Abstract
BACKGROUND:
Midwifery services help maintain and improve the health of the community. However, a comprehensive examination reduces students’ psychological well-being by creating anxiety. For this purpose, the present study was conducted to determine and compare the effect of two educational methods based on mindfulness and cognitive emotion strategies on psychological well-being and anxiety of eighth-semester midwifery students before the final clinical trial.
MATERIALS AND METHODS:
This study was a quasi-experimental three-group study with available sampling method that was performed on 30 eighth-semester midwifery students of the School of Nursing and Midwifery of Isfahan University of Medical Sciences in 2020–2021. Data collection tools were psychological well-being and Test Anxiety Questionnaire. Two intervention groups were trained for eight sessions. The control group did not receive any training program. The data collected by SPSS version 22 software were analyzed by analytical statistical tests of ANOVA and least significant difference post hoc test.
RESULTS:
The results showed that there was a statistically significant difference between the three groups in terms of components of test anxiety and psychological well-being. Furthermore, emotion regulation training and mindfulness-based training reduced test anxiety and increased students’ psychological well-being before the comprehensive test (P = 0.001).
CONCLUSION:
It is recommended that educational programs be considered before the comprehensive examination to promote the mental health and success of these students.
Keywords: Anxiety, cognitive emotion regulation, education, mental health, mindfulness, psychological well-being
Introduction
Midwifery as a branch of medical sciences has a wide range of roles in the field of mother and child, whose services help maintain and improve the health of society. For this reason, a comprehensive pregraduation examination for midwifery students is held to assess students’ skills.[1] Anxiety is one of the factors affecting the success rate of midwifery students in the comprehensive examination of midwifery students.[1] Test anxiety is a special form of anxiety that can be associated with physical, cognitive, and behavioral symptoms.[2,3] Given the high impact of anxiety and its negative consequences, the sources of anxiety and its effects should be identified.[4,5,6,7,8] Controlling anxiety in students can be associated with increasing students’ academic success.[9,10,11] Examination anxiety has a negative and significant relationship with psychological well-being, and the higher the test anxiety, the lower the psychological well-being.[12] The goal of psychological well-being is to create mental health and a healthy environment for establishing proper human relationships.[13] As a result, various methods of psychological interventions on test anxiety and psychological well-being have been studied.[11] The results of studies have shown that behavioral–cognitive interventions including interventions based on mindfulness and cognitive emotion regulation have received strong support due to their effect on reducing anxiety and psychological well-being.[8,9,10,11] Mindfulness-based interventions require the development of judgment avoidance, intentional awareness, and focus on the present moment in the individual's attention, which focuses on the present moment of processing all aspects of immediate experience.[14,15,16] Mindfulness therapies focus on both physical and mental dimensions.[17] In psychotherapy research, mindfulness is considered a state of promoting self-awareness thinking to improve well-being and anxiety.[18] Cognitive regulation of emotion is also one of the factors that is considered a mediating variable to reduce anxiety and increase mental health and psychological well-being.[18,17] Cognitive emotion regulation is defined as the mode of cognitive processing for the management of emotion-stimulating information that encompasses a wide range of cognitive, behavioral, emotional, and physiological responses.[18,19] In this regard, the results of the study of Capa Aydin (2009) showed that emotion regulation strategies significantly predict test anxiety.[20] Pasandideh and Abolmaaly study also showed that mindfulness-based cognitive therapy increases comprehensive well-being.[17] A study by Beirami and Abdi also showed that mindfulness training significantly reduces test anxiety.[10] The study of Haghighat et al. showed that increasing positive cognitive emotion regulation strategies could reduce anxiety.[21]
Examination anxiety at the university level can interfere with the achievement of educational goals and on the other hand, endanger the mental health and ability of students. Medical students are a group that plays an important role in providing care, treatment, and physical and psychological support to patients. Therefore, the health of these students must be considered from now on. Considering the importance of the comprehensive midwifery examination and that the comprehensive examination is one of the main concerns of midwifery students during their studies, the researcher decided to conduct a study to compare the effect of two educational methods on mindfulness and cognitive strategies of emotion on psychological well-being and anxiety of eighth-semester midwifery students before the final clinical trial.
Materials and Methods
Study design and setting
The present study is a quasi-experimental study of three groups and two-stage that was performed on eight-semester midwifery students of the School of Nursing and Midwifery of Isfahan University of Medical Sciences in 2020–2021.
Study participants and sampling
This study was performed by available sampling method. The sample size was calculated ten people in each group. Inclusion criteria were having written consent to participate in the study, being in the eighth semester of midwifery, do not take drugs that affect the psyche, lack of experience of an unfortunate, anxious or stressful accident during the last 6 months, and no medical disease. Exclusion criteria were nonparticipation in more than 50% of training programs and unwillingness to continue participating in the study.
Data collection tool and technique
Data collection tool was a questionnaire which was demographic questionnaire, Test Anxiety Questionnaire, and psychological well-being questionnaire.
The Friedman Test Anxiety Questionnaire has 23 items that are scored from 0 (strongly disagree) to 3 (strongly agree).[22] In the study of Baezzat et al. (2012), its validity and reliability have been confirmed.[22] In the present study, a retest–test was used to determine the reliability, which was confirmed with an alpha of 0.89.
The Psychological Well-Being Scale questionnaire includes 18 questions that are graded on a Likert scale with six grades from 1 (strongly disagree) to 6 (strongly agree) and six components, which are self-acceptance, positive relationships with others, autonomy, environmental mastery, purpose in life, and personal growth. According to the study of Khanjani et al., this questionnaire is valid and reliable.[23] In the present study, a retest–test was used to determine the reliability, which was confirmed with an alpha of 0.82.
After approval of the design by the Research and Approval Center in the University Ethics Committee (IR.MUI.RESEARCH.REC.1398.823) and registering the design in the Iranian Clinical Trial Center (IRCT20160224026756N7), the researcher started sampling. First, we made telephone calls to all eighth-semester midwifery students and encouraged them to participate in the research by attending the students’ internship. Students interested in participating in the research were then asked to inform the researcher of their participation in the research. The researcher randomly divided the people into three groups. Then, a WhatsApp group was formed for each of the studied groups. First, the objectives of the research and the method of work were explained to the participants, and then, the forms of informed satisfaction, test anxiety, and psychological well-being were provided to the participants to complete through Porsline software. Participants were then trained based on the intervention group. The training program was eight sessions for each group (two sessions per week, each session for 2 hours). The sessions were conducted by a person with a doctorate in psychology. No training program was held for the control group. One week after the last session in all three groups, psychological well-being and retest anxiety questionnaires were completed with Porsline software. The educational content of the sessions is listed in [Table 1]. Finally, the collected data were coded and entered into SPSS version 22 (IBM, SPSS Inc., Chicago, Illinois, USA) software and analyzed by descriptive and analytical statistical tests of ANOVA variance along with least significant difference post hoc test.
Table 1.
Content of emotion regulation training sessions and mindfulness training
| Meetings | Educational content of the sessions |
|---|---|
| 1 | Familiarity and introduction, review of primary and secondary emotions/automatic guidance |
| 2 | Naming emotions/dealing with obstacles |
| 3 | Description and function of emotions/presence of mind on breathing |
| 4 | Reduce vulnerability to negative emotions/stay in the present |
| 5 | Learn to increase positive experiences and emotions/focus on thoughts, emotions and mental images |
| 6 | Get rid of annoying emotions/thoughts, not facts |
| 7 | An overview of emotion regulation/How can I best take care of myself? |
| 8 | An overview of emotion regulation/learning versus negative mood |
Ethical consideration
This study was conducted after obtaining permission from the Ethics Committee of Isfahan University of Medical Sciences with the code IR.MUI.RESEARCH.REC.1398.823. This study was also registered in the Iranian Clinical Trial Registration Center with the code IRCT20160224026756N7. Written consent was obtained from all participants in the study. Participants were assured that their information would be kept confidential.
Results
Data analysis was performed on 30 undergraduate midwifery students in three groups. Most of the participants in all three groups were single (seven people [70%] in the control group, eight people [80%] in the emotion regulation training group, and seven people [70%] in the mindfulness training group).
The mean scores of test anxiety and psychological well-being and their dimensions before and after the intervention are listed in Table 2. The results showed that there was a statistically significant difference between the three groups in terms of components of test anxiety and psychological well-being. Furthermore, emotion regulation training and mindfulness-based training reduced test anxiety and increased students’ psychological well-being before the comprehensive test (P = 0.001) [Table 2].
Table 2.
Evaluation and comparison of mean and standard deviation of test anxiety scores and psychological well-being of study participants in three groups before and after the intervention
| Variable | Studied groups | |||
|---|---|---|---|---|
|
| ||||
| Emotion regulation training group | Mindfulness training group | Control group | P - Intergroup | |
| Test anxiety | ||||
| Social humiliation | ||||
| Before intervention | 16.50±5.33 | 15.47±5.55 | 16.63±4.98 | 0.001 |
| After intervention | 13.30±4.21 | 12.72±5.02 | 16.42±4.52 | |
| P interagroup | 0.001 | 0.001 | 0.345 | |
| Cognitive error | ||||
| Before intervention | 18.63±4.30 | 17.52±4.42 | 18.92±3.99 | 0.001 |
| After intervention | 15.43±4.01 | 14.33±4.12 | 17.92±4.02 | |
| P interagroup | 0.001 | 0.001 | 0.412 | |
| Tension | ||||
| Before intervention | 12.34±3.45 | 12.77±3.52 | 11.42±3.72 | 0.001 |
| After intervention | 10.32±3.51 | 10.03±3.12 | 11.32±3.45 | |
| P interagroup | 0.001 | 0.001 | 0.298 | |
| Overall test anxiety score | ||||
| Before intervention | 47.47±13.08 | 45.76±13.49 | 46.97±12.69 | 0.001 |
| After intervention | 39.05±11.73 | 37.08±12.26 | 45.66±11.99 | |
| P interagroup | 0.001 | 0.001 | 0.531 | |
| Psychological well-being | ||||
| Objective life | ||||
| Before intervention | 12.52±2.33 | 11.35±2.44 | 12.97±2.45 | 0.001 |
| After intervention | 15.98±2.45 | 15.41±2.74 | 12.35±2.60 | |
| P interagroup | 0.001 | 0.001 | 0.742 | |
| A positive relationship with others | ||||
| Before intervention | 13.42±2.73 | 12.72±2.35 | 13.45±2.21 | 0.001 |
| After intervention | 15.42±2.35 | 14.25±2.46 | 13.85±2.21 | |
| P interagroup | 0.001 | 0.001 | 0.301 | |
| Personal growth | ||||
| Before intervention | 13.88±2.55 | 12.98±2.32 | 13.92±2.30 | 0.001 |
| After intervention | 15.55±2.31 | 15.01±2.03 | 13.41±2.85 | |
| P interagroup | 0.001 | 0.001 | 0.364 | |
| Your acceptance | ||||
| Before intervention | 13.13±2.58 | 13.45±2.98 | 13.72±2.02 | 0.001 |
| After intervention | 15.12±2.74 | 16.77±2.35 | 13.45±2.12 | |
| P interagroup | 0.001 | 0.001 | 0.751 | |
| Independence | ||||
| Before intervention | 11.47±2.52 | 11.12±2.74 | 11.53±2.72 | 0.001 |
| After intervention | 14.52±2.31 | 15.23±2.45 | 11.32±2.75 | |
| P interagroup | 0.001 | 0.001 | 0.632 | |
| Mastery of the environment | ||||
| Before intervention | 13.31±2.64 | 12.92±2.73 | 13.41±2.49 | 0.001 |
| After intervention | 16.74±2.03 | 15.33±2.45 | 13.14±2.54 | |
| P interagroup | 0.001 | 0.001 | 0.358 | |
| Overall psychological well-being score | ||||
| Before intervention | 77.73±15.35 | 74.54±15.56 | 79.00±14.19 | 0.001 |
| After intervention | 93.33±14.19 | 90.00±14.48 | 77.52±15.07 | |
| P Interagroup | 0.001 | 0.001 | 0.154 | |
Discussion
According to the results of this study, education can reduce test anxiety scores and increase students’ psychological well-being scores. In this regard, the results of the study of Beirami et al. (2018) showed that mindfulness-based education significantly reduced test anxiety.[24] Furthermore, the study of Manavipour and Darabi (2018) showed that mindfulness-based education significantly reduced test anxiety.[25] In addition, the results of the study of Arab Ghaeni et al. showed that the mindfulness training method was significantly effective in increasing courage and reducing impulses.[26] Furthermore, the study of Ghadampour et al. (2020) showed that mindfulness based on cognitive therapy increases psychological well-being and reduces students’ academic stress.[27] The results of Aghababaei and Taghavi study showed that mindfulness-based cognitive therapy training has a significant effect on mothers’ psychological well-being. All studies were in line with the results of the present study.[28]
Furthermore, the results of the present study showed that emotion regulation training reduces anxiety scores and increases students’ psychological well-being scores before the comprehensive examination. In this regard, the results of Rahmani and Hashemniyan's study showed that cognitive emotion regulation program has an effective role on the symptoms of depression and especially anxiety.[29] Furthermore, the results of the study of Alidoosti et al. (2020) showed that emotion regulation training is a good way to improve emotional regulation and reduce anxiety and depression.[30] In addition, the results of the study of Beyrami et al. (2015) showed that therapeutic methods of emotion regulation training and mindfulness-based cognitive therapy have a positive effect on anxiety, stress, and depression.[31] The results of a study by Ashkani and Heydari showed that emotional regulation treatment program has an effect on psychological well-being and attributional styles.[32] The study of Moradikia et al. showed that emotion regulation training is effective in promoting mothers’ psychological well-being.[33]
To justify this finding, it can be pointed out that emotion regulation and especially positive strategy of cognitive reassessment of emotions reduces negative emotions and increases positive emotions and restless behavior.
Limitations
Since the whole country was involved in a corona pandemic at the time of the study, sampling of this study was performed on two groups of undergraduate midwifery students. Anxiety about getting the disease while in the hospital could also add to the pretest anxiety. These training programs were held virtually. It is recommended that this study be performed in a postcoronary condition on a group of midwifery students in person.
Conclusion
The results of the present study showed that mindfulness training and cognitive emotion regulation training could reduce anxiety scores and increase psychological well-being scores in midwifery students before the comprehensive examination. For this purpose, it is recommended to consider educational programs to promote the mental health of this group.
Financial support and sponsorship
Isfahan University of Medical Sciences, Yazd.
Conflicts of interest
There are no conflicts of interest.
Acknowledgments
The article is the result of a research project approved by the Vice Chancellor for Research of Isfahan University of Medical Sciences with the ethics code IR.MUI.RESEARCH.REC.1398.823. We would like to thank the Isfahan University of Medical Sciences and all the students participating in this study.
References
- 1.Aramarzi M, Bakhtiari A, Pasha H, Agajani Delavar M, Salmalian H, Nasiri Amiri F, et al. Effective factors on successful comprehensive exam in midwifery students. Med Educ J. 2015;3:52–8. [Google Scholar]
- 2.Latas M, Pantić M, Obradović D. Analysis of test anxiety in medical students. Med Pregl. 2010;63:863–6. doi: 10.2298/mpns1012863l. [DOI] [PubMed] [Google Scholar]
- 3.Francini PM. Anselm: Department of Psychology at saint Colleg; 2004. The Effects of time constraint on test performance in an 8-Arm virtual reality maz in high and low test-anxious college students. [Thesis] [Google Scholar]
- 4.Schaefer A, Matthess H, Pfitzer G, Köhle K. Mental health and performance of medical students with high and low test anxiety. Psychother Psychosom Med Psychol. 2007;57:289–97. doi: 10.1055/s-2006-951974. [DOI] [PubMed] [Google Scholar]
- 5.Sansgiry SS, Sail K. Effect of students’ perceptions of course load on test anxiety. Am J Pharm Educ. 2006;70:26. doi: 10.5688/aj700226. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Heravi M, Jadid Milani M, Regea N, Valaie N. The effect of relaxation training on exam driven anxiety level among nursing students. J Mazandaran Univ Med Sci. 2004;14:86–92. [Google Scholar]
- 7.Baldwin DR, Chambliss LN, Towler K. Optimism and stress: An African-American college student perspective. Coll Stud J. 2003;37:276–85. [Google Scholar]
- 8.Khadivzadeh T, Seif AA, Valaei N. Learning and study strategy and success rate in university students, Mashhad University of Medical Sciences, 1999. Res Bull Med Sci. 2002;7:35–42. [Google Scholar]
- 9.Gregor A. Examination anxiety, live with it, control it or make it work for you? School Psychol Int. 2005;26:617–35. [Google Scholar]
- 10.Beyrami M, Abdi R. The effect of mindfulness-based techniques in reduction of students test anxiety. J Educ Sci. 2009;2:35–54. [Google Scholar]
- 11.Heidari SH, Nejad Gorji M, Liani F. The International Conference on Behavioral Sciences and Social Studies. The Institute of Managers of the Vida Institute of Ideas; 2014. The Role of Psychological Well-Being and Emotional Intelligence in Anticipating Student Test Anxiety. [Google Scholar]
- 12.Ryff C, Keyes C, Shmotkin D. Optimal well-being: The empirical encounter of two tradition. J Pers Soc Psychol. 2002;62:1007–22. [PubMed] [Google Scholar]
- 13.Ost LG. Efficacy of the third wave of behavioral therapies: A systematic review and meta-analysis. Behav Res Ther. 2008;46:296–321. doi: 10.1016/j.brat.2007.12.005. [DOI] [PubMed] [Google Scholar]
- 14.Segal ZV, Williams MG, Teasdale JD. New York: Guilford Press; 2002. Mindfulnessbased Cognitive Therapy for Depression. [Google Scholar]
- 15.Semple RJ, Reid EF, Miller L. Treating anxiety with mindfulness: An open trial of mindfulness training for anxious children. J Cogn Psychother. 2005;19:372–92. [Google Scholar]
- 16.Baer RA. USA: Academic Press is an imprint of Elsevier; 2006. Mindfulness-Based Treatment Approaches: Clinicians Guide to Evidence Base and Application. [Google Scholar]
- 17.Pasandideh R, Abolmaaly KH. The effectiveness of mindful cognitive therapy on enhancement of overall well-being. J Behav Clin Psychol. 2016;10:7–16. [Google Scholar]
- 18.Ghribnavaz S, Moghadasin M, Nouri R. Relationship between metacognition believes and exam anxiety: Mediating role of cognitive emotion regulation. J Cogn Psychol. 2018;5:1–15. [Google Scholar]
- 19.Szczygie D, Buczny J, Bazinska R. Emotion regulation and emotional information processing: The moderating effect of emotional awareness. Pers Individ Dif. 2012;52:433–7. [Google Scholar]
- 20.Capa Aydin Y. High School Student Emotion and Emotional Regulation during Test Taking. Department of Educational Science Middle East Technical University Ankara, Turkey. 2009 [Google Scholar]
- 21.Haghighat S, DashtBozorgi Z, Arabsalari Z, Ashoori J. Pridiction of anxiety based on schemas and positive and negative cognitive emotion regulation strategies. J Anal Cogn Psychol. 2016;7:43–54. [Google Scholar]
- 22.Baezzat F, Sadeghi M, Eizadifard R, Robenzadeh S. Validation and standardization of Persian version of Friedben test anxiety scale (FTA) Psychol Stud. 2012;8:29. [Google Scholar]
- 23.Khanjani M, Shahidi SH, Fath-Abadi J, Mazaheri MA, Shokri O. Factor structure and psychometric properties of the Ryff's scale of Psychological well-being, short form (18-item) among male and female students. J Behav Clin Psychol. 2014;8:27–36. [Google Scholar]
- 24.Beirami M, Hashemi T, Mirnasab M, Kolyaei L. Effectiveness of social problem solving training on the components of social competence in students victim of bullying. Soc Cogn. 2018;7:51–72. [Google Scholar]
- 25.Manavipour D, Darabi M. The effect of mindfulness training on problem solving styles and test anxiety in students. Soc Cogn. 2018;7:41–53. [Google Scholar]
- 26.Arab Ghaeni M, Hashemian K, Mojtabaei M, Majd Ara E, Aghabeiki A. The effect of mindfulness training (MBSR) on the increasing assertiveness among anxious students. Stud Med Sci. 2017;28:119–29. [Google Scholar]
- 27.Ghadampour E, Amirian L, Roshannia S, Adavi H. The effect of mindfulness based on cognitive therapy on psychological well-being and academic stress in high school students. J Educ Scholast Stud. 2020;8:65–82. [Google Scholar]
- 28.Aghababaei S, Taghavi M. Effectiveness of mindfulness-based cognitive therapy on mothers’ psychological well-being of children with Autism and reduction of symptoms these children. Shenakht J Psychol Psychiatry. 2020;6:88–100. [Google Scholar]
- 29.Rahmani F, Hashemniyan K. The effectiveness of cognitive emotion regulation on reduction of depression and anxiety symptoms of adolescences. J Psychol Stud. 2016;12:47–62. [Google Scholar]
- 30.Alidoosti F, Jangi F, Shojaeifar S. The effectiveness of emotion regulation training based on Gross model on emotion regulation, anxiety and depression in mothers of children with intellectual disability. Fam Psychol. 2020;7:69–80. [Google Scholar]
- 31.Beyrami M, Hashemi T, Bakhshipour A, Alilou MM, Eghbali A. Comparison of the effect of two methods of emotion regulation training and mindfulness-based cognitive therapy on psychological distress and cognitive emotion regulation strategies of mothers of mentally retarded children. J Mod Psychol Res. 2015;9:43–59. [Google Scholar]
- 32.Ashkani F, Heydari H. Effects of emotional adjustment on psychological welfare and attributional styles of students with learning disabilities in primary school. J Learn Disabil. 2014;4:6–22. [Google Scholar]
- 33.Moradikia H, Arjmandnia AA, Ghobari Bonab B. Effectiveness of emotion regulation training on psychological well-being of mothers of students with intellectual disability. J Pediatr Nurs. 2016;3:51–60. [Google Scholar]