Abstract
A pre-exam guided imagery intervention was implemented with 49 senior baccalaureate nursing students to address test anxiety. The intervention consisted of listening to a 10-minute recorded audio guided imagery exercise. Self-reported anxiety levels were measured using a Likert scale pre- and post-guided imagery. Most students demonstrated a reduction in test anxiety postintervention.
The American Nurses Association (ANA) designated 2017 as the Year of the Healthy Nurse (ANA, 2017). The ANA recognizes that nurses may benefit from techniques contributing to better health and refers nurses to information provided by the American Holistic Nurses Association (AHNA) that encourages nursing self-care by offering numerous tools for stress relief, including mindfulness and relaxation techniques (AHNA, 2017). The Healthy People 2020 overarching goal that applies to all is to “promote quality of life, healthy development, and healthy behaviors across all life stages” (US Department of Health and Human Services, 2018, para 2). Nursing students should be encouraged to learn strategies and techniques such as guided imagery to promote healthy behaviors to manage their stress and model these behaviors with patients/clients.
Test anxiety is a very real concern when preparing for the National Council Licensure Exam for Registered Nurses (NCLEX-RN). For nursing students, test anxiety is typically based on a fear of failing to meet passing standards and being unable to practice in the profession for which they have worked so long and hard (Duty, Christian, Loftus, & Zappi, 2016; Quinn & Peters, 2017; Gibson, 2014). Students’ anticipation before an exam may contribute to physical symptoms such as headaches, palpitations, and/or gastrointestinal symptoms (Gibson, 2014; Thomas & Baker, 2011). Cognitive symptoms such as forgetfulness and inability to concentrate may also be present (Gibson, 2014). Moreover, researchers have found increased Cortisol levels in nursing students before taking an exam (Clutter, Potter, Alarbi, & Caruso, 2017).
Research with nursing students indicates that high levels of test anxiety correlate with lower test scores (Duty et al., 2016), suggesting the need for interventions that will decrease test anxiety. In a literature review by Quinn and Peters (2017) that revealed a variety of interventions implemented by faculty to reduce test anxiety, the authors classified interventions as either environmental or behavioral. Environmental interventions included pet therapy, essential oils, and classical music. Behavioral interventions included biofeedback relaxation and progressive muscle relaxation.
Nursing students should be encouraged to learn strategies and techniques such as guided imagery to promote healthy behaviors to manage their stress, and to model these behaviors with patients/clients.
Beggs, Shields, and Janiszewski Goodin (2011) explored guided imagery, which combines environmental and behavioral components, to decrease test anxiety. They suggested a nine-step process that involved hour-long meetings with nursing students 4–5 times over a 12- to 18-week period. This time-consuming process may not be practical for many faculty. Rather, guided imagery visualization immediately prior to administration of exams may be more realistic for faculty to implement, although it has not been explored with nursing students.
Students with test anxiety may be hesitant to admit to it. Markman, Balik, Braunstein-Bercovitz, and Ehrenfeld (2011) found that students were reluctant to seek professional care for test anxiety. There are also many health beliefs related to cultural and social concerns that impact students’ reluctance to seek treatment and the potential stigma toward those who seek these treatments (Markman et al., 2011). Conventional treatment programs for test anxiety range from “counseling, relaxation exercises, and cognitive behavioral therapy to psychiatric intervention” (Markman et al., 2011, p. 248). Offering a voluntary strategy such as pre-exam guided imagery in the classroom may help mitigate test anxiety and be less stigmatizing for students.
Guided Imagery Intervention Method
Nursing students at a Northeastern US baccalaureate program enrolled in a Population Health in the Community course over four semesters from the Fall of 2015 to the Spring of 2017 were invited to participate in the study. The guided imagery exercise chosen by the faculty for the test anxiety intervention is approximately 10 minutes in duration and uses visualization to promote relaxation and cognitive retrieval of information. See Podbay (2012) for an example of the exercise.
The intervention was provided by faculty in the classroom setting immediately prior to the course midsemester and final exams. Students were notified of the guided imagery option 1 week before the exam. The students were told by their instructor that the guided imagery was a 10-minute online audio recording that specifically targeted pre-exam anxiety; if they wanted to participate, they should arrive 15 minutes before the start of the exam. Forty-nine of the 74 eligible students opted to participate in the exercise. Students who opted out of the guided imagery intervention could either wait outside the classroom until the door was opened or sit quietly in the classroom. Most students who opted out chose to wait outside the classroom.
Lights in the classroom were turned off to create a more relaxed environment. Students present for the guided imagery were given a paper with two 10-point Likert scales (one being least anxious and 10 most anxious) for rating their anxiety preguided imagery and postguided imagery. The students were asked to indicate their level of anxiety before the guided imagery exercise. Although students did not include names on the forms, in order to assure confidentiality, faculty could have noticed who participated, which may be a source of potential bias. The intervention and Likert scale surveys were presented to the college's Institutional Review Board (IRB), which deemed them exempt from IRB review as they related to classroom management in an educational setting.
The 10-minute recorded audio was accessed from the Website via classroom media. Faculty attended to minimizing distractions and promoting active listening to the recorded audio. Immediately after the recorded guided imagery concluded, the students rated their level of anxiety using the same scale. Students who did not participate in the guided imagery were then invited into the classroom, and the exam commenced.
Results
Forty-nine of a possible 74 students (66.2%) voluntarily participated in the guided imagery exercise. The intervention was conducted prior to 10 exams: three final exams and seven midsemester exams.
The preguided imagery self-reported anxiety level ranged from 3 to 10. The postguided imagery anxiety level ranged from 1 to 8. One student with a level of anxiety at 8 had no change postintervention. All other students (98%) reported a decrease in anxiety postguided imagery. Test anxiety decreased by an average of 2.7 points (See Table 1).
Anxiety Ratings Pre- and Post-Guided Imagery Exercise
Anecdotally, the students who participated reported that they liked the guided imagery exercise and requested that the instructor continue providing the exercise before future exams.
Project Implications and Limitations
The student ratings suggest that immediate pre-exam guided imagery was a successful intervention to decrease test anxiety. The intervention was simple to administer, and self-reported anxiety levels were easily obtained. Students who participated were observed by faculty to be calm and have relaxed facial expressions. The project did not identify factors contributing to students’ decisions to participate (e.g., academic standing, degree of motivation) or individual sources of anxiety (e.g., effectiveness of individuals’ study habits).
On a few occasions, nonparticipants entered the classroom during the guided imagery session. In the future, a sign will be posted outside the classroom door to indicate that guided imagery is in progress to limit interruptions during each session.
Students who experience test anxiety during nursing school may experience anxiety about the NCLEX-RN; furthermore, students who have not previously experienced test anxiety may be anxious about the NCLEX-RN (Thomas & Baker, 2011). Guided imagery may be a helpful intervention as students prepare for the NCLEX-RN. Recommendations include future research on the impact of classroom pre-exam guided imagery on Cortisol levels and exam scores.
Offering a voluntary strategy such as pre-exam guided imagery in the classroom may help mitigate test anxiety and be less stigmatizing for students.
Conclusion
Immediate pre-exam guided imagery is a simple and easy intervention that may help to decrease students’ test anxiety. Nursing faculty implementing pre-exam guided imagery or other stress-relieving interventions could offer students a useful tool to use independently to support success in nursing school and in their future professional practice. Ultimately, it is hoped that guided imagery or other techniques to decrease test anxiety will help students meet passing standards for nursing school and the NCLEX-RN. Guided imagery techniques may also benefit practicing nurses by offering an option to relieve stress and improve health for themselves and their patients.
Footnotes
Gail Grammatica, MS, RN, CNE, is a Senior Lecturer at Curry College in Milton, Massachusetts.