Running head: STRESS AND ANXIETY
1
Evidence-based Paper: Effects of Stress and Anxiety on Personal Performance
Submitted by Louise Lane, Jennifer Neuman, Ashley Rethman, Tammy Spears, and Karla Tailele
(Estrogen Initiative)
Washburn University School of Nursing
For NU 475 Nursing Research
June 28, 2011
Running head: STRESS AND ANXIETY
2
Effects of Stress and Anxiety on Personal Performance
Introduction
Anxiety is a multisystem response to a perceived threat or danger. (Gale, 2008) It can also be described as
a human response to stress and involves physical, psychological, and environmental factors. (Vitasari, Wahab,
Othman, & Awang, 2010) Anxiety may present itself in various forms including excessive displays of worrying,
fear, or restlessness. In fact, 75% of individuals with anxiety disorders will experience it during study at university
level. (Vitasari et al., 2010) “Psychological symptoms among students include feeling nervous before attending
class, panicking, going blank during tests, feeling helpless while doing assignments, or lack of interest in subjects
considered difficult.” (Vitasari et al., 2010) Whereas, physical symptoms may include sweaty palms, racing
heartbeat, or an upset stomach. (Vitasari et al., 2010)
Anxiety can also be categorized into state anxiety and trait anxiety. State anxiety is apprehension
experienced at a certain period of time. Trait anxiety is a predisposition of an individual to anxious living. (Ozen,
Ercan, Irgil, and Sigirli, 2010) Individuals with high levels of anxiety generally have heightened trait anxiety.
(Vitasari et al., 2010) Unresolved, extended or heightened periods of anxiety can lead to negative thinking that
builds towards overly emotional responses to simple issues. It can also reduce working memory, impair
concentration, and reasoning. (Vitasari et al., 2010) Heightened anxiety is associated with overall lower performance
and may interrupt quality of life. Additionally, “a survey conducted by Nursing Times in 1991, which included
responses from 1800 nurses, indicated that stress is a major problem in nursing today. Nine out of 10 nurses in this
study said they suffered from stress at work. “(Sharif & Armitage, 2004).
Review of Literature
The focus of anxiety among university students’ overall performance was investigated June 2010 using the
Academic One File, Sage Premier, Psycinfo and the Mabee Library Science Direct: College Edition: Social and
Behavior Science databases. The following keywords with the number of hits revealed in the parentheses were used:
anxiety (48,141 hits), stress (35,313 hits), college students (25,382), anxiety and academic performance (1,377 hits),
and stress, nursing student, academic performance and clinical (51 hits). The number of hits was reduced to journals,
behavior research and therapy, and the years 2006-2011 as selection parameters. Twelve articles were reviewed and
five nursing research studies relevant to the area of anxiety among university students were selected for the
foundation in this review of literature.
Running head: STRESS AND ANXIETY
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Critical Appraisals
Article 1 as submitted by Louise Lane
This study conducted at the University of Malaysia, Pahang was designed to test the Study Anxiety
Intervention to promote study anxiety resilience and positive coping skills that improve academic performance. A
random quantitative study of 12 participants, 6 in the control group and 6 in the experimental group, underwent pre
and post testing which utilized State Trait Anxiety Inventory and GPA as measures for reliability and validity.
(Vitasari et al., 2010) The experimental group was taught biofeedback techniques in six classes, which were
designed to help students reduce anxiety levels during study. The control group did not receive any instruction.
It was reported in the review of research that many studies have been conducted on anxiety level, but not
many have been done to design an intervention program with tools to reduce the anxiety level and then measure
student’s academic performance. (Vitasari et al., 2010) The Study Anxiety Intervention included biofeedback
training, which can be classified into module intervention and protocol techniques. Biofeedback assisted breathing
retraining and muscle relaxation were two identified techniques taught during the classes. Heart rate and respiration
assessment were also preformed during pre and post tests, in addition to the STAI and measures of GPA. (Vitasari et
al., 2010)
The major themes identified in the research indicated a strong correlation between the student’s anxiety
level and academic performance. There was also a significant difference between the test results of the experimental
and control groups, as well as, between the pre and post test results. State Trait Anxiety Inventory scores are
significant on a level .024 with p≤.05 and GPA scores are significant on a level .05 with p≤.05. (Vitasari et al.,
2010) The strength of the study lies with the results identified. However, this appears to be pilot study and further
research was recommended to gain results from high school students. In addition, a larger number of participates
would help quantify the study.
Article 2 as submitted by Tammy Spears
Anxiety among university students authored by Ozen, Ercan, and Sigirli in 2010 and published in the AsiaPacific Journal of Public Health. This research article dealt with measuring state and trait anxiety among university
aged students in Turkey and the factors affecting outcomes. The study was a quantitative, cross-sectional, quasiexperimental design with 4,850 male and female students randomly chosen among the student population. State
anxiety was defined as a subjective fear resulting from a stressful situation. Trait anxiety describes the predisposition
Running head: STRESS AND ANXIETY
4
to an anxious response in what are objectively neutral situations. The study found women were more likely to
experience stress, and those students who reported a need for social support also rated the most anxiety. Data was
collected using Spielberger’s State-Trait Anxiety Inventory. Variables included were gender, age, department of
study, year of study, living arrangements, marital status, region of longest residence, number of co-residents, family
income, financial support, relationship status, parents alive, parents’ level of education, difficulty understanding
lectures, adapting to university life, self-sufficiency, way of solving a problem, negative life experience, and
satisfaction with department of study.
This study demonstrated a clear audit trail of data collection and analysis. The logistic regression
analysis of both state and trait anxiety showed risk factors were significantly associated with results being
statistically significant (p<.001). The results of the study reflected similar findings of research studies conducted at
several international universities. After controlling for gender and family socioeconomic status, risk factors for
anxiety were discussed as well as suggested policy changes to alleviate student stress and promote better academic
performance in the university setting.
Article 3 as submitted by Karla Tailele
Azizah, Chong, Noraini, Norzaidi, Rafidah and Salwani (2009) conducted a study to determine the
relationship between stress factors, perceived stress and academic performance from Pre-Diploma students in
Malaysia. The purpose was to investigate throughout the semester the affects of stress on academic performance
among the students. This was a quantitative, non experimental and longitudinal design among 154 students at the
UiTM Negeri Sembilan campus. To examine the relationship between the affects of stress factors, perceived stress
and academic performance the researchers detailed the items on the questionnaires that were developed to measure
the variables identified in the study. The variables relevant to this study were based on the students GPA and the
level of perceived stress in relation to the beginning, middle, and end of the semester.
In conducting this study, the authors initiated a convenience sample to administer their population. The data
collections used were the PSS (perceived stress scale), Stress Factor Survey and the GPA results which were reliable
in this study. The findings indicated that students experienced a moderate level of stress and there was a correlation
between the levels of perceived stress at the end of semester affecting the students’ academic performance. The p
value was less than 0.05 which implied that when the level of perceived stress was higher, the academic
performance would be lower.
Running head: STRESS AND ANXIETY
5
The ANOVA was used to test the significant differences during the different periods of the semester.
Indicated in the Pearson Correlation Coefficient results shown students grade point average in the beginning at a (0.05). The statistical significant correlation between the perceived stress at the end of the semester and the students
academic performance relationship value was (r =-0.201 implicating when the level of perceived stress increases the
students academic performances decreases. The reliability of the study was credible with a clear purpose of the
study, it was accessible, and surveys were anonymous. Although the study had a few credible resources, the study
was uncontrolled, has a weak correlation and absence of evidence and on the effects of the stress factors on
academic performance. Other downfalls of the study were the small campus population used and the difficulties with
understanding the statistics. Overall in order to replicate the study it needed specific information to support the main
variables.
Article 4 as submitted by Ashley Rethman
In a study done by Keogh, Bond, and Flaxman (2006), it was found that students who went through a stress
management intervention group improved there test scores almost an entire letter grade after completion of the
program. One hundred and sixty students were selected with a control group containing 80 students and an
experimental group containing 80 students. The study used pre and post testing to determine the effects of the
intervention. The tests used were the general health questionnaire, the need for achievement scale, the revised test
anxiety scale, the dysfunctional attitude survey and the cognitive abilities test. An exam was completed after the
intervention to determine if test scores really did improve. Due to differences in intelligence levels, it was suggested
that this could be a co-variable in determining the success of the intervention and the maintained level of motivation
to do well. Also, because a placebo group was not used due to ethical purposes it is hard to know if the effects of
the intervention were simply due to the fact that the experimental group knew they were being treated. The 50%
attrition rate also presented a weakness in this study and left the question, did intelligence keep some students there
while less intelligent students tended to drop out of the intervention. P values were all in acceptable ranges. Overall
this study demonstrated a clear improvement when stress management is used and opens the door to further study
and research.
Article 5 as submitted by Jennifer Neuman
In a study done by Sharif & Armitage (2004), it was found that students who underwent psychological and
educational counseling had a reduction in anxiety and an improvement in their grade point average. There was no
Running head: STRESS AND ANXIETY
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funding source that was noted and no mention of approval from any type of authority. One hundred second and
fourth year nursing students were selected for the study from Shiraz University of Medical Sciences, Iran. The
control group and the experimental group each had 50 participants who were randomly selected. The experimental
group received counseling while the control group did not. The counseling consisted of a weekly 2-hour program
over 12 weeks that focused on psychological and educational counseling. The study used a pre-test, a post-test, and
a follow-up to gather information from the groups. The Hamilton Anxiety Scale was used to measure the
participant’s feelings of anxiety during the three interviews. The study also used the participant’s grade point
average as an indicator of performance.
The studies outcomes supported the idea that anxiety affects a student’s performance in a negative way.
The student’s from the experimental group showed an improved grade point average. The study used the t-test and
ANOVA to analyze the information gathered from the participant’s. The ANOVA results from the pre-test showed
no significance difference between the groups with F = 12.97 and P<0.001. While at the end of the semester in the
follow-up it showed a reduction in anxiety with F = 6.06 and P = 0.003. The mean GPA of the control group in the
pre-test was 15.5 and 15 in the experimental group. The follow-up reported a mean GPA of 15.3 for the control
group and 16.4 for the experimental group.
Conclusion
Five articles were analyzed in the review of literature section. Each study focused on factors related to
anxiety and the affects on academic performance of students. Azizah et al. (2009) found that stress affected
academic performance (p<.05). Ozen, et al. (2010) reflected these findings on the affects of anxiety on academic
performance (trait=40.52+/-10.51; state=43.37+/-8.32). Going a step further, Vitasari, et al. (2010) found that
anxiety interventions provided a positive impact on academic performance (r=.024, p<.05). Sharif & Armitage
(2004), and Keogh et al. (2006) produced similar results.
Each of the studies reviewed were of a quantitative design and international in origin. The studies varied in
size from 12 to 4850. Vitasari et al. (2010) was an experimental design. In contrast, Azizah et al. (2009) and Ozen et
al. (2010) were non-experimental design studies. Sharif & Armitage (2004) and Keogh et al. (2006) were quasiexperimental design studies.
Evaluation
Intervention appears to play a significant role in the management of anxiety. Adequate academic services
Running head: STRESS AND ANXIETY
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and educational interventions may assist students in developing a positive self-image and decrease chances for
emotional problems. It is recommended that universities’ consulting centers employ a sufficient number of
psychologists and psychiatrists utilizing individual and group therapy modalities. Medical personnel should be
trained to deal with issues related to anxiety in late adolescence to the benefit of students, universities, and the
community at large. It has been observed that women do not handle stress as effectively as men. It is also notable
that a greater number of nurses are women as opposed to men. If taught to manage anxiety early during study then a
foundation would be laid to handle stress effectively in clinical practice.
As the review of literature reflects, anxiety is an area of research that is of interest worldwide. These
studies are generalizable and repeatable, and offer potential for international collaboration of nursing research. The
target population of these studies primarily focused on university age participants. “University youth are generally
open to change and are more sensitive to personal, interpersonal, and sociocultural differences and conflicts.”
(Ozen, et al., 2010) The mechanisms learned during university years will transition well into valuable resources to
be utilized in clinical practice of nurses. “Long hours of study, academic stressors, pressure of clinical practice and
learning difficult materials are some of the stressors reported by nursing students.” (Sharif & Armitage, 2010)
Future research areas recommended would be to extend these studies to high school students and to those beyond
college age in order to determine how anxiety affects performance at work. It is also valuable to mention that stress
management classes or interventions may be beneficial for nurses in practice, either to seek out on their own or be
provided at their place of work.
Running head: STRESS AND ANXIETY
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References
Anxiety. (n.d.) in Gale Encyclopedia of Medicine. (2008). Retrieved from http://medicaldictionary.thefreedictionary.com/anxiety
Azizah, A., Chong, C. S., Noraini I., Norzaidi, D. M., Rafidah, K., & Salwani, I. M. (2009).
Stress and academic performance: Empirical evidence from university students. Academy of Education
Leadership Journal, 13 (1), 37-51.
Keogh, E., Bond, F. W., Flasman, P. E. (2004) Improving academic performance and mental
health through a stress management intervention: Outcomes and mediators of change. Behavior Research
and Therapy, 44, 339-357. Doi: 10.1016/j.brat.2005.03.002
Ozen, N. S., Ercan, I., Irgil, E., Sigirli, D. (2010). Anxiety prevalence and affecting factors
among university students. Asia-Pacific Journal of Public Health, 22 (1), 127-133. Doi:
10.1177/1010539509352803
Sharif, F. & Armitage, P. (2004). The effect of psychological and educational counseling in
reducing anxiety in nursing students. Journal of Psychiatric and Mental Health Nursing, 11, 386-392. Doi:
10.1111/j.1365-2580.2003.00720.x
Vitasari, P., Wahab, M. A., Othman, A., Awang, M. G. (2010). The use of study anxiety
intervention in reducing anxiety to improve academic performance among university students.
International Journal of Psychological Studies, 2 (1), 89-95.
Running head: STRESS AND ANXIETY
9
Appendix A
Evidence Base Paper Grid of Article Critical Appraisals
Student
Louise
Reference
source
Author/
Year
Purpose/Questi
on/
Hypothesis
Design
Variables
Sample
& Size
Internation
al Journal
of
Psycholog
ical
Studies
Vol 2 No
1
Vitasari,
P;
Wahab,
M;
Othman,
A;
Awang,
M
2010
The study was
designed to
test the Study
Anxiety
Intervention to
promote study
anxiety
resilience and
Quantit
ative
experi
mental
with
control
group
Study
Anxiety
Interventio
n
With
Biofeedba
ck;
Anxiety;
Academic
Performan
ce;
University
Students
Nonprob
ability
purposiv
e
N=12
6=experi
mental
6=control
Data
Collection
Significant
Findings
STAI scores is
significant on
level .024 with
P<.05 and
GPA scores is
significant on
level .05 with
p<.05
Reliability &
Validity
State Trait
Anxiety
Inventory
& GPA. These
were stated to be
consistent with
reliability &
validity but stats
were not shared
Strengths & Weakness
The results show
significant difference
between pre and post
tests between the
experiment and the
control group.
Running head: STRESS AND ANXIETY
Karla
Academy
of
Education
al
Leadershi
p Journal,
Vol. 13
No. 1
Azizah,
Chong,
Noraini,
Norzaid
i,
Rafidah,
Salwani,
2009
No hypothesis.
This study was
designed to
investigate
throughout the
semester the
affects of stress
on academic
performance
among
students.
Quantit
ative
Nonexperi
mental/
Longit
udinal
10
The GPA
and level
of
perceived
stress in
the
beginning,
middle,
and end of
the
semester.
Convenie
nce
sample
N=154
Self
administere
d
questionnai
re over the
semester (6
mos.)
timeframe.
The three
sections:
1) Students
profile
2) PSS
(perceived
stress scale)
3) Stress
Factors
Survey
The findings
indicate a
moderate level
of stress
experienced
and there was a
correlation
between the
level of
perceived
stress at the
end of
semester and
the students’
academic
performance.
The p value
was -0.05
which implied
that when the
level of
perceived
stress was
higher, the
academic
performance
would be
lower
Verified results
of students
profile, PSS scale
and Stress Factor
Survey to
strengthen the
study.
STR-study conducted last 5
years
-clear purpose
-accessible
-survey remain
anonymous
WEAKNESS- weak correlation
among less stress level
having less affect on
academic
-small student
population of campus
-difficult
understanding of
statistics
--time consuming
Running head: STRESS AND ANXIETY
Tammy
AsiaPacific
Journal of
Public
Health,
Vol. 22
No. 1
Ozen,
Ercan,
Sigirli,
2010
Jennifer
N
euman
Journal of
Psychiatri
c and
Mental
Health
Nursing
Sharif,
F.,
Armitag
e, P.
(2004)
This study was
designed to
identify risk
factors for
university
students that
affect
performance
and what steps
school
administrators
can take to
reduce anxiety.
To find out if
anxiety is
reduced in
nursing
students will
there be
improvement
in overall
performance.
11
Quantit
ative
Nonexperi
mental
Crosssection
al
Difficulty
understand
ing
lectures,
status of
family
relationshi
ps, and
satisfactio
n with
departmen
t of study.
N=4,850
Random
Spielberger
’s StateTrait
Anxiety
Inventory
Point means
were 40.51 +/10.51 for state
anxiety and
43.37+/-8.32
for trait
anxiety. P
value for both
trait and state
was <.001.
Clear audit trail
of data collection
and analysis.
Cronbach’s alpha
coefficient was
.92 for trait and
.85 for state.
STR-Large
generalizable random
sample. Strong
statistical results with a
95% confidence
interval. IVs clearly
defined.
WKNS- No DV
clearly defined. Too
many IVs.
Quasiexperi
mental
with
pre,
posttest,
and
follow
up. A
control
group
and
focus
groups
were
used.
12 week
interventio
n program
(counselin
g), 2nd and
4th year
baccalaure
ate
nursing
students,
anxiety,
GPA
N = 100,
control =
50 and
experime
ntal = 50.
Pre, Post,
and follow
up using
Hamilton
Anxiety
rating scale
and GPA.
From the
pretest, the
Hamilton
anxiety rating
scale showed
that most of
the students in
the nursing
The Hamilton
Anxiety Rating
Scale, GPA with
tables and clear
The study was only 12
weeks long which may
have not been enough
time for the program to
take full effect. The
study was done within
last 5 years, it had a
strong correlation
between anxiety
reduction and GPA
increase.
Running head: STRESS AND ANXIETY
Ashley
Rethma
n
Behavior
Research
and
Therapy
Vol. 44
Iss. 3
Keogh,
Bond,
Flaxma
n (2006)
Purpose:
Determine
whether or not
a SMI is
effective in
improving
mental health
and
maximizing
GCSE
performance
and identifying
the
mechanisms by
which such
benefits occur,
if indeed they
do so.
Hypothesis:
The SMI will
improve
students’
mental health
because it
makes their
cognitions
more
functional. An
increase in
motivation will
mediate the
relationship
between our
CBT SMI and
GCSE
performance.
No question.
Quantit
ative
quasiexperi
mental
with
pre and
post
tests
and a
standar
dized
text
(GCSE
). text
(GCSE
).
12
Dependent
: selfreport
measures
of stress
and exam
performan
ce.
Independe
nt:
Interventio
n group
(attended
ten week
trainin g
group one
hour a
week),
Control
group
N=80
40 in
experime
ntal
group
and 40
in control
group
Pre and
post tests
including:
General
Health
Questionnai
re using
likert-type
scale, Need
for
achievemnt
scale with
42 yes/no
queestions,
Revised
test anxiety
scale using
a four-point
Likert
rating scale,
dysfunction
al attitude
survey with
40-item
measure
using a
seven point
Likert
scale,
cognative
abilities test
to measure
intelligence
.
GCSE
examinatio
n results .
High levels of
dysfunctional
attitudes wer
significantly
associated with
mental ilhealth in pre
and post tests.
High levels of
motivation
during pre and
post tests were
significantly
related GCSE
scores were
signigicantly
different
between the
experimental
and control
group.
Tables were used
to clearly show
data and tests
used were well
known.
This study used well
known tests most of
which had good
variability and
reliability however, the
article did not give this
information
completely for all tests
used. There was a50%
attrition rate and there
was no placebo group
so there could have
been some level of
change in exam scores
just because students
in the experimental
group knew they
should do better when
taking the GCSE.
Running head: STRESS AND ANXIETY
13
Appendix B
Articles Reviewed
1.
Vitasari, P., Wahab, M. A., Othman, A., Awang, M. G. (2010). The use of study anxiety
intervention in reducing anxiety to improve academic performance among university students. International Journal of Psychological Studies, 2 (1),
89-95.
2.
Ozen, N. S., Ercan, I., Irgil, E., Sigirli, D. (2010). Anxiety prevalence and affecting factors
among university students. Asia-Pacific Journal of Public Health, 22 (1), 127-133. Doi: 10.1177/1010539509352803
3.
Azizah, A., Chong, C. S., Noraini I., Norzaidi, D. M., Rafidah, K., & Salwani, I. M. (2009).
Stress and academic performance: Empirical evidence from university students. Academy of Education Leadership Journal, 13 (1), 37-51.
4.
Keogh, E., Bond, F. W., Flasman, P. E. (2004) Improving academic performance and mental
health through a stress management intervention: Outcomes and mediators of change. Behavior Research and Therapy, 44, 339-357. Doi:
10.1016/j.brat.2005.03.002
5.
Sharif, F. & Armitage, P. (2004). The effect of psychological and educational counseling in
reducing anxiety in nursing students. Journal of Psychiatric and Mental Health Nursing, 11, 386-392. Doi: 10.1111/j.1365-2580.2003.00720.x