Relationship between mindfulness, test anxiety, and academic performance among nursing students

Abstract

BACKGROUND:

The content of mindfulness-based social-emotional learning (MBSEL) concentrates on conscious attention to thoughts, emotions, and bodily senses, which reduces test stress and anxiety and also leads to an increase in students’ performance regarding stress management and improving responsible behaviors. This study aimed to explore the relationship between the degree of test anxiety and the level of students’ mindfulness and the academic performance of nursing students.

MATERIALS AND METHOD:

This descriptive cross-sectional study was conducted during 2021–2022, and the target population included all nursing students of the Faculty of Nursing and Midwifery, Shiraz University of Medical Sciences, Shiraz, Iran. The sample size is determined by Cochran’s formula (151 participants). The sampling method was also simple random. The Sarason’s test anxiety questionnaire and the short form of the Freiburg Mindfulness Inventory were used to collect data. The student’s academic performance was also evaluated based on their previous academic semester scores. Data were analyzed by SPSS version 23 software through descriptive statistics, Pearson correlation coefficient, and an independent t-test.

RESULT:

According to the Pearson correlation coefficient, there was an inverse and significant correlation between the variable of mindfulness and the level of test anxiety in nursing students (r = -170, P = 0.033), a positive and significant correlation between academic performance and mindfulness (r = 0.284, P = 0.001), and a negative and significant correlation between academic performance and test anxiety level (r = -0.170, P = 0.037).

CONCLUSION:

Mindfulness-based cognitive therapy is effective in reducing negative thoughts, ineffective attitudes, depression, stress, and anxiety, and this therapy strategy can be used to reduce or treat anxiety and worry in students.

Introduction

Anxiety disorders, including generalized anxiety disorder, panic disorder/agoraphobia, and social anxiety disorder, are the most common psychiatric conditions and carry a significant burden of illness.[1] Emotional states are one of the issues that humankind has always faced and has never been able to get rid of it completely. Meanwhile, the most common emotional reaction is anxiety.[2] The anxiety phenomenon is not a new issue, and a majority of the population has experienced it at least once in their lifetime.[3,4] Anxiety is not necessarily a bad thing, but if it exceeds the limit, it will be problematic.[5] Stress level in all aspects of life is growing at an exponential rate, but stress level in students is alarming.[6] Among dimensions of anxiety, test anxiety is the one that can be seen in universities and educational centers.[7]

Test anxiety is an internalizing behavior among students and a major emotional problem that has a negative effect on learning. It is a reaction of an emotional negative character generated before the expectation created by the imminence or presence of a test, and many students perceive it as a threat to themselves.[8] Arana and Furlan (2016) consider test anxiety as a set of phenomenological, physiological, and behavioral responses related to the fear of failure and the person experiencing it in assessment situations.[9] The consequences of poor coping with test anxiety may be the inability to pass an exam, reduced success in studies, increased dropout rates at the university, and a decline in self-esteem.[10] Nursing students often experience anxiety and stress when taking exams that test their fundamental nursing skills. Additionally, they are required to take various courses in their major. Consequently, they experience higher levels of stress than students in other majors.[11] Studies have shown that between 50% and 100% of nursing students have been shown to experience test anxiety and are at increased risk due to several factors, including the need to work outside of school and academic workload.[12] Although researchers believe that the main cause of test anxiety in students is diverse, they consider that psychological services effectively lessen test anxiety.[13] Researchers consider the ability to handle problems caused by stress a relatively conscious process based on which a person changes himself or herself and sometimes changes the environment.[14] Some researchers have also mentioned that other factors such as personality traits,[15] mindfulness,[16] and spiritual intelligence[17] have a significant impact on test anxiety. Mindfulness training is an effective method of treatment in reducing test anxiety and increasing the attitude toward the educational environment.[18] Mindfulness is commonly defined as the awareness that arises when paying attention to the present moment nonjudgmentally[19] and is a technique whereby a person becomes purposefully cognizant of the present moment and learns to address their thoughts, feelings, and sensations in a nonjudgmental manner.[20] Its skills have been associated with higher levels of life satisfaction, lower levels of anxiety and stress, and the well-being of university students.[21] Mindfulness can directly reduce stress and anxiety by increasing the clarity of a person’s current experience and having direct and moment-to-moment contact with life.[22] Additionally, it can also indirectly impact a person’s psychological aspects by increasing self-regulation capacity.[23]

Anxiety and stress caused by the test can affect students’ mental health. Considering the vital role of nurses in providing healthcare, the importance of the mental health status of nursing students is more important than ever. Therefore, paying attention to ways such as mindfulness and stress management to control this stress and anxiety is crucial. Because nursing students, who are on the front line of fighting the disease and in direct contact with patients, have experienced the corona and postcorona eras, the study of this issue was considered by the researchers. Thus, this study intends to explore the relationship between the level of mindfulness, test anxiety, and nursing students’ academic performance.

Materials and Methods

Study design and setting

This was a cross-sectional study conducted in the academic year 2021–2022 to explore the relationship between the level of mindfulness, test anxiety, and nursing students’ academic performance. The target population included all students of the School of Nursing and Midwifery at Shiraz University of Medical Sciences, Shiraz, Iran.

Study participants and sampling

The total population consisted of 260 nursing students. The sample size was determined to be 151 (n = 151) using Cochran’s sample size formula. A simple random sampling technique was used. The sample of the study consisted of 155 nursing students. A total of 151 completed questionnaires were returned. Four questionnaires filled out incompletely were excluded from this study. The inclusion criteria were signing the informed consent to participate in the study, willingness to participate in the study, and being an associate or bachelor’s degree nursing student.

Data collection tool and technique

Research instruments included the personal information form, Sarason’s test anxiety questionnaire, and the short form of the Freiburg mindfulness inventory (FMI).

Sarason’s test anxiety questionnaire

Sarason’s test anxiety questionnaire is a reliable and valid measurement tool for measuring, evaluating, and diagnosing test anxiety. The original questionnaire has 37 items, and its shortened form includes 25 items. For this study, a 25-item form was employed.

The score interpretation in this questionnaire is that choosing the right option indicates greater anxiety and gets a score of 1, while choosing the wrong option means the absence of anxiety and gets a score of 0. The higher score of the person in this questionnaire indicated greater anxiety. A score of 8 and below indicates normal and low anxiety; 8–14 is a sign of mild anxiety; and greater than 14 indicates the presence of pathological test anxiety that causes a person to have dysfunction. The validity and reliability of this questionnaire in Iran have been confirmed through a study conducted by Yazdani et al.[24] The Cronbach’s alpha coefficient of this questionnaire, internal consistency, and content validity are 0.88, 0.95, and 0.72, respectively. In this study, the reliability of Cronbach’s alpha of the Sarason’s test anxiety questionnaire was 0.87.

Freiburg mindfulness inventory (FMI)

In its long form, the FMI designed by Buchheld et al.[21] included 30 items that measure mindfulness as a general construct that has some interrelated attention, awareness, and acceptance facets. However, it is difficult to apply to people without any background knowledge of mindfulness. The published short form (14 items) designed by Walach et al.,[22] captures all aspects of the long form. It is semantically independent of a Buddhist or meditation context and applies to all population groups. Considering that the short form of this questionnaire is more suitable for implementation in groups that are not familiar with the Buddhist field of mindfulness and can be used in different cultures, therefore, it was used for the current study. The validity and reliability of the FMI in Iran were investigated by Ghasemi Jobaneh et al.[20] Its Cronbach’s alpha and ordinal theta are 0.92 and 0.93, respectively. In the four-week retest reliability check, the retest reliability coefficient is 0.83. So, they found that in an Iranian population, the validity and reliability of FMI were acceptable. In this study, Cronbach’s alpha reliability coefficient was 0.87. The short version used in this study consists of 14 items and is rated on a 4-point Likert scale, with answer options ranging from 1 (rarely) to 4 (almost always). The minimum and maximum scores are 14 and 56, respectively. A higher score indicates that you are more mindful. To measure academic performance, the student’s academic semester grade point average (GPA) was used as a self-report. Data were analyzed by SPSS version 23 software through descriptive statistics, the Pearson correlation coefficient, and an independent t-test.

Ethical consideration

This research was carried out by the Ethics Committee of Shiraz University of Medical Sciences with the ethical code of IR.SUMS.REC.1400.481.

Result

This study included 151 participants. Sixty percent of the population were male, and 40% were female.

This study revealed that the average total mindfulness score among nursing students was 34.88, and the minimum and maximum mindfulness levels were 19 and 52, respectively. This means that students’ mindfulness levels were higher than average [Table 1].

Table 1.

Description of nursing students’ mindfulness states based on Freiburg scale

Variable		Minimum		Maximum		Mean		SD		Number
Level of Mindfulness		19		52		34.88		6.53		151

Regarding test anxiety, results showed that 49 (32.5%) students reported mild or low levels of anxiety, 67 (44.3%) reported moderate levels of anxiety, and 35 (23.2%) reported severe levels of anxiety [Table 2].

Table 2.

Frequency distribution of students according to the test anxiety level

Level of anxiety		Frequency		Percentage
Low		49		32.5
Moderate		67		44.3
High		35		23.2
Total		208		100

A Pearson correlation test was run to determine the relationship between mindfulness and test anxiety among nursing students. Data analyses revealed a significant negative relationship between test anxiety and mindfulness (r = -0.170, P- value ≤ 0.001). The results showed a lower level of anxiety among nursing students with higher levels of mindfulness and vice versa.

According to the results, the study found that there is a positive and significant correlation between academic performance and mindfulness level but a significant and negative correlation between academic performance and test anxiety (r = -0.170, P = 0.037). This implies that as students’ mindfulness levels improved, their academic performance also increased, while an increase in test anxiety decreased academic performance. Therefore, by decreasing their levels of anxiety, students were able to enhance their academic performance [Table 3].

Table 3.

Correlation between mindfulness, test anxiety, and academic performance among nursing students

Variables		n		Mean		SD		Correlation coefficient (r)		p
Mindfulness		151		34.88		6.53		0.284		0.001
Academic performance		151		16.27		1.87
Test anxiety		151		10.98		4.46		-0.170		0.037
Academic performance		151		16.27		1.87

Furthermore, an independent t-test was conducted to assess the difference between obtained scores, test anxiety, mindfulness level, and academic performance based on gender. The finding revealed that there is no significant difference in the mindfulness level and academic performance of students based on gender. In other words, gender is not an influencing factor in the variables of mindfulness and academic performance among nursing students. Based on the mean scores of male (X̄=11.89) and female students (X̄=10.37) and the significance level of 0.04, it can be inferred that male students experienced a higher degree of test anxiety compared to their female counterparts.

Discussion

This study was conducted to investigate the relationship between mindfulness, test anxiety, and academic performance among nursing students at Shiraz University of Medical Sciences. The results indicated that as test anxiety levels increased among students, their academic performance levels decreased, and as they decreased, their academic performance levels improved. In line with the present study, Yazici and von der Embse et al. demonstrated that academic performance has a significant negative correlation with test anxiety and that test anxiety can affect academic performance.[25,26] However, the results of Cochanco et al.’s[27] (2021) study demonstrated that test anxiety has a positive effect on the academic performance of information technology students, and a small level of anxiety allows individuals to work harder and be more responsible towards their work. This could be due to differences in the study’s statistical population. Test anxiety among nursing students is often more prevalent and effective than among information technology students, and the working environment of these two groups differs significantly.

Teaching cognitive-behavioral strategies reduces students’ test anxiety and improves their academic performance. Furthermore, the results showed that an increase in students’ mindfulness led to an improvement in their academic performance, which is consistent with the findings of the study done by Vorontsova-Wenger et al.[28] Additionally, Real et al.’s[29] findings showed that residents with higher levels of mindfulness had better performance, which is similar to the findings of the present study. The reason for this similarity in findings could be due to the similar study population.

Alzahrani et al.[30] were unable to find a relationship between mindfulness and students’ academic performance; they considered the limited range of GPA as the reason for the lack of a significant correlation. Considering the high prevalence of stress and anxiety among medical students,[30] it is important to seek solutions to reduce and manage this stress. One of these solutions is to improve mindfulness.

The present study investigated the relationship between the level of mindfulness and test anxiety among nursing students, and the results indicated a significant negative correlation between these two variables.

In line with the results of this study, Snippe et al.’s[31] study showed that mindfulness-based stress reduction (MBSR) training significantly reduces perceived stress, negative emotions, and stress sensitivities. Furthermore, the results of Goldin and Gross’s study demonstrated that a mindfulness-based therapeutic program leads to the improvement of symptoms related to stress, anxiety, and self-esteem.[32] They also found that MBSR training reduces symptoms of stress, anxiety, and depression in adolescents with social anxiety disorder.[32]

Regarding the relationship between the study variables (mindfulness, test anxiety, academic performance) and gender, the results showed that the level of mindfulness and academic performance did not differ significantly based on gender among nursing students; in other words, gender did not play a significant role in the relationship between mindfulness and academic performance. However, male students experienced significantly higher levels of test anxiety compared to female ones. Contrary to these findings, Putwain et al.[33] demonstrated that female students reported higher levels of test anxiety, indicating that females perceived evaluative situations as more threatening. This difference could be due to differences in the study population.

Mindfulness training exerts a noteworthy and opposite impact on students’ test anxiety, leading to a reduction in their levels of test-related stress. This training lessens an individual’s anxiety and physical tension by heightening their awareness of present experiences and redirecting attention toward cognitive processes, resulting in more effective information handling. It aids in the modification of negative behaviors and automatic thoughts while fostering positive behaviors relevant to health and education. The influence of mindfulness training extends to shaping an individual’s perspective on school situations and exams, reshaping interpretations, and ultimately diminishing test anxiety among students.[34] Hayat et al.[35] conducted a study to explore the connection between test anxiety and students’ academic resilience. The results revealed that academic resilience was found to have a notable negative impact on test anxiety. Students with higher levels of resilience tended to experience less test anxiety, enabling them to maintain their performance even when faced with evaluative pressure. Thus, it can be inferred that test anxiety may arise as a result of academic resilience. Noroozi et al.[36] asserted that participating in mindfulness-based training could lead to a decrease in test anxiety and an enhancement of students’ psychological well-being before the comprehensive test.

Limitations and recommendations

This study had two limitations. First, the research paper’s cross-sectional design may limit the ability to establish causal relationships between mindfulness, test anxiety, and academic performance. Two, the use of self-report measures for academic performance introduces the potential for response bias.

Future research is recommended to compare the relationship between mindfulness, test anxiety, and academic performance across different healthcare disciplines (e.g., medicine, pharmacy) to shed light on potential variations in the relationships and inform targeted interventions for specific student populations. It is suggested to conduct longitudinal studies to examine the temporal relationships between mindfulness, test anxiety, and academic performance among nursing students to determine whether changes in mindfulness levels precede changes in test anxiety and academic performance or vice versa.

Conclusion

The findings of the research indicated that an increase in test anxiety can lead to a decline in academic performance among students. Additionally, there was a negative and significant correlation between mindfulness and test anxiety among nursing students, indicating that an increase in mindfulness can decrease test anxiety. It is recommended that the process of mindfulness should be explained to students through designing macro-programs, holding educational workshops. Students should be taught that they have many positive, acquirable traits, and that through timely and accurate training, they can grow and develop.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.