The Effects of Therapeutic Touch on Test Anxiety among Nursing Students: A Randomized Controlled Trial

Abstract

AIM:

Test anxiety is widespread among nursing students. It is a condition that negatively affects academic success, skills, and personality development. Therapeutic touch is one of the nonpharmacological methods utilized for anxiety management. The purpose of this study is to investigate the effects of therapeutic touch administered to nursing students on test anxiety.

METHODS:

This randomized controlled trial was conducted with 46 undergraduate nursing students. Participants were randomly assigned to either the therapeutic touch group (n = 23) or the control group (n = 23). The intervention group received a 20-minute Krieger–Kunz therapeutic touch session from a certified practitioner in a quiet room 1 hour before the test. The control group was invited to the same setting but received no intervention. Test anxiety was measured using the State Test Anxiety Scale in both groups before the intervention and 10 minutes prior to the exam. The data were analyzed using ANCOVA.

RESULTS:

According to the ANCOVA results, the nursing students who were applied therapeutic touch had significantly lower anxiety scores compared to the students who did not receive the intervention (F = 144.685, p < .001, η_p ² = 0.771).

CONCLUSION:

It was concluded that therapeutic touch, one of the complementary treatment methods, can effectively lower the test anxiety of nursing students before written tests.

What is already known on this topic?

• Test anxiety is common among nursing students and negatively affects academic performance, self-confidence, and well-being.

• Various complementary and non-pharmacological interventions (e.g., music, aromatherapy, massage, guided imagery) have been used to reduce test anxiety.

• Therapeutic touch has been shown to reduce anxiety, stress, and discomfort in different populations, but evidence regarding its effect on test anxiety is limited.

What this study adds on this topic?

• This randomized controlled trial demonstrates that therapeutic touch significantly reduces test anxiety among nursing students before a written examination.

• Therapeutic touch is shown to be a simple, non-invasive, cost-effective, and safe complementary intervention for managing test anxiety.

• The findings support that therapeutic touch can be integrated into nursing education processes to support students’ emotional well-being before examinations.

Introduction

Assessment and evaluation are highly valued in the identification of the future career paths of students in today’s education system. Students respond to tests and the pressure of tests with varying emotions. Test anxiety is one of the most common emotions among students (Kaur Khaira et al., 2023). Test anxiety has cognitive, emotional, and physiological aspects. It occurs as a combination of symptoms such as overstimulation, tension, and concern, which causes unwanted emotions to arise during the test, and the fear of failure (Zahra et al., 2022). This situation is common among students and negatively affects test success, academic performance, and skills and personality development of students (Klug et al., 2021; Özer et al., 2022; Zahra et al., 2022). Students become anxious under the influence of test anxiety and face symptoms such as lack of self-worth and deterioration in their cognitive functions (Klug et al., 2021; Özer et al., 2022). Moreover, before a test, individuals may also experience physiological symptoms such as sweating, headache, tachycardia, and severe gastrointestinal disorders due to the increased autonomic response (Kaur Khaira et al., 2023).

Students experiencing test anxiety often tend to compare their own performances with those of their peers (Luan & Yang, 2023; Özer et al., 2022). Studies show that nursing students generally have higher test anxiety than university students in other departments, with undergraduate nursing students exhibiting particularly pronounced levels of worry (Chıkwana 2023; Driscoll et al., 2009).It is thought that this may be due to the fact that education in nursing is very stressful as it involves learning and teaching processes with both theoretical and practical (Özer et al., 2022). In a study carried out to determine the stress and anxiety levels of nursing students, it is emphasized that students need to strengthen their coping mechanisms against situations in which they feel stressed and anxious and that interventions to reduce anxiety should be developed (Chıkwana, 2023).

Therefore, to alleviate the negative impact of test anxiety, it is necessary to provide effective therapeutic solutions with complementary and alternative techniques to nursing students (Kaur Khaira et al., 2023). It is known that many complementary methods such as music (Eyüboğlu et al., 2021; İnangil et al., 2020), animal-assisted interventions (Anderson & Brown, 2021), aromatherapy (Jafarbegloo et al., 2020; Johnson, 2019; Özer et al., 2022), massage (Farner et al., 2019), and guided imagery (Maghaminejad et al., 2020) are utilized for reducing test anxiety. As a complementary treatment method, therapeutic touch (TT) is defined as an approach that supports the natural healing process of the body by balancing the flow of energy through the body (Garrett & Riou, 2021). Therapeutic touch is a preferred approach to reduce stress, relieve pain, improve symptoms such as anxiety, and increase general well-being by supporting emotional and spiritual balance (Marta et al., 2010; Senderovich et al., 2016; Yalcinkaya & Gozuyesil, 2024). Therefore, it plays an important role in holistic health approaches (Pinar & Demirel, 2021; Senderovich et al., 2016). In the relevant literature, TT, one of the energy-based interventions, has been investigated in the context of symptoms including comfort, pain, anxiety, fatigue, stress, sleep quality, vital signs, and nausea in different samples (Alp & Yucel, 2021; Doğru et al., 2021, Mueller et al., 2019; Vanaki et al. (2015); Yalcinkaya and Gozuyesil, 2024; Yücel et al., 2020; Zolfaghari et al., 2012), but no such study on test anxiety could be found. The fact that TT is a reliable intervention, has no side effects, is economical, and does not require any tools in the application makes it an ideal option. Hence, this study aimed to identify the effects of TT administered to nursing students on their test anxiety levels.

Hypotheses

H1:Therapeutic touch applied to students taking a test reduces their anxiety level.

Methods

Study Design

This study was performed with a randomized controlled group design.

Setting and Sample

The study was carried out with undergraduate nursing students who were going to take a written examination in the nursing department of a state university. There were 85 undergraduate nursing students in the nursing department and 46 students comprised the sample of the study, including 23 in the TT group and 23 in the control group. In the post hoc power analysis performed using the G*Power statistics program, the power of the study was found to be 99%.

Inclusion Criteria

The inclusion criteria were agreeing to take part in the study, being over 18 years old, and being an undergraduate student.

Exclusion Criteria

The exclusion criteria were being under 18 years old, being diagnosed with a psychiatric disorder, using antidepressants, anxiolytics, or using any other Complementary and Alternative Medicine method.

Randomization

Using an online random allocation program (Research Randomizer, https://www.randomizer.org), the students were randomly divided into the TT and control groups. Figure 1 displays the Consolidated Standards of Reporting Trials (CONSORT) diagram of the enrollment, allocation, follow-up, and analysis steps of the study.

Figure 1.

CONSORT Flow Diagram.

Data Collection Instruments

The data collection process included a Student Information Form and the State Test Anxiety Scale.

Student Information Form

This form includes seven questions, including information such as the student’s age, gender, income, place of residence, perception of academic success, and the education level of the mother and father (Klug et al., 2021; Özer et al., 2022; Zahra et al., 2022).

State Test Anxiety Scale

The scale was developed by Şahin (Şahin, 2021) to measure the anxiety level of students before a test. The 4-point Likert scale consists of 22 statements. It consists of three dimensions: cognitive, psychosocial, and physiology. There are no inversely scored items in the scale. While the minimum score that can be obtained on the scale is 22, the maximum is 88. An increase in the scale score is interpreted as a higher level of anxiety. The Cronbach’s alpha value of the scale is 0.94. In this study, the Cronbach’s alpha value of the scale was determined to be 0.95.

Interventions

A pilot test was conducted with a total of six students, three involved in TT and three involved as controls, to examine the functionality of the survey and scale forms. After the pilot test, there was no need to adjust the forms, and the data of those who were included in the pilot test were not used in the analyses.

Therapeutic touch group: The students were invited to a room in the building of the Faculty of Health Sciences 1 hour before the test. Before the intervention, the anxiety levels of the students were measured. It took an average of 5 minutes to fill in the data collection forms. Therapeutic touch was applied by the certified second researcher. The sessions were held individually in a calm and noise-free environment, with the participant in a sitting position. The participant was given explanations about the procedure, and then, the practitioner “scanned” the entire body of the participant from head to toe. During the scanning process, the practitioner moved her hands in a uniform and rhythmic manner, keeping them approximately 5 cm away from the body of the participant, to prevent and treat imbalances in the student’s energy field. Afterwards, the energy field was re-evaluated from top to bottom, and if an obstructed region was encountered, the region was rebalanced. The second researcher applied TT for 20 minutes according to the Krieger–Kunz method (Alp & Yucel, 2021; Yücel et al., 2020).After the intervention was completed, the students were allowed to rest. Their anxiety levels were then measured and recorded again 10 minutes before the final exam of the primary nursing course for that academic year.

Control group:Similar to the TT group, the students were invited to a room within the faculty and their anxiety levels were measured. No intervention was made to the students in this group. Their anxiety levels were measured and recorded again in the last 10 minutes before the test.

Ethical Consideration

The students were given information about the objective and procedures of the study, and their written consent was received. Institutional permission was obtained from the faculty where the study was conducted, and written approval was provided by the Scientific Research and Publication Ethics Board (Decision No.: 2023/9/8; Approval Date: 29.12.2023). The practitioner did not have the authority to grade the students, and it was clearly stated that participation in the study was entirely voluntary. The students were informed that their academic grades would not be affected in any way, whether they chose to participate.

Data Analysis

The study data were analyzed with the SPSS 26.0 (IBM SPSS Corp.; Armonk, NY, USA) software. The normality of the distributions of the continuous numeric variables was checked with the Kolmogorov–Smirnov, kurtosis and skewness values, and histograms. Descriptive statistics were calculated for the normally distributed variables as mean and standard deviation values. Percentages were used to present the descriptive characteristics of the students, and chi-squared tests were used to compare the characteristics of the students between the TT and control groups. Since the data were normally distributed and it was an experimental study, parametric tests were applied (Tabachnick & Fidell, 2015). Analysis of covariance was performed to evaluate the differences between the TT and control groups based on their post-intervention scores while controlling for their pre-intervention scores.

Results

There was no statistically significant difference (p > .05) (Table 1) between the TT and control groups in terms of their age, gender, income level, the places where they lived for the longest time, perceived academic success, and maternal and paternal education levels.

Table 1.

Descriptive Characteristics of Participants in the Therapeutic Touch and Control Groups (n = 46)

Variables	TT Group (n = 23)		Control Group (n = 23)		Total (n = 46)		χ2, p
Age
Years (Mean, SD)	22.22 ±0.79		22.00 ± 0.85				t = .894 p = .376
	n	%	n	%	n	%
Gender
Female	11	47.8	11	47.8	22	47.8	x2 = .000 p = 1.000
Male	12	52.2	12	52.2	24	52.2
Income level
Income is less than expenses	11	47.8	7	30.4	18	39.1	x2 = 1.556 p = .459
Income equals expenses	10	43.5	14	60.9	24	52.2
Income is more than expenses	2	8.7	2	8.7	4	8.7
Place of residence for a long time
Village	4	17.4	6	26.1	10	21.7	x2 = 3.385 p = .184
District	3	13	7	30.4	10	21.7
Province	16	69.6	10	43.5	26	56.5
Perception of academic success
Low	4	17.4	4	17.4	8	17.4	x2 = .452 p = .798
Medium	11	47.8	13	56.5	24	52.2
High	8	34.8	6	26.1	14	30.4
Education level of the mother
Illiterate	3	13	6	26.1	9	19.6	x2 = 5.316 p = .256
Literate	0	0	2	8.7	2	4.3
Primary school	12	52.2	7	30.4	19	41.3
Secondary school	3	13	5	21.7	8	17.4
University	5	21.7	3	13	8	17.4
Education level of the father
Literate	1	4.3	3	13	4	8.7	x2 = 2.831 p = .418
Primary school	14	60.9	9	39.1	23	50
Secondary school	6	26.1	7	30.4	13	28.3
University	2	8.7	4	17.4	6	13
Total	23	100	23	100	46	100

Note: SD = Standard deviation; TT = Therapeutic touch.

In the pre-test measurement, the mean score for anxiety in the control group (40.26 ± 9.51) was lower than that of the experimental group (58.91 ± 10.81) (Table 2). Therefore, ANCOVA was used to examine the effectiveness of the intervention administered to the students on their anxiety levels and to control the effect of the pre-intervention anxiety score on the post-test anxiety score. After the intervention, while the anxiety score of the TT group decreased to (25.60 ± 2.10), that of the control group increased to (47.43 ± 9.37). ANCOVA results showed that the participants who were applied TT had significantly lower anxiety scores than those who were not (F = 144.685, p < .001, η_p ² = 0.771).

Table 2.

Effectiveness of Therapeutic Touch on Test Anxiety Levels Using ANCOVA (n = 46)

	TT Group (n = 23) X̅ ± SD	Control Group (n = 23) X̅ ± SD	F
	p	ηp 2
Test anxiety-pre-test	58.91 ± 10.81	40.26 ± 9.51	144.685	<.001	.771
Test anxiety-post-test	25.60 ± 2.10	47.43 ± 9.37

Note: SD = Standard deviation; TT = Therapeutic touch; η_p ² = Partial eta squared.

Discussion

When the literature is examined, it is reported that nursing students experience moderate-to-high levels of test anxiety, which leads to a decrease in their academic success and self-confidence and inability to finish the undergraduate degree and work as a nurse (Kaur Khaira et al., 2023). This study investigated the impact of TT applied to nursing students before the written examination on test anxiety and revealed that this complementary technique was efficacious in lowering the test anxiety levels of nursing students.

When the test anxiety scores before TT are evaluated, it is seen that the score of the experimental group (58.91 ± 10.81) is higher than that of the control group (40.26 ± 9.51). Although the students were randomly selected into the groups, it is thought that the reason for this difference between the two groups may be due to the tension experienced by the experimental group because they knew that an intervention would be made for them. However, when the anxiety data were re-evaluated after the TT intervention, it was seen that the anxiety levels of the intervention group decreased, and there was a significant difference between the two groups (p = < .001) (Table 2). Moreover, this effect persists with a large effect size even when the pre-test score between the two groups is controlled in ANCOVA, confirming the hypothesis. In the control group, test anxiety levels increased compared to the beginning. The reason for this may be that students’ anxiety increases as the test time approaches.

In the literature, there are studies evaluating the effects of TT on the management of anxiety. In their study evaluating the efficacy of TT in reducing the adverse immunological impact of stress in healthy medical and nursing students, Olson et al. found differences in IgG levels (Olson et al., 1997). In their study investigating the effects of the TT technique on postoperative patients, Coakley and Duffy (2010) measured cortisol levels before and after TT and found that the cortisol level was lower in the group that received TT (Coakley & Duffy, 2010). A systematic review concluded that TT, as a noninvasive method, is useful in reducing anxiety (Sujianto & Johan, 2019). In their study with nursing and midwifery students, Doğru et al. (2021) found that TT reduced the level of stress (Doğru et al., 2021). Different studies in the literature also demonstrate that TT reduces anxiety (Alp & Yucel, 2021; Pinar & Demirel, 2021; Zolfaghari et al., 2012) and these results are similar to those of this study. This is thought to be a result of TT, which is considered to allow the free flow of energy by repairing energy imbalances and obstructions, stimulate the self-healing process of the body, ensure the integration of physical, emotional, mental, and spiritual dimensions, and reduce stress (Yücel et al., 2020).

Strengths and Limitations

A strength of this study was its randomized controlled design. Additionally, since TT is a simple, nonpharmacological, and noninvasive technique and does not require any tools, no adverse effects were seen in the participants. Another strength of it was that a valid and reliable measurement tool was used to assess anxiety.

The fact that this study was conducted with 46 undergraduate nursing students taking the final exam is the limitation of this study. This is because the researcher who applied TT left the institution. Therefore, the study can be repeated with larger samples in future studies. Moreover, it may be recommended to conduct studies evaluating different variables in different groups or to compare the effectiveness of TT with different techniques in different studies.

Conclusion and Recommendations

It was found that TT is effective in alleviating test anxiety in nursing students before a written examination. The results of the study may guide nursing students and educators to reduce test anxiety. After all, if students can better control their anxiety, their written examination success will likely be higher. Educators in the field of nursing should be aware of test stress and implement supportive strategies to increase students’ academic success. Therapeutic touch can be recommended as one of these strategies. Providing nursing students with training in TT as a complementary and alternative approach may be considered a supportive strategy for enhancing their psychological well-being and academic performance. Furthermore, such training may contribute to their professional competence by equipping them with a skill that can be applied in patient care. In addition to its potential for reducing test anxiety, TT education can also be integrated into nursing education curricula, clinical practices, and management strategies as a supportive approach, thereby promoting student well-being, enhancing the quality of care, and strengthening the philosophy of holistic nursing.

Funding Statement

The authors declared that this study has received no financial support.

Data Availability Statement:

The data that support the findings of this study are available on request from the corresponding author.