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Biofeedback-assisted relaxation training to decrease test anxiety in nursing students.

ABSTRACT

Background. Nursing students experiencing debilitating test anxiety may be unable to demonstrate their knowledge and have potential for poor academic performance.

Method. A biofeedback-assisted relaxation training program was created to reduce test anxiety. Anxiety was measured using Spielberger's Test Anxiety Inventory and monitoring peripheral skin temperature, pulse, and respiration rates during the training. Participants were introduced to diaphragmatic breathing, progressive muscle relaxation, and autogenic training.

Results. Statistically significant changes occurred in respiratory rates and skin temperatures during the diaphragmatic breathing session; respiratory rates and peripheral skin temperatures during progressive muscle relaxation session; respiratory and pulse rates, and peripheral skin temperatures during the autogenic sessions. No statistically significant difference was noted between the first and second TAI. Subjective test anxiety scores of the students did not decrease by the end of training.

Conclusion. Autogenic training session was most effective in showing a statistically significant change in decreased respiratory and pulse rates and increased peripheral skin temperature.

Key Words Test Anxiety--Biofeedback--Diaphragmatic Breathing Progressive Muscle Relaxation--Autogenics--Nursing Students

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NURSING IS ONE OF THE MOST DEMANDING AND STRESSFUL MAJORS WITHIN A UNIVERSITY SETTING (DEARY, WATSON, & HOSTON, 2003; GIBBONS, DEMPSTER, & MOUTRAY, 2008; WATSON ET AL., 2008). It requires the integration of large amounts of knowledge and technical skills, coupled with the development of appropriate attitudes and responses to highly emotional settings. Thus, nurse faculty demand high performance on examinations, with students subjected to the stress of testing and high threshold standards. Many programs require that students achieve certain percentages on every examination in order to progress. As testing has high consequences, nursing students who experience debilitating test anxiety may be unable to demonstrate their knowledge and have the potential for poor academic performance.

Schools of nursing should not decrease the requirements for progression within their programs and graduation. However, it is important to identify students who are struggling with test anxiety and implement interventions aimed at decreasing anxiety and alleviating the negative consequences. A biofeedback-assisted relaxation training (BART) program for nursing students may help students learn to control their physiological and psychological reactions associated with test anxiety and positively impact attrition rates.

The purpose of this study was threefold: 1) to identify which semester of an upper-division baccalaureate nursing program is associated with the highest test anxiety; 2) using participants from that semester, to determine if an intervention including diaphragmatic breathing, progressive muscle relaxation, and autogenic training assists students control their physiological responses; and 3) to determine if relaxation training decreases test anxiety.

Physiological Measures Related to Anxiety Test anxiety has been conceptualized in multiple ways throughout the years. Some researchers refer to the cognitive impairments involved and others to the emotional reactions. There is broad agreement that anxiety can be classified into two components, state and trait anxiety (Cheung, 2006). Trait anxiety is the stable individual differences in anxiety proneness (Spielberger, 1983) or a general way of responding to the world, which becomes stable over time (Zeidner, 2007). State anxiety is a transitory emotional condition that is characterized by subjective, consciously perceived feelings of tension, apprehension, nervousness, and worry (Spielberger). Spielberger defined test anxiety as an emotional state at a given moment in time and at a particular level of intensity that is characterized by "tension, apprehension, nervousness, and worry., and an activation of the autonomic nervous system" (p. 4).

Anxiety reactions are characterized by physical and autonomic changes with autonomic function a reflection of psychological state (Shinba et al., 2008). A relationship exists between respiration patterns and emotions (Homma & Masaoka, 2008); when a stressor is introduced, respiratory and pulse rates increase while peripheral skin temperatures decrease. Mental stress elicits the release of hormones such as epinephrine and norepinephrine, and the hormone release prepares the body for "fight or flight" (Webb et al., 2008). When an individual is anxious, there is an increased sensitivity to elevations in partial pressure of carbon dioxide (pC[O.sub.2]) levels that trigger the medullary suffocation alarm that stimulates breathing (Conrad et al., 2007). At the first response to anxiety, breathing is rapid and shallow; once the medulla is stimulated, the breathing rate and depth increase to expel the excess pC[O.sub.2]. Overactivity of the respiratory muscles contributes to feelings of dyspnea in anxious individuals because the shortening of the inspiratory muscles reduces efficiency of the lungs, thereby increasing the work of breathing (Ritz, Leupoldt, & Dahme, 2006).

When individuals experience anxiety, their sympathetic nervous systems are activated, causing elevated pulse (Hughes, 2005; Selye, 1976; Wardell & Engebretson, 2001) and respiratory rates. Blood volume is shifted away from digestive organs and skin toward larger skeletal muscles, causing blood to move away from the peripheral surfaces, which results in lowered skin temperature (Wardell & Engebretson).

Relaxation and Biofeedback Psychological interventions such as relaxation training have been shown to be effective in reducing stress; and relaxation techniques have a significant effect on emotional variables such as anxiety (Barlow et al., 1984; Leon-Pizarro et al., 2007; Luebbert, Dahme, & Hasenbring, 2001; Pluess, Conrad, & Wilhelm, 2009). Relaxation, a mind-body intervention used to decrease stress and promote a sense of well-being (Louie, 2004), is aimed at providing a distraction from anxious thoughts and changing one's physiology to a more relaxed state (Naussau, 2007). This approach seems as effective in reducing anxiety as medication, and teaching individuals how to control their physiological reactions to anxiety can help empower them (La Torre, 2001).

Biofeedback is generally integrated with relaxation (McGinnis, Cox, McGrady, & Grower-Dowling, 2005). Interventions used with biofeedback training include guided imagery and breathing retraining, techniques shown to reduce subjective levels of anxiety (Goodwin & Montgomery, 2006). Sessions that incorporate relaxation tend to focus on increasing awareness, allowing individuals to have a greater coping range (La Torre, 2001). Biofeedback-assisted relaxation to treat anxiety is effective in modifying the autonomic nervous system by decreasing physiological arousal (Goodwin & Montgomery; Reiner, 2008), leading to decreases in chronic stress, peripheral vasoconstriction, and anxiety (McGinnis et al.).

Method DESIGN A pre-post test design was used to test BART as an intervention to reduce test anxiety. The study was approved by the university's Institutional Review Board for the Protection of Human Subjects, and all participating students signed a written consent document.

PARTICIPANTS To determine which level of students to invite to participate, the study was divided into two parts. After a scheduled class, students in all four semesters of an upper-division nursing program were asked to complete Spielberger's Test Anxiety Inventory (TAI). Those wishing to participate signed a consent form and completed a demographic form and the TAI. A total of 156 students participated in this part of the study; one student did not complete the demographic data form. Of the remaining 155 students, 80 percent were female with a mean age of 25 [+ or -] 5.5.

Ethnicity was reported as follows: white, 75 (48.4 percent); black, 10 (6.5 percent), Hispanic, 14 (9 percent), and Asian/Pacific Islander, 55 (35.5 percent). The TAI for these students is shown in Table 1. There were no statistically significant differences in TAI by age, gender, ethnicity, or semester.

Because third-semester students showed the highest level of anxiety, these students were invited to participate in the second part of the study. Test anxiety is a subjective feeling; therefore, the study was open to any third-semester nursing student who self-reported test anxiety and was willing to complete the five-week BART sessions. These students were taking Nursing Care of Acutely Ill Populations, Nursing Research Methods, and Nursing Care of Mental Health Populations (15 credits). Participating students came to a private office in the nursing school for their individual BART sessions.

VARIABLES Test anxiety was defined as an emotional state at a given moment in time and at a particular level of intensity that is characterized by "tension, apprehension, nervousness, and worry, and an activation of the autonomic nervous system" (Spielberger, 1983, p. 4). Test anxiety was quantified using the TAI, which measures proneness to anxiety in testing situations. The TAI is a 20-item scale that asks respondents to report how frequently they experience specific symptoms of anxiety before, during, and after tests; it involves a Likert-style scale with anchors of 1 (almost never) to 4 (almost always), with total scores ranging from 20 to 80. "The TAI norms for college students are based on 1,449 undergraduates (654 males, 795 females) and 1,129 incoming freshmen (533 males, and 596 females) from the University South Florida" who were taking an introductory psychology class (Spielberger, 1980, p. 5). The mean for females was 42.79; the mean for males was 38.48. Test-retest reliability for the TAI is .80 to .81 for a two-week to one-month period and .62 for a six-month period. Studies of test-retest and internal-consistency reliability as well as concurrent and construct validity have supported the use of the TAI (Taylor & Dean, 2002).

RELAXATION INTERVENTION BART involved a series of relaxation training sessions where the students learned diaphragmatic breathing, progressive muscle relaxation, and autogenic training. It was followed by 15 minutes of practice at home every day until the next relaxation training session. BART was supported by the ProComp (Thought Technology Ltd., Montreal, Canada), an eight-channel, multi-modality, physiological monitoring device for use with biofeedback software applications. Respiration, pulse rates, and skin temperature were measured simultaneously during training. For home practice, students were provided with a Digital Feedback Thermometer (model SC911, Bio-Medical Instruments, Inc.). This personal biofeedback trainer is easy to use, portable, and accurate to 0.1[degrees]F. It reads temperatures between 50[degrees] and 158[degrees] and displays them on a three-quarter-inch high digital liquid crystal display; the reading updates every 2 seconds.

PROCEDURE AND DATA COLLECTION Test anxiety was measured using the TAI before two separate tests: pre-BART and post-BART. Also, the study required students to attend individual relaxation training sessions on campus every week for four weeks, practice the relaxation techniques taught to them at home, and monitor and record their physiological measurements. The two research questions addressed were: 1) By the end of the study, will nursing students have learned to decrease pulse rate, decrease breathing rate, and increase peripheral skin temperature using biofeedback-assisted relaxation training? 2) Does relaxation training decrease test anxiety?

Every BART was an individual session in which the primary investigator followed a prepared script to ensure consistency among students. The investigator rehearsed the training sessions with a faculty member who is board-certified in Biofeedback.

During the first baseline session, students sat quietly for 15 minutes while respiratory and pulse rates and peripheral skin temperature were measured. For homework, the students were asked to sit quietly while measuring and recording these variables on a take-home sheet every day for 15 minutes. The students were informed that after each training session they should practice the relaxation techniques taught to them and they should continue to monitor and record their respiratory and pulse rates and peripheral skin temperature for 15 minutes every day between sessions. During the second relaxation training session, the students were taught slow diaphragmatic breathing at a rate of six breaths per minute. The third session was dedicated to learning progressive muscle relaxation techniques. During the fourth intervention session, the students were taught autogenic training techniques. Autogenic training involves repeating a phrase over in one's mind. The phrases focus on relaxation feelings, such as "my hands are warn?' and "I feel relaxed."

At the end of the study, the students completed a Likert-type questionnaire about the study's usefulness and their anxiety level since the training program. Two questions were asked: 1) How useful was the biofeedback training experience? 2) How anxious have you felt about tests you have had since learning these techniques? The students were compensated monetarily throughout part 2 of the study.

DATA ANALYSIS To determine if the nursing students had learned to decrease respiratory and pulse rates and increase peripheral skin temperature using BART, paired t-tests were used to examine data collected in sessions three, four, and five. The mean of the first minute (baseline minute) was compared to the mean of the last minute (end-of-training minute) for respiratory and pulse rates and skin temperature. To determine if the relaxation training decreased the students' test anxiety, a paired t-test was used to compare TAI scores pre- and posttraining.

Results Fourteen students, 13 of whom were female (92.8 percent), participated in the training. The mean age of the sample was 24.5 [+ or -] 4.7. Seven students (50 percent) self-identified as white, two (20 percent) as Hispanic, and five (30 percent) as Asian/Pacific Islander.

DIAPHRAGMATIC BREATHING The means, standard deviations, t-values, and significance for the diaphragmatic breathing sessions are shown in Table 2. The respiratory rate decreased from 12 to 7 breaths per minute (p = .000) during the session. There was no correlation between baseline and end-of-training (EOT) respiratory rates; this finding was expected because students were being trained to decrease their respiratory rate. There was a small decrease in pulse rate that was not statistically significant. The increase in peripheral skin temperature was statistically significant. Baseline and EOT pulse rates were highly correlated (r = .974, p = .000), as were skin temperatures (r = .726, p = .003).

PROGRESSIVE MUSCLE RELAXATION Next, the students were introduced to progressive muscle relaxation. The means, standard deviations, t-values, and significance are shown in Table 2. The respiratory rate decreased from 12.6 to 10.6 (p = .018) breaths per minute with training. There was a moderate correlation between baseline and EOT respiratory rate (r = .548, p = .043). These were accompanied by a rise in skin temperature from 90.4 to 92.9[degrees] F (p = .001). There was a small decrease in pulse rate that was not statistically significant (p = .133). Baseline and EOT pulse rates were highly correlated (r = .924, p = .000), as were skin temperatures (r = .876, p = .000).

AUTOGENIC TRAINING The final training session was autogenic training. The means, standard deviations, t-values, and significance are shown in Table 2. The decrease in the pulse rate and respiratory rate, and the increase in peripheral skin temperature, were all statistically significant at the end of the autogenic training. The correlations and p values between the pre- and EOT minutes were: pulse rate, r = .851 (p = .000); respiratory rate, r = .498 (p = .070); and skin temperature, r = .57 (p = .002).

TEST ANXIETY The pre-BART TAI was 53.4 [+ or -] 14.1; the post-BART TAI was 54.8 [+ or -] 15.0. A paired t-test showed no statistical significance between them (t = -.852, p = .412). This lack of difference could be due to students' inability to learn the relaxation techniques. Therefore, the researcher divided the students into those who learned the relaxation techniques and those who did not. The criteria for "learned the relaxation technique" were defined as being able to: decrease respiratory rate, decrease pulse rate, and increase peripheral skin temperature. Eight of the 14 students were able to meet these criteria, but there was still no statistically significant difference between the scores for the two groups (t = -1.151, p = .277). This suggests that the lack of effect of training on test anxiety was not related to the ability to learn the relaxation techniques.

Discussion As students progressed through the BART, they were generally able to decrease their respiratory rates and pulse rates and increase their skin temperature. Nevertheless, there was no change in test anxiety. Relaxation techniques have been used to reduce test anxiety with varying results. However, test anxiety was not measured using the TAI, which was developed in 1980; this may account for the difference in findings.

Students in this study reported that the BART was useful in reducing test anxiety, even though the TAI did not change. At the completion of the study, the students completed a questionnaire about the study's usefulness and their anxiety level since the training program; a Likert scale was used with a range from 0 to 10, 10 being the highest rating. Two questions were asked: 1) How useful was the biofeedback training experience? 2) How anxious have you felt about tests you have had since learning these techniques? The range of the scores for the first question was 6 to 10, indicating that students generally found the training experience useful. The range for the second question was 2 to 8, suggesting that the self-report effect of training on test anxiety was more variable among participants, with some finding it useful and some finding it not useful.

Diaphragmatic breathing is a meditation activity that is quickly learned (Paul, Elam, & Verhulst, 2007). The techniques have been incorporated into behavioral modifications for anxiety (Conrad et al., 2007) because focusing on one's breathing patterns can easily help the individual become centered and calm (Harris & Coy, 2003). The participants in this study learned diaphragmatic breathing quickly and were able to decrease their respiratory rates during the training sessions. Progressive muscle relaxation has also been widely used with patients with anxiety disorders; it is effective in decreasing respiratory and pulse rates and increasing alpha waves in the brain that are responsible for producing feelings of calmness (Hall & Long, 2009). This study's findings align with these reports; during the progressive muscle relaxation session, breathing and pulse rates decreased for all participants.

This study had a small sample and used an abbreviated relaxation training program. These factors may account for the nonsignificant effect on test anxiety as measured by the TAI. The TAI is a measurement of a situation-specific personality trait (Spielberger & Vagg, 1995), which this five-week session may not have been intense enough or long enough to change.

Gonzalez (1976) reports various treatments have been tested to reduce test anxiety, but the largest change in subjective test anxiety scores and physiological reactions to test anxiety has occurred when counseling is coupled with structural behavioral techniques aimed at teaching students how to observe, measure, and change their behaviors. Algaze (1980) believes a combination of cognitive therapy, systematic desensitization, and study counseling may be the optimal approach for decreasing test anxiety. This study examined the effects of relaxation training alone and did not incorporate these methods.

Other study designs may lead to significant effects on test anxiety. For example, with a longitudinal design, a group of students could be followed throughout their nursing education program to determine if their test anxiety can be decreased with consistent, long-term training. This would allow the researchers to follow students' TAI scores throughout the nursing program and to determine the appropriate length of the training program. It is also recommended that nurse educators ask students which relaxation techniques worked best for them; some of the students responded better to one relaxation method over another.

Conclusion This study has revealed that nursing students report test anxiety. The diaphragmatic breathing and progressive muscle relaxation sessions resulted in a statistically significant change in respiratory rate and skin temperature. The autogenic training session appeared to be most effective in showing a statistically significant change in decreased respiratory and pulse rates and increased peripheral skin temperature. As this was the third training session, the stronger effects may be due to cumulative effects of training.

The lack of change in test anxiety was not due to the ability of the students to learn the relaxation techniques or to their starting level of test anxiety. Nurse educators should be encouraged to consider biofeedback relaxation techniques that reduce physiological responses to stress while also investigating other strategies. Identifying those students who suffer from test anxiety and teaching them simple strategies is recommended. For example, diaphragmatic breathing training is a simple relaxation training strategy that can be taught to students within 15 minutes. Autogenic training is also a simple relaxation training strategy that the students enjoyed and learned quickly. Once the students controlled their breathing, the other physiological measures responded accordingly. This is an easy, inexpensive way to help students take control of their physiological stress and become relaxed.

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Catherine A. Prato, PhD, RN, is assistant professor of nursing, National University School of Health and Human Services, Henderson, Nevada. Carolyn B. Yucha, PhD, RN, FAAN, is a professor and dean, University of Nevada, Las Vegas School of Nursing. For more information, contact Dr. Prato at cprato@nu.edu.
Table 1. Test Anxiety Among Nursing Students

 TAI
 N Mean & SD

Semester 1 42 41.0 [+ or -] 10.8
Semester 2 40 43.6 [+ or -] 13.6
Semester 3 37 47.5 [+ or -] 16.5
Semester 4 37 39.8 [+ or -] 13.5

Table 2. Comparison of Baseline and End-of-Training (EOT) Results
for Training Sessions

 Mean
 [+ or -]
 SD

Diaphragmatic Pulse rate Baseline 77.2 [+ or-] 3.4
Breathing Training EOT 76.2 [+ or-] 2.8
Session
 Respiratory Baseline 12.2 [+ or-] .77
 EOT 7.0 [+ or-] .64

 Skin Baseline 90.3 [+ or-] .75
 temperature EOT 92.2 [+ or-] .87

Progressive Muscle Pulse rate Baseline 86.8 [+ or-] 15.8
Relaxation Training EOT 84.2 [+ or-] 13.7
Session
 Respiratory Baseline 12.6 [+ or-] 2.7
 EOT 10.6 [+ or-] 2.9

 Skin Baseline 90.4 [+ or-] 3.7
 temperature EOT 92.9 [+ or-] 2.1

Autogenic Training Pulse rate Baseline 82.8 [+ or-] 10.0
Session EOT 76.8 [+ or-] 7.8

 Respiratory Baseline 12.0 [+ or-] 1.6
 EOT 9.5 [+ or-] 3.2

 Skin Baseline 90.4 [+ or-] 3.9
 temperature EOT 92.3 [+ or-] 1.4

 t p

Diaphragmatic Pulse rate Baseline 1.07 0.301
Breathing Training EOT
Session
 Respiratory Baseline 5.26 .000
 EOT

 Skin Baseline -3.03 .010
 temperature EOT

Progressive Muscle Pulse rate Baseline 1.60 .133
Relaxation Training EOT
Session
 Respiratory Baseline 2.67 .018
 EOT

 Skin Baseline -4.17 .001
 temperature EOT

Autogenic Training Pulse rate Baseline 4.17 .001
Session EOT

 Respiratory Baseline 3.33 .005
 EOT

 Skin Baseline -2.36 .034
 temperature EOT
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Title Annotation:NURSING EDUCATION RESEARCH / RELAXATION AND TEST ANXIETY
Author:Prato, Catherine A.; Yucha, Carolyn B.
Publication:Nursing Education Perspectives
Date:Mar 1, 2013
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