In the United States, academic stress and test anxiety continue to affect nursing students during their institutional learning experiences. Researchers suggested that nursing students experience more stress in their nursing program than during their first year of employment (Aslan & Akturk, 2018; Evans, Ramsey, & Driscoll, 2010; Kanji, White, & Ernst, 2006; Senturk & Dogan, 2018; Wright et al., 2018). According to Gonzalez, Hooper, Lee, and Lin (2010), a small amount of stress and test anxiety is normal for nursing students during their academic preparation; this was echoed by Ghai, Dutta, and Garg (2014), who indicated that a small amount of stress is healthy and necessary for the production of life. However, too much stress will alter judgment and ability to cope and may increase risk of illness, as students should not experience dizziness, nausea, rapid heart rate, or excessive amount of sweating resulting from test anxiety or academic stress.
Labrague (2013) noted that high-volume course assignments, examinations, and clinical settings are major reasons for academic stress, as reported by students and faculty. The reasons listed for stress in a clinical setting were fear of the unknown; a new workplace; conflict between the ideal and real clinical practice; lack of knowledge regarding patient medical history; diagnoses and treatment; lack of professional nursing skills; providing physical, psychological, and social care to patients; giving medication to children; and the death of a patient. Factors found to increase nursing students' stress and anxiety levels are an unexpected life crisis, the application of theory to practice, fear of failing, and making mistakes (Blomberg et al., 2014; Labrague, 2013; Labrague, McEnroe-Petitte, Leocadio, Van Bogaert, & Cummings, 2018; Oner Altiok & Ustun, 2013; Yonge, Myrick, & Haase, 2002).
Although some nursing students may experience academic stress and test anxiety during their institutional learning experiences, it is suggested that nursing faculty instructional practices are informed by the ethics of their care. The purpose of this mixed-methods study, then, was to examine whether or not a relaxation technique intervention given to first-year Bachelor of Science in Nursing (BSN) students prior to examinations decreased their academic stress and test anxiety. The relaxation technique intervention included breathing retraining, adult coloring, aromatherapy, stretching exercises, guided imagery, and music therapy. Following the relaxation technique intervention, a focus group interview was conducted to provide students with an opportunity to share their lived experiences. The research question guiding the study was: “How nursing students describe the effect of relaxation techniques on their test anxiety and academic stress?”
Watson (1988) is a nursing theorist who focused on the theory of human caring. This theory developed from her own study in a doctoral program. Watson discussed how nurses can guide students from carative to caritas, which is the result of developing the student in the academic setting and continuing the application to the clinical setting. In order for nurse educators to facilitate students' achievement, they should demonstrate an interest in creating an academic setting that decreases students' academic stress and test anxiety. When students learn to decrease anxiety, they are able to develop the critical thinking skills related to nursing care that demonstrate proficiency in the classroom and clinical settings. Relaxation techniques are strategies that enhance relaxation by decreasing the heart rate, blood pressure, and respiratory rate, thus reducing stress and anxiety.
Nursing literature indicates that a significant number of nursing students experience academic stress and test anxiety during the first year of nursing school. Many students are concerned about their academic performance and fear failing the nursing program, which increases their academic stress and test anxiety. Students typically describe their anxiety as a feeling of nervousness and anxiousness characterized by physical symptoms such as palpitations, sweating, and feelings of stress (Fischer & Ehlert, 2018; Shaikh & Kumar, 2013). Although Murdock, Naber, and Perlow (2010) suggested that nursing students should have learned stress management prior to entering the nursing program, many continue to experience academic stress and test anxiety because of the high pressure in the academic learning environment (Labrague, 2013), academic workload, teachers' attitudes toward examinations, and examination outcomes (Chamberlain, Daly, & Spalding, 2011).
Relaxation techniques decrease academic stress and test anxiety among students at all levels of education. Larson, El Ramahi, Conn, Estes, and Ghibellini (2010) discussed elevator breathing and guided relaxation used in their study. They found that “school counselors and teachers can have a scheduled time of the day to teach students how to respond to physiological and psychological responses to stress and anxiety through the utilization of relaxation training” (p. 14). The outcome of the relaxation training was positive for the students, who most likely will continue to use the practices in future classes to reduce their stress and anxiety.
Essential oils, such as lavender, are thought to promote a sense of psychological, physical, and emotional well-being (Kunstler, Greenblatt, & Moreno, 2004; Qadeer et al., 2018). Studies indicate that essential oils are safe and people respond positively to reduced anxiety, signs of distress, and agitation. In addition to essential oils used as a relaxation technique to reduce stress and anxiety, color treatment was suggested by Rhynard (2012) to be useful to manipulate feelings, as colors affected behavior, mood, and physical well-being. Walsh, Chang, Schmidt, and Yoepp (2005) stated “use of the creative arts intervention with BSN students appears to be effective at lowering stress, reducing anxiety, and increasing positive emotions” (p. 332). Nurse educators can include in their instructional practices relaxation techniques appropriate for use during courses, laboratories, and clinical experiences. Bolstering their practices may decrease students' academic stress and test anxiety and increase the likelihood of them being successful in their academic pursuits in the nursing program.
Following IRB approval, 50 students enrolled in a BSN program in suburban New York were invited to participate in this mixed-methods study regarding their perceptions of academic stress and test anxiety. Of them, 45 first-year nursing students (34 women and 11 men) volunteered to participate in the study. Nursing students completed a pretest survey that measured two variables: academic stress and test anxiety. Students were invited to an intervention that consisted of the following relaxation technique sessions: breathing retraining, guided imagery, stretching exercise, listening to music, adult coloring, and aromatherapy using lavender essential oil. A 6-week intervention program included 15 to 30 minutes per week for each relaxation technique session. Following the intervention program, students were instructed to use the relaxation techniques prior to three of their course examinations and one laboratory examination. A posttest survey was disseminated at the end of the semester to determine the effects of the relaxation techniques, which were self-reported by the students. Following the posttest survey, all 45 students were invited to participate in a focus group interview; seven students volunteered to participate in the focus group. A semi-structured interview protocol based on themes identified in the research literature was used to explore students' perceptions of the effect of the relaxation techniques on their academic stress, test anxiety, and matriculation in the nursing program.
A significant finding in this study indicated that after the relaxation technique sessions, nursing students reported a statistically significant (p < .001) decrease in test anxiety and academic stress. Paired t-test results indicated a significant difference in the means between test anxiety pretest and test anxiety posttest among students in a nursing program, indicating there was a decrease in their test anxiety following use of the relaxation technique (Table 1).
Paired-Sample t Test
The anxiety test contained 15 items. Table 1 shows that on a frequency scale, students went from often feeling anxious before a test (M = 2.36) to sometimes anxious (M = 1.98). The academic stress survey contained 11 items. Table 1 shows that on a frequency scale, students went from feeling often stressful (M = 2.54) to sometimes stressful (M = 2.25).
Following the posttest, seven nursing students volunteered to participate in a focus group interview guided by a semistructured interview protocol. This phenomenological approach allowed participants to describe their experiences regarding the effect of the relaxation treatment on their academic stress, test anxiety, and their matriculation in the nursing program. Once the interview data were transcribed, they were coded, analyzed, and interpreted through thematic analysis using units of text from interview data to support emergent themes (Gay, Mills, & Airasian, 2012). The following three themes emerged: Mental and Physical Stress, wherein students expressed feelings of nervousness and physical symptoms associated with anxiousness such as racing heart and sweaty palms because they perceive they will not remember information during examinations and laboratories. This led to the second theme of Fearful of Failure. Participants were fearful about how to deliver care in the clinical setting if they did not pass examinations or laboratories; they indicated the consequence of failing is that ultimately, they would have to leave the program. The third theme, Intention to Stay in the Nursing Program, emerged as participants described the effects of the relaxation techniques. Nursing students stated that prior to learning the relaxation techniques, they were nervous before examinations. After the intervention sessions, they felt that the use of various relaxation techniques prior to their examinations helped to reduce their stress and anxiety. They indicated their intention to stay in the nursing program is increased because they plan to use relaxation techniques to stay calm. Regarding their intention to stay in the program, following are sample focus group responses:
- I am going to do any type of relaxation technique that will help me to stay calm because I want to stay in the program.
- If I listened to music in the classroom before a test to relax then I would do better on exams and I can stay in the nursing program.
First-year nursing students, after receiving a relaxation technique intervention, reported a lower level of academic stress and test anxiety while taking course and laboratory examinations. There was a significant difference between students' reported pretest anxiety and students' reported academic stress, suggesting that students experiencing a high level of test anxiety may also experience a high level of academic stress and vice versa. To triangulate the statistical data, a focus group interview was conducted regarding the effects of the relaxation techniques. The thematic analysis indicated the following emergent themes: Mental and Physical Stress, Fearful of Failure, and Intention to Stay in the Nursing Program. Participants reported prior to the relaxation technique intervention that they experienced academic stress and test anxiety. Participants used the relaxation techniques prior to taking examinations and indicated that guided imagery, adult coloring, and aromatherapy decreased their stress and anxiety while taking examinations. They felt “relaxed, calm, and able to recall material,” which they attributed to the relaxation technique intervention. A result of feeling calm and relaxed, they also indicated their intention to stay in the nursing profession is increased because the relaxation techniques decreased their academic stress and test anxiety.
Given the results of the study, how can nurse educators assist nursing students with reducing their academic stress and test anxiety that have adverse effects on students' intention to stay in the nursing program? Although the sample size in the current study presents a limitation with the generalizability of the results, participants' open-ended responses during the focus group interview endorse the idea that nurse educators should assist nursing students in identifying their stressors and give them the tools to cope with their academic stressors early in the nursing program, which is consistent with Watson's (1988) theory of human caring. Teaching nursing students' relaxation techniques has potential to help them transfer skills learned during the intervention into their health profession when coping with high stress crisis such as illness or death and dying, which are stressors for nurses (Sorensen & Iedema, 2009; Valdez & Nichols, 2013). Gammon and Morgan-Samuel (2005) suggested that nurse educators who recognize the stressors can be proactive and support nursing students.
Results of this study are consistent with those of Supon (2004), Prato and Yucha (2013), and Koren (2017), who indicated that educators should implement effective strategies to assist test-anxious students. Educators realized the impact of testing the students—especially in higher education—and the amount of testing. The students are overwhelmed, which can cause test anxiety if they are studying for multiple tests. In order to assist the students with test anxiety, educators need to be aware of the issue with the students, and students should be encouraged to come forth for assistance.
Findings from the study indicate several ways to assist students with academic stress and test anxiety. By acknowledging testing anxiety at an early stage, students can use relaxation techniques to be successful in their nursing program. Nursing students are under a great deal of physical and mental stress due to their intense training and the high level of expectation for them to deliver impeccable nursing care to patients. Nursing students have to be able to think critically when caring for their patients and to provide accurate and safe nursing care. The results of this study show that use of some relaxation techniques can lower students' stress and anxiety levels and motivate them to stay in the nursing program. Due to the anticipated shortage in the nursing profession (American Association of Colleges of Nurses, 2019), relaxation techniques should be part of the curricula in nursing programs to provide aspiring nurses with institutional learning experiences designed to reduce academic stress and test anxiety, which can motivate them to stay in the nursing program and profession.
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Paired-Sample t Test
| Pretest anxiety||35.47||45||9.21||1.37||4.91||44||0|
| Posttest anxiety||29.71||45||7.23||1.08|
| Preacademic stress||28.01||45||5.19||0.77||4.23||44||0|
| Postacademic stress||24.78||45||5.31||0.79|