two-group comparisons, we included studies with an MBI group and a no-treatment control group. For the pretest/posttest comparison, we included studies where researchers employed single group pre- test/post-test designs.

In this meta-analysis, we adhered to specific inclusion criteria to ensure the rigor and relevance of our investigation. The studies selected for analysis were required to utilize mindfulness-based interventions (MBIs) as the primary independent variable, with a specific focus on test anxiety as the outcome variable. Our analysis was restricted to experimental study designs; consequently, correlational and qualitative studies were excluded. Eligible experimental studies needed to include both pre- and post-test comparisons, as well as a control group. There were no restrictions based on age group; studies encompassing diverse age demographics were included. Language and publication criteria were also established: studies had to be conducted in English and either published in an academic journal or accepted as a master’s or doctoral thesis. Lastly, it was imperative for the studies to provide necessary statistical data, including means, standard deviations, and sample sizes (N) for both experimental and control groups, to facilitate a comprehensive statistical analysis.

Search strategy

Through search conducted in multiple electronic databases up until May 2023, we sought to identify relevant primary studies. The databases consulted included Seven electronic databases were searched for the studies to be included in the study. These are; Proquest, Science Direct, Springer link, Taylor&Francis, Web of Science, Wiley.

Key search terms employed were “mindful” in conjunction with “test anxiety.” The use of an asterisk as a truncation symbol enabled the inclusion of all possible word endings. Furthermore, to maximize the comprehensiveness of the search, subject headings were thoroughly expanded. A follow-up systematic search was executed employing the same methodology to capture any new studies that may have been published or overlooked during the initial search process, thereby ensuring a comprehensive inclusion of relevant literature in our analysis.

Data extraction

To facilitate structured data collection and analysis, a codebook was developed. It included the following components: study reference (author’s last name and publication year), intervention duration (specified as one session, several weeks, etc.), the number of intervention sessions (counting each meeting as a session), mode of intervention delivery (online or face-to-face), utilized measurement tools along with their respective scoring range (minimum and maximum scores), mean age of participants, and for both experimental and control groups, the sample size, pre-test and post-test means and standard deviations. Additional data extracted included the length of each session, the intervention’s domain, and the type of source (academic article or thesis).

Coding process

The coding process used in the research consists of three parts. In the first part, the imprint of the studies is given. In this context, study number, author/authors, year of publication, type of publication are given. In the second section, information about the content of the research is given. In this context, the name of the mindfulness intervention or technique applied in the research, the application period, the name of the scale applied, the number of sessions, the follow-up test, the placebo group, the session duration and the type of application are given. In the last section, coding was made by giving information about the research data, namely the numbers, averages and standard deviation values of the research groups. In the data coding phase, firstly, all studies were filed in a folder in the form of an electronic file with PDF extension. Then, each study was listed in Microsoft Excel worksheet according to author names and study number. A command connection was established between author names and PDF files. Thus, the necessary connection was provided to obtain the desired information during the coding process. In the third part of the coding process, the coding process was completed by including the data related to the research groups, mean and standard deviation values together with the study numbers and author names of the studies on a separate research Microsoft Excel worksheet.

In all of the studies whose effects were analyzed in this study, different scales were used to measure test anxiety. Sarason test anxiety, Revised test anxiety, State trait anxiety, and Test anxiety scale for maths were used to measure pre-test anxiety level.

Data analyses

Data entry was performed in duplicate to ensure accuracy, and any inconsistencies were rectified. Effect sizes for comparisons between treatment and control groups at the conclusion of the interventions were computed using RStudio software (version 2023.12.0 + 369). We employed a random-effects model that postulates variation in true effect sizes across studies, attributable to disparities in participant demographics and intervention protocols. This approach presupposes a normal distribution of the true effect sizes. Each study was allocated a weight inversely proportional to its internal and between-study variance, facilitating the calculation of the aggregate effect size. To adjust for potential small sample size distortions, Hedge’s g values were calculated. Confidence intervals were set at 95%, assuming a standard normal distribution while accommodating a 2.5% margin of error on both extremes. We assessed heterogeneity by reviewing Forest plots and computing the Q statistic for overall variance, T2 for inter-study variance, and I2 to measure the proportion of effect size variability due to genuine differences among studies. Moderator analyses incorporated variables such as participant age, mode of intervention (online versus face-to-face), session count, and intervention length to investigate sources of heterogeneity. For categorical moderators, we applied methods analogous to ANOVA, whereas for continuous variables, we conducted meta-regression akin to multiple regression. Publication bias risk was evaluated through various methods, including funnel plot analysis of standard errors, Egger’s regression, the Begg and Mazumdar rank correlation test, and the Duval and Tweedie trim and fill procedure. This last method entails estimating and adjusting for the number of missing studies that might skew the funnel plot, recalculating the central effect size and variance accordingly. A significant reduction in the overall effect size raised concerns about potential publication bias. MS Office Excel 2007 and Comprehensive Meta-Analysis (CMA) program were used to create the calculations, tables and graphs used in the findings and interpretation section of the study.

A meticulous search strategy was executed across multiple databases to collate studies investigating the impact of mindfulness-based interventions (MBIs) on test anxiety. Our search encompassed articles up to year 2022, ensuring a comprehensive capture of relevant research. The initial retrieval from electronic databases yielded a substantial volume of studies, which was then meticulously refined. Duplicates were systematically removed, leaving 86 studies for closer examination. The first screening stage involved assessing abstracts against our stringent inclusion criteria, which focused on the use of MBIs as an independent variable and test anxiety as an outcome measure. This stage concluded with 27 studies earmarked for full-text review. Each potential study underwent a thorough full-text evaluation to confirm compliance with our inclusion standards. During this scrutiny, studies lacking adequate statistical information, such as pre-test and post-test means and standard deviations, were excluded. Despite efforts to retrieve missing data by contacting authors, some studies were inevitably omitted from further analysis due to incomplete datasets. Of particular note, one study presented two distinct interventions—one delivered online and the other face-to-face both compared against a control group. To account for the unique characteristics and potential differential effects of each intervention mode, we considered these as separate comparisons within our analysis. Another study explored the efficacy of MBIs over varying durations, specifically 3 weeks and 8 weeks, also in comparison to a control group. Given the differential time frames, these were likewise treated as individual studies. Our meticulous selection process culminated in the inclusion of 18 studies, which encapsulated 20 comparisons due to the distinct intervention types and durations within certain studies. This rich dataset provided a robust foundation for our meta-analytical investigation into the effectiveness of MBIs on test anxiety (see Figure 1 ).

Figure 1 . Funnel plot observed effect sizes (Cohen’s d) against standard errors.

Descriptive statistics

The analysis encompassed 18 primary studies, yielding 20 distinct comparisons. The studies included a cumulative total of 1,275 participants, with 595 enrolled in mindfulness-based intervention (MBI) groups (mean = 29.75, SD = 21.61) and 680 in control groups receiving no treatment (mean = 34.00, SD = 28.23). Geographically, the studies were predominantly conducted in the United States (9 studies), followed by Iran (4 studies), and one each in Canada, India, Iraq, Norway, and South Korea. The majority of the studies (15) were journal publications, while the remaining three were doctoral dissertations.

The average age of participants across studies was 18.93 years, with a standard deviation of 4.52. The duration of MBI programs averaged 4.05 weeks, with a standard deviation of 3.03, encompassing an average of 9.2 sessions (SD = 11.43). Out of the 20 comparisons, 15 were conducted face-to-face, and 5 employed online modalities. Descriptive characteristics of these studies are given in Table 1 .

Table 1 . Main characteristics of studies included in the meta-analysis.

Overall summary effect

The meta-analysis, employing a random-effects model, assessed the efficacy of mindfulness-based interventions (MBIs) compared to no-treatment control groups across 20 comparisons. The aggregated effect size was found to be −0.716 (SE = 0.340; 95% CI -1.383 to 0.049; Z  = −2.11, p  = 0.035). This effect size is indicative of a moderate to large negative effect, suggesting a substantial reduction in test anxiety due to MBIs. Notably, the analysis uncovered a high degree of heterogeneity among the studies ( I 2  = 99.95%), with a Q statistic of 104,553.6 ( df  = 19, p  < 0.0001), pointing to substantial variability in the effect sizes across studies. The estimated variance of the true effects ( T 2  = 2.1275), highlighting the diversity in intervention outcomes. The forest plot, illustrating the individual study contributions, underscores the direction and magnitude of these effects. Each study’s impact is represented proportionally, reflecting its relative weight in the overall effect size calculation. In conclusion, the meta-analysis provides an evidence for the effectiveness of MBIs in diminishing test anxiety. The majority of the included studies reported statistically significant effect sizes, affirming the practical significance of MBIs in this area. The negative sign of the effect size aligns with the anticipated outcome of reduced anxiety levels post-intervention.

Publication bias

Upon scrutiny of the funnel plot, asymmetry was observed, indicating potential publication bias. Egger’s regression revealed a significant intercept [ b  = 2.93, 95% CI: 2.74–3.13; t (18) = −2.44, p  = 0.025], suggesting bias presence. In contrast, Begg and Mazumdar’s test did not signal publication bias (Kendall’s tau = 0.63, p  < 0.0001). Duval and Tweedie’s trim and fill method detected no missing studies, implying no adjustment to the effect size was necessary. Due to these mixed findings, caution is advised in interpreting the meta-analytic results ( Figure 2 ).

Figure 2 . Forest plot—Cohen’s d.

Moderation analysis

Moderation analyses were conducted to examine the influence of participant age, number of intervention sessions, and intervention delivery mode on the variability of effect sizes. The meta-regression approach was utilized, treating continuous moderators analogously to a multiple regression framework and categorical moderators through an analysis of variance equivalent. Mean participant age was not a significant moderator of effect sizes in the interventions ( b  = 0.04, SE = 0.08, z  = 0.45, p  = 0.65, 95% CI: −0.12 to 0.19), suggesting that the age of participants did not account for the observed heterogeneity in outcomes. Similarly, the number of sessions constituting the interventions did not significantly moderate the effect sizes ( b  = −0.05, SE = 0.03, z  = −1.59, p  = 0.11, 95% CI: −0.11 to 0.01), indicating that the frequency of sessions was not a determinant of intervention efficacy within the studies considered. The mode of intervention delivery, categorized as online versus face-to-face, was also not a significant moderator (b = 0.054, SE = 0.82, z  = 0.066, p  = 0.95, 95% CI: −1.54 to 1.65), pointing to a similar effectiveness of the interventions regardless of delivery method. No substantial reduction in residual heterogeneity was achieved through the inclusion of these moderators, as indicated by high I 2 values in excess of 99% for all models. Consequently, the significant heterogeneity among studies persists unexplained by these moderator variable ( Figure 3 ).

Figure 3 . Forest plots of mindfulness interventions on test anxiety.

Many meta- analysis have been conducted on the effects of mindfulness for anxiety disorder but not specifically for test anxiety. Centralized exams or exams required for specialization in a field are included in the education systems of all countries, and uncontrollable test anxiety negatively affects physiological, emotional and performance levels of all age groups. Considering the limited studies on test anxiety, which is an indispensable part of the lives of individuals at all age levels and the increasing anxiety levels of various groups as the exams approach, it is thought that there is a need for studies that reveal the effectiveness of mindfulness studies. Therefore, this meta-analysis is conducted for revealing the effect of mindfulness-based interventions on test anxiety.

Researches have shown that mindfulness can affect exam anxiety. Although there are some researches about the interventions of mindfulness on exam anxiety have conducted, no meta-analysis have examined the effects of mindfulness on test anxiety. This article is a meta-analysis of effects of mindfulness interventions on exam anxiety which is conducted with secondary, middle, college, high school and adolescent students sample. At the same time, a limited number of studies examining exam anxiety, which is extremely important for students, have been accessed. The majority of the included studies reported statistically significant effect sizes, affirming the practical significance of MBIs in this area. The negative sign of the effect size aligns with the anticipated outcome of reduced anxiety levels post-intervention.

Although there are many studies demonstrating the positive effect of mindfulness studies on general anxiety disorders ( Spijkerman et al., 2016 ), common psychiatric disorders ( Hedman-Lagerlöf et al., 2018 ), adolescents’ stress, depression, and anxiety in school settings ( Fulambarkar et al., 2023 ), stress management in the general population ( Zhang et al., 2024 ), cognitive performance, emotional problems, stress and coping, resilience in school environment ( Zenner et al., 2014 ), there has been no meta-analysis conducted specifically on the effects of MBSR practices on exam anxiety. This study is important because it is the first study to show that mindfulness-based interventions are effective in reducing students’ test anxiety. According to this research results, MBIs demonstrating a moderate to large negative effect on test anxiety. While supporting the conclusion, we inform that the findings related to publication bias should be taken into account when evaluating the results. Although Duval and Tweedie’s crop and fill method has not detected any missing studies, it is recommended to be careful in interpreting the meta-analytical results. Fulambarkar et al. (2023) conducted a met-analysis of mindfulness studies on adolescents’ stress, depression and anxiety levels in the school setting. As a result of the meta-analysis, the overall effect including stress, depression, and anxiety resulted in a significant improvement with a small effect size.

In a meta-analysis of mindfulness intervention on general anxiety of college students ( Bamber and Morpeth, 2019 ), a certain high effect value was found in the group in which mindfulness meditation was applied compared to the control group. Although there is a meta-analysis on the effect of mindfulness interventions on general anxiety rather than exam anxiety, it was found important to be conducted on student population in order to compare the results.

Another meta-analysis on the effect of mindfulness interventions on the psychological health of children and adolescents ( Kallapiran et al., 2015 ) includes 11 studies and according to the results, it was stated that the psychological health and life satisfaction of children and adolescents in the group with mindfulness intervention increased.

In prior meta-analyses, researchers studied the effects of MBIs on psychological distress and well-being, and attrition rates in university students and adolescents’ stress, depression, and anxiety in school settings ( Fulambarkar et al., 2023 ; Alrashdi et al., 2024 ). There are other meta-analysis about mindfulness intervention effects on anxiety disorders, and anxiety symptoms in clinical and non-clinical samples ( Zhihong et al., 2018 ; Fumero et al., 2020 ; Reangsing et al., 2023 ; Williams et al., 2023 ). Researchers reported that MBIs significantly reduced anxiety in both clinical and non- clinical samples in the youth population and reduced overall anxiety in adult clinical and non-clinical populations.

When the findings of our study were examined, it was found that mindfulness practices had a positive effect on reducing exam anxiety to a reasonable level. When the control and experimental groups of the studies included in the study were compared, it was found that mindfulness practices had a significant effect on reducing test anxiety of students at various levels. Each study’s impact is represented proportionally, reflecting its relative weight in the overall effect size calculation. In conclusion, the meta-analysis provides an evidence for the effectiveness of MBIs in diminishing test anxiety.

In the literature, there is no study examining the effects of MBIs on test anxiety. This study is considered to be the first meta-analysis of school-based MBIs on test anxiety in the academic field. It provides supportive evidence that students from various levels had reduced test anxiety after MBIs. There is a previous meta-analysis that investigated the effect of MBIs on the general anxiety of university students ( Bamber and Morpeth, 2019 ) and the general ES findings of this study are consistent with the results of our meta-analysis study. Another review and meta-analysis is a school-based mindfulness study ( Zenner et al., 2014 ), which included 19 studies and 1,348 students from Grade 1 to Grade 12. The findings of this meta-analysis are similar to ours. It was found that MBIs contributed positively to the psychological well-being of children and youth. And as similar to our study, heterogeneity calculated as high.

When the moderator variables in our study were examined (age, number of sessions, frequency of sessions and type of intervention), it was found that they did not mediate the effect level of mindfulness-based interventions. It is an important result that the studies conducted in a wide age range from middle school students to university students did not show a significant difference at the age level. While mindfulness-based interventions conducted with children and adolescents had significant effects in children but not in adolescents ( Odgers and Jensen, 2020 ), other studies found that mindfulness interventions conducted with children and adolescents did not have any effect according to age ( Zoogman et al., 2015 ; Kander et al., 2024 ). On the contrary, in other studies, age was found to be an important moderator ( Dunning et al., 2019 ; Mettler et al., 2023 ). However, it is useful to emphasize at this point. Although these studies were based on mindfulness, they did not specifically examine its effects on test anxiety and investigated its effects on different variables such as mental health, wellbeing, psychological symptoms, academic achievement, impulsivity, and interpersonal relationships. Looking at the results of the meta-analysis, it can be stated that there is a need for a comprehensive research that reveals the effects of developmental levels as an important moderator. In addition, it should be noted that this study did not include children, but included an age range from middle school to university students and the average age was 18.93.

In this study, it was also observed that other moderator variables such as the number and frequency of sessions and the type of intervention (online or face-to-face) did not have a significant mediating effect of mindfulness-based interventions on test anxiety. This finding is consistent with some of the previous meta-analytic studies on the effects of mindfulness-based interventions ( Zoogman et al., 2015 ; Kander et al., 2024 ). Previously, in a meta-analysis conducted with college students examining the effect of mindfulness on general anxiety, it was shown that the face-to-face and long-term mindfulness studies of MBIs increased the effectiveness ( Bamber and Morpeth, 2019 ). However, in our study, we observed that these differences in practice did not reveal a significant effect. This may be the result of MBIs worked on general anxiety. This made us think that MBI is more effective in more specific problems and groups. We can say that MBIs are more effective in a specific state anxiety such as exam anxiety.

The findings of the study showed that mindfulness interventions reduced test anxiety in student groups at various levels, but since one of the main problems of meta-analysis studies is publication bias, it is necessary to consider the possibility of publication bias.

Implementing mindfulness-based interventions in schools helps students learn efficiently with mindfulness and then demonstrate what they have learned by controlling their anxiety. These interventions can also be beneficial for both students and teachers’ psychological resilience, psychological well-being, self-esteem and prevention of burn out.

Limitations

One limitation in this meta-analysis is the small number of studies that met our inclusion criteria. Additionally, there was significant heterogeneity among studies.

Data availability statement

The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.

Author contributions

EY: Data curation, Methodology, Writing – original draft, Writing – review & editing. ZH: Supervision, Writing – review & editing. FT: Supervision, Validation, Writing – review & editing.

The author(s) declare that no financial support was received for the research, authorship, and/or publication of this article.

Conflict of interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher’s note

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Keywords: mindfulness-based interventions (MBIs), test anxiety, meta-analysis, anxiety, school environment

Citation: Yılmazer E, Hamamci Z and Türk F (2024) Effects of mindfulness on test anxiety: a meta-analysis. Front. Psychol . 15:1401467. doi: 10.3389/fpsyg.2024.1401467

Received: 15 March 2024; Accepted: 29 May 2024; Published: 24 June 2024.

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Copyright © 2024 Yılmazer, Hamamci and Türk. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Eda Yılmazer, [email protected]

Disclaimer: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.

• Open access
• Published: 29 July 2022

Medical science students’ experiences of test anxiety: a phenomenological study

• Majid Badrian 1 ,
• Leila Bazrafkan 2 &
• Mahsa Shakour 3  

BMC Psychology volume  10 , Article number:  187 ( 2022 ) Cite this article

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Introduction

The studies show test anxiety is a common disorder in students that causes academic failure. There are not enough studies and specific theoretical background about test anxiety and ways to deal with it, so the purpose of this study was to do a qualitative study to fully understand the ways to deal with test anxiety in medical Sciences students.

Materials and methods

This is a qualitative study. The participants are the students of the last 2 years of pharmacy, medicine and dentistry at Isfahan University of Medical Sciences. Ten students were selected by purposeful sampling, and interviews continued until the data saturation stage and the lack of access to new data. The data were analyzed by seven-level Colaizzi method.

After analyzing data, about 50 codes were extracted. These codes divided into 16 subclasses, and among them, ultimately five main themes are extracted: “Prayer and Dialogue with God”, “Interaction and communication with friends and relatives”, “studying strategies”, “Finding ways to relax and self-care” and “Negative strategies” were extracted.

Conclusions

The result of this study showed that students often use positive strategies to overcome the test anxiety and try to use positive strategies, but some students are advised of undesirable strategies such as misuse of authorized drugs and writing cheating that that lead to a lot of complex problems. The educational system should do its utmost effort to empower students to manage the anxiety by learning the best strategies.

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One of the concerns of the educational system in universities is the test anxiety [ 1 ]. Test anxiety is a special type of anxiety that is characterized by physical, cognitive, and behavioral symptoms when preparing for the test and performing test, It becomes a problem when high levels of anxiety interfere with preparing for and taking the test. Test anxiety is characterized by severe fear of poor performance in tests [ 2 ]. In fact, the test anxiety is an emotional experience, feelings and anxiety in situations in which a person feels that his/her performance is evaluated [ 3 ]. Test anxiety is defined as the experience of fear, apprehension, and worry before, during, or after a test that can lead to mental distraction, memory impairment, and physical symptoms such as nausea, headache, and tachycardia [ 4 ].

This type of anxiety occurs between the ages of 10 and 12 and increases with increasing age and maximizes in higher education [ 5 ]. According to estimates by researchers in the United States, 15% of students experience different levels of anxiety annually [ 6 ]. In the study by Tsegay et al. [ 7 ] it was reported that the rate of test anxiety in medical students was 52.3% and significantly higher in female students. Test anxiety is important because it affects test success [ 8 ]. Test anxiety can cause academic failure by reducing intrinsic motivation and existing cognitive ability [ 9 ]. Sarason [ 10 ] considers test anxiety as a self-preoccupation, which is characterized by self-defeat and doubt about his/her abilities. this anxiety often leads to negative cognitive assessment, undesirable physiological reactions and the decline of academic performance. As a result, there is a significant reverse relationship between anxiety scores and test scores [ 10 ]. Various studies have shown that test anxiety has a significant and important effect on the academic performance of students. Cassady [ 11 ] showed in his study that students with higher test anxiety had a weaker academic performance [ 11 ].

Students try to cope with anxiety in order to manage it. Coping is the effort to control and manage situations that seem dangerous and tense [ 12 ]. There are two main strategies for coping with anxiety that are known as problem-focused coping and emotion-focused coping strategies. The problem-focused coping strategy in which the main objective is to dominate the position and change in the source of anxiety, and emotion-focused coping strategies in which the main objective is to reduce or transform the emotional disturbance quickly [ 13 ].

Narimany and et al. stated that students manage their anxiety through conventional methods such as: they think about good memories of the past, praying and eliminating negative thoughts and beliefs [ 14 ].

In previous studies, descriptive studies have focused more on estimating the extent to which positive methods have been used, and less on the overall evaluation of all coping strategies that students use. Also, in this study, an attempt has been made to study the strategies of medical students to deal with test anxiety in Eastern and Islamic countries. In Eastern countries, beliefs are different from some other countries where previous studies have been conducted, so its findings can help improve knowledge in this area. On the other hand, this study has selected medical students as the target population because these students face a high volume of difficult. They may also choose different strategies to deal with test anxiety. In this regard, the present study was designed in qualitative study in this target group and conducted with the aim of identifying strategies to deal with test anxiety in medical students.

This study is qualitative. The qualitative research method adopted for this study is interpretative phenomenological analysis (IPA), because IPA is a qualitative thematic approach developed within psychology, focusing on the subjective lived experiences of individuals. The participants were students of pharmacy, medicine and dentistry at Isfahan University of Medical Sciences. A purposeful method was used for targeted sampling. Inclusion criteria included studying in the last 2 years of dentistry, medicine and pharmacy, as well as having the desire to participate in the study. Sampling was continued until data saturation.

This study received ethical approval from the Institutional Review Board (IRB) to which the researchers are affiliated. All study protocols were performed in accordance with the Declaration of Helsinki. This study considered ethical considerations such as the confidentiality of the interviewees’ names and the written consent of interviewees. Interviews were conducted in 2020. Informed consent of every participant was obtained after clearly explaining the objectives as well as the significance of the study for each participant. We advised the participants about the right to participate as well as refuse or discontinue participation at any time they want and the chance to ask anything about the study. The participants were also advised that all data collected would remain confidential.

Data collection was done in a semi-structured interview. The questions were about the test anxiety manage strategies used by students. Interviews continued until data saturation and lack of access to new data. Interview questions were semi-structured and probing questions were asked. Every interview lasted roughly between 30 and 70 min. Interviews were recorded by audio tape and at the earliest opportunity verbatim transcription of interview data was done. Statements were written word-by-word and then were manually coded.

Data was analyzed by the seven-level Colaizzi method. The Colaizzi steps were performed as follows; (1) Transcribing all the participants’ descriptions. participant narratives transcribed from the audio-taped interviews. We didn’t use any software. (2) Extracting significant statements, statements that directly relate to the test anxiety. The researchers repeated all participants’ descriptions and in order to understand these concepts, it was felt by them, then extracted the sentences and vocabulary related to the phenomenon under study and gave a special meaning to each of the extracted sentences. (3) Creating formulated meanings. In this stage, each significant statement is extracted from the participant’s narratives. (4) Aggregating formulated meanings into theme clusters. We organized formulated meanings into groups of similar type. (5) Developing an exhaustive description. An exhaustive description developed through a synthesis of all theme clusters and associated formulated meanings explicated by the researchers. (6) After articulation of the symbolic representation which occurred during the interview. Researchers did an interpretative analysis of symbolic representations for test anxiety. (7) We tried to identify the fundamental structure of the test anxiety by explication’ through a rigorous analysis of the exhaustive description of it.

In order to ensure the accuracy of the data, rigor and trustworthiness was determined based on Guba and Lincholn criteria (1994) which include Credibility, Dependability, Confirmability and Transferability [ 15 , 16 ]. Therefore, we used member checking, researcher creditability, prolonged engagement (semi-structured interview) with the participants, the use of peer debriefing. A follow-up appointment was made between the researcher and each participant for the purpose of validating the essence of the phenomenon with students.

In order to get rigor and trustworthiness data, we established comfortable interactions at the beginning of the interviews, which was maintained until the end of the interview. Participants were also surveyed about the codes for approval after each interview. Data, coding and themes were also reviewed by an expert in this subject.

Ten students participated in the study, of which 7 persons were females and 3 persons were males. Students were selected of pharmacy, medicine and dentistry.

After analyzing the data, about 50 codes were extracted. These codes are divided into 16 subclasses, and among them, ultimately, five main themes, called “prayer and dialogue with God”, “Interaction and communication with friends and relatives”, “studying strategies”, “Finding ways to relax and self-care” and “Negative strategies” were extracted.

Prayer and dialogue with God:  Pray to God and trust in God led to the extraction of this theme. Participant No. 3 stated: “I am asking the mother to pray for me to take my test successfully and reduce my anxiety”. Participant No. 7 stated that “I believe in the Jafar e Tayyar prayers (it is a special continuous prayer for one’s requests from God) and at night before of test, and I would be very calm”.

Participant No. 1 stated that “I already have a good relationship with the Quran (Islam’s book), and I read a Quran page before the test and it calmed me”.

The other subtheme was trusting in God. A student on this subtheme stated that “I vow about tests that I have a lot of anxiety, and this creates peace in me”.

Participant No.3 said: “I trust in God and I ask him to help me, and thereby keep calm down and begin studying with greater focus”.

Interaction and communication with friends and relatives : This theme was included two subthemes: “communication with the family” and “communication with friends”. Participant No. 4 about communication with the family said, “I talk to my parents over the phone at the test night in the dormitory, and they will calm me with their words”.

On communication with friends, Participant No. 10 stated: “I talk to friends who are very intimate and express my anxiety and this reduces my anxiety”. Participant No. 2 said, “I talk to classmates who have a joint test, and talk about the test. This will reduce my anxiety”.

Studying strategies : This theme includes two subthemes: “More effort in education” and “Applying different study strategies”. For “Studying earlier” Participant No. 1 stated that “I’ve been studying for weeks before the test, this will reduce my anxiety”.

Participant No. 4 about using the different strategies of study, said that “I will try to study with other friends (group study) for any test that I have anxiety”. Participant No. 3 stated: “I am studying similar questions to reduce my anxiety”. Participant No. 7 said that; “Reading the summary of the important content that other friends extracting from my booklet and book reduces my anxiety”.

Finding ways to relax and self-care : it was another major theme that was included subthemes: “relaxing activities”, “exercise”, and “consuming Caffeinated beverages”.

Regarding this theme, Participant No. 5 stated that; “When I have anxiety due to the test, I try to listen to my favorite music. This will manage my thoughts and also do not sleep”. Or Participant No. 1 said that; “Walking in the open air helps me become more fluent and calm down”. Participant No. 3 noted that “I usually drink coffee or Nescafe when I have hard and difficult test, this will reduce my anxiety”.

“ Negative strategies ” This theme has two subthemes: “drug abuse” and “rely on cheating”. Participant No. 9 about rely to the cheating said that “I am cheating to reduce the anxiety of the test, even if I do not intend to use it, this makes calm down me”. Participant No. 8 about drug abuse stated that, “I’m eating a Propranolol 10 when I having an overwhelming anxiety”. Participant No. 6 stated that, “I used the Ritalin tablet when I fear from test and anxietyed me, although it did not work as a result of my test”.

In the present study, with a qualitative approach and interviews with students, researchers tried to identify and describe the experiences of strategies for coping with the anxiety of the test among students in dentistry, medicine and pharmacy.

One of the main themes that students use to cope test anxiety is “prayer and dialogue with God”. Students use prayer and dialogue with God to reduce their anxiety. Among the religious and spiritual sources, the greatest source used to reduce anxiety and anxiety is “prayer”. The prayer is derived from the Latin word of precarious meaning “obtained by pray and pleasure” [ 17 ]. The other studies showed praying is an effective strategy to cope with test anxiety. Adroishi et al. [ 18 ] showed that listening to pray could significantly reduce the test anxiety in students. The study of Masomi et al. showed that listening to the Quran sound, such as the sound of music before the test, is an effective strategy for the anxiety test, and the Quran sound is more effective in reducing student test anxiety [ 19 ]. In a study conducted by Narimany et al., 44.5% and 27.5% of the students used the use of prayer as a strategy for coping with anxiety [ 14 ]. Also, training religious values [ 20 ] and spiritual training, including prayer, forgiveness, transcendental and spiritual meditation [ 21 ] have also been reported to reduce the depression and anxiety of students. Ganji et al. also reported that religious beliefs are related with anxiety levels and reduce it [ 22 ]. In Papazisis et al. research, strong religious and spiritual beliefs have positive relationships increasing, the self-confidence, and a negative relationship with depression, anxiety and anxiety as a personality trait [ 23 ].

Based on the findings of various studies, spiritual health determines the integrity of the person, and is the only force that harmonizes the physical, psychological and social dimensions. Religious and spiritual beliefs make a person calm and play a vital role in adapting to tension [ 24 ]. Most people believe that the influence of uncontrollable positions can be controlled through relay to God [ 25 ]. Religion, spirituality, and existential health are important predictors of mental health [ 26 , 27 ].

Another strategy for students to calm down and manage their anxiety was to communicate with those who had some kind of attachment to them. In fact, this communication with people such as parents or intimate friends has made them relaxed and helped them better control the tension of the test. Cassidy and Shaver, in their justification of the relationship between attachment style and mental health, stated that the consequence of a safe attachment process is creating a sense of safety in a person, and the consequence of an unsafe attachment process is to create fear in a person [ 28 ]. Roberts et al. in their justification of this relationship, believe that the psychological consequence of unsafe attachment styles in tension situations is anxiety and depression. The psychological consequence of a safe attachment style in such situations is mental relaxation [ 29 ]. By studying 314 surviving adults from Bam earthquake, Rahimian Bouger et al. found that there was a significant positive relationship between safe attachment style and mental health, and a significant negative relationship between avoidance and ambivalent attachment styles with mental health [ 30 ]. The study of Besharat et al. revealed that the subjects with a safe attachment style rather than an unsafe type and those with an avoidant attachment style had fewer interpersonal problems than ambivalent styles. The results of this study refer to authenticity of safe attachment to the first requirement and its transfer to subsequent generations [ 31 ]. Safford has shown that people with an unsafe attachment style are more likely to experience anxiety and depression [ 32 ].

Morey and Taylor [ 33 ] study, which was similar to the present study in terms of quality with in-depth interviews, found that exercise and talking to friends are two important strategies for students to deal with stress. Fujii [ 34 ] reported that one of the ways to deal with English test anxiety in students is “cooperation with others” and “building confidence”.

Studying strategies which were students’ strategies to cope with test anxiety, can be considered as a kind of sensitization to manage anxiety and manage of the situation. These strategies are effective and positive strategies that can help the student in a constructive way to gain more control and to manage negative thoughts, and reduce his own anxiety through such actions. Motevalli et al. [ 35 ] reported that teaching new and practical study skills helps students manage test anxiety. They found that learning some skills such as time managing for studying, properly review and summarize, how to answer multiple-choice questions, correct/incorrect and descriptive questions can control test anxiety [ 35 ]. Yusefzadeh et al. [ 36 ] reported that based on the findings of a training and evaluation program (teacher 10–35% of the final grade of the course is based on activity during the semester), the implementation of such programs significantly reduces anxiety Students are tested. Ozbiçakçi et al. [ 37 ] also believe that teaching method reduces test anxiety. But L. Hsu mentioned that further research is needed to determine best practices for alleviating student stress and anxiety [ 38 ].

“ Finding ways to relax and self-care ” is the other main theme for coping with test anxiety. It included Relaxing activities, consuming caffeine and Soothing food. Findings of the study by Mojarrab et al. [ 39 ] showed that the use of relaxation techniques along with playing soothing music reduces nursing students’ test anxiety and also improves their clinical test scores. Morey and Taylor [ 33 ] reported that many students believed exercise would distract them from test anxiety and lead to be calm. Walking, running and yoga were among the activities that students focused on, with more emphasis on walking [ 33 ].

In this study, negative strategies were also used to manage the anxiety by the students, such as Unusual use of some medications . Evidences show that the consumption of stimulants and non-drug use of a variety of drugs is one of the threats to students. Several evidences suggest that consuming drug abuse among young prople, especially students, is increasing. Methylphenidate or Ritalin is one of the most widely used drugs that has recently been abused among adolescents, especially students [ 40 ]. Many students take this medicine to stay awake for several hours and to maintain their unusual focuses for a long time. During the tests, the use of such drugs, including Ritalin, increases. Ritalin is the most common prescribed psychotropic drug for children in the USA [ 14 ]. Currently, non-medical consumption of prescription stimulants, including Methylphenidate, is a growing problem among students in the USA. Statistics have shown that 7% of American students have at least once used this drug over their lifetime, and the prevalence of Methylphenidate consumption among students over the course of 1 year was 3% [ 13 ]. In this regard, several studies have reported 3–35% of Ritalin abuse among students [ 41 , 42 , 43 , 44 , 45 , 46 ]. The most common side effects of consuming Ritalin are insomnia, nervousness, anxiety, headache, and loss of appetite. In excessive consumption, restlessness, delirium, psychosis, hypertension, seizure, hyperthermia, and arrhythmias may occur [ 47 ].

Writing cheating was one of the other negative strategies that students used to reduce their test anxiety, although they had no intention of using this cheating during the test. The student, by writing cheat, wants to create a reliance point on himself/herself and thereby calm himself down and overcome his anxiety. In fact, cheating as a reliance point of its existence is an important part of assurance, not to applying it.

The result of this study showed that students often use positive strategies to overcome the test anxiety and try to use positive strategies, but some students are advised of undesirable strategies such as misuse of authorized drug and writing cheating that lead to a lot of complex problems. Given that the test are an important part of academic life and that every student is always involved in a test and study evaluation, the educational system should do its utmost effort to empower students to manage anxiety by learning the best strategies.

Availability of data and materials

The datasets used and analyzed during the current study are not publically available due to ethical restriction and personal data protections but are available from the corresponding author on reasonable request.

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Acknowledgements

The authors thank the students who took part in this study and generously granted us their time and provided us details about their experiences in test anxiety.

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LB conceived the study and was involved in the study design, reviewed the manuscript, analysis, report writing and drafted the manuscript. MB and MSH were involved in the study design, analysis and drafted the manuscript. All authors read and approved the final manuscript.

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Badrian, M., Bazrafkan, L. & Shakour, M. Medical science students’ experiences of test anxiety: a phenomenological study. BMC Psychol 10 , 187 (2022). https://doi.org/10.1186/s40359-022-00896-4

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Interventional Strategies to Reduce Test Anxiety among Nursing Students: A Systematic Review

Manjit kaur khaira.

1 Department of Community Health, Faculty of Medicine, Universiti Kebangsaan Malaysia, Cheras, Kuala Lumpur 56000, Malaysia

2 Faculty of Nursing, University of Cyberjaya, Cyberjaya 63000, Malaysia

Raja Lexshimi Raja Gopal

Suriati mohamed saini.

3 Department of Psychiatry, Faculty of Medicine, Hospital Canselor Tuanku Muhriz, Universiti Kebangsaan Malaysia, Kuala Lumpur 56000, Malaysia

Zaleha Md Isa

Associated data.

The data presented in this study are available in the list of the references.

Nursing students are reported to have moderate to high test anxiety, leading to reduced academic performance, poor self-esteem, and failure to complete the program and practice nursing. This review aims to examine the interventions for test anxiety reduction in nursing students. Following the PRISMA guidelines, peer-reviewed experimental studies published in English between 2016 and 2021 from four databases, EBSCOhost, PubMed, Science Direct, and Scopus, were systematically searched. The findings were presented in tabular and narrative form. Among the 722 studies retrieved, 14 selected studies were critically appraised, guided by the Joanna Briggs checklist for Randomized Controlled Trials and the checklist for Quasi-Experimental Studies, resulting in 11 studies for inclusion in the systematic review. Test anxiety was assessed by different scales. Aromatherapy hand massage, aromatherapy using a diffuser in combination with music therapy, confidence training for test relaxation, coping program, music therapy, emotional freedom technique, animal-assisted intervention, and guided imagery were all found to be effective in reducing test anxiety. In conclusion, while numerous interventions to reduce test anxiety in nursing students were found to be effective, the quality of the studies investigating these interventions was varied with generally small sample sizes and limited follow-up. Future research should be conducted, and the same interventions should be carried out using a larger sample size to strengthen the body of evidence.

1. Introduction

University is one of the most important stages in a person’s life, and in today’s educational system, testing and evaluation have become a high priority in determining a student’s future career path. Students react to test and examination pressure with different emotions, but one prominent emotion commonly found in students is test anxiety (TA).

‘Test anxiety’ refers to the set of phenomenological, physiological, and behavioral responses that accompany concern about possible negative consequences or failure on an examination or similar evaluative situation [ 1 ]. The severity of TA is related to peer pressure, inability to concentrate, concern about previous examinations, and interpersonal issues [ 2 ]. Failure during the examination and the excessive course load [ 3 ], unsatisfactory examination preparation, and discomfort with testing methods were some of the major factors influencing test anxiety.

The heightened autonomic response causing symptoms ranging from perspiration and headaches to severe gastrointestinal disturbances and tachycardia are some of the physiological symptoms experiences before an exam [ 4 ]. In terms of cognitive symptoms, nursing students who experienced some level of anxiety reported specific cognitive symptoms, such as the inability to recall information and negative self-talk during examination [ 5 ]. Anxious students are easily distracted during tests, making it difficult for them to understand instructions.

Nursing education is based on both theory and clinical practice. Tests are an integral part of nursing students’ experience and test anxiety is prevalent among them. Test anxiety (TA) is common in nursing education when students are exposed to assignments and written examinations in the classroom, as well as rating scales, written assignments, e-portfolios, projects on clinical experiences, and examinations, such as the objective structured clinical examination (OSCE) in clinical practice. Test anxiety ranged from moderate to severe among nursing students [ 6 , 7 , 8 ].

Previous research on TA among nursing students found that it was a significant problem that resulted in negative symptoms that were detrimental to academic success. Poor results, low self-esteem, failure to pass the nursing examination, failure to complete the program and practice nursing [ 9 ], and reduced academic performance [ 10 , 11 ] are the outcomes of TA. Exam stress resulted in attentional bias and functional perturbations of a brain circuit that reacted swiftly to test-related threats in highly test-anxious persons [ 12 ], resulting in an underestimating of a student’s performance, hence compromising validity and test bias. Mastery over emotions may lead not only to better simulation outcomes, but also to optimal professional performance and improved healthcare quality [ 13 ].

Therefore, effective therapeutic interventions that employ complementary alternative methods to reduce test anxiety among nursing students are required to reduce the adverse effects of test anxiety.

While there have been studies conducted on specific interventions to reduce test anxiety, there are only a few systematic evaluations on the topic of test anxiety and interventions. Moreover, only two reviews have examined the effectiveness of complementary alternative techniques for reducing test anxiety among nursing students [ 14 , 15 , 16 ]. These two comprehensive reviews determined that music therapy, systematic desensitization, hypnotherapy, relaxation training, stress inoculation aromatherapy, cognitive desensitization, and biofeedback-assisted relaxation training had the ability to treat test anxiety [ 17 , 18 ]. However, there have been no further reviews since the year 2017 on the types of interventional therapies to reduce test anxiety among nursing students.

Therefore, this systematic review aims to investigate papers published after the year 2017 to contribute to the body of knowledge by highlighting the different types of alternative therapies that can effectively address TA among nursing students. As the author’s aim is to synthesize primary studies and explore heterogeneity descriptively rather than statistically, a narrative review was carried out. The review is led by the key research question: What interventional strategies have the potential to decrease nursing students’ test anxiety?

2. Materials and Methods

Following the identification of the review’s objective, a search strategy was used to identify and retrieve the relevant published studies. The articles were screened and appraised, and data were extracted.

2.1. Search Strategy

A preliminary search of the Cochrane Library and the Centre for Reviews and Dissemination was done to access systematic reviews on test anxiety among nursing students before searching a specific database. The search was carried out initially by two reviewers. To find relevant literature, a search strategy was devised. This search strategy was tailored to four databases, EBSCOhost medical collection (MEDLINE, CINAHL, Psychology and Behavioural Sciences Collection), PubMed, Science Direct, and Scopus, using the search terms TITLE-ABS-KEY (“test anxiety” OR “Examination anxiety” OR “Evaluative Anxiety” OR “Evaluation Anxiety”) AND (“Nursing student” OR “student nurse” OR “undergraduate nursing student”) AND (“Interventional strategies” OR “Intervention”). These four major electronic databases were chosen because they are authoritative and include a substantial number of publications in the English language on the subject of test anxiety. They are also commonly used in previously published works. All the searches spanned from databases for publication from the year 2016 to 2021, were journal articles, and are published in English. In addition, the reference to published articles was also searched manually.

2.2. Selection Criteria

The selection criteria were based on the Preferred Reporting Items for Systematic Review and Meta-Analysis: the PRISMA 2020 statement: An updated guideline for reporting systematic reviews [ 19 ]. The primary goal of the search was to locate the literature on test anxiety in the fields of nursing education, psychology, and behavioral sciences. The search was then narrowed to the field of nursing education. Filters were also used to limit the search to full-text articles published in peer-reviewed journals in English over the last 5 years.

The study eligibility criteria were:

• Either quantitative or qualitative experimental study;
• Samples comprised of test-anxious undergraduate nursing students;
• Psychological or educational interventions or alternative therapies to manage test anxiety;
• The primary outcome is test anxiety severity measured by scores on any psychometrically reliable and valid self-report instrument;
• The secondary outcome is the effectiveness of the interventions to manage test anxiety measured by scores on any psychometrically reliable and valid self-report instrument, or through any qualitative data collection and analysis method.

The exclusion criteria for the review include:

• Studies related to pharmacological trials;
• Systematic reviews;
• Articles published in another language;
• Articles published in other fields (apart from nursing);
• Articles published before 2016;
• Articles that include postgraduate nursing students.

2.3. Quality Assessment

Studies that met the inclusion criteria were then assessed for methodological quality using the Joanna Briggs Institute (JBI) critical appraisal tool for systematic review. The Joanna Briggs checklist for Randomized Controlled Trials and the checklist for Quasi-Experimental studies were used to appraise the studies [ 20 ]. The assessment was undertaken by author 1 and author 2 independently and the studies were selected as “Include” and “Exclude”. The decision to include or exclude was based on the appraisal tool items.

2.4. Data Extraction

Data extracted from the included studies were presented in tabular and narrative form using a predefined table. The extracted data included the objective of each study, study design, population (total sample/intervention), instrument, intervention (types and duration), and outcome/results.

The initial search yielded 722 titles. All articles were gathered into a single folder. Duplicates were removed first. The titles and abstracts were reviewed for relevance by the main author and all authors then independently assessed the eligibility of all potential studies based on their full-text reports.

The number of papers was reduced to 90 after examining the titles and removing duplicates, followed by an additional filtering process focused on publication year and inclusion and exclusion criteria. A review of the abstracts of these papers led to a further narrowing to 40 studies, which the authors then reviewed in depth.

Studies that did not meet the inclusion criteria were then excluded, leaving a total of 14 studies. Discrepancies were discussed among all the authors and after a critical appraisal of the 14 studies, another 3 studies were excluded, leaving a total of 11 studies to be included in the review. The PRISMA diagram (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) [ 19 ] depicts the steps in the selection and screening process, as well as the reasons for exclusion. Figure 1 describes the Prisma 2020 Flow Diagram to show search results. Table 1 presents the results of the critical appraisal for RCT studies and Table 2 presents the results of the critical appraisal for quasi-experimental studies.

PRISMA flow diagram.

Results of the Critical Appraisals for Inclusion or Exclusion of Randomised Controlled Trials.

NOTE., Y = yes, U = unclear.

Results of the Critical Appraisals for Inclusion or Exclusion of Quasi-Experimental Design.

NOTE., Y = yes U = unclear, N = no, NA = not applicable.

3.1. General Characteristics of the Included Studies

The review included eleven studies from four different countries. There were four from the United States, two from Iran, three from Turkey, and one from Korea. Five of the studies utilized a quasi-experimental design, five used an RCT design, and one was a mixed-method study that used both an RCT design and a qualitative design. All eleven included studies investigated the effectiveness of the intervention on test anxiety, but one of the studies also evaluated the effect of the intervention on self-efficacy [ 29 ].

Nine studies investigated the effect of the intervention on written tests, with three of them focusing on the effect of the intervention on the objective structured clinical examination (OSCE). The largest sample size was n = 132, while the smallest sample size was n = 14. The number of times an intervention was carried out ranged from one to five times, in a period of 10 min to 60 min, spread out over one day to two weeks. In all 11 studies, post-intervention analysis was performed immediately after the intervention, or after the examination. However, none of the 11 studies included post-intervention follow-ups.

3.2. Characteristics of the Interventions

The eleven studies were all designed to determine the effectiveness of interventions in reducing test anxiety among nursing students. Three studies compared aromatherapy hand massage to unscented hand massage [ 29 ], emotional freedom technique with music therapy [ 24 ], and music therapy with aromatherapy and a combination of both [ 25 ].

Both [ 24 , 29 ] compared the interventions to control groups, whereas [ 25 ] did not compare the interventions to a control group. One study examined the effectiveness of confidence training for relaxation [ 34 ], while another looked at a coping program [ 27 ].

Two studies investigated the effectiveness of aromatherapy on test anxiety [ 26 , 28 ]. The remaining four studies investigated interventions such as emotional freedom technique [ 30 ], music therapy [ 21 ], animal-assisted intervention with dog therapy [ 22 ], and guided imagery intervention [ 23 ]. Six studies compared the level of test anxiety before and after an intervention [ 21 , 24 , 25 , 28 , 29 , 30 ].

Other studies assessed test anxiety levels at the beginning of the term and then after an OSCE examination [ 27 ], before the first examination and then one week after the third examination [ 34 ], one day before the examination and one day after the examination [ 26 ], and before a mid-semester examination and then just before a final examination [ 23 ]. Reference [ 22 ] assesses test anxiety at four different points; pre-pre-test at the time of consent (in the middle of the semester), pre-prior to intervention (start of the next semester), post-immediately after the intervention, and post-post immediately after the examination.

Nine of the included study interventions were solely implemented in nursing institutions, whereas the confidence training interventions were also carried out at home by participants on their own time [ 34 ]. In only one study, the intervention was completely carried out by participants at their own homes daily for one week before the final examination [ 23 ].

3.3. Test Anxiety Measuring Instruments

The State-Trait Anxiety Inventory (STAI) [ 35 ] was the most commonly used tool to measure test anxiety and was used in five studies [ 21 , 22 , 25 , 27 , 30 ]. The STAI, developed by Spielberger in 1983, consists of 40 items with 20 items pertaining to state anxiety and 20 items measuring trait anxiety. The questionnaire has been translated into many languages. State anxiety items include: “I am tense; I am worried” and “I feel calm; I feel secure”. Trait anxiety items include: “I worry too much over something that really doesn’t matter” and “I am content; I am a steady person”. The intensity of the participants’ feelings is rated on a 4-point Likert scale: 1 (not at all), 2 (somewhat), 3 (moderately so), and 5 (very much so). The total score for each 20 items STAI Form ranged from a minimum of 20 to a maximum of 80. Higher scores denote a higher level of anxiety. The reliability and validity of the questionnaire in the research, including the Korean, Turkish, and Persian versions of STAI, varied between 0.86, 0.95, 0.65, and 0.85, respectively.

Two studies [ 29 , 34 ] used the Westside Test Anxiety Scale (WTAS) [ 36 ]. The scale is constructed to measure anxiety impairments, with most items asking directly about performance impairment or about worrying, which interferes with concentration. This instrument involves 10 items on a 5-point Likert scale ranging from 1 (not at all true or never true) to 5 (extremely or always true). Six of 10 items are based on test anxiety, and 4 items are based on worry and dread when taking a test. Each score is tallied, with a possibility of 50 total points, which are then divided by 10 with the results given: 1.0 to 1.9 low test anxiety, 2.0 to 2.5 normal test anxiety, 2.5 to 2.9 high normal test anxiety, 3.0 to 3.4 moderate high-test anxiety, 3.5 to 3.9 high test anxiety, and 4.0 to 5.0 extremely high-test anxiety. As this tool has been used to measure test anxiety in many different studies and has an alpha of 0.78, a split-half reliability of 0.77, and a validity coefficient of 0.51, it was determined to be a well-suited instrument for the studies.

Two other studies [ 23 , 28 ] used the Test Anxiety Inventory (TA Inventory) [ 37 ], which consisted of 25 multiple choice questions rated on a four point scale from 0 to 3 (as “Never”, “Seldom”, “Sometimes”, and “Often”, respectively). Thus, the lowest and the highest possible total scores of the inventory were, respectively, 0 and 75, with higher scores showing higher levels of TA.

The Situational-Continuous Anxiety Inventory [ 24 ], Beck Anxiety Inventory (BAI) [ 38 ], Cognitive Test Anxiety Scale (CTAS) [ 39 ], and Revised Test Anxiety Scale (RTAS) [ 40 ] were used in the remaining studies. All these instruments contained items to which participants reported on a Likert scale of 1–4 whereby a higher score indicates a higher level of test anxiety. The Cronbach’s alpha value of all these instruments were high, ranging between 0.88 to 0.96. Self-efficacy was measured using the General Self-Efficacy Scale (GSES) [ 41 ] in one of the studies [ 29 ].

The Subjective Unit of Distress scale (SUD) [ 42 ] was used to assess the severity of the participant’s symptoms and as a repeated measure to assess the progress of an intervention [ 30 ]. The severity of distress is evaluated by subjects on an 11-point Likert scale. 0 corresponds to absolutely no distress, while 10 corresponds to the maximum possible distress. Cronbach’s alpha and the correlation coefficient for the SUD scale were found to be 0.95 and 0.90, respectively, in this study.

3.4. Test Anxiety Interventions

Three of the studies compared aromatherapy hand massage to unscented hand massage, emotional freedom technique with music therapy, and music therapy with aromatherapy and a combination of the two. One study evaluated the effectiveness of confidence training for relaxation, while another looked at a coping program. Two studies investigated the effectiveness of aromatherapy on test anxiety. The remaining four studies focused on interventions like emotional freedom technique, music therapy, animal-assisted intervention with dog therapy, and guided imagery intervention.

Eight studies investigating the effectiveness of the intervention reported statistically significant results. While there was a significant reduction in test anxiety levels after the implementation of aromatherapy hand massage compared to unscented hand massage [ 29 ], there was no significant reduction reported in the implementation of aromatherapy of lemon essential oil using a handheld nasal inhaler [ 26 ] and through a diffuser [ 28 ]. However, aromatherapy using essential oils in a diffuser in combination with music therapy was found to be more effective than either intervention alone [ 25 ].

Confidence training for test relaxation, which utilizes active physical exercises that seek to control anxiety and adaptive image which improve attitudes (STARS) [ 34 ], and a coping program that included relaxation and soothing techniques, diaphragmatic breathing training, and progressive muscle relaxation training accompanied by light instrumental music [ 27 ], were both reported to be significantly effective in reducing test anxiety among nursing students.

Music therapy was found to be effective in one study [ 24 ], whereas, in another study there was no significant difference in the outcome [ 21 ]. The emotional freedom technique (EFT) was found to be effective in reducing test anxiety in both studies in the review [ 24 , 30 ]. Animal-assisted intervention using dog therapy [ 22 ] and guided imagery [ 23 ] were all found to be effective in reducing test anxiety.

The qualitative findings were categorized into three main contexts, themes, and subthemes [ 21 ]. Anxiety coping methods (positive mindset, listening to music, and spending time with positive-minded friends), students’ perspectives on music therapy (not affecting anxiety about the OSCE, inability to distinguish positive/negative effect, and perceived as a waste of time), and students’ suggestions for reducing anxiety about the OSCE (detailed information about OSCE and more practical applications) were the three main contexts and themes reported. Focus group interviews with students revealed that music was suitable for lowering anxiety regularly, but not before an exam. The details of the test anxiety interventions are summarized in Table 3 .

Summary of results of extraction-test anxiety interventions.

4. Discussion

This systematic review’s purpose was to examine the effectiveness of interventions in reducing test anxiety among nursing students. The eleven papers that investigated the effectiveness of therapies on test anxiety in nursing students were found and analyzed. Eight out of the eleven studies reported a statistically significant reduction in the level of TA experienced by nursing students. The findings of the review corroborate those of previous systematic reviews and meta-analyses of TA and its interventions evaluated in various student populations [ 15 , 16 , 17 , 18 , 43 , 44 , 45 ].

In contrast to the systematic review conducted by [ 18 ], our review did not attempt to examine the contributing factors to test anxiety or the effect that test anxiety has on academic achievement, however, it expands Shapiro’s review in several ways. While Shapiro’s review was from studies dated 2002 to 2012 and included both intervention and non-intervention studies, as well as grey literature and studies that include both graduate and prelicensure students, our review focused exclusively on peer-reviewed studies on interventions for TA in nursing students carried out after the year 2016.

This review suggests that test anxiety is a significant health problem affecting nursing students, as evidenced by studies investigating the effectiveness of an intervention to reduce it. While test anxiety is a universal problem and research on the subject has been conducted extensively throughout Asia, North America, and Europe, only limited studies in a few geographical locations such as Turkey, the USA, Korea, and Iran met the inclusion criteria of this review. This could be due to a limitation in the review inclusion criteria, or it could indicate the need to broaden this research into a global context.

The interventions found to be effective in reducing test anxiety varied, and a few were evaluated in more than one study. Two out of the four studies examining aromatherapy in this review found aromatherapy to be effective in reducing test anxiety. However, aromatherapy was delivered differently in these studies. While aromatherapy delivered through hand massage for 10 min [ 29 ] and air diffusion using a lamp for 20 min were both found to be effective in reducing test anxiety, a combination of aromatherapy and music therapy was found to be more significant in reducing test anxiety [ 25 ]. Aromatherapy using lavender, on the other hand, administered via humidifier and handheld nasal inhaler did not result in a reduction in anxiety [ 26 , 28 ]. This finding contradicts the findings of a review by [ 18 ], who found that aromatherapy, particularly lavender, was effective in reducing test anxiety among nursing students. However, the small sample size in comparison to the larger sample size in Shapiro’s review may have influenced the outcome. These findings also contradicted the findings of the review by [ 46 ], where aromatherapy using essential lemon oil diffused in a classroom reduced test anxiety of the nursing students.

Confidence training for the test which utilizes active physical exercises [ 34 ] and a coping program that included relaxation and soothing techniques, diaphragmatic breathing training, and progressive muscle relaxation training accompanied by light instrumental music [ 27 ], were found to be effective, however, due to the small sample size in this study, larger studies are required to replicate these findings. While a recent systematic review with a larger sample size found exercise to be effective in alleviating students’ test anxiety [ 16 ], the studies included in the review were not specifically on nursing students.

The emotional freedom technique (EFT) was found to be effective in reducing test anxiety in both studies in this review [ 24 , 30 ]. The findings of the studies in this review correlated with findings by [ 47 , 48 ] who found EFT to be an effective tool in reducing anxiety and stress among nursing students. A similar finding was found in a review of interventions to reduce stress, anxiety, and depression [ 49 ].

While music therapy was found to be effective in reducing test anxiety before an OSCE [ 24 ], a focus group interview reported otherwise as they claimed that while music therapy helps to reduce anxiety in their daily lives, it was not effective before an OSCE [ 21 ]. However, a reduction in test anxiety was noted when music therapy was used in combination with aromatherapy [ 25 ]. As both the studies on music therapy in this review focused only on test anxiety before an OSCE, further studies on the effectiveness of music therapy to reduce test anxiety before examination besides the OSCE are needed as the findings of the review by [ 18 ] did indicate that music therapy reduced test anxiety among nursing students. This finding correlated with similar findings among undergraduate students, whereby the findings suggest a benefit of music therapy among nursing students and other undergraduate students experiencing test anxiety [ 50 , 51 ].

Guided imagery and animal-assisted intervention using dog therapy in this review were both found to be equally effective in reducing test anxiety [ 22 , 52 ]. The finding in this review correlated with studies on the effectiveness of guided imagery in reducing test anxiety among nursing students [ 53 ] and other categories of students in colleges [ 54 ]. Similarly, animal-assisted interventions were found to reduce the anxiety of pharmacy and physical graduate students before a practical exam [ 31 ].

An evaluation of the designs, samples, interventions, procedures, tools, analyses, and findings provided in the publications demonstrated good reporting quality in this review. Most studies provided adequate information to allow replication of the interventions, and the effectiveness of the interventions was assessed using a valid and reliable instrument. The State-Trait Anxiety Inventory (STAI), a well-known and established instrument for assessing test anxiety, was used in most of the studies because of its high levels of both internal reliability and validity. However, when completing self-report measures of anxiety, nursing students at each institution may favor the intervention out of a desire to assist instructors or researchers.

The studies were conducted at a nursing institution, which increased their logical validity. Although sufficient statistical analysis was provided in most studies, the absence of power analyses, the smaller sample size in some of the studies, and the restriction of all investigations to single institutions limit the generalizability of the study findings.

The positive effects of intervention strategies on test anxiety may not have lasted if the possible impact of test anxiety symptoms on individuals were directly affected because the therapies in the review were not generally evaluated over an extended period.

5. Limitations

This review has several limitations. Firstly, the search was limited to English-language, peer-reviewed research. Excluding published studies that were not peer-reviewed and reported in a different language may have restricted the possibility to provide a more comprehensive assessment of the effectiveness of various types of interventions in reducing test anxiety. Secondly, although there is a large amount of literature on test anxiety, there is limited information about strategies to minimize test anxiety in nursing students, and therefore only 11 studies were selected for the review. The third limitation of this review is that different outcome measurement instruments were utilized in the included studies. A quantitative analysis (meta-analysis of the data) was not possible due to the heterogeneity between studies that resulted from differences in the types of interventions, sample sizes, and scales used.

6. Future Direction

Additional rigorous research and long-term monitoring of outcomes are required to corroborate these findings. In the future, larger-sample, higher-quality RCTs will be required to allow the analysis of the results of a meta-analysis. Further research is required that explicitly describes the lived experiences of university students and nursing students in relation to therapies for test anxiety. With this information, a more complete picture of the experience of test anxiety and the success of treatments may emerge. In addition, future research should study the minimal intervention duration and the question of whether a shorter intervention period might ease students’ test anxiety in a timely and effective manner. Furthermore, because test anxiety is a situation-specific condition, future research should also include when post- and follow-up assessments are conducted so that the efficacy of interventions can be better determined. All university students are anticipated to continue experiencing test anxiety in the future. Educators should explore adding interventions to prevent, manage, and minimize test anxiety in students, despite the limited evidence base for each specific intervention.

7. Conclusions

It cannot be argued that test anxiety will persist as long as exams are given, however, the issue of test anxiety cannot be disregarded. In light of the changing educational environment and the pressures experienced by nursing students, research to determine effective interventions to cope with test anxiety is essential. This review updated the findings of the review [ 17 , 18 ] in which both aromatherapy and music therapy interventions were found to be effective. This review compared both these interventions with other more recent types of interventions. Although aromatherapy, Confidence Training for Tests Relaxation (STARS), the Emotional Freedom Technique (EFT), a coping program that included relaxation and soothing techniques, diaphragmatic breathing training, and progressive muscle relaxation training accompanied by light instrumental music, and music therapy, were reported to be effective in reducing test anxiety among nursing students, the smaller sample size in some of the studies and the heterogeneity of the results make it difficult to conclude that these interventions are effective.

Our current review updating the findings of [ 17 , 18 ] indicated a lack of empirical evidence of effective interventions to lower nursing students’ test anxiety. This review’s findings suggest the need for additional studies on effective methods to assist nursing students on how to manage test anxiety. While the current use of interventions requires further research to determine the success and gaps, educators need this review of the literature to understand the existence of various types of interventions and how these interventions can help students overcome test anxiety. Furthermore, due to a lack of evidence for long-term effectiveness, we recognize the need for further research on these interventions’ post-implementation.

While this paper could only capture the existing literature, we believe the next stage of literature needs to address broader implications than short-term test anxiety-reducing interventions in order to achieve institutional strategies, such as student well-being and success.

Funding Statement

The authors received funding from the Fundamental Research Grant, Universiti Kebangsaan Malaysia (FF-2021-388).

Author Contributions

M.K.K. conceived and designed the study. M.K.K., Z.M.I., R.L.R.G. and S.M.S. screened the title and abstract and critically appraised the selected studies. M.K.K. wrote the manuscript. Z.M.I. and S.M.S. reviewed and edited the manuscript. M.K.K., Z.M.I., R.L.R.G. and S.M.S. contributed to the final manuscript. All authors have read and agreed to the published version of the manuscript.

Institutional Review Board Statement

Not applicable.

Informed Consent Statement

Data availability statement, conflicts of interest.

The authors declared no conflict of interest.

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