Test Anxiety Among US Medical Students: A Review of the Current Literature

Purpose

Medical students experience anxiety at higher rates than the general public and many are uniquely affected by additional test anxiety throughout their medical education. Although test anxiety has been studied for decades, little evidence has been published suggesting interventions improve examination performance in medical education. Therefore, we set out to review the current literature to elucidate efforts so far and establish trends in research.

Methods

Databases searched included PubMed, EMBASE, PsychINFO, ERIC, SCOPUS, and CINAHL. English language articles published between 2010 and 2021 were loaded into a reference manager to screen out duplicate articles. During the full-text screen and data extraction phase, reference lists were also inspected to identify additional articles for inclusion in the study.

Results

Of 883 studies identified, 860 were excluded resulting in 22 studies for extraction and analysis. First-year (n = 15) and second-year (n = 12) students were primarily tested. Less than 10 included third- or fourth-year students. Self-help and wellness interventions were employed, though interventions ranged from dog therapy to deep breathing techniques to fish oil supplementation. Test anxiety was evaluated using self-report questionnaires, such as the Westside Test Anxiety Scale, Beck Anxiety Inventory, and State-Trait Anxiety Inventory. None of the studies reported improved examination scores.

Conclusion

This review identifies a variety of measurement tools and interventions attempting to mitigate test anxiety. As far as improving examination performance, none of the interventions reported was successful. Further research addressing test anxiety that results in improved medical student academic performance should be conducted and also use established assessment tools.

Current and Future Approaches to Pediatric Anxiety Disorder Treatment

This overview critically appraises the literature on the treatment of pediatric anxiety disorders. The two established treatments for these conditions comprise cognitive-behavioral therapy (CBT) and antidepressant medications. Many youths receiving these treatments fail to achieve remission, which creates a need for new treatments. After summarizing the literature on CBT and currently available medications, the authors describe research that lays a foundation for improvements in the treatment of pediatric anxiety disorders. This foundation leverages neuroscientific investigations, also described in the overview, which provide insights on mechanisms of successful treatment.

A theory of the skill-performance relationship

The skill-performance relationship is a cornerstone of a meritocratic society. People are selected for schools, colleges and jobs based on the premise that more skillful individuals perform better. Scientific understanding of the skill-performance relationship demands that the effect of skill on performance is objectively assessed without subjective, social, and political considerations. One of the best areas for this analysis is sports. In many sports settings, the skill-performance relationship can objectively be examined at the technical, behavioral, psychological, and neurological levels. This examination reveals that skill and performance are inextricably intertwined. While skill affects performance, performance in turn defines and affects skill. To disentangle the previously confusing and interchangeable use of these key constructs, the paper presents a theoretical model specifying that ability and effort have their own direct effects on performance, as well as indirect effects on performance through skill possession and skill execution in cognitive and physical domains of human performance. Thus, ability and skill are not the same. Although skill is a key determinant of performance, recent theory and research suggests that successful performers are successful not just because of their skills per se, but because they take advantage of their skills by creating more occurrences of momentum, making them last longer, and using them to bounce back faster from streaks of unsuccessful performance. Thus, momentum is an important mediator of the effects of skill on performance.

Psychological and physiological effects of an acute bout of yoga before a simulated academic exam in university students

Objective: Test anxiety is common among nursing students. Yoga is one form of physical activity which may be beneficial for pretest anxiety. Participants: Thirteen undergraduate students (85% nursing majors, 15% awaiting program entry, 20 ± 4.9 years of age) completed the crossover design study. Methods: Participants completed a yoga or control intervention (independent quiet study) on opposing testing days. At three time points, participants provided ratings of anxiety (visual analog scales), saliva samples for cortisol and alpha amylase, and seated heart rate variability (HRV, time and frequency domains) was recorded. Results: Yoga prior to a simulated exam had a positive impact on subjective measures of stress but did not positively impact cortisol or HRV compared to the control condition. Conclusions: There may be benefits to participating in 30 min of moderate intensity yoga for reduced perception of stress before a scholarly examination. Further research regarding the impacts of acute yoga on physiological measures of HRV and/or cortisol are warranted.

Emotional processing of math-related words in people with math anxiety

BACKGROUND

Research exploring emotional responses to math-related words in individuals with math anxiety (MA) is scarce. Here, we examined MA participants' subjective emotional processing of math-related cues within Lang's bioinformational model of emotion to further understand the role of those cues in MA.

METHODS

In total, 41 high-MA and 32 low-MA undergraduates rated math-related words, along with neutral, pleasant, and unpleasant words, from the Affective Norms for English Words. The Self-Assessment Manikin was used to calculate valence, arousal, and dominance scores for each word.

RESULTS

The low-MA group rated math-related words as neutral on the three emotional scales, however, the high-MA group rated them lower and higher for valence and dominance than neutral and unpleasant words, respectively. Moreover, math-related words were rated as more and less activating than neutral and unpleasant words, respectively. The two groups significantly differed in scores on the three scales only for the math-related words.

CONCLUSIONS

These results provide evidence that individuals with high MA show altered emotional processing of math-related words, experiencing them as moderately aversive and moderately activating. The findings emphasize that the altered emotional processing of words associated with math should be considered a symptom of MA.

Gendered Performance Gaps in an Upper-Division Biology Course: Academic, Demographic, Environmental, and Affective Factors

Despite the existent gender parity in undergraduate biology degree attainment, gendered differences in outcomes are prevalent in introductory biology courses. Less is known about whether these disparities persist at the upper-division level, after most attrition is assumed to have occurred. Here, we report the consistent presence of gender equity gaps across 35 offerings (10 years) of a large-enrollment upper-division biology course at a research-intensive public university. Multilevel modeling showed that women's grades were lower than men's, regardless of prior GPA. These gender gaps were present even when controlling for students' race/ethnicity, socioeconomic status, first-generation college-going status, international status, and transfer status. Class size, gender representation in the classroom, and instructor gender did not significantly relate to course grades. Student questionnaires in a subset of offerings indicated gendered differences in course anxiety, science identity, and science self-efficacy, which correlated with grade outcomes. These results suggest that women experience differential outcomes in upper-division biology, which may negatively influence their persistence in STEM fields postgraduation. Our findings suggest that gender disparities are a systemic problem throughout the undergraduate biology degree and underscore the need for further examination and transformation of upper-division courses to support all students, even at late stages of their degrees.

Strategies for remediating the impact of math anxiety on high school math performance

Students with math anxiety experience excessive levels of negative emotion, including intrusive and distracting thoughts, when attempting to learn about math or complete a math assignment. Consequently, math anxiety is associated with maladaptive study skills, such as avoidance of homework and test preparation, creating significant impediments for students to fulfill their potential in math classes. To combat the impact of math anxiety on academic performance, we introduced two classroom-based interventions across two samples of high school math students: one intervention focused on emotion regulation (ER) using cognitive reappraisal, a technique for reframing an anxious situation, and the other intervention encouraged students to improve their study habits. The Study Skills (SS) intervention was associated with increased grades for highly anxious students during the intervention period, whereas the ER intervention was less efficacious in countering anxiety-related decreases in grade performance. The SS intervention encouraged highly math-anxious students to incorporate self-testing and overcome avoidant behaviors, increasing academic performance and ameliorating performance deficits associated with increased anxiety that were observed in both groups prior to intervention, and that persisted in the ER group. Notably, the benefits observed for the SS group extended to the post-intervention quarter, indicating the potential lasting effects of this intervention. These results support the hypothesis that using better study strategies and encouraging more frequent engagement with math resources would help highly-anxious students habituate to their math anxiety and ameliorate the negative effects of anxiety on performance, ultimately increasing their math comprehension and academic achievement.

Does anxiety explain why math-anxious people underperform in math?

Math-anxious people consistently underperform in math. The most widely accepted explanation for why this underperformance occurs is that math-anxious people experience heightened anxiety when faced with math, and this in-the-moment anxiety interferes with performance. Surprisingly, this explanation has not been tested directly. Here, using both self-report and physiological indices of anxiety, we directly test how much in-the-moment anxiety explains math-anxious underperformance. Results indicate that in-the-moment anxiety indeed explains why math-anxious people underperform-but only partially, suggesting a need to seriously consider alternative mechanisms. Results also showed that while some highly math-anxious individuals-those with high levels of heart rate variability-experienced less in-the-moment anxiety, they nevertheless performed no better at math. For these individuals, math-anxious underperformance must occur for reasons unrelated to in-the-moment anxiety. More broadly, our findings point to substantial individual heterogeneity in the mechanisms underlying math-anxious underperformance. Accounting for this mechanistic heterogeneity may prove vital for optimally boosting math performance in math-anxious individuals.

Effects of Expressive Writing on "Choking under Pressure" in High Test-Anxious Individuals

(1) Background: High test-anxious students often fail to perform at their actual level and are prone to choking under pressure (CUP). The aim of the present study was to investigate whether expressive writing (EW) can help high test-anxious individuals reduce the degree of the CUP effect, and whether the intervention effects were different in people with different working memory capacities. (2) Methods: High test-anxious participants wrote expressively (EW group) or neutrally (control group) according to guidance, and then completed a modular arithmetic (MA) task under a high-stress condition. (3) Results: The state anxiety score of the control group was significantly higher than that of the EW group in the high-pressure situation, indicating that the EW intervention was helpful to alleviate the state anxiety. Subjects with high working memory capacity in the control group performed the complex MA task significantly less accurately in the high-stress situation than in the low-stress situation, showing the CUP effect. There was no significant difference in complex MA task scores between high- and low-stress situations for subjects with high working memory capacity in the EW group, indicating that the EW intervention can reduce the degree of the CUP effect. (4) Conclusions: EW intervention was effective in reducing state anxiety levels and attenuating the detrimental effects of test stress on cognitive processing in test-anxious individuals with high working memory capacity.

Effects of educational music training on music performance anxiety and stress response among first-year undergraduate music education students

BACKGROUND

The effectiveness of educational music training in lowering stress and performance anxiety among first-year undergraduate music education students is an understudied area. The goal of this study was to determine if educational music training affects first-year undergraduate music education students' stress and anxiety associated with musical performance.

METHODS

A randomized controlled trial design was used in this study. A waiting list group of 35 students and an educational music training intervention group of 35 first-year undergraduate music education students were randomized for the study to commence. The Kenny music performance anxiety (MPA) scale and perceived stress scale (PSS) were used as outcome measures.

RESULTS

The findings show that, among first-year undergraduate music education students, educational music training decreased their stress level associated with music performance [F(1, 68) = 390.751; P = .001, ηp2 = 0.270]. It was also found that after the educational music training, the students reported decreased anxiety level associated with music performance [F(1, 68) = 1375.495; P = .001, ηp2 = 0.344]. Significant interaction effects of educational music training and time on students' stress [F(2, 68) = 127.301; P = .001] and anxiety levels [F(2, 68) = 260.535; P = .001] were also found.

CONCLUSION

Educational music intervention can be successful as a means of reducing anxiety and stress in undergraduate music education students during the first year of study.

Confidence in COVID problem solving: What factors predict adults' item-level metacognitive judgments on health-related math problems before and after an educational intervention?

The advent of COVID-19 highlighted widespread misconceptions regarding people's accuracy in interpreting quantitative health information. How do people judge whether they accurately answered health-related math problems? Which individual differences predict these item-by-item metacognitive monitoring judgments? How does a brief intervention targeting math skills-which increased problem-solving accuracy-affect people's monitoring judgments? We investigated these pre-registered questions in a secondary analysis of data from a large Qualtrics panel of adults (N = 1,297). Pretest performance accuracy, math self-efficacy, gender, and math anxiety were associated with pretest item-level monitoring judgments. Participants randomly assigned to the intervention condition, relative to the control condition, made higher monitoring judgments post intervention. That is, these participants believed they were more accurate when answering problems. Regardless of experimental condition, those who actually were correct on health-related math problems made higher monitoring judgments than those who answered incorrectly. Finally, consistent with prior research, math anxiety explained additional variance in monitoring judgments beyond trait anxiety. Together, findings indicated the importance of considering both objective (e.g., problem accuracy) and subjective factors (e.g., math self-efficacy, math anxiety) to better understand adults' metacognitive monitoring.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1007/s11409-022-09300-3.

Ace Your Self-Study: A Mobile Application to Support Self-Regulated Learning

Without guidance, students typically overestimate their understanding and memory of learning materials, which can have detrimental effects on the learning process. However, most students do not receive guidance or instruction about how to study. Moreover, students are largely unaware of strategies to self-regulate their learning and study effectively. Research has shown that prompting both cognitive and metacognitive strategies is effective to support self-regulated learning (SRL). Therefore we developed a mobile application, the Ace your self-study app, to prompt both cognitive and metacognitive strategies to support learning processes. In this article a theoretical background, description of the app's features and design choices are presented. Also, data from the application in presented to give provide an idea of how the app has been used.

Mathematics–gender stereotype endorsement influences mathematics anxiety, self‐concept, and performance differently in men and women

Mathematics anxiety (MA) is negatively associated with mathematics performance. Although some aspects, such as mathematics self‐concept (M self‐concept), seem to modulate this association, the underlying mechanism is still unclear. In addition, the false gender stereotype that women are worse than men in mathematics can have a detrimental effect on women. The role that the endorsement of this stereotype (mathematics–gender stereotype (MGS) endorsement) can play may differ between men and women. In this study, we investigated how MA and mathematics self‐concept relate to arithmetic performance when considering one's MGS endorsement and gender in a large sample (n = 923) of university students. Using a structural equation modeling approach, we found that MA and mathematics self‐concept mediated the effect of MGS endorsement in both men and women. For women, MGS endorsement increased their MA level, while in men, it had the opposite effect (albeit weak). Specifically, in men, MGS endorsement influenced the level of the numerical components of MA, but, unlike women, it also positively influenced their mathematics self‐concept. Moreover, men and women perceived the questions included in the considered instruments differently, implying that the scores obtained in these questionnaires may not be directly comparable between genders, which has even broader theoretical and methodological implications for MA research.

Math anxiety and deficient executive control: does reappraisal modulate this link?

The literature suggests an interplay between executive control functions and emotion regulation processes, with each playing a key role in math anxiety. We examined the relation between the use of two different emotion regulation strategies (reappraisal and suppression) and the ability to reduce emotional interference in high‐conflict situations (i.e., executive control of attention) in cases of math anxiety. A sample of 107 adults completed emotion regulation tendencies and math anxiety questionnaires and performed a flanker task following the priming of a math‐related or negative word. The findings revealed: (1) highly math‐anxious individuals had difficulty controlling emotional distractions induced by math information, even as simple as math‐related words, in high‐conflict conditions; and (2) the tendency to use reappraisal in everyday situations was associated with math‐anxious individuals’ ability to avoid heightened emotional reactions when encountering math‐related (i.e., threatening) information. These findings point to the efficacy of reappraisal‐focused intervention and suggest an innovative mechanism through which reappraisal reduces emotional reactions and improves performance among math‐anxious individuals, indicating a new way to approach interventions for math anxiety.

Disentangling the effects of trait and state worry on error-related brain activity: Results from a randomized controlled trial using worry manipulations

Enhanced amplitudes of the error-related negativity (ERN) have been suggested to be a transdiagnostic neural risk marker for internalizing psychopathology. Previous studies propose worry to be an underlying mechanism driving the association between enhanced ERN and anxiety. The present preregistered study focused on disentangling possible effects of trait and state worry on the ERN by utilizing a cross sectional observational and a longitudinal randomized controlled experimental design. To this end, we examined the ERN of n = 90 students during a flanker task (T0), which were then randomly assigned to one of three groups (worry induction, worry reduction, passive control group). Following the intervention, participants performed another flanker task (T1) to determine potential alterations of their ERN. Manipulation checks revealed that compared to the control group, state worry increased in the induction but also in the reduction group. ERN amplitudes did not vary as a function of state worry. An association of trait worry with larger ERN amplitudes was only observed in females. Furthermore, we found larger ERN amplitudes in participants with a current or lifetime diagnosis of internalizing disorders. In summary, our findings suggest that the ERN seems to be insensitive to variations in state worry, but that an elevated ERN is associated with the trait-like tendency to worry and internalizing psychopathology, which is consistent with the notion that the ERN likely represents a trait-like neural risk associated with anxiety.

Mathematics anxiety-where are we and where shall we go?

In this paper, we discuss several largely undisputed claims about mathematics anxiety (MA) and propose where MA research should focus, including theoretical clarifications on what MA is and what constitutes its opposite pole; discussion of construct validity, specifically relations between self‐descriptive, neurophysiological, and cognitive measures; exploration of the discrepancy between state and trait MA and theoretical and practical consequences; discussion of the prevalence of MA and the need for establishing external criteria for estimating prevalence and a proposal for such criteria; exploration of the effects of MA in different groups, such as highly anxious and high math–performing individuals; classroom and policy applications of MA knowledge; the effects of MA outside educational settings; and the consequences of MA on mental health and well‐being.

Autonomic Nervous System Response Patterns of Test-Anxious Individuals to Evaluative Stress

Test anxiety is a widespread and primarily detrimental emotion in learning and achievement settings. This research aimed to explore the autonomic nervous system (ANS) response patterns of test-anxious individuals in response to evaluative stress. By presenting a standard interview task, an evaluative scenario was effectively induced. Heart rate variability (HRV), a biomarker that can accurately reflect the ANS activity, was used to reflect the physiological responses of 48 high test-anxious subjects and 49 low test-anxious subjects. Results indicate that: (1) both groups show a significantly increased emotional arousal in the evaluative scenario; (2) high test-anxious individuals show a significantly decreased emotional pleasantness in the evaluative scenario, whereas low test-anxious individuals show no significant changes; (3) both groups show a significantly increased low-frequency HRV; (4) high test-anxious individuals show a significantly decreased high-frequency HRV and root mean square of successive heartbeat interval differences (RMSSD), whereas low test-anxious individuals remain stable. These findings suggest that high test-anxious individuals display an increased sympathetic nervous system (SNS) activity and a decreased parasympathetic nervous system (PNS) activity in response to evaluative stress, while low-anxious individuals display an increased SNS activity and a stable PNS activity in response to evaluative stress.

Relations between prior school performance and later test anxiety during the transition to secondary school

BACKGROUND

When exposed to evaluative situations, up to 40% of students develop test anxiety, reflected, namely, by extensive worry, intrusive thoughts, and physiological arousal. Though the negative influence of test anxiety on later school performance is well documented, the role of students' initial achievement in the development of later test anxiety is less clear.

AIMS AND SAMPLE

To better capture the nature of the relations between prior mathematics and language arts achievement and later test anxiety across genders, this study examined linear and curvilinear relationships among 1,569 French-speaking Canadian students followed across the transition to secondary school, a critical period for test anxiety.

METHODS

Students completed a questionnaire at the beginning and the end of the first year of secondary school, and schools provided us with students grades at the end of 6th grade and the fall of 7th grade.

RESULTS

Multilevel regression analyses showed that only mathematics achievement at the end of elementary school predicted test anxiety at the beginning of secondary school. In secondary school, beginning-of-year achievement in both mathematics and language arts predicted test anxiety at the end of this same year, but different patterns were observed for boys and girls.

CONCLUSIONS

Because nonlinear relations were observed at each timepoint, low achievers may not be the only group of students who are at greater risk of developing high levels of test anxiety. Therefore, interventions targeting students with different achievement profiles might help to reduce test anxiety and facilitate the transition to secondary school.

Relationships between Nursing Students’ Skill Mastery, Test Anxiety, Self-Efficacy, and Facial Expressions: A Preliminary Observational Study

Test anxiety and self-efficacy significantly influence the mastery of nursing skills. Facial expression recognition tools are central components to recognising these elements. This study investigated the frequent facial expressions conveyed by nursing students and examined the relationships between nursing skill mastery, test anxiety, self-efficacy, and facial expressions in a test-taking situation. Thirty-three second-year nursing students who were attending a university in a Korean metropolitan city participated. Test anxiety, self-efficacy, and facial expressions were collected while the students inserted indwelling catheters. Using Microsoft Azure software, the researchers examined the students’ facial expressions. Negative facial expressions, such as anger, disgust, sadness, and surprise, were more common during the test-taking situation than the practice trial. Fear was positively correlated with anxiety. None of the facial expressions had significant relationships with self-efficacy; however, disgust was positively associated with nursing skill mastery. The facial expressions during the practice and test-taking situations were similar; however, fear and disgust may have been indicators of test anxiety and skill mastery. To create a screening tool for detecting and caring for students’ emotions, further studies should explore students’ facial expressions that were not evaluated in this study.

Revisiting the Role of Worries in Explaining the Link Between Test Anxiety and Test Performance

The inverse relationship between test anxiety and test performance is commonly explained by test-anxious students' tendency to worry about a test and the consequences of failing. However, other cognitive facets of test anxiety have been identified that could account for this link, including interference by test-irrelevant thoughts and lack of confidence. In this study, we compare different facets of test anxiety in predicting test performance. Seven hundred thirty university students filled out the German Test Anxiety Inventory after completing a battery of standardized tests assessing general intelligence and mathematical competencies. Multiple regressions revealed that interference and lack of confidence but not worry or arousal explained unique variance in students' test performance. No evidence was found for a curvilinear relationship between arousal and performance. The present results call for revisiting the role of worries in explaining the test anxiety-performance link and can help educators to identify students who are especially at risk of underperforming on tests.

Math Anxiety Is Related to Math Difficulties and Composed of Emotion Regulation and Anxiety Predisposition: A Network Analysis Study

Current evidence suggests emotion regulation is an important factor in both math anxiety and math performance, but the interplay between these constructs is unexamined. Given the multicomponent structure of math anxiety, emotion regulation, and math performance, here, we aimed to provide a comprehensive model of the underlying nature of the links between these latent variables. Using the innovative network analysis approach, the study visualized the underlying links between directly observable and measurable variables that might be masked by traditional statistical approaches. One hundred and seventeen adults completed a battery of tests and questionnaires on math anxiety, emotion regulation, and math performance. The results revealed: (1) state math anxiety (the emotional experience in math-related situations), rather than trait math anxiety, was linked to anxiety predisposition, subjective valence of math information, and difficulties in emotion regulation; (2) the link between state math anxiety and math performance partialed out the link between trait math anxiety and performance. The study innovatively demonstrates the need to differentiate between traits and tendencies to the actual emotional experience and emotion regulation used in math anxiety. The results have important implications for the theoretical understanding of math anxiety and future discussions and work in the field.

Control-Value Theory of Achievement Emotions and Its Relevance to School Psychology

The control-value theory (CVT) of achievement emotions is a well-established theoretical framework which delineates the predictive relationships among distal and proximal antecedents, academic emotions, and student engagement and achievement. Although most research anchored in CVT is conducted by educational psychologists, the theory is arguably applicable to the field of school psychology. In this article, we first provide a brief overview of the theory, with a specific focus on the proximal antecedents (i.e., cognitive appraisals), as well as academic emotions and performance. Given that school psychologists are often consulted with strategies regarding students’ emotional challenges exhibited in the classroom, we then discuss empirical evidence of control- and value-based interventions (e.g., attributional retraining, utility-value), both of which can be posited to address the cognitive appraisals of achievement emotions. Lastly, we discuss the implications of CVT and control- and value-based interventions to school psychologists’ work.

Motivation: bringing up the rear in nursing education. Motivational elements in simulation. The participants' perspective

BACKGROUND

Motivation is a fundamental element of human behavior and learning. We believe that this aspect has not been sufficiently addressed in the field of simulation-based learning in nursing.

PURPOSE

The aim of this study was to explore the views and perspectives of students involved in simulation-based learning related to their process of motivation. Also, to identify the motivational elements they perceived, as well as the aspects that could reduce their motivation in the simulation sessions.

METHODS

A qualitative study was conducted based on content analysis from 7 focus groups composed of simulation students (n = 101).

RESULTS

The study obtained 26 subcategories, 10 categories, and 2 emerging themes (in total, 17 motivational elements and 7 demotivational elements).

CONCLUSION

The motivational elements were related with the non-directive/imposing style of the facilitator, the adequate structure and planning of the sessions, the possibility of transferring what was learned to the real world, and especially the atmosphere created in the simulation session. The main demotivational elements were directed simulation, an uncomfortable environment, and the planning and structure of the sessions (with an excessive theoretical content or with stringent evaluations).

Neural evidence for cognitive reappraisal as a strategy to alleviate the effects of math anxiety

Math anxiety (MA) describes feelings of tension, apprehension and fear that interfere with math performance. High MA (HMA) is correlated with negative consequences, including lower math grades, and ultimately an avoidance of quantitative careers. Given these adverse consequences, it is essential to explore effective intervention strategies to reduce MA. In the present functional magnetic resonance imaging (fMRI) study, we investigated the efficacy of cognitive reappraisal as a strategy to alleviate the effects of MA. Cognitive reappraisal, an emotion regulation strategy, has been shown to decrease negative affect and amygdala responsivity to stimuli that elicit negative emotion. We compared a reappraisal strategy to participants’ natural strategy for solving math problems and analogies. We found that HMA individuals showed an increase in accuracy and a decrease in negative affect during the reappraisal condition as compared to the control condition. During math reappraise trials, increased activity in a network of regions associated with arithmetic correlated with improved performance for HMA individuals. These results suggest that increased engagement of arithmetic regions underlies the performance increases we identify in HMA students when they use reappraisal to augment their math performance. Overall, cognitive reappraisal is a promising strategy for enhancing math performance and reducing anxiety in math anxious individuals.

Does expressive writing or an instructional intervention reduce the impacts of test anxiety in a college classroom?

Test anxiety is a major concern in education because it causes uncomfortable feelings in test-anxious students and may reduce the validity of exam scores as a measure of learning. As such, brief and cost-effective interventions are necessary to minimize the negative impact of test anxiety on students’ academic performance. In the present experiment, we examine two such interventions: expressive writing (Experiment 1) and an instructional intervention (Experiment 2), with the latter developed from a similar intervention for stereotype threat. Across four authentic exams in a psychology class, students alternated between completing the intervention and a control task immediately before completing the exams. Neither intervention was effective at reducing test anxiety or improving exam performance. The present results suggest that these interventions may not be successful in addressing the impacts of test anxiety in all classroom settings.

The Association Between Emotion Regulation, Physiological Arousal, and Performance in Math Anxiety

Emotion regulation (ER) strategies may reduce the negative relationship between math anxiety and mathematics accuracy, but different strategies may differ in their effectiveness. We recorded electrodermal activity (EDA) to examine the effect of physiological arousal on performance during different applied ER strategies. We explored how ER strategies might affect the decreases in accuracy attributed to physiological arousal in high math anxious (HMA) individuals. Participants were instructed to use cognitive reappraisal (CR), expressive suppression (ES), or a “business as usual” strategy. During the ES condition, HMA individuals showed decreases in math accuracy associated with increased EDA, compared to low math anxious (LMA) individuals. For both HMA and LMA groups, CR reduced the association between physiological arousal and math accuracy, such that even elevated physiological arousal levels no longer had a negative association with math accuracy. These results show that CR provides a promising technique for ameliorating the negative relationship between math anxiety and math accuracy.

Medication math dosage assessment anxiety in undergraduate nursing students: A systematic review

BACKGROUND

Medication calculation assessment is commonplace in undergraduate nursing programs. A test is routinely used to assist in the determination of safe medication administration practice in a clinical setting. Multiple factors negatively impact student performance.

AIM

The aim of this article is to analyze current literature related to medication calculation assessment and undergraduate nursing student anxiety.

METHOD

A systematic review was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. Articles included were peer-reviewed publications focused on undergraduate nursing student anxiety related to medication dosage calculation.

FINDINGS

Anxiety related to medication calculation assessments can stem from students' personal lives and previous math experiences. Interventions related to increasing self-efficacy can impact student performance on assessments.

CONCLUSION

A variety of interventions to assist undergraduate nursing students increase performance on assessments were indicated in the literature. Advances in educational technologies allow for more assessment options to facilitate safe medication practices.

Instructor Strategies to Alleviate Stress and Anxiety among College and University STEM Students

While student stress and anxiety are frequently cited as having negative effects on students' academic performance, the role that instructors can play in mitigating these challenges is often underappreciated. We provide summaries of different evidence-based strategies, ranging from changes in instructional strategies to specific classroom interventions, that instructors may employ to address and ameliorate student stress and anxiety. While we focus on students in science, technology, engineering, and mathematics, the strategies we delineate may be more broadly applicable. We begin by highlighting ways in which instructors can learn about and prepare to act to alleviate stress and anxiety. We then discuss how to better connect with students and build an inclusive, equitable, and empowering classroom environment. When coupled with strategies to change student evaluation and assessment, these approaches may collectively reduce student stress and anxiety, as well as improve student performance. We then discuss the roles that instructors may play in empowering students with skills that improve their time management, studying, and approach toward learning, with an eye toward ensuring their success across all their academic endeavors. We conclude by noting areas in which further research is needed to determine best practices for alleviating student stress and anxiety.

Comparative efficacy and acceptability of expressive writing treatments compared with psychotherapy, other writing treatments, and waiting list control for adult trauma survivors: a systematic review and network meta-analysis

BACKGROUND

Expressive writing about a traumatic event is promising in treating posttraumatic stress disorder (PTSD) symptoms in adult trauma survivors. To date, the comparative efficacy and acceptability of this approach is uncertain. Therefore, we aimed to examine the comparative efficacy and acceptability of expressive writing treatments.

METHODS

We included 44 RCTs with 7724 participants contributing 54 direct comparisons between expressive writing (EW), enhanced writing (i.e. including additional therapist contact or individualized writing assignments; EW+), PTSD psychotherapies (PT), neutral writing (NW), and waiting-list control (WL).

RESULTS

EW, EW+, PT, and NW were statistically significantly more efficacious than WL at the longest available follow-up, with SMDs (95% CI) of -0.78 (-1.10 to -0.46) for PT, -0.81 (-1.02 to -0.61) for EW+ , -0.43 (-0.65 to -0.21) for EW, and -0.37 (-0.61 to -0.14) for NW. We found small to moderate differences between the active treatments. At baseline mean PTSD severity was significantly lower in EW+ compared with WL. We found considerable heterogeneity and inconsistency and we found elevated risk of bias in at least one of the bias dimensions in all studies. When EW+-WL comparisons were excluded from the analyses EW+ was no longer superior compared with EW.

CONCLUSIONS

The summarized evidence confirms that writing treatments may contribute to improving PTSD symptoms in medium to long-term. Methodological issues in the available evidence hamper definite conclusions regarding the comparative efficacy and acceptability of writing treatments. Adequately sized comparative randomized controlled trials preferably including all four active treatment approaches, reporting long-term data, and including researchers with balanced preferences are needed.

Factors of choking under pressure in musicians

Under pressure, motor actions, such as those required in public speech, surgery, or musical performance, can be compromised, even when these have been well-trained. The latter is often referred to as 'choking' under pressure. Although multifaceted problems mediate such performance failure in anxiogenic situations, such as compromised motor dexterity and cognitive disruption, the fundamental set of abnormalities characterizing choking under pressure and how these abnormalities are related have not been elucidated. Here, we attempted, first, to classify behavioural, psychological, and physiological abnormalities associated with choking under pressure in musicians and, second, to identify their relationship based on datasets derived from a questionnaire with 258 pianist respondents. Explorative factor analysis demonstrated eight functional abnormalities related to the musicians' choking, such as attention to the audience, erroneous motor actions, perceptual confusion, and failure of memory recall, which however did not include exaggerated attention to the performance. This suggests distraction of attention away from skill execution, which may underlie the spoiled performance under pressure. A structural equation analysis further inferred causal relationships among them. For instance, while failure of memory recall was influenced by passive behaviours manifesting under pressure, erroneous motor actions during performance were influenced by feeling rushed and a loss of body control. In addition, some specific personal traits, such as neuroticism, public self-consciousness, and a lack of confidence, were associated with the extent to which pressure brought about these abnormalities. These findings suggest that distinct psycho-behavioural abnormalities and personal traits underlie the detrimental effects of pressure on musical performance.

Reducing Test Anxiety and Related Symptoms Using a Biofeedback Respiratory Practice Device: A Randomized Control Trial

Test Anxiety is a widespread psychological phenomenon. With prevalence rates of 20-40 percent of university students, it impedes adaptive functioning and life quality. Many available treatments for Test Anxiety involve the intervention of clinicians and usually a few months are required before symptom reduction is reported. The present randomized controlled trial examined a simple behavioral intervention-the use of breathing tools-as an exclusive therapy for Test Anxiety. Specifically, the efficacy of a biofeedback respiratory practice device was examined. 34 students were assigned to 3 treatment groups during their exam period: Biofeedback device group, self-directed breathing exercise group, and psychoeducation group. Self-report measures of Test Anxiety were collected pre- and post-intervention. Participants also reported additional exploratory measures such as depression and anxiety, quality of life, and their perceived adaptive functioning post-intervention. The results reveal that only participants from the biofeedback device group reported a significant reduction in Test Anxiety symptoms (p's < 0.05). Participants from the biofeedback device group also reported a decrease in depression and anxiety symptoms and an increase in psychological wellbeing (p's < 0.05), a subscale of the quality of life questionnaire. Findings support the notion that using biofeedback respiratory devices may reduce students' Test Anxiety symptoms. Indications for further research are discussed.

Home-School Cultural Value Mismatch: Antecedents and Consequences in a Multi-Ethnic Sample Transitioning to College

Qualitative work has documented home-school cultural value mismatch-a mismatch between collectivistic family obligations and individualistic academic obligations-experienced by Latinx first-generation college students during their first year of study at a 4-year university. This study extends prior research by examining home-school cultural value mismatch among a larger, multi-ethnic sample from Latinx, Asian and European American backgrounds (N = 155) in order to quantify the phenomenon and generalize it across multiple ethnic groups. Antecedents and consequences of different forms of mismatch were assessed in separate models. In modeling antecedents, we found that Latinx background, first-generation college status and low parental income were interconnected. However, among these three variables, it was first-generation college status that was the sole predictor of strong collectivistic motives for attending college; these motives were, in turn, associated with more frequent mismatch between family obligation and academic obligation. In addition, being female directly related to mismatch prevalence, as did living close to home. In modeling consequences of cultural value mismatch, frequent home-school cultural value mismatch predicted mental and physical health distress, which predicted academic problems; such problems were, in turn, related to lower grades. Our findings document the generalizability of this experience for first-generation college students from all ethnic backgrounds, as well as the unique experiences of students who identify as female or live close to home. Our findings also reveal the health and academic costs associated with this mismatch. Implications for research, intervention, and institutional change are discussed and have become increasingly important, given recent societal events that require most students to remain closer to home during distance learning.

Systematic review of student anxiety and performance during objective structured clinical examinations

INTRODUCTION

Test anxiety is well studied in higher education, but studies primarily concern traditional assessments, such as written examinations. As use of objective structured clinical examination (OSCE) in pharmacy education increases, a closer examination of non-cognitive factors such as test anxiety is warranted. The purpose of this review was to determine the association between OSCE-associated test anxiety with OSCE performance in health professional students.

METHODS

A literature search was conducted to identify peer-reviewed literature concerning test anxiety in health professional students associated with OSCE. Investigators searched for a combination of OSCE-related terms with anxiety-related terms using PubMed. Articles were included if they assessed OSCE-related anxiety by quantitative or qualitative methods. Data extracted from eligible articles included demographic data, type of the anxiety survey, associations between OSCE-related anxiety and performance, and other student-factors associated with OSCE-related anxiety.

RESULTS

The literature search yielded 339 articles. Nine articles met eligibility criteria and were included in the review. Results included students from medical, pharmacy, dental, and nursing professional programs. Anxiety was assessed via multiple scales. Six out of the eight studies assessing the relationship OSCE-related anxiety and OSCE performance found no association between the two measures. Contrary to literature concerning test anxiety in higher education, female gender was not associated with OSCE-related anxiety.

CONCLUSION

OSCE-related anxiety appears to have minimal to no influence on student performance. Future studies should utilize standardized anxiety assessments and should seek to understand anxiety's effects on student wellbeing and burnout.

Effort Self-Talk Benefits the Mathematics Performance of Children With Negative Competence Beliefs

Children with negative competence beliefs often achieve below their potential in school. This randomized field experiment tested whether engaging in positive self-talk may benefit these children's mathematics performance. Participants (N = 212, Grades 4-6, Mage  = 10.6) worked on the first half of a standardized mathematics test, engaged in effort self-talk ("I will do my very best!"), ability self-talk ("I am very good at this!"), or no self-talk, and worked on the second half of the test. Compared to both the conditions, effort self-talk benefited the performance of children holding negative competence beliefs: It severed the association between negative competence beliefs and poor performance. By internally asserting that they will deliver effort, children with negative competence beliefs can optimize their achievement in school.

Translation of a scale measuring cognitive test anxiety (G-CTAS) and its psychometric examination among medical students in Germany

Aim of the study: Test anxiety expresses itself in a variety of physical and cognitive processes. Due to its influence on test performance, the cognitive component in particular can have a negative impact on those affected. A measuring instrument for this is not yet available in the German-speaking world but does exist in the form of the "Cognitive Test Anxiety Scale" (CTAS), among other languages, in English. The aim of this work was the creation and psychometric review of a German version of the scale (G-CTAS). Methods: A German translation of the scale was created using a forward-backward procedure. Statistical investigations were then carried out on a cohort of medical students, which included an item analysis with calculation of difficulty, variance and item discrimination as well as the determination of the scale's internal consistency. The criterion validity was examined using test performance and gender-specific differences. Results: The final version contains 26 matching items with acceptable item parameters (mean values >1.46, <3.13; variances >0.48; part-whole-discrimination-indices >0.37). Cronbach's alpha was 0.92, the scale was therefore found to be a reliable measuring instrument. The scale validity could be confirmed by significant differences (p<0.01) between total values of female and male participants as well as significant correlations (p<0.001) between total values and test performance in the written and oral part of the first state examination. Conclusion: With G-CTAS a suitable measuring instrument for cognitive test anxiety within the German-speaking world is available, which can be used, among other things, for studies concerning the relationship between stress, exams and test anxiety among medical students.

State and Trait Rumination Effects on Overt Attention to Reminders of Errors in a Challenging General Knowledge Retrieval Task

Rumination is a recurrent and repetitive manner of thinking that can be triggered by blockage of personally relevant goals, creating a temporary state of abstract and evaluative self-focus. Particularly when focused on passive “brooding” over one’s problems and feelings, however, rumination can increase negative affect, interfere with problem-solving, and, through a negative feedback cycle, become a chronic trait-like style of responding to personal challenges, particularly in women. Given the pervasiveness of rumination and its potential impact on cognitive processes and emotional states, the present study asks how it impacts attention to feedback that either reminds individuals of goal-state discrepancies (reminders of errors) or could help to remediate them (corrective information). Using eye-tracking, we examined both state and trait rumination effects on overt measures of attention [first fixation duration (FFD) and total fixation duration (TFD)] during simultaneous presentation of these two types of feedback following failed attempts to answer challenging verbal general knowledge questions (average accuracy ∼30%). After a pre-induction baseline, we induced either a state of rumination using a series of writing exercises centered on the description of an unresolved academic concern or a state of distraction by centering writing on the description of a neutral school day. Within our women-only sample, the Rumination condition, which writing analysis showed was dominated by moody brooding, resulted in some evidence for increased initial dwell time (FFD) on reminders of incorrect answers, while the Distraction condition, which did not elicit any rumination during writing, resulted in increased FFD on the correct answer. Trait brooding augmented the expression of the more negative, moody brooding content in the writing samples of both Induction conditions, but only influenced TFD measures of gaze duration and only during the pre-induction baseline, suggesting that once the inductions activated rumination or distraction states, these suppressed the trait effects in this sample. These results provide some support for attentional-bias models of rumination (attentional scope model, impaired disengagement hypothesis) and have implications for how even temporary states of rumination or distraction might impact processing of academic feedback under conditions of challenge and failure.

Auricular stimulation vs. expressive writing for exam anxiety in medical students - A randomized crossover investigation

OBJECTIVE

Auricular stimulation (AS) is a promising method in the treatment of situational anxiety. Expressive writing (EW) is an established psychological method, which reduces test anxiety and improves exam results. The aim of this crossover trial was to compare AS with EW, and with the no intervention (NI) condition, for treatment of exam anxiety.

METHODS

Healthy medical students underwent 3 comparable anatomy exams with an interval of one month, either performing EW, receiving AS or NI prior to the exam; the order of interventions was randomized. AS was applied using indwelling fixed needles bilaterally at the areas innervated mostly by the auricular branch of the vagal nerve on the day before the exam. Anxiety level, measured using State-Trait-Anxiety Inventory (STAI) before and after the interventions and immediately before exam, was the primary outcome. Quality of night sleep, blood pressure, heart rate and activity of salivary alpha-amylase (sAA) were analyzed across 3 conditions.

RESULTS

All 37 included participants completed the study. Anxiety level (STAI) decreased immediately after AS in comparison with baseline (P = 0.02) and remained lower in comparison with that after EW and NI (P<0.01) on the day of exam. After EW and NI anxiety increased on the day of exam in comparison with baseline (P<0.01). Quality of sleep improved after AS in comparison with both control conditions (P<0.01). The activity of sAA decreased after EW and after AS (P<0.05) but not after NI condition.

CONCLUSION

Auricular stimulation, but not expressive writing, reduced exam anxiety and improved quality of sleep in medical students. These changes might be due to reduced activity of the sympathetic nervous system.

An Empirical Study on the Relationship between Causes of Teacher Examination Anxiety and Dimensions of Coping with Pre-Exam Anxiety: A Structural Equation Modelling Approach

In recent years, examination anxiety among teachers assumes a critical sphere in the global academic environment. The causes of teacher examination anxiety in education have been reviewed by a few scholars. This shows that teacher examination anxiety and its impact on academic development are limited in research. Therefore, this study investigated the linear relationship between two self-report instruments – the causes of teacher examination anxiety and dimensions of coping with pre-exam anxiety. The study adopted a quantitative approach with three-hundred teachers from four secondary schools in Nigeria and twenty teachers from two secondary schools in North Cyprus participated in the survey. Also, a Structural Equation Modeling (SEM) was utilized for the analysis. The results of the study indicate that the two factors (teacher causes of exam anxiety and dimensions of coping with pre-exam anxiety) are interconnected. The results also indicate teachers’ preparation for examinations coupled with various dimensions of anxiety is a complex task that demands educational stakeholders to constantly improving on causes of examination anxiety and factors of pre-exam anxiety among teachers for better academic and ethical development.

Cognitive-Load Theory: Methods to Manage Working Memory Load in the Learning of Complex Tasks

Cognitive-load researchers attempt to engineer the instructional control of cognitive load by designing methods that substitute productive for unproductive cognitive load. This article highlights proven and new methods to achieve this instructional control by focusing on the cognitive architecture used by cognitive-load theory and aspects of the learning task, the learner, and the learning environment.

Music Performance Anxiety: Can Expressive Writing Intervention Help?

Performance is an essential part of music education; however, many music professionals and students suffer from music performance anxiety (MPA). The purpose of this study was to investigate whether a 10-min expressive writing intervention (EWI) can effectively reduce performance anxiety and improve overall performance outcomes in college-level piano students. Two groups of music students (16 piano major students and 19 group/secondary piano students) participated in the study. Piano major students performed a solo work from memory, while group/secondary piano students took a sight-reading exam of an eight-measure piano musical selection. All students performed twice, at baseline and post-EWI, with 2 or 3 days between performances. During the EWI phase, students were randomly divided into two groups: an expressive writing group and a control group. Students in the expressive writing group wrote down feelings and thoughts about their upcoming performances, while students in the control group wrote about a topic unrelated to performing. Each student's pulse was recorded immediately before performing, and each performance was videotaped. Three independent judges evaluated the recordings using a modified version of the Observational Scale for Piano Practicing (OSPP) by Gruson (1988). The results revealed that, by simply writing out their thoughts and feelings right before performing, students who had high MPA improved their performance quality significantly and reduced their MPA significantly. Our findings suggest that EWI may be a viable tool to alleviate music performance anxiety.

Effectiveness of mindfulness-based coloring for university students' test anxiety

Objective: This study compared the effectiveness of mindfulness coloring (mandala), free drawing/coloring, and a noncoloring control activity for university students' test anxiety, and assessed the relationship of dispositional mindfulness and response to intervention on mindfulness and test anxiety states. Participants: University students (n = 167; 81.4% female; M_age = 21.29 years, SD = 4.46) were randomly assigned to a mandala (n = 57), free draw/coloring (n = 58), or noncoloring condition (n = 52). Methods: Participants completed standardized measures assessing test anxiety and state mindfulness pre-postactivity before completing a test, and two dispositional mindfulness measures. Results: Participants in both coloring conditions reported significant decreases in test anxiety and significant increases in state mindfulness pre-postintervention, and participants in the control condition reported significant increases in test anxiety. Reports of preintervention state mindfulness and test anxiety fully mediated relations between dispositional mindfulness and postintervention state mindfulness and test anxiety. Conclusions: Implications for research and practice on mindfulness coloring and test anxiety are discussed.