Anxiety and performance in a structured objective clinical examination of undergraduate physical therapy students
Luis Gómez Miranda1, 2, Hernán Andrés de la Barra Ortiz2*
1Programa de Doctorado en Políticas y Gestión Educativa, Facultad de Ciencias de la Educación, Universidad de Playa Ancha, C.P. 2360072, Av. Playa Ancha 850, Playa Ancha, Valparaíso, Chile. 2Exercise and Rehabilitation Sciences Institute, School of Physical Therapy, Faculty of Rehabilitation Sciences, Universidad Andres Bello, Santiago de Chile 7591538, Chile.
Correspondence: Hernán Andrés de la Barra Ortiz, Exercise and Rehabilitation Sciences Institute, School of Physical Therapy, Faculty of Rehabilitation Sciences, Universidad Andres Bello, Santiago de Chile 7591538, Chile. [email protected]
ABSTRACT
Exam anxiety is a common experience among healthcare students, and this phenomenon is accentuated during evaluations such as the Objective Structured Clinical Examination (OSCE). This study aimed to examine the relationship between anxiety and undergraduate students' performance on an OSCE. A descriptive cross-sectional survey was conducted among physical therapy students at Andrés Bello University in Chile, specifically in the Physical Agents course, employing the OSCE. Prior to the examination, students' anxiety levels were assessed using the State-Trait Anxiety Inventory (STAI). The odds ratio and correlations were analyzed to investigate the relationship between anxiety and OSCE performance. The passing score for the exam was established at 39 points out of a maximum of 55. The study analyzed the OSCE performance of 113 students, revealing an average score of 41.6 (SD±6.6) and a passing rate of 61%. Among the participants, 61 were evaluated for state anxiety and 68 for trait anxiety. However, the odds ratio did not demonstrate significance for state anxiety (STAI-S: 0.49, 95% CI: 0.23,1.05, p=0.06) or trait anxiety (STAI-T: 1.49, 95% CI: 0.68,3.33, p=0.99). The absence of significant correlations between anxiety and performance confirmed this. Despite its high prevalence among students, anxiety did not emerge as a risk factor for failing the OSCE. Moreover, there were no discernible gender differences in anxiety levels and performance correlations. Exploring other influential variables and employing regression models to assess their impact on OSCE performance is suggested.
Keywords: Physical therapy specialty, Undergraduate medical education, Anxiety, Performance anxiety, Clinical competence, Academic performance
Introduction
Physical therapists excel at mastering diverse clinical skills to enhance individual patient function [1]. These skills involve patient-centered reasoning, interaction, and the application of procedures like therapeutic exercises, physical agents, and patient education [1, 2]. Due to their direct impact on patient health, mastering these skills is essential for making effective clinical decisions and adapting to diverse professional contexts [1, 3].
The acquisition of clinical skills in healthcare professional training is very important and has become necessary [4]. Nevertheless, assessing these skills in education remains challenging, often due to instruments lacking objectivity, validity, and reliability [5]. This poses significant difficulties for assessment during the training process [6].
Physical therapists utilize physical agent modalities, including electrotherapy, ultrasound, and temperature-based techniques like heat or cold, to enhance treatment outcomes [7]. Nevertheless, using these resources is not without risks and requires a comprehensive understanding, continuous practice, and clinical experience to guarantee their secure and efficient application [7, 8].
Its use should be based on adequate formation and training of these clinical skills, with strategies to develop and evaluate the ability to use physical agents [9, 10].
In recent years, the OSCE has emerged as a widely employed method for assessing clinical skills in training healthcare undergraduates [11-13]. This exam is characterized by its structured approach to evaluating performance components, with an emphasis on objectivity [14]. The OSCE provides a controlled environment to evaluate various clinical skills with unbiased stations and evaluators. Moreover, it allows extensive coverage of the contents of a course and uses simulated patients and clinical materials to reduce dependence on real patients and the risks associated with the intervention [12, 14]. The OSCE can be challenging due to its costly and time-consuming preparation, which can lead to logistical and financial complications [11, 15].
It is widely acknowledged that practical exams like the OSCE can induce stress and anxiety in students, impacting their learning and memory in diverse ways [16, 17]. Student anxiety, characterized by restlessness and insecurity, varies based on factors like preparation, content difficulty, and rest [17, 18]. Anxiety is linked to the fear of not meeting personal or familial expectations, resulting in physiological symptoms such as palpitations and sweating, as well as behavioral consequences like procrastination and study avoidance [16, 18, 19].
The State-Trait Anxiety Inventory (STAI) is a widely employed instrument in psychology and education to assess anxiety across two dimensions: state (A/S) and trait (A/T) [20]. The A/S dimension assesses a temporary, modifiable emotional state characterized by heightened autonomic nervous system activity, increased attention, and apprehension. In contrast, A/T pertains to a stable anxious predisposition in individuals who perceive situations as threatening. The inventory consists of two separate self-assessment scales, each comprising 20 criteria for measuring both dimensions [21].
As the use of the OSCE in higher education expands, conducting a more comprehensive analysis of non-cognitive factors, such as exam-related anxiety, becomes pertinent. This analysis can elucidate its influence on academic performance, thereby expediting the implementation of supportive strategies aimed at enhancing academic well-being [13-16]. These strategies, while assisting students in anxiety management, also hold the potential to positively impact the educational environment. Hence, the aim of this study was to explore the correlation between anxiety levels and the performance of physical therapy students in an OSCE and to discern whether anxiety serves as a risk factor for performance outcomes in this exam.
Materials and Methods
Type of study
Non-experimental, cross-sectional descriptive study
Participants
The study encompassed a cohort of 118 students (62 males and 56 females) with an average age of 21.3 years (SD ± 1.9). These students were enrolled in the Physical Therapy program at the Santiago campus of Andrés Bello University (UNAB), Chile, and were participating in the Physical Agents course during the first semester of 2022. This course is an integral component of the mandatory curriculum for the seventh semester, spanning 116 semester hours. The course structure entails 2.5 hours of in-person instruction and 5 hours of independent study per week, contributing to a total of 5 standard academic credits.
The Physical Agents course is an integral component of the disciplinary field and is designed to conduct a comprehensive analysis of the various physical resources employed in physical therapy. It assesses their physical, physiological, and therapeutic impacts. Throughout this course, students develop the capacity to judiciously apply and evaluate non-ionizing physical resources in diverse clinical contexts, addressing the needs and issues of individuals with varying health conditions. The course evaluation with Objective Structured Clinical Examination (OSCE) comprehensively covers the entire course content.
Selection criteria
The study included participants who were physical therapy students in the fourth level of the program and were actively enrolled in the physical agents course, which featured the OSCE assessment. Exclusion criteria comprised students who did not grant written consent for their results to be used, as well as those who formally withdrew from the course or did not complete the OSCE.
Instruments: OSCE
The OSCE methodology was introduced at the outset of the course and was developed collaboratively by the course instructors to align with the program's learning outcomes [11]: (LO1) analyze the physical and physiological effects of non-ionizing physical agents; (LO2) evaluate various modalities of physical agents in professional contexts to address deficiencies; and (LO3) evaluate deficiencies and functional problems related to health, considering intervention with physical agents.
During a three-month period, the course comprehensively explored the biophysical fundamentals, physiological effects, and practical applications of physical agents and resources, with a specific emphasis on transcutaneous electrical nerve stimulation (TENS), interferential currents, Russian currents, and therapeutic ultrasound. Practical activities, clinical case resolutions, and peer simulation stations were implemented to train students for the OSCE. Table 1 illustrates the OSCE's structure, outlining the distinct features of each station and its intended purpose.
|
Table 1. Physical agents OSCE stations |
|||||||
|
Number |
Station Name |
Learning Outcome |
Station Modality |
Station Aim |
Station Criteria |
Instrument |
Station Score |
|
S1 |
Connective tissue flexibility |
LO 1 |
Standardized patient |
Administer therapeutic ultrasound to enhance connective tissue flexibility |
1. Choose conventional ultrasound |
Checklist |
13 |
|
S2 |
Pain management |
LO 1 |
Standardized patient |
Administer Transcutaneous Electrical Nerve Stimulation (TENS) for pain relief |
1. Choose transcutaneous nerve stimulation |
Checklist |
11 |
|
S3 |
Oedema drainage |
LO 1 |
Standardized patient |
Administer neuromuscular electrical stimulation (NMES) for edema reduction |
1. Choose a neuromuscular electrical stimulation (NMES) modality |
Checklist |
11 |
|
S4 |
Muscle strengthening |
LO 1 |
Standardized patient |
Conduct electric muscle strengthening to enhance muscle tropism |
1. Select Russian currents (Kots). |
Checklist |
11 |
|
S5 |
Electrotherapy installation |
LO 2 |
Dummy (phantom) |
Install electrotherapy equipment safely |
1. Position the user in accordance with the therapeutic objective |
Checklist |
9 |
The OSCE consisted of five stations, with four involving standardized patients (S1–S4) and one utilizing a phantom (S5). Each station underwent an assessment based on a checklist that had been reviewed and validated by course instructors and peers. A week prior to the examination, a pilot exam was conducted involving actors and teachers to fine-tune timing, review assessment criteria, and provide additional training to actors for handling clinical cases. A total of 40 minutes were allotted for the entire OSCE, allowing for eight minutes to complete each station.
Students were organized into time blocks on the day of the exam. Before beginning the OSCE, instructions regarding exam time, number of stations, and direction of rotation were provided. A teacher monitored the exam time and guided the students in the rotations. Post-examination, data were collected, and tabulated the total and station scores as a measure of student performance.
The OSCE comprised a total of 55 points, derived from the summation of scores allocated to individual stations (S1: 13 points; S2: 11 points; S3: 11 points; S4: 11 points; S5: 9 points). A passing score of 39 points was established, equating to 70% of the maximum achievable score, according to institutional guidelines.
State-trait anxiety inventory (STAI)
Student anxiety was evaluated using the STAI inventory, considering both its STAI-S (state anxiety) and STAI-T(train anxiety) dimensions [21]. The instrument was administered to the cohort one day before the OSCE to gather information about their anxiety levels preceding the exam.
The STAI offers various categories for assessing anxiety levels, with scores differentiated by gender [19, 21]. For the STAI-S dimension, anxiety levels are classified as follows: low anxiety (men: 14–18; women: 15–19), average (men: 19; women: 20–22), moderate anxiety (men: 20–28; women: 23–31), and high anxiety (men: 29–60; women: 32–60). Regarding the STAI-T dimension, scores are represented as follows: low anxiety (men: 14–18; women: 15–19), average (men: 19; women: 24–25), moderate anxiety (men: 20–25; women: 26–32), and high anxiety (men: 26–60; women: 33–60).
The STAI scores in its two dimensions (STAI-S and STAI-T) were recorded by one of the researchers (HDB) in a Microsoft Excel® sheet.
Statistical analysis
The statistical analysis included the assessment of normality for the variables, including observed performance in OSCE (OSCE scores) and anxiety (STAI-S and STAI-T), which was verified using the Shapiro-Wilk test [22]. To analyze the likelihood of not approving the OSCE when experiencing anxiety, the odds ratio (OR) with a 95% confidence interval (CI) was calculated [23]. An OR less than 1 was interpreted as a protective association, while an OR greater than 1 indicated an association that increased proportionally with higher values.
A correlation analysis between observed performance and anxiety was conducted in the entire cohort as well as in subgroups by gender. The correlation coefficients employed included Pearson's correlation coefficient (r) and Spearman's correlation coefficient (Rho), chosen based on data distribution [24]. Analyses were performed using Statistical Package for the Social Sciences (SPSS) software version 26.
Results and Discussion
In the Physical Agents course, 118 students were officially enrolled. Of this group, 113 met the study selection criteria, excluding 5 due to their absence from the exam, which represented a participation rate of 96% of the cohort.
STAI score
Table 2 presents a summary of the STAI results in both its STAI-S and STAI-T dimensions, following the analysis of scores from the 113 students who participated in the OSCE. Notably, a non-normal distribution is evident in both STAI dimensions. Central tendency statistics reveal that for STAI-S, the average score stands at 28.4 (±6.6) with a median of 28, while for STAI-T, the average is 29.4 (±7.5) with a median of 29. To categorize anxiety levels, a cutoff point of 28 points for STAI A/S and 29 points for STAI A/T delineates the presence of 'high anxiety.' Conversely, STAI categories representing average and low anxiety were combined into the 'low anxiety' group.
Within the cohort, 54% exhibited anxiety based on the STAI-S, and 60% did so based on the STAI-T. When the data was stratified by gender, it was found that 27% of both men and women demonstrated anxiety according to the STAI-S, while 30% of men and 29% of women exhibited anxiety according to the STAI-T dimension.
|
Table 2. State-Trait Anxiety Inventory results (n=113) |
||||||||||||||
|
STAI |
Distribution* |
mean |
SD |
median |
P25-P75 |
minimum score |
maximum score |
Anxiety cutoff score |
High Anxiety |
Low anxiety |
High anxiety (men) |
Low axienty (men) |
High anxiety (women) |
Low anxiety (women) |
|
STAI A/S |
p < 0.01 |
28.4 |
6.6 |
28 |
24-33 |
15 |
60 |
28 |
61 (54%) |
52 (46%) |
31 (27%) |
29 (26%) |
31 (27%) |
22 (19%) |
|
STAI A/T |
29.4 |
7.5 |
29 |
24-35 |
15 |
60 |
29 |
68 (60%) |
45 (40%) |
35 (30%) |
25 (22%) |
33 (29%) |
20 (17%) |
|
|
*The distribution was determined with the Shapiro-Wilk test (95% confidence interval) |
||||||||||||||
OSCE scores
Table 3 provides a comprehensive view of 113 students' scores, categorized by station and analyzed with central tendency statistics. Notably, scores for individual stations (S1–S5) deviate from a normal distribution, suggesting variations in station difficulty or student performance. Conversely, the cumulative exam score adheres to a normal distribution, indicating an even distribution of student performance on the overall exam.
The OSCE results indicate that 61% of the students successfully passed the exam. The exam displayed an average score of 41.4 (±6.6) and a median of 42, signifying an overall performance level exceeding the passing score for most students. Among the specific stations, station S1 achieved the highest pass rate at 81%, whereas station S2 had the lowest pass rate, standing at 58%.
Relevantly, the interquartile range (P25–P75) spans from 37 to 46, underscoring that students who didn't pass were near the passing score. This highlights the potential for a marginal difference in scores for those who did not meet the passing criteria.
|
Table 3. OSCE scores achieved for individual stations (n=113) |
||||||||||||
|
Station number |
Station name |
Station score |
Distribution* |
mean |
SD |
median |
P25-P75 |
minimum score |
maximum score |
passing score |
approved |
not approved |
|
S1 |
Connective tissue flexibility |
13 |
p < 0.01 |
10.8 |
1.9 |
11 |
10-12 |
5 |
13 |
9 |
91 (81%) |
22 (19%) |
|
S2 |
Pain management |
11 |
7.5 |
2.7 |
8 |
5-10 |
2 |
11 |
8 |
65 (58%) |
48 (42%) |
|
|
S3 |
Oedema drainage |
11 |
8.0 |
2.5 |
9 |
7-10 |
2 |
11 |
8 |
78 (69%) |
35 (31%) |
|
|
S4 |
Muscle strengthening |
11 |
7.9 |
2.5 |
9 |
7-10 |
2 |
11 |
8 |
77 (68%) |
36 (32%) |
|
|
S5 |
Electrotherapy installation |
11 |
7.2 |
1.4 |
8 |
6-8 |
3 |
9 |
7 |
78 (69%) |
35 (31%) |
|
|
S1-S5 |
overall |
55 |
p > 0.05 |
41.4 |
6.6 |
42 |
37-46 |
26 |
55 |
39 |
69 (61%) |
44 (39%) |
|
*The distribution was determined with the Shapiro-Wilk test (95% confidence interval) |
||||||||||||
Odds ratio of failing OSCE due to anxiety
Table 4 provides an OR analysis concerning the likelihood of failing the OSCE and its individual stations. This analysis considers anxiety levels, specifically focusing on its STAI-S and STAI-T dimensions, which are considered potential risk factors (25).
The findings do not demonstrate a statistically significant association between anxiety in its two dimensions and the overall OSCE performance, nor with non-passing in stations S2 and S4 (p > 0.05). However, a noteworthy relationship emerges in the STAI-T dimension for stations S2 and S5, where the presence of anxiety increases the risk of not passing by 8.5 and 3.5 times, respectively (p < 0.05). Conversely, it was observed that the presence of STAI-S serves as a protective factor for performance in S3 (p < 0.05).
|
Table 4. The likelihood of failing OSCE due to anxiety |
||||||
|
OSCE overall score |
||||||
|
STAI dimension |
Level of anxiety |
Not approved |
approved |
OR |
CI 95% |
p-value |
|
STAI-S |
High Anxiety |
19 |
42 |
0.49 |
0.23,1.05 |
p = 0.06 |
|
Low anxiety |
25 |
27 |
||||
|
STAI-T |
High Anxiety |
29 |
39 |
1.49 |
0.68,3.3 |
p = 0.992 |
|
Low anxiety |
15 |
30 |
||||
|
S1: Connective tissue flexibility |
||||||
|
STAI-S |
High Anxiety |
12 |
49 |
1.02 |
0.4,2.6 |
p = 0.95 |
|
Low anxiety |
10 |
42 |
||||
|
STAI-T |
High Anxiety |
20 |
48 |
8.95 |
1.9,40.5 |
p < 0.01* |
|
Low anxiety |
2 |
43 |
||||
|
S2: Pain management |
||||||
|
STAI-S |
High Anxiety |
24 |
37 |
0.75 |
0.33,1.66 |
p = 0.73 |
|
Low anxiety |
24 |
28 |
||||
|
STAI-T |
High Anxiety |
27 |
41 |
0.75 |
0.33,1.67 |
p = 0.73 |
|
Low anxiety |
21 |
24 |
||||
|
S3: Edema drainage |
||||||
|
STAI-S |
High Anxiety |
12 |
49 |
0.31 |
0.13,0.71 |
p < 0.01 |
|
Low anxiety |
23 |
29 |
||||
|
STAI-T |
High Anxiety |
18 |
50 |
0.59 |
0.26,1.33 |
p = 0.21 |
|
Low anxiety |
17 |
28 |
||||
|
S4: Muscle strengthening |
||||||
|
STAI-S |
High Anxiety |
17 |
44 |
0.67 |
0.30,1.48 |
p = 0.32 |
|
Low anxiety |
19 |
33 |
||||
|
STAI-T |
High Anxiety |
21 |
47 |
0.89 |
0.39,1.99 |
p = 0.78 |
|
Low anxiety |
15 |
30 |
||||
|
S5: Electrotherapy installation |
||||||
|
STAI-S |
High Anxiety |
18 |
43 |
0.86 |
0.38,1.91 |
p = 0.37 |
|
Low anxiety |
17 |
35 |
||||
|
STAI-T |
High Anxiety |
26 |
42 |
2.47 |
1.02,5.96 |
p < 0.05* |
|
Low anxiety |
9 |
36 |
||||
*p<0.05
Table 5 summarizes the correlations between STAI-S and STAI-T dimensions and overall OSCE scores by station and gender. Notably, no statistically significant correlations were found between anxiety and overall OSCE performance (p > 0.05). However, exceptions include a weak, negative correlation for STAI-T anxiety with overall performance and similar correlations for male students. Figures 1 and 2 illustrate the primary correlations in the study.
|
Table 5. Correlation between STAI dimensions and OSCE scores |
||||||||
|
Overall OSCE score |
S1 score |
S2 score |
S3 score |
S4 score |
S5 score |
Men OSCE score |
Women OSCE score |
|
|
STAI-S |
113 |
113 |
113 |
113 |
113 |
113 |
60 |
53 |
|
STAI-T |
113 |
113 |
113 |
113 |
113 |
113 |
60 |
53 |
n = number of observations
The correlation was determined using Spearman's Rho test. *p<0.05
|
|
|
a) Correlation of STAI-S-OSCE score |
|
|
|
b) Correlation of STAI-T-OSCE score |
|
Figure 1. Correlation between anxiety and performance |
|
|
|
a) Correlation of STAI-S-OSCE score (men) |
|
|
|
b) Correlation of STAI-T-OSCE score (men) |
|
|
|
c) Correlation of STAI-S-OSCE score (women) |
|
|
|
d) Correlation of STAI-T-OSCE score (women) |
|
Figure 2. Correlation between anxiety and performance by gender |
In this observational study, the principal aim was to examine anxiety levels among physical therapy students and their correlation with OSCE exam performance. Additionally, the study aimed to investigate the likelihood of not passing the exam by considering anxiety as a potential risk factor. The research hypothesis posited that heightened anxiety levels would be linked to diminished performance on the OSCE among students.
The primary findings suggest that the presence of anxiety in the STAI-S and STAI-T dimensions does not appear to pose a risk of failing the physical therapy OSCE. This is supported by the absence of a significant correlation between the STAI scores and the overall OSCE score. Nevertheless, upon closer examination of performance at individual stations, it becomes evident that there is an association between anxiety and performance at certain stations. This underscores the necessity for a more targeted and specific analysis of these station-specific relationships.
Anxiety in students
It is well established that assessment scenarios often trigger elevated stress and anxiety among students, particularly during their initial and intermediate training cycles, especially when they encounter their first clinical interactions [25-27]. Anxiety levels vary by profession, with higher rates observed in health students [26]. Moreover, the COVID-19 pandemic has contributed to increased anxiety among university students, placing a greater burden on their mental health [27].
Anxiety is often prominent in contexts requiring precise and efficient procedures, creating significant performance pressure [28]. In psychology, this is known as performance anxiety, which manifests as tension when performing tasks that are under evaluation, like exams [29]. It can detrimentally impact student performance and overall well-being [30].
Identifying anxiety in students accurately is challenging due to its diverse symptoms and manifestations [30, 31]. This identification can be complicated by symptom overlap with other medical conditions and the social stigma surrounding mental health [31]. Among the primary factors identified as determinants of academic anxiety are emotional and economic factors, residence location during the academic year, the need to balance work and studies, family responsibilities, changes in social support networks, and the perception of inadequate support [30]. Furthermore, intrinsic factors, such as exam preparation, the student's stage of training, and the utilization of study resources like textbooks, also play a significant role in influencing anxiety levels during assessments [30, 32, 33].
Anxiety in the OSCE
The OSCE has been recognized as a rigorous assessment method for evaluating clinical skills. It systematically evaluates performance and its components in a structured manner, with a strong emphasis on maintaining objectivity throughout the examination process [14]. A factor that significantly influences students' attitudes is the presence of stress and anxiety when facing interactions with real or simulated users or clinical procedures for the first time [16, 24].
According to the study, anxiety in its STAI-S and STAI-T forms is not a major risk factor for overall performance on the OSCE. This is shown by the fact that there was no significant inverse correlation. These findings align with prior research investigating the link between anxiety and performance, which similarly concluded that neither anxiety nor stress significantly correlates with performance on the OSCE [16, 34].
Existing literature has documented higher rates of anxiety disorders in women; however, the impact of gender on the age of onset and severity of these disorders remains less comprehensively understood [35]. Nevertheless, this study does not reveal a distinct correlation between gender, anxiety, and performance on the OSCE. Intriguingly, it was found that initial anxiety levels were higher in men, both supporting and challenging previous research in this regard [16, 30]. These findings emphasize the intricate nature of the link between gender and anxiety, underscoring the necessity for ongoing research in this area.
Given the wide range of factors capable of inducing anxiety, it is crucial to acknowledge that OSCEs and other training-related examinations, while occasionally linked to elevated anxiety in specific students, should not be solely attributed to the exclusive source of this emotional response. As a result, the OSCE or other exams may have a limited impact compared to these factors, which each student may perceive as anxiety-inducing [17]. Therefore, while significant levels of anxiety have been identified, we cannot directly attribute them solely to the exam, and further investigation of these factors is essential for a comprehensive understanding.
In this context, a viable strategy for quantifying the impact of various factors on performance could involve the use of logistic regression models [36]. This methodology is particularly suitable when aiming to predict the presence or absence of a specific characteristic, such as academic performance, by considering the values of a set of predictors, which may encompass variables related to anxiety [37].
The researchers propose that several factors could have contributed to the reduction in anxiety within the analyzed context. These factors encompass the depth of content, regular peer interactions during weekly training sessions, and the practice of conducting mock tests. Additionally, the academic cycle in which students are positioned may have played a role, with the experience gained in previous courses emerging as a significant influencing factor. Furthermore, highlighting the rigorously validated instrument is essential. This process minimizes evaluation biases, instilling student confidence in its objectivity and reliability.
Another factor to consider is the weight assigned to the OSCE, which constitutes 30% of the total course grade. This weight does not exert a decisive impact on the overall course grade, irrespective of the result obtained. It is hypothesized that assessments or exams with greater significance could exert a more direct influence on anxiety levels. This aspect underscores the necessity for research in more pivotal stages of the training process.
A hypothesis has been postulated concerning State anxiety as a plausible protective factor in station S3, with Trait anxiety being deemed a potential risk factor in stations S1 and S5. The subject matter covered in station S3 received comprehensive practice during pre-exam training sessions due to its difficulty. This exposure may have induced anxiety in students, as they anticipated encountering it in the actual exam. However, this anxiety could have served as a motivating factor, prompting them to prepare more diligently and potentially converting it into a protective element. This is evident in its notably high pass rate, positioning it as the second-best performing station. In contrast, the researchers found that stations S1 and S5 had a higher level of specificity and complexity, which could be seen as possible risk factors for initial anxiety levels (STAI-T). This underscores the importance of enhancing practice for these procedures to reduce the potential influence of anxiety.
Conclusion
Despite the widespread presence of anxiety among students, this study does not reveal significant correlations between anxiety and performance on the OSCE, nor does it establish anxiety as a predictive factor for failure. Furthermore, no substantial gender-related effects on anxiety levels or the risk of lower OSCE performance were discerned. It is recommended that further comprehensive research be conducted to investigate the variables influencing anxiety in university students. Additionally, the development of regression models is encouraged to provide a more profound understanding of how anxiety interacts with other factors to affect OSCE performance.
Acknowledgments: Exercise and Rehabilitation Sciences Institute and School of Physical Therapy. Universidad Andrés Bello.
Conflict of interest: None
Financial support: None
Ethics statement: The study protocol and its ethical aspects were approved by the Department of Physical Therapy and Faculty of Rehabilitation Sciences of Andrés Bello University on April 5, 2022 (reference number 50423).
References
1. Dean E, Skinner M, Myezwa H, Mkumbuzi V, Mostert K, Parra DC, et al. Health competency standards in physical therapist practice. Phys Ther. 2019;99(9):1242-54. doi:10.1093/ptj/pzz087
2. Rethorn ZD, Covington JK, Cook CE, Bezner JR. Physical therapists' knowledge, skills, beliefs, and organizations impact physical activity promotion: A systematic review and meta-analysis. Phys Ther. 2022;102(3):pzab291. doi:10.1093/ptj/pzab291
3. Kinney M, Seider J, Beaty AF, Coughlin K, Dyal M, Clewley D. The impact of therapeutic alliance in physical therapy for chronic musculoskeletal pain: A systematic review of the literature. Physiother Theory Pract. 2020;36(8):886-98. doi:10.1080/09593985.2018.1516015
4. Young M, Thomas A, Gordon D, Gruppen L, Lubarsky S, Rencic J, et al. The terminology of clinical reasoning in health professions education: Implications and considerations. Med Teach. 2019;41(11):1277-84. doi:1080/0142159X.2019.1635686
5. Leite S de S, Áfio ACE, Carvalho LV de, Silva JM da, Almeida PC de, Pagliuca LMF. Construction and validation of an Educational Content Validation Instrument in health. Rev Bras Enferm. 2018;71(suppl 4):1635-41. doi:10.1590/0034-7167-2017-0648
6. Elvén M, Hochwälder J, Dean E, Söderlund A. Predictors of clinical reasoning using the reasoning 4 change instrument with physical therapist students. Phys Ther. 2019;99(8):964-76. doi:10.1093/ptj/pzz044
7. Allen RJ. Physical agents used in the management of chronic pain by physical therapists. Phys Med Rehabil Clin N Am. 2006;17(2):315-45. doi:10.1016/j.pmr.2005.12.007
8. Argenis G, Juárez S. Physical Agents and Therapeutic Modalities: Main concepts implicated in Physiotherapy treatment prescription and into advanced physical therapy practice. Eur Sci J. 2023;1. doi:19044/esipreprint.1.2023p553
9. Electrophysical Agents - contraindications and precautions: An evidence-based approach to clinical decision making in physical therapy. Physiother Can. 2010;62(5):1-80. doi:10.3138/ptc.62.5
10. Springer S, Laufer Y, Elboim-Gabyzon M. Clinical decision making for using electro-physical agents by physiotherapists, an Israeli survey. Isr J Health Policy Res. 2015;4(1):14. doi:10.1186/s13584-015-0015-x
11. De la Barra-Ortiz HA, Gómez-Miranda LA, De la Fuente-Astroza JI. Objective structured clinical examination (OSCE) to assess the clinical skills of physical therapy students when using physical agents. Rev Fac Med Univ Nac Colomb. 2021;69(3):e83545. doi:10.15446/revfacmed.v69n3.83545
12. Alkhateeb N, Salih AM, Shabila N, Al-Dabbagh A. Objective structured clinical examination: Challenges and opportunities from students' perspective. PLoS One. 2022;17(9):e0274055. doi:10.1371/journal.pone.0274055
13. Ribeiro AM, Ferla AA, Amorim JSC de. Objective structured clinical examination in physiotherapy teaching: a systematic review. Fisioter Em Mov. 2019;32(0). doi:10.1590/1980-5918.032.ao14
14. Majumder MAA, Kumar A, Krishnamurthy K, Ojeh N, Adams OP, Sa B. An evaluative study of objective structured clinical examination (OSCE): students and examiners perspectives. Adv Med Educ Pract. 2019;10:387-97. doi:10.2147/AMEP.S197275
15. Lebdai S, Bouvard B, Martin L, Annweiler C, Lerolle N, Rineau E. Objective structured clinical examination versus traditional written examinations: a prospective observational study. BMC Med Educ. 2023;23(1):69. doi:10.1186/s12909-023-04050-5
16. Martin RD, Naziruddin Z. Systematic review of student anxiety and performance during objective structured clinical examinations. Curr Pharm Teach Learn. 2020;12(12):1491-7. doi:10.1016/j.cptl.2020.07.007
17. Brand HS, Schoonheim-Klein M. Is the OSCE more stressful? Examination anxiety and its consequences in different assessment methods in dental education: Examination anxiety in dental education. Eur J Dent Educ. 2009;13(3):147-53. doi:10.1111/j.1600-0579.2008.00554.x
18. Quek TT-C, Tam WW-S, Tran BX, Zhang M, Zhang Z, Ho CS-H, et al. The global prevalence of anxiety among medical students: A meta-analysis. Int J Environ Res Public Health. 2019;16(15):2735. doi:10.3390/ijerph16152735
19. Franzoi IG, Sauta MD, Granieri A. State and trait anxiety among university students: A moderated mediation model of negative affectivity, alexithymia, and housing conditions. Front Psychol. 2020;11:1255. doi:10.3389/fpsyg.2020.01255
20. Ormond KE, Pergament E, Fine BA. Pre-screening education in multiple marker screening programs: The effect on patient anxiety and knowledge. J Genet Couns. 1996;5(2):69-80. doi:10.1007/BF01408532
21. Julian LJ. Measures of anxiety: State-trait anxiety inventory (STAI), Beck anxiety inventory (BAI), and hospital anxiety and depression scale-anxiety (HADS-A). Arthritis Care Res (Hoboken). 2011;63 Suppl 11(S11):S467-72. doi:10.1002/acr.20561
22. Gupta A, Mishra P, Pandey C, Singh U, Sahu C, Keshri A. Descriptive statistics and normality tests for statistical data. Ann Card Anaesth. 2019;22(1):67. doi:10.4103/aca.aca15718
23. Hoppe FM, Hoppe DJ, Walter SD. Explaining odds ratios as conditional risk ratios. J Clin Epidemiol. 2018;97:123-4. doi:10.1016/j.jclinepi.2017.10.009
24. Zhuo B, Jiang D, Di Y. Test-statistic correlation and data-row correlation. Stat Probab Lett. 2020;167(108903):108903. doi:10.1016/j.spl.2020.108903
25. Tan Z. Analysis of odds, probability, and hazard ratios: From 2 by 2 tables to two-sample survival data. J Stat Plan Inference. 2022;221:248-65. doi:10.1016/j.jspi.2022.05.002
26. Moreira de Sousa J, Moreira CA, Telles-Correia D. Anxiety, depression and academic performance: A study amongst Portuguese medical students versus non-medical students. Acta Med Port. 2018;31(9):454-62. doi:10.20344/amp.9996
27. Lee J, Jeong HJ, Kim S. Stress, anxiety, and depression among undergraduate students during the COVID-19 pandemic and their use of mental health services. Innov High Educ. 2021;46(5):519-38. doi:10.1007/s10755-021-09552-y
28. Orfus S. The Effect Test Anxiety and Time Pressure on Performance. Huron Univ Coll J Learn Motiv. 2008;46(1). Available from: https://ir.lib.uwo.ca/hucjlm/vol46/iss1/7
29. Chow K, Mercado III E. Performance anxiety and the plasticity of emotional responses. Cogn Emot. 2020;34(7):1309-25. doi:10.1080/02699931.2020.1749568
30. Memon I, Omair A, Barradah OM, Almegren NM, Almuqbil MM, Batarfi OH, et al. Measurement of exam anxiety levels among medical students and their association with the influencing factors. Cureus. 2023;15(7):e41417. doi:10.7759/cureus.41417
31. Penninx BW, Pine DS, Holmes EA, Reif A. Anxiety disorders. Lancet Lond Engl. 2021;397(10277):914-27.
32. Cipra C, Müller-Hilke B. Testing anxiety in undergraduate medical students and its correlation with different learning approaches. PLoS One. 2019;14(3):e0210130. doi:10.1371/journal.pone.0210130
33. Ortiz HA de la B, Astroza JI de la F, Miranda LG. Efficacy of the digital textbook for the autonomous work of physical therapy students. J Adv Pharm Educ Res. 2022;12(4):39-48. doi:10.51847/ku0mar1ayo
34. Ferreira É de MR, Pinto RZ, Arantes PMM, Vieira ÉLM, Teixeira AL, Ferreira FR, et al. Stress, anxiety, self-efficacy, and the meanings that physical therapy students attribute to their experience with an objective structured clinical examination. BMC Med Educ. 2020;20(1):296. doi:10.1186/s12909-020-02202-5
35. McLean CP, Asnaani A, Litz BT, Hofmann SG. Gender differences in anxiety disorders: prevalence, course of illness, comorbidity and burden of illness. J Psychiatr Res. 2011;45(8):1027-35. doi:10.1016/j.jpsychires.2011.03.006
36. Zhang L, Zhao S, Lin Q, Song M, Wu S, Zheng H. Algorithms to predict anxiety and depression among university students in China after analyzing lifestyles and sports habits. Neuropsychiatr Dis Treat. 2021;17:2011-25. doi:10.2147/NDT.S315148
37. Marwood L, Wise T, Perkins AM, Cleare AJ. Meta-analyses of the neural mechanisms and predictors of response to psychotherapy in depression and anxiety. Neurosci Biobehav Rev. 2018;95:61-72. doi:10.1016/j.neubiorev.2018.09.022
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