Original Article

Analysis of licensure examination anxiety and its

influencing factors among undergraduate nursing
students
ABSTRACT
Background: Examination anxiety is a concern for educational policymakers because of the impact it can have on the overall outcome of
the performance of the candidates who partake in such examinations.
Aim: The aim of this study is to determine the examination anxiety level of students of Nursing and Midwifery College, Agogo, and Presbyterian
University College and to evaluate the factors affecting them.
Materials and Methods: A total of 160 undergraduate nursing students comprising 80 degree and 80 diploma students were conveniently
sampled for the study. The study was conducted in September 2019 using a descriptive cross‑sectional design. The Westside Test Anxiety Scale
was used to measure examination anxiety among the participants. A researcher‑designed questionnaire in which participants responded to a
three‑point Likert scale was used to assess factors influencing examination anxiety.
Results: The findings of the study showed that test anxiety was higher among the diploma candidates (M = 3.60) than the degree
candidates (M = 2.95) and the difference was statistically significant (P = 0.024). Demographic characteristics such as age (P = 0.009),
sex (P = 0.003), study hours per day (P = 0.001) were found to be significantly associated with test anxiety. The factors found to influence
examination anxiety among students were volume of materials to study (P = 0.044), level of preparation (P = 0.005) perceived difficulty of the
questions (P = 0.033) and myth about examinations (P = 0.000). The perceived importance of the examination (P = 0.057) and schedule of
the exams (P = 0.68) did not influence examination anxiety.
Conclusion: Candidates for the licensure examination organized by the Nursing and Midwifery Council of Ghana should be assessed for
test anxiety and offered the necessary psychological support where necessary.

Keywords: Education, Ghana, licensure, nursing, test anxiety, undergraduate

INTRODUCTION improvement over a specific period, examining strong and

Summative assessment typically includes the evaluation of
individuals after which their progress is summarized at a
specific time within a course or program through feedback
and a grade.[1] Usually, it emphasizes on the outcome of a
task and seeks to monitor educational outcomes. In higher
education, the most frequently used summative assessment
methods are examinations and written tests.[2,3] Examinations
are regarded as useful academic exercise,[4] with varying
purposes. They include; making judgments with regards to
the skills or knowledge acquired by an individual, evaluating
weak points, or classifying students whether they should be
included or excluded.[5] In nursing and midwifery education,
student nurses are challenged with the sine qua non of
Doreen Asantewa ABEASI, Frank Bediako AGYEI
Department of Nursing and Midwifery, Presbyterian University
College, Asante‑Akyem, Ghana
Address for correspondence: Ms. Doreen Asantewa ABEASI,
Department of Nursing and Midwifery, Presbyterian University
College, P. O. Box: 42, Agogo, Asante‑Akyem, Ghana.
E‑mail: reenasantewa@gmail.com

Submitted: 05‑Jun‑2021 Revised: 28-Jun-2021

Accepted: 08‑Jul‑2021 Published: 28-Sep-2021
Access this article online
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DOI:
How to cite this article: Abeasi DA, Agyei FB. Analysis of licensure
10.4103/jin.jin_33_21 examination anxiety and its influencing factors among undergraduate
nursing students. J Integr Nurs 2021;3:110-6.

110 © 2021 Journal of Integrative Nursing | Published by Wolters Kluwer ‑ Medknow

 Abeasi and Agyei: Licensure examination anxiety
successfully finishing various forms of assessment of which
includes examinations if they are to achieve their goals
personally and professionally.[5]
In Ghana, the Nursing and Midwifery Council (NMC), has
the mission to ensure the highest standards of not only
training but also the practice of nursing and midwifery.
The mandate of the NMC is from the Health Professions
Regulatory Bodies Act (Act 857).[6] As part of their mission,
the NMC thus organizes licensure examinations for student
nurses at the end of their training. The assessment procedure
is most at times regarded as one of the crucial aspects of a
student nurse’s course as it measures students’ competency
to practise.[5] This implies that the practice of an individual
who has completed the training of nursing would be deemed
illegal if the person has not satisfied all the requirements
of the NMC.[1] Thus, such a person may face the full rigor of
the law. Success in the licensure examination is therefore
the only legal requirement to practice as a nurse in Ghana.[7]
It is, therefore, not surprising that most students after their
stipulated period of training attach so much importance to
the licensure examinations.[7] However, a report by the NMC
has revealed that a large number of students who sit for
the exams fail in their first attempt[7,8] which is attributed
to a myriad of factors. One of the main factors that have
been linked to such unfortunate outcomes is examination
anxiety.[9‑13] Examination anxiety is also referred to as test
anxiety.
It is normal to have some form of anxiety during examinations
as such anxiety may not be entirely bad. Some studies
have reported positive impact of moderate anxiety during
examinations.[14,15] Kumari and Jain[15] reported that anxiety
can compel the student to focus on a given task. On the other
hand, too much stress and anxiety during the examination
can be distressing to the student and may affect him/her in
multifaceted ways including physically, emotionally, socially,
and cognitively.[16] Some studies have reported that high test
anxiety is likely to lead to poor performance.[10,17] This makes
it necessary to identify the factors behind such anxiety to
offer the needed guidelines for students when preparing for
or writing such examinations. Some factors that have been
associated with examination anxiety are fear of failure,[18]
inappropriate style of learning,[19] negative and irrational
thinking about exams,[18] inadequate rest, examination
schedule,[20] excessive course load,[18] gender,[20] previous
exams experience,[21] and lack of preparation.[22]
A review of the literature reveals most studies have reported
high prevalence of test anxiety among undergraduate
students[17,19,23] and high school students,[21,24,25] but those
Journal of Integrative Nursing / Volume 3 / Issue 3 / July‑September 2021
examinations were internal examinations organized by the
institutions. Few studies have looked at test anxiety among
nursing students.[26,27] Some studies have also examined
academic anxiety but not necessarily test anxiety.[28] A study
that compared two groups, looked at undergraduate and
postgraduate students’ levels of test anxiety.[22] Few studies
have reported on examination anxiety of nursing students
in Ghana.[27] This study, therefore, seeks to take another
look at the determinants of examination anxiety among
nursing students in Ghana. If anxiety is a key factor behind
the failure of the candidates in Ghana,[8] it may have effect on
the health care system of the country since there would be
the inadequate number of practicing nurses in the country.[7]
Thus, the higher the pass rate, the better would it be for the
country. Consequently, identifying the sources of such anxiety
is critical for Ghana.
The current study makes three key contributions to literature.
It is the first study to evaluate examination anxiety among
candidates preparing to write their licensure examinations in
Ghana. In addition to the above, the study tries to examine
the prevalence of examination anxiety of two groups of
undergraduate students, such evidence which is missing in
the Ghanaian context. Such comparison is necessary to find
out if the duration of the training program has any effect on
the candidates’ examination anxiety. Finally, the current study
seeks to assess factors influencing examination anxiety among
nursing students sitting for an external examination as most
studies in literature have focused on examination anxiety
among nursing students sitting for internal examinations
and not external examinations. The study, therefore, seeks to
examine the level of examination anxiety and its influencing
factors among degree students of Presbyterian University
College, Ghana (PUCG) and diploma students of the Nursing
and Midwifery Training College (NMTC), Agogo.
MATERIALS AND METHODS
Study design and setting
To examine the prevalence of examination anxiety among
undergraduate and diploma nursing students as well as the
influencing factors, a cross‑sectional design was used for the
study. The study was conducted at the PUCG and the NMTC,
Agogo. The former has a department of nursing which trains
nursing students for 4 years for the award of Degree while
the later trains for 3 years for the award of a Diploma.
Sampling technique and sample size
The convenience sampling method was used to select
participants of the study. The population consisted of 274
candidates preparing to write their licensure examination.
Using the Krejcie and Morgan sample size estimation
111
 Abeasi and Agyei: Licensure examination anxiety

formula,[29] a sample size of 159 was arrived at. A total of used to describe the basic features of the data in the study
160 licensure candidates comprising 80 each from the two including the age and sex of participants. One-way analysis of
the institutions were recruited for the study. variance (ANOVA) was used to determine differences between
Degree and Diploma students on test anxiety. Regression
Inclusion criteria analysis was done to identify factors which could predict test
The inclusion criteria were as follows: (1) The student anxiety. A P-value was considered to be statistically significant
should be in the final year preparing for the licensure if it was less than 0.05.
examination; (2) The student should be a registered candidate
for the Registered General Nursing examinations; (3) The Ethical considerations
student should provide consent to take part in the study. The participants were informed of the research objectives and
were given the opportunity to ask questions for clarification.
Exclusion criteria
They were assured of the confidentiality of the collected
The exclusion criteria were students who were not in their
information and also of anonymity. They were informed
final year and refused to wilfully participate or offer consent.
of the freedom to withdraw from the study whenever they
Data collection and instrument wanted without facing any negative consequences. Informed
The participants responded to a questionnaire divided into consent was obtained from all the subjects by signing the
three sections. The first section examined the demographic consent form.
information of the participants. The second section
assessed examination anxiety using the Westside Test RESULTS
Anxiety Scale (WTAS) and the last, factors likely to influence
examination anxiety. Demographic data of respondents
The results from Table 1 showed that majority of the candidates
Demographic questionnaire were between 20 and 25 years for both NMTC (diploma) and
The questionnaire included items on the demographic and PUCG (degree) students. Females comprised the majority of
social variables of the participants including their age, gender, respondents in both groups. Majority of respondents had CGPA
academic institution, Cumulative Grade Point Average (CGPA). between 3.0 and 3.59. Most of the candidates studied between
2 and 4 hours in both groups. A combination of personal studies
Westside Test Anxiety Scale and group discussion was the preferred mode of study in both
WTAS is a 10‑item self‑reporting instrument used to groups.
measure test anxiety among students. The scale is brief
and takes about 8–10 min to administer. It consists of Table 1: Demographic data of respondents
a five‑point scale response ranging from always true to Variables Frequency, n (%)
never true. The highest score is 50 and the least being Degree students Diploma
10. The higher the score, the higher the level of test (n=80) students (n=80)
anxiety and vice versa. To determine the level of test Age (years)
20‑25 61 (76.25) 57 (71.25)
anxiety, the score is divided by 10. The score ranges and
26‑30 16 (20.00) 20 (25.00)
interpretations are as follows: 1.0–1.9 (comfortably low),
31‑35 3 (3.75) 3 (3.75)
2.0–2.4 (normal), 2.5–2.9 (high normal), 3.0–3.4 (moderately Sex
high), 3.5–3.9 (high), and 4.0–5.0 (extremely high).[30,31] It is Male 39 (48.75) 36 (45.00)
a reliable and valid instrument for the measure of anxiety Female 41 (51.25) 44 (55.00)
impairment. A Cronbach's alpha coefficient of 0.78 and CGPA
split‑half reliability of 0.77 as well as concurrent validity of 3.6‑4.0 8 (10.0) 4 (5.00)
0.51 have been reported.[32] 3.0‑3.59 30 (37.50) 28 (35.00)
2.5‑2.99 27 (33.75) 27 (33.75)
2.0‑2.49 13 (16.25) 19 (23.75)
Predictors of examination anxiety questionnaire
1.0‑1.99 2 (2.50) 2 (2.50)
The participants were required to respond to a three‑point
Study hours per day
Likert scale with the options as agree, neutral, and disagree. 2‑4 41 (51.25) 40 (50.00)
5‑7 27 (33.75) 30 (37.50)
Statistical analysis 8‑10 9 (11.25) 8 (10.00)
IBM SPSS Statistics for Windows, version 24.0 (Arrmonk, NY: >10 3 (3.75) 2 (2.50)
IBM) was used to analyze data. Descriptive statistics were CGPA: Cumulative grade point average

112 Journal of Integrative Nursing / Volume 3 / Issue 3 / July‑September 2021

 Abeasi and Agyei: Licensure examination anxiety

Test anxiety among diploma and degree students Table 2: Test anxiety among diploma and degree students
The results from Table 2 showed that majority of the Diploma Test anxiety Frequency, n (%)
students (58.75%) reported high test anxiety scoring between Diploma Degree students
3.0 and 5.0 on the test anxiety scale. Only a few, 11 (13.75%), students (n=80) (n=80)
16 (20.00%), and 6 (7.50%) reported low, normal, or high 1.0‑1.9 (comfortably low) 11 (13.75) 29 (36.25)
2.0‑2.4 (normal) 16 (20.00) 13 (16.25)
normal test anxiety respectively. On the other hand, only
2.5‑2.9 (high normal) 6 (7.50) 8 (10.00)
30 (37.5%) of the Degree students reported moderate to
3.0‑3.4 (moderately high) 20 (25.00) 6 (7.50)
extremely high test anxiety with majority (62.5%) reporting 3.5‑3.9 (high) 15 (18.75) 11 (13.75)
low, normal, or high normal test anxiety. 4.0‑5.0 (extremely high) 12 (15.00) 13 (16.25)

Further analysis was done to find out if the differences

between the two groups on test anxiety will be significant Table 3: Examination anxiety difference among diploma and
degree students
using one‑way ANOVA [Table 3]. The findings showed
that participants who offered diploma scored higher Groups n Mean SD F‑stat P
Diploma students 80 3.60 1.66 5.185 0.024
mean (M = 3.60) for test anxiety than those who offered
Degree students 80 2.95 1.93
degree (M = 2.95). The difference was significant (P = 0.024).
SD: Standard deviation

Association between selected demographic variables and

test anxiety Table 4: Association between demographic variables and
examination anxiety for both degree and diploma candidates
Using a univariate analysis, results showed that females
(n=160)
had a higher mean score (M = 4.03) to high test anxiety
Variables Test anxiety P
than males (M = 3.34), thus females experience high test
Mean SD
anxiety than males (P = 0.009). Furthermore, respondents
Sex
with older ages recorded lower mean score (M = 3.33) for Male 3.34 1.73 0.009
test anxiety than those with younger ages, 20–25 years Female 4.03 1.53
(M = 3.86) and 26–30 years (M = 3.50). The difference Age (years)
observed among the age groups was statistically significant 31‑35 3.33 1.44 0.003
(0.003). On CGPA, respondents with higher CGPA recorded 26‑30 3.50 1.62
lower mean score for test anxiety than those with lower 20‑25 3.86 1.74
CGPA even though this was not significant (P = 0.075). CGPA
3.6‑4.0 2.58 2.15 0.075
Furthermore, respondents with longer or more than 10-hour
3.0‑3.59 3.62 1.51
study recorded lower mean score (M = 2.60) than those
2.5‑2.99 3.61 1.66
with 5–7 (M = 3.53), 8–10 (M = 3.53) and 2–4 (M = 3.85) 2.0‑2.49 4.00 1.73
respectively. Thus, respondents with longer study hours 1.0‑1.99 4.18 1.67
experience lower or less test anxiety than those with shorter Personal study hours per day
study hours (P = 0.001) [Table 4]. 2‑4 3.85 1.63 0.001
8‑10 3.53 1.67
Factors influencing licensure examination anxiety 5‑7 3.53 1.91
The myth about the licensure examination (P = 0.000), >10 2.60 1.34
SD: Standard deviation, CGPA: Cumulative grade point average
inadequate preparation (P = 0.005), volume of materials to
study (P = 0.044), and perceived difficulty of questions (P =
0.033) were found to predict test anxiety as shown in Table Table 5: Factors predicting examination anxiety
5. The perceived importance of the examination (P = 0.057) Factors Unstandardized Standardized
and the schedule of the exams (P = 0.680) did not predict coefficients coefficients
test anxiety. B SE B P
Constant 2.637 0.455 0.000
Myth about the exams 0.656 0.172 0.336 0.000
DISCUSSION
Inadequate preparation 0.147 0.137 0.085 0.005
Volume of materials to study 0.483 0.186 0.233 0.044
The findings of the current study revealed that examination Perceived difficulty of questions 0.122 0.165 0.059 0.033
anxiety was significantly high among diploma students than Schedule for exams −0.035 0.174 −0.016 0.680
degree students. The above differences could be due to Perceived importance of exams 0.389 0.150 0.209 0.057
several factors. First and foremost, degree students of PUCG SE: Standard error

Journal of Integrative Nursing / Volume 3 / Issue 3 / July‑September 2021 113

 Abeasi and Agyei: Licensure examination anxiety
go through 4 years of nursing education whilst diploma
students of NMTC use 3 years. This means that the degree
students have an extra year as an added advantage to cover
extensively the curriculum. Also, because a Bachelor’s
degree is awarded at the end of the 4 years of training, it
appears most of the students do not feel pressured as several
opportunities exist for them in other sectors apart from the
clinical environment.
The finding is consistent with a study conducted by Li et al.[33]
who examined anxiety and influencing factors of nursing
students in different levels before the National Council
Licensure Examination for Registered Nurses (NCLEX‑RN).
Their study reported that among the 1527 nursing students,
154 had mild anxiety, 688 with moderate anxiety, and 685
with severe anxiety. The same study also reported that
anxiety levels were severe among the lower educational
levels as compared to higher educational levels. The
percentage of severe anxiety for the various levels was
46.80%, 44.83%, and 27.59% for the diploma, advanced
diploma, and baccalaureate degree, respectively. Atindanbila
et al.[27] also found that students pursuing Health Assistant
Clinical which is a certificate program reported more test
anxiety than those pursuing diploma, though their study
was not in relation to licensure examination. The current
finding is worrying because high test anxiety scores have
been linked to low academic performance on the test.[11,12]
Considering this reported impact of high test anxiety,
then it means high test anxiety can negatively affect the
performance of the candidates in the licensure examination.
The study sought to find out demographic factors which
influenced test anxiety among licensure candidates. The
current study found that gender influenced test anxiety.
Females reported high test anxiety than males. Females have
been found to be more uncomfortable and self‑conscious
in testing situations than males. From the cultural point of
view, males are socialized not to overtly express how they
feel as that is seen as a sign of weakness. Again, males may
feel they have a huge social responsibility of making it thus
no need to entertain any form of anxiety. In consistent with
the current study, other studies have reported that females
had high test anxiety than males.[34] On the contrary, Bashir
et al.[21] mentioned in their study that females were less likely
to develop test anxiety as compared to males. In that study,
males had 2.501 times higher odds of having test anxiety.
Other studies did not find a significant relationship between
test anxiety and gender.[27,35]
The researcher did not find any significant relationship
between test anxiety and students’ CGPA. Candidates in
114 Journal of Integrative Nursing / Volume 3 / Issue 3 / July‑September 2021
the current study may view CGPA as a cumulative record of
internal examinations which may not have direct bearing
on an external examination like the licensure examinations.
Similarly, Dawood et al.[13] did not find any significant
relationship between the test anxiety and GPA. On the
contrary, Bashir et al.[21] and Onyeizugbo[32] found that those
with high grades were less likely to have high test anxiety.
In the current study, age was found to influence test anxiety
which is consistent with other studies.[14] Similarly, a study
reported that younger people are more likely to develop
anxiety that older people.[36] Several studies did not find any
significant relationship between age and test anxiety.[21,35,37,38]
The results also showed that students who studied for
few hours presented with high levels of test anxiety. The
number of study hours is somewhat directly related to the
level of preparation. Adequate preparation is likely to boost
a student’s self‑esteem and self‑confidence in taking an
examination. Thus, regardless of the likely questions and level
of difficulty the candidate can be rest assured that he/she will
not be clueless. The finding is consistent with other studies
which have cited inadequate preparation as a contributing
factor to higher test anxiety.[21,22] It is, therefore, not surprising
that the schedule of the exams did not predict test anxiety.
If a student is adequately prepared, the student may not be
so much worried about the schedule of the exams.
The findings indicated that the myth surrounding the
examination is a factor influencing licensure examination
anxiety. The licensure examination is surrounded by a lot
of myths. Some of these myths come from candidates who
have gone through the exams previously. The fact that the
examination is being organized by an external body creates
a certain impression in the minds of the students. There is a
myth that yearly, the NMC has a quota in terms of the number
of students they expect to pass the licensure examinations.
These myths are usually accepted by the students which
affect them psychologically and lead to examination anxiety.
Although the NMC has a requirement where examiners meet
candidates a day before the examinations, these meetings
may not have a significant impact on the candidates for
several reasons. First, the examination anxiety may have
developed already. Second, the focus of such meetings is to
provide the candidates’ information on the dos and don’ts
and not necessarily aimed at demystifying the negative
perceptions on the licensure examinations. The study by
Johnson[39] corroborates the current findings as he also found
that myths about NCLEX exams led to anxiety.
The volume of materials to study for the examination was
identified to affect anxiety. The end‑of‑semester examinations
 Abeasi and Agyei: Licensure examination anxiety
in the various institutions usually cover the content that was
studied for that particular semester. However, with regards to
the licensure examinations, they cover everything that was
learnt throughout training. This appears quite burdensome
for the students. The perceived burdensomeness of the
volume of materials to study might also be due to the fact
that students are not prepared adequately and may wait
when the examinations is so close before they start to learn.
Other studies have reported that too much course load was
a factor influencing test anxiety.[40] Regardless of the volume
of materials to study, adequate preparation can mitigate its
impact on test anxiety.
In addition, the perceived difficulty of the licensure examination
was identified as a factor contributing to examination anxiety.
This is consistent with the findings by von der Embse et al.[41]
When students perceive that the examination is difficult it
means they anticipate there are a lot of expectations from them.
These expectations may create stress on these students and
lead to anxiety. The perceived importance of the examination
and the schedule of the exams were not identified as predictors
of examination anxiety. Possibly participants in the current study
did not consider the examination to be a to do-or-die affair
as the NMC gives opportunity to candidates who are referred
in the first attempt to re‑sit. Furthermore, students were not
anxious about writing a paper every day for 3 days. This means
that other factors might be contributing to examination anxiety
than the perceived level of importance and the schedule of
examination.
CONCLUSION
Anxiety has a significant impact on the performance in an
examination, hence, the current study sought to examine
the level of examination anxiety among two undergraduate
nursing student groups and also to find out factors
influencing it. The study found that examination anxiety was
high among diploma nursing students as compared to degree
nursing students. Age, gender, number of study hours were
demographic factors found to influence test anxiety. Based
on the findings, the following recommendations are made: (1)
The NMC of Ghana should collaborate with the training
institutions, to hold seminars for students concerning the
licensure examinations. This should not be done only before
the exams but can begin when the students enter their final
year.(2) Candidates should be assessed by psychologists
before the licensure examinations. Students who are found
with high levels of anxiety should be offered psychological
support before they begin the exams. (3) The various health
training institutions should teach candidates how to prepare
adequately for examinations with more emphasis on deep
Journal of Integrative Nursing / Volume 3 / Issue 3 / July‑September 2021
learning as compared to surface learning since the later does
not emphasize on synthesis and application of information
which is crucial for success in the licensure examination. (4)
Future studies should explore the role of psychological factors
like self‑esteem in examination anxiety.
Acknowledgement
The researchers would like to express their profound
appreciation to licensure candidates of NMTC, Agogo, and
PUCG who wholeheartedly and willingly participated in the
study. Dr. Paul Adjei Kwakwa is also acknowledged for his time
in reading through the manuscript and offering meaningful
as well as constructive criticisms.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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