RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES

BANGALORE, KARNATAKA
ANNEXURE II
PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION

NAME OF THE

CANDIDATE

BINCY KURIAKOSE

AND ADDRESS (IN BLOCK

1 YEAR M.Sc NURSING

LETTERS)

B G S

COLLEGE OF

NURSING
APOLLO BGS HOSPITAL
MYSORE- 23
2

NAME OF THE INSTITUTION

B G S COLLEGE OF
NURSING
KUVEMPUNAGAR

COURSE

OF

STUDY

SUBJECT
4
5

DATE OF ADMISSION
TITLE OF THE TOPIC

AND

MYSORE- 23
1ST YEAR M.Sc NURSING
MENTAL

HEALTH

NURSING
15- 06- 2010

A STUDY TO ASSESS THE EFFECTIVENESS OF BIBLIOTHERAPY ON

TEST ANXIETY REDUCTION AMONG FIRST YEAR B. Sc. NURSING
STUDENTS IN A SELECTED NURSING COLLEGE AT MYSORE

BRIEF RESUME OF INTENDED WORK:

INTRODUCTION
We read books to find out who we are. What other people, real or
imaginary, do and think and feel is an essential guide to our understanding
of what we ourselves are and

may become.

-Ursula Le Guin
Adolescence, the transitional stage of development between childhood
and adulthood, represents the period of time during which a person experiences a
variety of biological changes and encounters a number of emotional issues.
adolescence covers the period of life between 10 and 20 years of age.
Adolescence is often divided by psychologists into three distinct phases: early,
mid, and late adolescence. They are freee from the responsibilities in general.
However, they have the right to get appropriate education. For that students has
to choose their area of interest and they have to study themselves. During this
period they may encounter some sort of anxiety, which is natural.

Students cannot escape from the responsibility of tomorrow

by evading it today; their only responsibility is the achievement of academic
perfection. However, students face problems during their examinations. Test
anxiety is a major psychological problem among students. Test anxiety has
been overwhelmingly identified as a two-factor construct, consisting of the
cognitive (often referred to as "worry") and emotional (or affective)

components.

Anxiety is a general feeling of apprehension about possible danger. It is

an alerting signal; it warns of threat, external or internal, and it is probably life
saving. Anxiety initiates person to take necessary steps to prevent threat or at
least to lessen its consequences

1, 2

. Severe anxiety is marked by a significant

reduction in the perceptual field.

In stressful situations, such as before and during an exam, the body

releases a hormone called adrenaline. This helps prepare the body to deal with
what is about to happen and is commonly referred to as the "fight-or-flight"
response. Essentially, this response prepares you to either stay and deal with
the stress or escape the situation entirely. In a lot of cases, this adrenaline rush
is actually a good thing. It helps prepare you to deal effectively with stressful
situations, ensuring that you are alert and ready3.

Test anxiety prevents students from demonstrating their

knowledge on examinations. Countless students are frustrated by the fact
that they do great on all their assignments and then when it comes to their
tests, they blow it. They are frustrated, discouraged and beat themselves
instead of understanding that this is a common phenomenon that can be
overcome4. Many alternative modalities are available to reduce test anxiety.

One technique that could be used to reduce this problem is bibliotherapy.

Bibliotherapy was found to be an effective treatment in certain instances.
First, it was found to be most effective with individuals whose mental health
issues are minimal to moderate in severity. Second, bibliotherapy is most
effective in combination with other treatments.

6.1. NEED FOR THE STUDY :

Nursing programs have been cited as being among the most stressful
undergraduate programs. Students knowledge and skills are consistently tested
and monitored, and students may fail a course or be dropped from their nursing
program if scores are not above a certain standard. Anxiety reactions are
common to situations perceived as threatening; however, excessive anxiety
may paralyze an individual and interfere with effective learning, functioning,
and testing. Numerous studies have found increased anxiety causes
physiological changes including increased respirations and heart rate, and
decreased peripheral skin temperature5. According to American Test Anxiety
Association the majority of students report being more stressed by tests and by
schoolwork than by anything else in their lives. About 16 to 20% of students
have high test anxiety, making this the most prevalent scholastic impairment in
our schools today. Another 18% are troubled by moderately-high test anxiety6.

A comparative study was conducted to assess the test anxiety of

nursing students with general education students. Statistically, test anxiety was

found to be significantly higher for the nursing students compared to other

students. The finding says

that most of (30%) nursing students have test

anxiety when compared with 17% among other students in general education4.

Nursing institutions are highly stressful. Two stressors related to these

institutions may be stress of testing and high threshold standards that nursing
institutions implement in their programs; many programs require that students
achieve certain percentages on every examination in order to progress. Thus,
testing has high consequences and this may exacerbate any anxiety associated
with testing. Test anxiety may place nursing students at risk for being
unsuccessful in their programs due to their inability to demonstrate their
knowledge base. The consequence of not receiving certain criterion scores on
every examination affects attrition rates of nursing students across the country,
compounding the problem of nursing shortages. Nursing faculty should not
decrease the requirements for progression within their program and graduation,
but they should identify students who are struggling with test anxiety and offer
methods of reducing it. Interventions aimed at decreasing test anxiety and
alleviating negative consequences of test anxiety must be implemented in
nursing programs5.

Test-anxiety, especially worry has impact on academic performance,

and working memory. Studies found that test- anxiety decreases attention span,
memory and concentration, then leads to low academic performance. When

attention and concentration are impaired, this will disrupt memory and as a
consequence will lead to low academic achievement 7. Approximately 21000
students are studying in first year of B.Sc. Nursing in 324 accredited colleges
of nursing in Karnataka. To achieve better academic performance alleviation of
test anxiety is important8.

Bibliotherapy is a therapeutic management which helps to manage

several adjustment and psychological problems including depression. Review
of literature shows that bibliotherapy is effective for certain problem types like
assertion training, anxiety, and sexual dysfunction 9. Although several studies
have been conducted on bibliotherapy no attempts have been made to
investigate its use in reduction of test anxiety among nursing students in India.

The researcher had personal experience during her stay with nursing
students, found that many of them had seen to be highly anxious about their
tests. This anxiety prevents them from better performance in their tests.
Students complained that they encounter much anxiety before, during and even
after their exams. Anxiety during examination can interfere with further
learning and it can affect badly on memory of the students. Test anxiety acts as
a cause for poor academic performance 10. Todays children are tomorrows
citizens. Decreased academic performance affects the society also. Hence, it is
important to provide psychological support and proper intervention inorder to
improve the academic performance of students thus the productivity of the

Nation.

6.2.

REVIEW OF LITERATURE:

1. Studies related to test anxiety.

2. Studies related to test anxiety in nursing student.

3. Studies related to bibliotherapy.

6.2.1.Studies related to test anxiety

A comparative study between boys and girls of 16-18 years was

conducted to know the academic anxiety prevailing amongst them. The
objective of the study was to find out the gender differences in incidences and
intensity of Academic Anxiety amongst adolescents. Incidental purposive
sampling technique was used in the selection of the sample. A total sample of
240 adolescent, 120 boys and 120 girls from different high schools of Jodhpur
city were selected. Self-constructed Adolescent Problem Inventory was pilot
tested and applied on the chosen sample. The obtained results were statistically
analyzed. The results revealed that considerable amount of Academic Anxiety
prevailed amongst the sample. It was seen that girls on the whole had more
incidences and intensity of academic anxiety in comparison to boys. All

adolescents had some amount of Academic anxiety, 35.4% had low level of
Academic anxiety, 41.3 had border line and as high as 23.3% had high
academic anxiety. However when split on gender it was observed that girls
(66.1%) as compared to boys (33.9%) were high on this problem11.

A correlational study is to determine the relationship between testanxiety and academic achievement among adolescents in Sanandaj, Iran. The
respondents comprised of 400 students (200 boys and 200 girls) in the age
range of 15-19 years old that were randomly selected from nine high schools in
Sanandaj, Iran. A self administered questionnaire was used for data collection
which includes a Test-Anxiety Inventory (TAI), Grade Point Average (GPA)
score and personal information. Result shows that there is a significant
correlation (r=-0.23, p=.000) between test anxiety and academic achievement
among adolescents. In addition, there is a significant difference (t= 5.47,
p=.000) of academic achievement between male and female adolescents
whereby female score higher in their academic achievement. It is
recommended that academic achievement and mental health be improved in
school settings with support strategies such as educational guidance,
counseling and psychotherapy or other psycho-educational program such as
teaching life skill7.

A survey conducted on Pharm D students at University of Houston,

198 students participated. There was a significant difference in students

perception of course overload, ability to manage time, and test anxiety scores
across the 4 years. Approximately 44%student experienced nervousness during
test. In addition, 66.2%experienced some level of anxiety during tests; even
though they were well prepared for a test. A Spearman correlation analysis
indicated that students perception of course load were positively correlated
with test anxiety(r=0.24). Students ability to manage time was however
negatively correlated with test anxiety (r= -0.20). Further, student age (r= 0.01)
was significantly associated with younger students reporting lower test anxiety
compared to older students12.

A study conducted to assess the effect of coaching and parental

pressure on the academic anxiety in adolescent boys and girls. A large sample
of 400 (200 coaching attending and 200 self studying) adolescents from the age
range of 16-18 years from Kota city in Rajasthan participated in this study.
There were equal number of boys and girls in both the subgroups. Self studying
adolescents were those who were not attending coaching and were preparing
entrance examinations at home. This sample was selected from various coeducational private CBSC Board English Medium schools of Kota city. All of
them were appearing for the first time in competitive exams. The degree of
encouragement which a child receives was assessed with the help of a verbal
scale developed by Sharma (1988). A scale developed by Lal, Mishra, and
Pandey (1985) was used to assess academic anxiety. The adolescents with high
perceived parental encouragement reported low level of anxiety (M=7.86) than

those with low perceived parental encouragement (M=10.50), F (1,392) =

17.82, p<0.01. A significant interaction of type of study x gender, F (1,392) =
7.88, p<0.01 showed that the coaching attending boys had high level of
academic anxiety (M=9.90) than self studying boys (M=8.18)13.

6.2.2. Studies related to test anxiety among nursing students

A study conducted to assess the level of test anxiety among nursing

students of four years in Las Vegas found that one specific stress that student
nurses often report is that of examination stress. Examination processes within
schools of nursing are rigorous. One hundred fifty-six nursing students
participated in the first part of the study which was conducted in the Spring of
2009, but one student did not complete the demographic form, therefore there
was missing data. Forty-two students from semester one, 40 students from
semester two, 37 students from semester three, and 37 students from semester
four participated in this portion of the study. Thirty-one students were male
(20.0%) and 124 were female (80.0%). The mean age of the sample was 25
years of age with a standard deviation of 5.5. There was no statistical
significance between ethnicity and test anxiety scores based on the Total TAI.
TAI Scores across Nursing Semesters Semester N Mean Standard Deviation :
One 42 41.0 10.8 Two 40 43.6 13.6 Three 37 47.5 16.5 Four 37 39.8
13.55

A comparative study conducted among 298 nursing students at two

colleges, and to a comparison group of 471 high school and college students.
Fully 30% of nursing students were found to have high test anxiety, versus
17% of students in the comparison populations. Statistically, test anxiety was
found to be significantly higher for the nursing students compared to other
students. Of the high school and college students in the samples, 17% were
found to have high test anxiety. The research literature reports approximately
16%20% of students in the high test anxiety range, so the calibration for the
Westside scale appears to be similar to that of other widely used scales. In
addition, another 18% of our high school and college samples had moderately
high anxiety, indicating modest anxiety impairment. So in all, 35% of students
had moderately high anxiety or higher. Among nursing students, 30% were
found to have high test anxiety, which is close to double the figures for the
comparison population samples. In addition, another 26% of nursing students
had moderately high anxiety, which is again higher than the comparison
figures4.

A study explores anxiety among baccalaureate nursing students in

their first year of nursing curriculum. Using a descriptive research design,
surveys were sent to twelve baccalaureate nursing programs in the Midwest
following IRB approval. Using a 1-10 Likert Scale, respondents were asked to
rate the number of anxiety episodes and their severity, while also considering
anxiety in relation to the nursing role. Fixed-alternative questions gained

information about GPA, age, and lifestyle (i.e. clinical time, class time,
activities, etc). Open-ended questions were used to explore students' thoughts
concerning anxiety. Data were analyzed using simple frequencies and
descriptive statistics through the SPSS computer program. There were 177
respondents that represented seven baccalaureate schools. Results showed that
86% claimed an increase in anxiety after entering their nursing program; 42%
stated a dramatic increase, and 44% indicated a slight increase in their level of
anxiety14.

6.2.3. Studies related to effectiveness of bibliotherapy

A study conducted to evaluate the efficacy of bibliotherapy in

clinical settings within the context of the North Inner City Book Prescription
Scheme. The participants interviewed for the study varied in terms of their
gender (7 men; 6 women), and their age (mean = 41.5 years; age range = 27
64 years). Participants spent an average of 13 years in education. Length of
involvement with the Books on Prescription Scheme varied among participants
from 1 month to 18 months, with average period of participation of 8.83
months. Of the 11 participants involved, 10 were referred with either
depression or anxiety as the primary psychiatric diagnosis Results indicate the
use of bibliotherapy is generally perceived to be effective as a treatment for
mild and moderate psychological difficulties, suggesting this may be a novel
therapeutic technique of significant potential within a clinical setting15.

6.3.

PROBLEM STATEMENT

A QUASI EXPERIMENTAL STUDY TO ASSESS THE EFFECTIVENESS

OF BIBLIOTHERAPY ON TEST ANXIETY REDUCTION AMONG FIRST
YEAR B.Sc, NURSING STUDENTS IN A SELECTED NURSING
COLLEGE AT MYSORE.

6.4. OBJECTIVES OF THE STUDY:

The objectives of the study are to:1. Determine the level of test anxiety among first year B.Sc. Nursing students
as

measured by Sarasons test anxiety scale.

2. Assess the effectiveness of bibliotherapy on test anxiety reduction among

first year

B.Sc.

Nursing students as measured by Sarasons test anxiety

scale.
3. Find out the association of test anxiety scores with selected demographic
variables of first year B.Sc. nursing students.

6.5. OPERATIONAL DEFINITIONS:

1.

Effectiveness:
Effectiveness refers to the reduction in anxiety during tests after the

implementation of bibliotherapy evidenced by the decreased scores in posttest

with Sarasons test anxiety scale.

2. Bibliotherapy:
Bibliotherapy is defined as the use of literature to help children identify
and express feelings within the structure and safety of the nurse-patient
relationship16.
In this study bibliotherapy refers to use of materials to help the students
to improve their motivation, and helps to improve confidence and reduce
anxiety during tests.
3. Test anxiety:
Test anxiety involves a combination of physiological over-arousal,
worry and dread about test performance, and often interferes with normal
learning and lowers test performance.
In this study it refers to moderate or high anxiety related to a test
characterized by physiological over-arousal, worry and dread about test
performance, and often interferes with normal learning; it will block the
performance during the examination.
4. First year B.Sc. nursing students:
The students who have selected nursing as a profession and exposed
to biological and

sociological subjects in their curriculum and, they are

attending internal examination for the first time.

6.6 VARIABLES
Dependent variables: anxiety of first year B.Sc. nursing students related to

tests
Independent variables: bibliotherapy
Extraneous variables: the demographic factors like age, sex, medium of
education in pre university classes.
6.7 ASSUMPTIONS:
The study assumes that
Nursing students usually experience anxiety during tests
Test anxiety may have both effect on the academic performance and their
personal
and social development.

Bibliotherapy will help to reduce test anxiety.

Level of test anxiety may vary according to selected demographic

variables

6.8.

DELIMITATIONS:

The study will be delimited to

First year B.Sc. nursing students of BGS College of nursing.

Students who are willing to participate in the study

Available at the time of the study.

6.9.

HYPOTHESIS:

H1: The mean post test level of test anxiety scores will be significantly lower
than the mean pre test level of test anxiety scores at 0.05 level of significance.
H2: There will be significant association between present anxiety scores and

selected demographic variables such as age, sex, and medium of education in

pre university classes.

7. MATERIALS AND METHODS:

7.1

Source of dataData will be collected from First year B.Sc. Nursing

students of BGS College of Nursing, Mysore

7.1.1. Research Design:
The study design selected for this study is one group pre-test and post-test
design17.
7.1.2. Settings:
The study will be conducted in BGS College of nursing at Mysore.
7.1.3. Population:
First year B.Sc. Nursing students of all College of nursing at Mysore.

7.2. METHOD OF DATA COLLECTION:

7.2.1 Sampling technique:
This research study will adopt purposive sampling for selecting
samples. Out of the total population defined, those who will meet the inclusion
criteria will be selected for the study .

7.2.2 Sampling Size:

Thirty first year B.Sc. nursing students will be selected for the study.
7.2.3 Inclusion Criteria for Sampling:
First year nursing students who are under moderate to high anxiety i.e.

students those who scored more than 15 in Sarasons Test Anxiety Scale during
pretest.
7.2.4 Exclusion criteria:
Students those who scored less than 15 in Sarasons Test Anxiety Scale
during pretest.
7.2.5 Instrument Used:
The researcher will be using- Standardized checklist to assess the level of anxiety by using Sarasons test
anxiety scale.
- The materials collected from the books and Internet for the intervention
7.2.6 Data collection method Data will be collected after obtaining consent
from the authority of the selected college. The students will be explained the
objectives of the study and consent taken from the participants in the study.
They will be screened with pretest tool using Sarasons test anxiety scale
checklist. Based on present level of test anxiety score bibliotherapy will be
given as an intervention followed by posttest using same tool at the time of
examination to evaluate the effectiveness.

7.2.7 Data Analysis Plan:

The data obtained would be analyzed using both descriptive and
inferential statistics. The analysis will be done on the basis of objectives and
hypothesis stated. Chi square test will be using to find out the association
between the variables. The significance of pre-test and post-test scores would

be tested using t test, at 0.05 level of significance.

7.3. DOES THE STUDY REQUIRE ANY INVESTIGATION ON
INTERVENTION TO BE CONDUCTED ON PATIENTS OR OTHER
HUMANS OR ANIMALS? IF SO PLEASE DESCRIBE BRIEFLY:
Yes, bibliotherapy will be given as an intervention.
7.4 HAS ETHICAL CLEARANCE BEEN OBTAINED FROM YOUR
INSTITUTION IN CASE OF 7.3:
Yes, consent obtained from the concerned authority of selected
college of nursing. Consent will be taken at the time of data collection.

LIST OF REFERENCES
1.

Glod Carol A. Contemporary psychiatric mental health nursing. 1 st ed.

Philadelphia: F.A Davis Company; 1998. pp. 379.

2. Ahuja Neeraj, Vyas J N. Text book of postgraduate psychiatry. 2 nd ed. New

Delhi: Jaypee Brothers Medical Publishers (P) LTD; 2003. PP.250
3. Kendra Cherry. What Causes Test Anxiety? The Potential Causes of Test
Anxiety.
URL: http://psychology.about.com/od/mentalhealth/a/test-anxiety-

causes.htm.
4. Mike Bius. Test Anxiety - Overcoming the 3 Causes for Doing Poorly on
Tests to Improve Your Grades. 2010. URL: http://ezinearticles.com/?
Test-Anxiety---Overcoming-the-3-Causes-For-Doing-Poorly-on-Teststo-Improve-Your-Grades&id=4732154
5. Catherine Andrea Prato. Biofeedback assisted relaxation training program to
decrease test anxiety in nursing students. University of Nevada Las Vegas.
2009.
URL: http://digitalcommons.library.unlv.edu/cgi/viewcontent.cgi?article=
1090&context=thesesdissertations
6. http://www.amtaa.org/
7. Fayegh Yousefi. The Effect of Test-Anxiety on Memory among Iranian
High School Students. International Journal of Psychological Studies
2010 June; VOL.2 (1).
URL:
http://www.ccsenet.org/journal/index.php/ijps/article/viewFile/5444/50711
37
8.

www.rguhs.ac.in

9.

Richard Driscoll, Ginger Evans, Gary Ramsey, Sara Wheeler. High Test
Anxiety

among

Nursing

Students2009.

URL:

http://www.eric.ed.gov/PDFS/ED506526.pdf
10. Prima Vitasari, Muhammad Nubli, Abdul Wahab. A Research for Identifying
Study

Anxiety Sources among University Students. International

Education Studies ; 2010 May; VOL.3 (2).

11. Reena Bhansali, Kunjan Trivedi. Is Academic Anxiety Gender Specific: A
Comparative Study. J. Soc. Sci., 2008; 17(1):p. 1-3.
12. Sujit S. Sansgiry, Kavita Sail. Effect of Students Perceptions of Course
Load on Test Anxiety. American J. of Pharmaceutical Education. 2006;
70 (2) Article 26
13. Madhu Jain, Jaishree Jain . Academic Anxiety among Adolescents: Role of
Coaching

and

Parental

Encouragement.

National

Academy

of

Psychology, India Vol. 52, No. 2,146-148; 2007.

14. Jean Heise, Heather Priessler. Exploration of Anxiety among First-Year
Nursing students. 2008.
URL: http://www.dominican.edu/query/ncur/display_ncur.php?id=2457
15. Grainne Mc Kenna. Bibliotherapy: A review of its efficacy in clinical
settings.

2008

August.

URL:

http://www.tcd.ie/Psychology/other/mscap_dissertations/pdf/Bibliotherapy.
%20A%20review%20of%20its%20efficacy%20in%20clinical%20settings
%20-%20Grainne%20McKenna.pdf
16. Laraia Michele T, Stuart Gail W. Principles and practice of psychiatric

nursing. 8th ed. New Delhi: Elsevier; 2005. pp.261.

17.

Bhaskara Raj D. Elakkuvana. Nursing research and biostatistics. 1st ed.

Banglore: EMMESS Medical Publishers; 2010.PP.101

18.

www.google.com

19.

http://www.ncbi.nlm.nih.gov/pubmed

09

Signature of candidate

10

Remarks of guide

11

Name and designation of (in block letters)

MRS. RAJULA ASIR R

11.1 Guide

ASST. PROFESSOR
DEPT. OF MENTAL HEALTH
NURSING
BGS COLLEGE OF NURSING
KUVEMPUNAGAR
MYSORE.

11.2. Signature
11.3. Co-guide (if any)
11.4. Signature
11.5. Head of department

MRS. RAJULA ASIR R

ASST. PROFESSOR
DEPT. OF MENTAL HEALTH
NURSING
BGS COLLEGE OF NURSING
KUVEMPUNAGAR
MYSORE.

11.6. Signature
12

12.1.

Remarks

Chairman and Principal

12.2. Signature

of