Study design and participants
The present two-stage interventional study was conducted during October-December 2018 at Hazrat-e-Fatemeh Nursing and Midwifery Faculty, Shiraz University of Medical Sciences, Shiraz, Iran. The research goals were to quantify the levels of test anxiety associated with the OSCE among two groups of nursing students and to assess the effect of anxiety coping program on the stress levels among the intervention group. The participants were recruited among nursing students enrolled in two consecutive academic calendar years; 2017-2018 and 2018-2019. Based on a simple random sampling method, 76 nursing students were recruited and divided into two groups, namely the control group and the intervention group. The control group (n=35) included those enrolled during the academic calendar year 2017-2018. At the time of the present study, these students had completed the first-year and had already experienced the anxiety associated with the OSCE. The intervention group (n=41) included freshly enrolled nursing students during the academic calendar year 2018-2019. These students had to take the OSCE as part of their curriculum. The anxiety coping program included a full explanation of the OSCE examination and its various stages, relaxation and soothing techniques, diaphragmatic breathing training, and progressive muscle relaxation training accompanied by light instrumental music.
Demographic characteristics of the participants included sex, age, marital status, kind of accommodation, diploma core curriculum, the city and year of the issued diploma, high school grade, and the average score of the university entrance examination.
State-Trait Anxiety Inventory (STAI).
The self-evaluation STAI questionnaire, developed by Spielberger in 1983, includes separate scales for measuring state (S-scale) and trait (T-scale) anxiety. In the present study, we only used the S-anxiety scale (STAI Form Y-1). The questionnaire consisted of 20 items that evaluated how the participants felt at the time of responding to each item. Note that 10 items were associated with the anxiety-present (items 3, 4, 6, 7, 9, 12, 13, 14, 17, 18) and the remaining items were associated with the anxiety-absent (items 1, 2, 5, 8, 10, 11, 15, 16, 19, 20). The intensity of the participants’ feelings was rated on a 4-point Likert scale: (i) not at all, (ii) somewhat, (iii) moderately so, and (iv) very much so. The anxiety-present items were scaled from 1 to 4 such that higher scores indicated the presence of a high level of anxiety. However, the anxiety-absent items were scaled in reverse from 4 to 1. The total score for the STAI Form Y-1 ranged from a minimum of 20 to a maximum of 80.
The reliability and validity of the questionnaire ranged 0.86-0.95 and 0.65-0.75, respectively. (Spielberger et al., 1983) The Persian version of the questionnaire was developed by Mahram, and its reliability for the anxiety-present and anxiety-absent (Cronbach's alpha 0.908 and 0.902, respectively) was confirmed. Additionally, they confirmed the reliability of the questionnaire by calculating the proportion of the true variance over the obtained variance (0.945). Furthermore, they confirmed the validity of the questionnaire using the concurrent validity method. Two other studies also reported 90% and 93% reliability of the questionnaire, respectively .
Upon formal approval by the university authorities, a list of nursing students for the academic calendar years 2017-2018 (control group) and 2018-2019 (intervention group) was obtained. The data associated with the control group were retrieved from the university database for comparison with the intervention group. Before the study, the research goals and procedure were explained after which written informed consent was obtained from the participants in the intervention group. At the beginning of the academic term, the participants in the intervention group were requested to fill in the demographic information form and the STAI Form Y-1 questionnaire. Subsequently, they followed an anxiety coping program that included relaxation and soothing techniques, diaphragmatic breathing training, and progressive muscle relaxation training accompanied by light instrumental music.
The initial research design included a total of six intervention sessions prior to the OSCE; three sessions per week, during 2 weeks, each of 30 minutes duration. However, due to the tight syllabus schedule of the university program and objection by the education deputy of the university, only one intervention session was conducted prior to the OSCE test. Nonetheless, the quality of the session was high and the students were fully informed on the purpose of the OSCE examination and its various stages. The explanation was given by the author with the help of a slideshow and video presentation showing former students taking the OSCE. In addition, certain relaxation techniques to reduce anxiety were taught by an experienced academic psychiatric nurse. Prior to taking the OSCE, the participants of the intervention group gathered in a quiet and calm room and were requested to exercise the relaxation techniques while light instrumental music was being played. Upon completion of the test, they filled in the STAI Form Y-1 questionnaire for the second time.
The data were analysed with the SPSS software (version 22.0) using descriptive and inferential statistics. Descriptive data were expressed as mean, standard deviation, number, and percentage. To compare the homogeneity of variables between the two groups, the Chi-square test and independent t-test were used. To compare the anxiety level in both groups pre- and post-intervention, the paired sample t-test and independent t-test were used. P<0.05 was considered statistically significant.