Currents in Pharmacy Teaching and Learning 12 (2020) 1491–1497

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Currents in Pharmacy Teaching and Learning

journal homepage: www.elsevier.com/locate/cptl

Review Article

Systematic review of student anxiety and performance during

T
objective structured clinical examinations
Randy D. Martina,c, , Zahra Naziruddinb
⁎

a
Texas Health Harris Methodist Fort Worth Hospital, Fort Worth, Texas, United States
b
University of North Texas System College of Pharmacy, Fort Worth, Texas, United States
c
Department of Medical Education, Texas Christian University, Fort Worth, Texas, United States

ARTICLE INFO ABSTRACT

Keywords: Introduction: Test anxiety is well studied in higher education, but studies primarily concern
Anxiety traditional assessments, such as written examinations. As use of objective structured clinical
Assessment examination (OSCE) in pharmacy education increases, a closer examination of non-cognitive
Clinical competence factors such as test anxiety is warranted. The purpose of this review was to determine the as­
OSCE
sociation between OSCE-associated test anxiety with OSCE performance in health professional
Objective structured clinical examination
students.
Performance anxiety
Test anxiety Methods: A literature search was conducted to identify peer-reviewed literature concerning test
anxiety in health professional students associated with OSCE. Investigators searched for a com­
bination of OSCE-related terms with anxiety-related terms using PubMed. Articles were included
if they assessed OSCE-related anxiety by quantitative or qualitative methods. Data extracted from
eligible articles included demographic data, type of the anxiety survey, associations between
OSCE-related anxiety and performance, and other student-factors associated with OSCE-related
anxiety.
Results: The literature search yielded 339 articles. Nine articles met eligibility criteria and were
included in the review. Results included students from medical, pharmacy, dental, and nursing
professional programs. Anxiety was assessed via multiple scales. Six out of the eight studies
assessing the relationship OSCE-related anxiety and OSCE performance found no association
between the two measures. Contrary to literature concerning test anxiety in higher education,
female gender was not associated with OSCE-related anxiety.
Conclusion: OSCE-related anxiety appears to have minimal to no influence on student perfor­
mance. Future studies should utilize standardized anxiety assessments and should seek to un­
derstand anxiety's effects on student wellbeing and burnout.

Introduction

The objective structured clinical examination (OSCE) was first introduced by Harden et al1,2 as a novel method of assessing
clinical competence for medical students and has since become a reference standard for performance assessment in numerous health
professions. The use of OSCE as a summative assessment for clinical competency has become common within medical, nursing,
dental, and pharmacy professional curricula.2–5 OSCE is very advantageous in evaluating students' competency in difficult-to-assess
areas, such as communication, problem solving, and sound decision-making.6,7 Additionally, compared to other types of clinical

⁎
Corresponding author at: Texas Health Harris Methodist Fort Worth Hospital Fort Worth, Texas, 76104, United States.
E-mail address: randy@martinpharmd.com (R.D. Martin).

https://doi.org/10.1016/j.cptl.2020.07.007

1877-1297/ © 2020 Elsevier Inc. All rights reserved.

R.D. Martin and Z. Naziruddin Currents in Pharmacy Teaching and Learning 12 (2020) 1491–1497

examinations, OSCE has relatively high reliability, validity, and objectivity.6 Certain factors, such as the number of stations and
overall variable control, can enhance OSCE reliability and validity. In practice and intent, most OSCE in healthcare serve as high-
stakes examinations, with the successful demonstration of clinical competency often as a condition of academic progression.
Despite apparent strengths and overall acceptance of the OSCE, there are many concerns with utilizing OSCE as a capstone, high
stakes assessment.8 The most significant limitation of OSCE is that poor performance may be a consequence of non-cognitive con­
founders rather than true clinical competence. Students' feelings of anxiety concerning OSCE have been identified as a potential non-
cognitive confounder of student performance on OSCE.
Anxiety, as discussed in this article, pertains to the acute emotion of anxiety. Anxiety, as a mental health disorder or disease is
beyond the scope of this article and will not be discussed. Gaudry et al.9 first differentiated between “trait” anxiety and “state”
anxiety. State anxiety is defined as an unpleasant arousal in the face of threatening demands or dangers and includes both cognitive
(i.e. worry) and non-cognitive (i.e. emotionality) components. Trait anxiety, by contrast, describes the stable individual differences in
the tendency to experience state anxiety in response to or anticipation of threatening stimuli.
Test anxiety is a type of state anxiety. Test anxiety is defined as a composite feeling of tension, apprehension, and the autonomic
activation that occurs when being evaluated for situations that are achievement based.10 It has been estimated that about one in five
students are affected by test anxiety. Incidence of test anxiety in students in higher education has been correlated with perceived
difficulty, which may also be driven by degree of preparation or low competency, and female gender.10–14 Test anxiety may be
experienced as a combination of physiologic, emotional, and behavioral responses that vary depending on the individual, resulting in
worry and irrelevant thoughts overburdening the cognitive system.15 While anxiety may enhance performance under certain si­
tuations, worry experienced during standardized tests has been demonstrated in numerous higher education studies to correlate
negatively with performance.15,16 However, these studies focus exclusively upon written examinations and do not address test an­
xiety experienced by students during simulated examination, such as OSCE.
It is anecdotally assumed that test anxiety may be more pronounced during OSCE compared to more traditional assessments. Prior
to matriculation into a professional program, such as pharmacy, most students have limited experience with such assessments.17
Furthermore, OSCE often functions as a high stakes examination that may determine the final course grade, academic progression, or
as a condition of licensure. OSCE is also unique in that it involves real time interaction and evaluation with a standardized patient.
Therefore, it is possible that state anxiety experienced by the student is actually a combination of test and performance anxiety,
leading to a higher state of arousal.
While OSCE is capable of teaching and evaluating essential clinical skills, it also creates a stressful environment that may increase
state anxiety, thereby preventing a student from being able to show their true knowledge and capabilities.18 Literature evaluating the
association between test anxiety and OSCE performance is limited when examining each health profession individually. This review
was conducted to examine the combined literature of OSCE-associated anxiety and determine to what extent it may influence student
performance on OSCE.

Methods

The literature search, screening, and data collection were conducted in accordance with the Preferred Reporting Items for
Systematic Reviews and Meta-Analyses (PRISMA) guidelines.19 Eligible studies were primarily identified through a literature search
of PubMed (1966-) using Boolean logic that combined an OSCE-related term with an anxiety-related term (see Fig. 1). OSCE-related
terms utilized in this search included: OSCE, objective structured clinical examination, and clinical competence. Anxiety-related
terms included: anxiety, performance anxiety, and test anxiety. Medical subject heading (MeSH) terminology was utilized when
possible. However, MeSH terminology at the time of the search did not include OSCE, objective structured clinical examination, or
test anxiety. For ease of review, search results were limited only to those studies with full text published in English. The final iteration
of the database search was conducted in March 2019. Following the formal literature search, additional articles were identified by
screening reference lists of articles deemed eligible through the search strategy.
Two investigators independently screened abstracts for all articles identified by the search for eligibility. During the initial
screening, records were deemed eligible if all of the following content requirements were mentioned in the text of the abstract: test or
performance anxiety, student performance, and standardized examination of clinical skills, including OSCE. Abstracts for reviews and
non-peer-reviewed literature, such as letters, editorials, and commentaries, were not eligible for inclusion. In the next stage, full text
articles were acquired for all abstracts deemed eligible. The process for identifying full text articles was similar to that of abstract
screening and both investigators agreed upon all articles that were ultimately included in this review. Full text articles were deemed
eligible if they described original research (i.e. primary literature), assessed anxiety of student test takers, and anxiety was assessed
relative to a clinical assessment that resembled OSCE. In addition, investigators reviewed reference lists for included articles to
identify relevant articles not captured by the search strategy. Discrepancies were discussed and both investigators reached mutual
agreement on all articles ultimately included in this review.
Data was extracted by a single investigator and validated by a second investigator. Demographic data extracted for each study
included: number of subjects, gender composition of the sample, and year of professional progression. Intervention data elements
included the type of anxiety assessment utilized and description of the OSCE administered (including number of stations), use of live
or video grading, and content assessed. Outcomes data extracted from each article included: correlation between anxiety and OSCE
scores, and correlations between anxiety and other demographic or outcome measures.

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Fig. 1. Literature search strategy and results.

Results

Using the literature search strategy described above, 339 articles were initially identified for abstract review. Following abstract
review, 13 studies were deemed eligible for full text review. The remaining abstracts were excluded from further review. Of 326
excluded abstracts, 285 did not meet content requirements and 41 were excluded because of article type (e.g., review, letter,
commentary). A majority of articles failed to meet more than one content eligibility criteria (285, 93%) and 180 (63%) met none of
the content criteria. The most common reason for abstract exclusion was a lack of an objective standardized clinical examination in
the study design. Full text articles for the 13 eligible studies were acquired and reviewed. One additional article was identified and
reviewed after scanning references of these articles.
There were very few discrepancies between investigators in terms of article eligibility. All discrepancies pertained to investigator
interpretations of operational definitions and were easily resolved upon discussion. Investigators agreed that residents did not meet
the definition for students and that skills laboratories did not meet the definition of OSCE. Thus, a total of five articles were excluded
because they assessed non-student learners (2), the assessment was a pre-clinical motor skill practicum (2), or investigators did not
assess test or performance anxiety (1). This yielded a total of nine articles that met a priori eligibility criteria (see Fig. 1).
Articles included in this review consisted of four studies performed in medical education, two studies each in pharmacy and dental
education, and one study in undergraduate nursing education (see Table 1). Study samples (n) ranged from 25 to 266 students (mean
132, median 94). Gender was noted in all nine studies and female gender composition ranged from 44% to 88%. Likewise, student
age was noted in five of nine studies with mean student age ranging from 19.6 to 26.8 years. Participants' year of progression varied
greatly among studies, with some focusing on a single year of progression, while others spanned their curriculums (see Table 1).
Assessment methods also varied. In terms of the anxiety assessment tools, externally validated, multi-element assessments were
utilized in seven of nine studies.17–22,25–27 The most frequently used assessment was the Spielberger State-Trait Anxiety Inventory
(STAI), which was utilized in four of nine studies.20,25–27 All four studies utilizing STAI, used the standardized 40-item version that
has been used since 1983 to assess state anxieties, including test anxiety.28 This survey has both a high internal consistency and
external validity. Other externally validated anxiety assessment surveys utilized to assess participants included the Korean
Achievement Emotions Questionnaire (K-AEQ), Test Anxiety Inventory (TAI), and the Performance Test Anxiety Questionnaire
(PTA).17,21,22 As implied by its name, K-AEQ is a culturally specific survey that consists of 80-items that measure nine types of
emotions in three contexts.17 Six items in the test-related context specifically relate to anxiety and were adapted for the study by
Kim17 to assess participant test anxiety. TAI, which is specific to test anxiety and was utilized by Hadi et al.,21 is a 20-item survey that
consists of two subscales, emotionality (TAI-E) and worry (TAIeW). The PTA used by O'Carroll and Fisher,22 was adapted from the
25-item Three-Factor Anxiety Inventory, which assesses worry and self-focus, physiologic arousal, and regulatory control. The re­
maining two studies utilized a single item, multiple choice question to assess anxiety that was not externally or internally

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Table 1
Primary literature examining OSCE-related anxiety and associations with OSCE performance and other student characteristics.
Professional Author, Year Subjects (n) Female (%) Professional year Anxiety survey Factors associated with OSCE- Factors not associated with Correlation between OSCE
program related anxiety OSCE-related anxiety performance & anxiety

Pharmacy Longyhore, 201720 59 58 P3 STAI None OSCE performance r = 0.11, P = .41 (state)
Gender
Hadi et al., 201821 25 60 P3 TAI OSCE performance Gender r = −0.33, P = .02 (worry)
Medical Kim, 201617 94 45 M3, M4 K-AEQ PPOSb OSCE performance r = 0.09, P > .05
Perceived value of OSCEb Gender
Academic progression
GPA
O'Carroll and Fisher, 240 54 M1 PTA MCQ-30b Gender not assessed
201322
Colbert-Getz et al., 202 47 M3 Single item 6-pt None OSCE performance F = 1.45, P = .24
201323 Likerta Gender

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b
Mavis, 200124 82 44 M2 Single item 6-pt Self-efficacy score None r = 0.06, P > .05
Likerta
b
Dental Kalantari et al., 138 53 D2–3 STAI Level of preparation OSCE performance Expectations P = 1.19
201726 Female genderc of performance
Brand et al., 200925 78 63 D3 STAI Level of preparationb OSCE performance Expectations r = 0.11, P = .41 (state)
of performance
Gender
Nursing Pai et al., 201827 266 88 1–4 STAI OSCE performancec None r = −0.28, P < .001
Task cognitive loadc

K-AEQ = Korean achievement emotions questionnaire; MCQ-30 = Metacognitions questionnaire; OSCE = Objective structured clinical examination; PPOS = Patient-practitioner orientation scale;
PTA = Performance test anxiety questionnaire; STAI = State-trait anxiety inventory.
a
Colbert-Getz and Mavis studies both use the same 6-point single item Likert scale.
b
Negative relationship with OSCE-related anxiety.
c
Positive relationship with OSCE-related anxiety.
Currents in Pharmacy Teaching and Learning 12 (2020) 1491–1497
R.D. Martin and Z. Naziruddin Currents in Pharmacy Teaching and Learning 12 (2020) 1491–1497

validated.23,24
Timing of administration of the assessment varied as well. Two assessments occurred immediately prior to the OSCE, three
immediately after the OSCE, one before and after the OSCE, and one during the course of the OSCE. Three of these anxiety as­
sessments were administered as OSCE rest stations either during or after other stations were complete.22,23,26
Eight studies evaluated the relationship between student anxiety and student performance (see Table 1).17,20,21,23–27 Six of these
studies detected no association between anxiety and OSCE performance. Only two studies, by Hadi et al.21 in pharmacy students and
Pai et al.27 in nursing students, found a statistically significant negative association between OSCE-related anxiety and OSCE per­
formance. The study by Hadi et al.21 was the only study to utilize the TAI assessment tool and determined that performance was
primarily associated with worry (TAIeW) rather than emotionality (TAI-E). The study by Pai et al.27 utilized the STAI assessment tool
and found additional correlations with student cognitive load.
Associations between OSCE-related anxiety and student-specific factors were also examined. Among these were gender, ex­
pectation to succeed, level of preparedness, self-efficacy, metacognitive assessment scores, patient-centered attitude, and perceived
value of the OSCE (see Table 1). The most frequently assessed factor was gender; seven studies evaluating its relationship with OSCE-
related anxiety.17,20–23,25,26 Six of the seven studies failed to find any association between gender and OSCE-related anxiety, which is
contrary to previous literature on test anxiety in higher education.11–14,17,20–23,25 The lone study that detected a correlation between
the two also detected a correlation to higher levels of preparedness and anticipated success.26
Two studies specifically assessed OSCE-related anxiety relative to test anxiety observed in other types of examinations.25,26 Both
sets of investigators found that test-taker anxiety, as measured by STAI, was significantly higher during OSCE compared to written
exam and a formative practical exam.
Lastly, another two studies examined anxiety in the broader context of other cognitive and non-cognitive factors to develop
theoretical models to better understand drivers of OSCE performance.24,27 The model proposed by Mavis24 indicated that student
anxiety exerted a negative downstream effect upon self-efficacy and preparedness, resulting in an indirect negative effect upon
student performance. Magnitude of effect for anxiety in Mavis' model was low (−0.02), with preparedness, student knowledge, and
self-efficacy serving as key drivers to student performance. By contrast, the model developed by Pai et al.27 situated anxiety further
downstream where it was believed to exert a more direct effect on student performance. Pai's model suggests that two psychological
states, anxiety and cognitive load, work synergistically to exert a direct negative effect on student performance.

Discussion

The current body of evidence concerning the complex relationship between the OSCE, testing anxiety, and student performance is
somewhat limited in terms of both quantity and consistency of methods. However, some conclusions can be drawn. First, a majority
of studies reviewed indicated that OSCE-related anxiety does not adversely impact student performance. Second, as hypothesized,
test anxiety experienced by students during OSCE is higher relative to more traditional examinations. Third, a majority of studies did
not find an association between gender and test anxiety, which is contrary to the wider body of evidence in higher education.11,15,29
The finding that test anxiety does not adversely impact OSCE performance in professional degree health science students is
important because it too varies significantly from the larger body of evidence in higher education and, quite possibly, may vary from
student and faculty perceptions.30 This implies that student maturation and/or increased tolerance to high cognitive load may affect
the strength of the association between test anxiety and performance during OSCE. Thus, students participating in graduate-level
professional programs may have developed increased test-induced stress tolerance and/or effective stress coping mechanisms for such
assessments.
Only two of the nine studies identified any association between OSCE-related anxiety and performance, which may be the result
of disparate study samples and assessment methods.21,27 Interestingly, the strongest association was observed in nursing students,
with results similar to those observed in other undergraduate programs.15,27,29,30 As the only undergraduate program included in this
review, these students were closer in age and at similar levels of academic progression as studies conducted outside of the health
professions.11,14,30 This further supports the aforementioned hypothesis that graduate and professional degree program students may
be more resilient to OSCE-related anxiety. The other study correlating OSCE-related anxiety to performance, by Hadi et al.21 observed
a weak association between test anxiety and OSCE performance and was somewhat limited by its small sample size relative to the
other studies included in the review. However, despite its small sample, the investigators did detect a correlation between worry (as
measured by TAIeW) and OSCE performance. As this is the only study that utilized the TAI scale, the implications of these results are
unclear and warrant further study.
Regardless of the impact on exam performance, OSCE-related anxiety should still be considered in the context of student wellness.
Of note, two studies included in this review determined that OSCE induced a higher level of test anxiety in students than written
examinations or formative practical assessments. Anecdotally, we have also observed that use of OSCE at our institution elicits a
strong emotional response in students and increases in the time leading up to the examination. Consequently, wellness initiatives in
health profession education programs should develop tools to address student emotional needs associated with stress and anxiety
induced by OSCE in their curricula.
Some evidence-based strategies that have been shown to reduce OSCE-related anxiety in health science students include the use of
deep breathing techniques, formative OSCE, and coaching sessions.31,32 Health profession programs could also adapt evidence-based
strategies developed in higher education to mitigate OSCE-related anxiety. One strategy, emotional reappraisal, addresses the
physiologic arousal component of test anxiety.33 With this strategy, students are provided specific readings that prompt them to
reinterpret the physiologic arousal that occurs prior to a stressful situation as helpful to their thinking rather than as a hindrance.

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Another strategy, expressive writing, targets the worry component of test anxiety.34 This strategy is designed to clear students'
cognitive memory of worrisome thoughts by having them write about their current emotional state immediately prior to an academic
assessment.
Testing programs have a duty to assure that OSCE performance is driven by test content, test difficulty, and student competency,
and minimize the impact of non-cognitive factors such as anxiety.16 Therefore it is critical that research evolve in this particular area
of study and results of this review serve to inform future research. Most importantly, future directions should include the consistent
use of well-validated and established surveys to assess OSCE-related anxiety. Single-item surveys should not be utilized to assess
OSCE-related anxiety due to their inability to comprehensively assess a complex emotional state and their lack of internal and
external validity. As the most utilized assessment in this area of research, STAI may be useful in future studies to allow for com­
parisons among different groups as well as comparison to previous literature. In addition, STAI is well established in the evaluation of
test anxiety and has excellent internal confidence and external validity. Although Hadi et al.21 were the only investigators to utilize
TAI, this allowed them to identify differences among the subunits of test anxiety, specifically worry. Consequently, use of TAI and its
sub-scales in future studies may allow educational researchers to better understand the relationship between worry and OSCE per­
formance and determine the degree of association. While the authors conclude that either STAI or TAI would be an acceptable
assessment tool to assess OSCE-related anxiety, investigators should select an assessment that best fits their study aim and objectives.
In addition, future studies should also consider the use of larger samples across multiple academic years to improve external validity
of their results.

Conclusion

Existing evidence suggests that there is minimal or no association between OSCE-related anxiety and student performance, al­
though test anxiety experienced by students does appear to be more pronounced than with more traditional assessments.
Additionally, gender had no association with OSCE-associated anxiety, which conflicts with broader literature in higher education.
Future studies should utilize larger sample sizes across multiple academic years and include consistent use of validated anxiety
assessment tools, such as STAI and TAI.

Declaration of Competing Interest

None.

Acknowledgements

The authors would like to thank Drs. Ryan Doyle and Hong Yen Pham for assisting with the literature search and contributions to
this article.

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