Overcoming OSCE anxiety

Objective structured clinical examinations (OSCEs) were developed 50 years ago to objectively assess the competency of medical students' clinical skills (Harden, 2016). A standardised patient scenario is used to examine clinical and communication skills, which are assessed against a marking criteria. OSCEs have become a widely accepted form of assessment in many professions including nursing, due to their reliability and validity (Taylor et al, 2019). OSCEs are used in post-graduate programmes such as non-medical prescribing and advanced practice to assess history taking, physical assessment and decision-making skills (Núñez-Peña et al, 2016). Some students report higher levels of anxiety and stress before OSCEs compared with other assessments (Nulty et al, 2011; Barry et al, 2012). As a high stakes examination, the pressure to pass and complete the programme adds to the OSCE being anxiety provoking (Martin and Naziruddin, 2020).

Stress is the feeling of emotional or physical tension in response to an external event, which leads to anxiety – the subjective feeling of unease in anticipation of a threat – and may lead to overthinking (Al-Ghareeb et al, 2017). The body's reaction to stress starts with the activation of the sympathetic autonomic nervous system (flight or fight response). If the stress response is excessive or ongoing, the sympathetic response may remain activated, which could potentially be overwhelming and affect the ability to cope (Mental Health Foundation, 2022). OSCE anxiety is caused by both stress and anxiety. Approximately 20% of students develop severe OSCE anxiety which negatively impacts on OSCE performance (O'Carroll and Fisher, 2013; Ariga, 2019). For most students some stress is beneficial, motivating them to prepare for the OSCE examination and increase clarity of thinking in the OSCE.

This article will explain what OSCE anxiety is and the various ways it can affect OSCE performance. It will go on to explore ways to ensure optimal preparation for OSCEs, including how to overcome OSCE anxiety.

What is OSCE anxiety?

OSCE anxiety is transient, unlike an anxiety disorder which is a common mental health presentation that persists for more than 6 months (American Psychiatric Association, 2013). Test anxiety can affect students in any assessment, but it is suggested in OSCEs the higher levels of anxiety are due to being observed in addition to test anxiety (O'Carroll and Fisher, 2013; Martin and Naziruddin, 2020). Test anxiety is when an assessment leads to fretful worrying, accompanied by feelings of apprehension and tension, which stimulates the sympathetic response (Wu et al, 2013; Al-Ghareeb et al, 2017). Being observed may provoke stage fright, which is associated with being watched. This fear of being watched by others is not present in other assessments and is thought to cause increased anxiety (Nielsen and Harder, 2013).

Understanding OSCE anxiety

The unpleasant feelings of anxiety are familiar to most people; with OSCE anxiety, this includes worrying response (cognitive) and the emotional response (non-cognitive), as well as feeling tense, which all trigger the sympathetic response (physical response) (Vasli et al, 2021). To overcome OSCE anxiety it is important to understand how these responses are interconnected and their impact on our thoughts, emotions and behaviours (Núñez-Peña et al, 2016).

Physical response (sympathetic autonomic nervous system)

The typical symptoms experienced when the sympathetic nervous system is triggered include feeling nervous which is characterised by:

• Dry mouth
• Nausea and gastrointestinal upset
• Shaking
• Perspiration
• Palpitations
• Changes in the speed of thinking including having irrelevant thoughts, catastrophising or thinking ‘going blank’.

When a stressful event triggers the sympathetic part of the autonomic nervous system, noradrenalin is released throughout the brain, which increases the vigilance of the brain to prepare it for an imminent threatening situation (Bremner and Bremner, 2016). The emotional memory centre of the brain, called the amygdala, is alerted, causing a cascade of distress signals. These distress signals bypass the prefrontal cortex; thereby missing input from the thinking part of the brain. Instead the limbic system – which monitors dangers and threats – takes over, along with the brainstem, which controls breathing, heart rate and sleeping. The ability of the prefrontal cortex to inhibit the sympathetic response varies, depending on previous experience and memories. If unchallenged, the heart and respiratory rate increases and gastrointestinal secretions dry up to prepare the individual to escape from perceived danger (the OSCE assessment) (McKimm and Phillips, 2010). With the thinking part of the brain ‘switched off’, it is difficult for the individual to think logically or feel normally, which leads to unexpected behaviour changes. The student may appear to be disengaged in the OSCE and their responses may be limited because they are distracted by a raft of irrelevant thoughts and feelings. In OSCEs where clinical judgement is needed, decision making can be disrupted, and the students' highly developed and mature emotional intelligence becomes unavailable to them due to OSCE anxiety.

OSCE anxiety can be increased by background stress which may be particularly high at the moment due to the strain of working as a health professional in a pandemic. Life stresses including family, finances and personal health concerns can also increase stress levels. If this is the case it may be that some demands need to be delegated. Other stressors such as the effect of the menopause on memory should be factored in and strategies developed to deal with these.

Worry response (cognitive)

Thought processes impact on OSCE anxiety and increase the sense of worry, which in turn can increase the sympathetic response further (O'Carroll and Fisher, 2013). In OSCE anxiety this stems from excessive worrying about making mistakes or failing, focussing on past failures, hypervigilance (heightened awareness of anxiety and possible threats) and attempts to stop thoughts of failing (O'Carroll and Fisher, 2013). This is accompanied by the fear of being different to their peers, which could lead to loss of status in the individual's social group (Sapp, 2014). This may trigger lack of confidence or fear of failure, especially if a poor result would lead to leaving the course. Self-doubt and loss of confidence can be experienced, which may then lead to increased worrying, and therefore increasing the sympathetic response further. Although there is uncertainty about how test anxiety develops, Sapp (2014) suggests that this altered pattern of thinking is linked to a child's experiences in their formative years. Unrealistic expectations may be placed on a child, which are unachievable and result in the child feeling like a failure. In a high-stakes OSCE, it may be that the individual's learnt childhood response returns, and negative thought patterns and emotions are reactivated (Berne, 1964; Stewart and Joines, 2018). Once recognised, these patterns of thinking can be addressed by reframing thought patterns and with interventions such as cognitive behavioural therapy (CBT).

Behavioural responses

Avoidance behaviour can be caused by OSCE anxiety, leading to isolation and failure to ask for help (Linnenbrink, 2007; Wu et al, 2013). Avoidance may also affect a students' ability to be present and respond verbally in an OSCE, or affect motivation to plan and prepare using appropriate learning strategies (Núñez-Peña et al, 2016). Some students may appear to not be present, which could be interpreted as not caring. These responses can be challenging to overcome. Through raising awareness of OSCE anxiety and its various presentations, both students and academic staff can identify the signs early and encourage access to self-help, study skills and CBT.

Overcoming OSCE stress

Mindfulness and grounding techniques

Activation of the sympathetic response can be overwhelming. There are several interventions that can help reduce sympathetic activation. Mindfulness has become widely used and is recommended by the National Institute of Health and Care Excellence (NICE, 2022). There are several apps that may be helpful (Table 1). All advocate similar activities and include deep breathing exercises and grounding techniques. Both techniques stimulate the parasympathetic nervous system to be activated which counteracts the sympathetic response and helps restore calmness. Deep breathing and grounding increase the sense of being in the present, rather than being caught up in worrying thoughts or emotions. Grounding is achieved through using the five senses to notice what is happening right now, which makes the student focus on their current situation and helps to distract them from worrying about the assessment and decreases random chaotic thoughts, which can overwhelm their thinking. Both these techniques take practice and it is best it they are used for some weeks before the OSCE assessment.

Cognitive behavioural therapy

Worrying takes a lot of energy and leads to the thought processes being taken up with going over things repeatedly in an anxious and unhelpful way, without sorting out the cause of the worry (Williams, 2012). Worrying thought patterns can increase the sympathetic autonomic response further. However, worrying is often based on negative learnt thought patterns and expectations, which may originate from childhood experiences. Online cognitive behavioural therapy (CBT) courses, such as Silver Cloud, or a CBT workbook (Table 1), can challenge these irrational thought patterns and reset them, which in turn can help reduce anxiety and decrease the sympathetic autonomic response. CBT can be helpful to increase self-confidence and allow the student to develop positive self-talk, which can directly impact on OSCE assessment results.

Eye movement desensitisation and reprocessing (EMDR)

A systematic review by Kotera et al (2019) found that there was anecdotal evidence that neuro-linguistic programming (NLP) and eye movement desensitisation and reprocessing (EMDR) could help self-esteem and stress. Evidence was sufficient for it to be recommended as a treatment option for post-traumatic stress disorder (World Health Organization, 2013; NICE, 2022). With a growing body of research, the EMDR tapping techniques have been applied to overcome stressful situations (Behnammoghadam et al, 2019). The technique involves tapping meridian points and can help to decrease behaviours which were based on fear. This is an upcoming area of research and is gaining acceptance for the treatment of a variety of mental health disorders (Castenuovo et al, 2019) and can be readily applied to OSCE anxiety.

As well as these interventions, other self-help including sleep hygiene, healthy eating, physical activity and getting outside can all a have a positive effect on coping strategies.

Conclusion

Severe OSCE anxiety can be a challenge for about 20% of students and can affect assessment outcomes particularly in the first OSCE (O'Carroll and Fisher, 2013). Preparation and practice are key in overcoming stress, while techniques to reduce autonomic nervous system activation help promote calmness. Early recognition of worrying thought patterns is essential, so reframing thoughts and using effective interventions such as CBT may be helpful. Preparation is key; knowing what is going to be examined as well as the timings of an assessment are essential to decreasing anxiety as well as planning a revision schedule (Merriman and Westcott, 2010). Understanding OSCE anxiety and knowing other students commonly experience it helps students normalise it and approach it with positivity and greater understanding (Dunne et al, 2018). All these techniques can help students to approach OSCEs with calmness and control, and can be helpful to anyone preparing for an examination and wanting to give their best performance.

KEY POINTS

• Anxiety can help motivate preparation for assessments and is beneficial to many students
• Objective structured clinical examination (OSCE) anxiety affects performance in 20% of students
• OSCE anxiety can be reduced with mindfulness, thought reframing or CBT, and careful preparation

CPD reflective practice

Reflect on how examinations have affected you in the past. Use these questions to help focus on the type of help which is going to help you most:

• Do you usually feel worried and stressed about examinations?
• Do you feel you are able to give your best in examinations?
• Are you confident and believe in yourself?
• What is the trend of your inner self-talk?
• What has worked well for you in the past?