by Jesse Foster, Pharm.D., PGY1 Pharmacy Practice Resident, Medstar Georgetown University Hospital
When I was a pharmacy student, I had a friend who seemed to understand the course content very well. When my friend took the final exam — an exam that weighed a lot toward our final grade — he failed the exam. It was a classic case of test anxiety. Test anxiety can be a serious problem for some students. An estimated 15-20% of students feel impaired by exam stress.2
The impact of test anxiety can lead to several negative outcomes. Students with test anxiety can have a good understanding of the material but may be unable to recall what they know. Anxiety can also impair problem solving and lead to poor decisions on exams. Some learners may develop avoidance behaviors and pass up learning opportunities. Avoidance behavior develops after past poor performance. Understandably, students don't want to repeat the negative experience. 4 Further, test anxiety shifts the focus toward performance and outcomes rather than on learning the subject matter. Lastly, poor performance due to test anxiety can lead to lost educational and job opportunities.2
At the heart of test anxiety is stress. In a study by Yusoff, the impact of stress on exam scores was examined in first year Malaysian medical students. This study looked at students' mental status immediately after taking a final exam. The results show that students with severe stress were 2.43 times more likely to fail the exam compared to students with normal to mild stress.5
Cognitive interference is a possible cause for exam anxiety. This model postulates that cognitive processes are occupied by negative and irrelevant thoughts resulting in poor exam performance.2 Test anxiety has been correlated to feelings of unpreparedness when students are unfamiliar with the exam style and content. Students can also feel unprepared when there is a large amount of content and limited amount of time to review what will be covered on the exam.5 Poor study habits add to test anxiety as well. Studies have shown that students with high test anxiety are more likely to procrastinate and use less effective studying strategies.1
The perception by the student that the exam or assessment has significant implications can also increase anxiety and stress. Students become overly concerned that poor performance on an exam will result in major negative consequences. If a student has an unrealistic expectation that he/she will achieve a perfect score on an exam, then stress and anxiety can increase when he/she is unable to answer an exam question.6
To help with cognitive interference, cognitive behavioral therapy can be used to help reduce stress. Expressive writing is a technique to help with these disruptive thoughts. Using this technique, the student writes out his/her negative thoughts for 10 minutes before the exam. This allows the student to vent and express their concerns on paper before the exam. Expressing their concerns will clear their mind so they can better focus on the exam. Another approach to help reduce test anxiety is relaxation techniques. These techniques have the student focus on deep breathing along with muscle relaxation of the arms, legs and stomach. Similar to expressive writing, this helps the person clear their mind of negative thoughts and anxiety.4
Reducing the perceived significance of the exam can help to alleviate the stress and anxiety that a student may feel. Both the learner and teacher can help minimize this type of stressor. Its important not to overemphasize the importance of an exam and its potential impact. Multiple exams in a course can help reduce anxiety by minimizing the impact any one exam might have on the overall outcome.2
Providing more realistic expectations for the exam will help students who panic when they don’t know or understand questions. Answering questions where the answers are known and understood first can improve test anxiety. This helps to improve confidence and in turn, reduce anxiety during the exam as well as diminishes the sensation that time is running out.3, 4
For students who feel unprepared, teachers can provide insight into the exam content and style to help reduce the fear of the unknown. Study habits can be improved by providing a clear, regimented course schedule. Study groups can also be beneficial by helping keep students focused. Having more frequent exams can also improve study habits since students will need to review material more frequently.1, 2
Test anxiety is a major concern for some students. It can prevent students from advancing academically and professionally. Test anxiety also causes students to avoid other educational experiences and to focus more on passing exams instead of learning the content. However, test anxiety can be minimized if both the student and teacher employ some proven strategies.
1. Sansgiry SS, Sail K. Effect of Students’ Perceptions of Course Load on Test Anxiety. Am J Pharm Edu. 2006; 70(2): Article 26.
2. Neuderth S, Jabs B, Schmidtke A. Strategies for reducing test anxiety and optimizing exam preparation in German university students: a prevention-oriented pilot project of the University of Wurzburg. J Neural Transm. 2009; 116: 785–90.
3. Abolafia J, Lumpkins A, Malandro T. High Stakes Testing: Managing Test Anxiety. [Internet]. Accessed April 27, 2013.
4. Paul A. Relax, It's Only A Test. Time 2013;181(5):42-5.
5. Yusof M, Associations of Pass-Fail Outcomes with Psychological Health of First-Year Medical Students in a Malaysian Medical School. Sultan Qaboos University Med. 2013; 13(1): 107-14.
6. Chinta R. Exam Anxiety Effect on Exam Performance: An Empirical Replication in the Middle East. Aryan Hellas Limited, IRBC Athens, 2005. Accessed 5 May 2013.