Teaching and Learning in Nursing 14 (2019) 225–230

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Teaching and Learning in Nursing

journal homepage: www.jtln.org

Aromatherapy hand massage for test anxiety and self-efficacy in

nursing students: A pilot study
Julia Farner, DNP, FNP-BC, RN a,⁎,1, Meghan Reed, BSN, RN a,1, Joanne Abbas, MSN, AGPCNP-BC a,1,
Kimberly Shmina, DNP, FNP-BC, RN, CLC a,b,1, Dawn Bielawski, PhD, CIP a,1
a
Wayne State University College of Nursing, Detroit, MI 48202, USA
b
University of Hawaii Hilo, Hilo, HI 96720, USA

a r t i c l e i n f o a b s t r a c t

Article history: The purpose of this study was to determine if aromatherapy hand massage (HM) could improve test anx-
Accepted 30 April 2019 iety and self-efficacy in nursing students. Participants were randomized to receive aromatherapy hand
massage (AHM), unscented HM, or no intervention (C) 60 minutes before an examination. No significant
Keywords:
differences were found, but analysis of the percentage change from the means demonstrated the largest de-
Test anxiety
crease in test anxiety in the AHM group (AHM = −12.4%, HM = −8.63%, C = −1.76%). Self-efficacy trends
Self-efficacy
Aromatherapy
followed a similar pattern (AHM = 5.93%, HM = −3.03%, C = 0.52%). The trends in the percentage change
Lavender oil from the means indicate that a larger sample may show improvements in test anxiety and self-efficacy with
Rosemary oil the use of AHM, which could improve nursing students' academic performance and decrease attrition rates.
Hand massage © 2019 Organization for Associate Degree Nursing. Published by Elsevier Inc. All rights reserved.

Test anxiety and low self-efficacy can negatively affect academic Essential oils are the volatile oils derived from plant flowers, stems,
performance and student retention rates (Harris, Rosenberg, & leaves, bark, roots, seeds, resins, or peels through methods of expres-
O'Rourke, 2014; Harvey & McMurray, 1994; Komarraju & Nadler, sion, extraction, or distillation. Both lavender and rosemary essential
2013; Onyeizugbo, 2010). Test anxiety includes feelings of dread, oils have been shown to reduce anxiety in nursing students
trepidation, fear, panic, or excessive worry in response to preparing (Kavurmaci, Küçükoğlu, & Tan, 2015; Kutlu, Yilmaz, & Çeçen, 2008;
for a test or taking a test (Onyeizugbo, 2010). It produces both phys- McCaffrey, Thomas, & Kinzelman, 2009). Unscented HM is also an ef-
iological and affective changes. Test anxiety has been found to be a fective intervention for reducing anxiety, although no studies have
significant problem for nursing students (Driscoll, Evans, Ramsey, & used HM to address test anxiety specifically (Brand, Munroe, &
Wheeler, 2009; Duty, Christian, Loftus, & Zappi, 2016). Self-efficacy Gavin, 2013; Dunn, Sleep, & Collett, 1995; Kim, Cho, Woo, & Kim,
is the belief in one's ability to perform tasks at a certain level of con- 2001; Kunikata, Watanabe, Miyoshi, & Tanioka, 2012; Mei, Miao,
fidence, which can determine motivation, thoughts and feelings, and Chen, Huang, & Zheng, 2017; Nazari, Ahmadzadeh, Mohammadi, &
action (Onyeizugbo, 2010). When a person has high self-efficacy for a Kiasari, 2012). This study aimed to determine if aromatherapy hand
task, he or she feels very confident that he or she can complete that massage (AHM) could reduce test anxiety and increase self-efficacy
task (e.g., successfully pass an examination). in nursing students.
Aromatherapy and hand massage (HM) are two interventions
that can reduce anxiety. Aromatherapy is the therapeutic use of
plant essential oils via inhalation, ingestion, or topical application. Background

The Effects of Test Anxiety and Self-Efficacy on Academic Performance

Acknowledgement of financial support: The study was funded with a grant by the
Alpha Psi Chapter of Sigma Theta Tau International. This organization had no involve- Nursing students suffer a disproportionately high level of test
ment in the study design; the collection, analysis, or interpretation of data; the writing anxiety compared with their peers studying in other disciplines
process; or the decision to submit to this journal. (Driscoll et al., 2009; Duty et al., 2016). Both test anxiety and self-ef-
Declarations of interest: None.
⁎ Corresponding author. Tel.: 1 517 763 9550.
ficacy can affect academic performance and rates of attrition. Nursing
E-mail address: [email protected]. (J. Farner). schools face high levels of student attrition. The average attrition rate
1
Tel.: 1 313 577 4070; fax: 1 313 577 4571. for baccalaureate nursing programs is 50% and can reach up to 85% for

https://doi.org/10.1016/j.teln.2019.04.008
1557-3087/© 2019 Organization for Associate Degree Nursing. Published by Elsevier Inc. All rights reserved.
226 J. Farner et al. / Teaching and Learning in Nursing 14 (2019) 225–230

minority students (Harris et al., 2014). These attrition rates can be Few studies have looked at improving self-efficacy in nursing stu-
detrimental in a nation that faces an ever-increasing shortage of dents. Those that have primarily focus on the use of clinical simula-
nurses. Although some scholars predicted a decrease in the shortage tion to improve self-efficacy (Akhu-Zaheya, Gharaibeh, & Alostaz,
following the economic downturn of the United States, recent re- 2013; Kameg, Howard, Clochesy, Mitchell, & Suresky, 2010). Other
search reports that the nursing shortage will reach nearly 1,000,000 studies have looked at the effect of different education methods on
by the year 2030 (Juraschek, Zhang, Ranganathan, & Lin, 2012). Iden- nursing students' self-efficacy in transcultural nursing and cultural
tifying interventions that may help to improve nursing student per- competence (Jeffreys & Dogan, 2011; Larsen & Reif, 2011; Peek &
formance and slow attrition rates is an important step toward Park, 2013). No studies have looked at the use of aromatherapy or
decreasing the projected nursing shortage. HM to improve self-efficacy.

Effect of HM and Aromatherapy on Test Anxiety

Test Anxiety
Test anxiety is a negative physiological and/or affective response
HM is an effective intervention for reducing stress and anxiety.
to academic examination or responsibility. Physical symptoms of
Patients undergoing ophthalmologic surgeries with local anesthesia
test anxiety are a result of the stimulation of the autonomic nervous
reported decreased anxiety after receiving HM (Kim et al., 2001;
system. These include elevated heart rate, blood pressure, and skin
Nazari et al., 2012). Brand et al. (2013) found that patients in the am-
temperature. The increase of salivary biomarkers of stress, including
bulatory surgery setting who were given HMs experienced lower
cortisol, immunoglobulin-A, and alpha-amylase, in response to aca-
levels of anxiety than those who received only routine nursing care.
demic examinations, is well documented in the research (Ouda,
Healthy volunteers who received HMs reported decreased anxiety
Alaki, Safi, Nadhreen, & Al-Johani, 2016). Mental indicators of test
and demonstrated physiological changes indicative of lowered anxi-
anxiety include hopelessness, fear, decreased attention and concen-
ety, such as lowered heart rate (Kunikata et al., 2012). Kolcaba,
tration, and cognitive test anxiety, or worry, which can lead to poor
Schirm, and Steiner (2006) developed an HM protocol, which was
academic performance and ineffective studying (Duty et al., 2016;
shown to increase comfort in nursing home residents. A comparison
McCaffrey et al., 2009; Onyeizugbo, 2010; Szafranski, Barrera, & Nor-
of AHM, unscented HM, and a rest period demonstrated that HM was
ton, 2012).
effective for improving physiological indicators of anxiety in inten-
Test anxiety is a growing problem among university students. Up
sive care unit patients (Dunn et al., 1995). Participants in this study
to 35% of college students suffer from test anxiety severe enough to
who received the AHM reported significantly higher subjective im-
cause some level of functional impairment, and research shows that
provements in anxiety than those who received unscented HM or
students are facing higher rates of this phenomenon than ever before
rest. Mei et al. (2017) found that participants who received Chinese
(Driscoll et al., 2009; Szafranski et al., 2012). Test anxiety is particu-
HM prior to coronary angiography reported lower levels of anxiety
larly prevalent in nursing students. Nursing students experience
than participants in a control (C) group who received routine care, al-
higher levels of test anxiety than their peers in other degree pro-
though this study did not find any significant changes in physiological
grams (Driscoll et al., 2009). Approximately 30% of nursing students
markers of anxiety, such as blood pressure and heart rate.
have reported “high” test anxiety, and another 26% note “moderately
Most of the participants in the studies looking at the use of HM for
high” test anxiety (Driscoll et al., 2009). Altogether, this shows that
reducing anxiety were middle-aged and elderly patients (Brand et al.,
more than 50% of nursing students suffer from some level of test
2013; Dunning & James, 2001; Kim et al., 2001; Nazari et al., 2012).
anxiety.
Whereas all of these studies found a reduction in pre-operative anx-
Several different interventions are available for addressing test
iety with HM, no studies have been found that looked at the effects of
anxiety. Most frequently studied are hypnotherapy and aromather-
HM on test anxiety in nursing students, or in any students in general.
apy (Shapiro, 2014). Progressive muscle relaxation can also be used
However, foot and back massage reduced both reported and physio-
to address test anxiety in nursing students. Zargarzadeh and Shirazi
logical markers of anxiety in college students (Leivadi et al., 1999;
(2014) studied the effects of a progressive muscle relaxation on test
Won et al., 2000).
anxiety in Iranian nursing students. They found this to be an effective
tool for decreasing test anxiety in this population. Prato and Yucha
Aromatherapy
(2013) found that biofeedback-assisted relaxation training was effec-
No standardized definition of aromatherapy exists. The U.S.
tive in decreasing biometric measures of test anxiety (respirations
Department of Health and Human Services, National Institutes of
and pulse), but it did not significantly lower participants' self-rating
Health, and National Cancer Institute (2016) study has reported aro-
of test anxiety or their score on Spielberg's Test Anxiety Inventory.
matherapy to be “the use of essential oils from plants (flowers, herbs,
or trees) as therapy to improve physical, emotional, and spiritual
Self-Efficacy well-being.” Essential oils are the volatile oils derived from plant
Self-efficacy also plays an important role in academia. Bandura parts through expression, extraction, or distillation. Administration
(1993) notes that “students' beliefs in their efficacy to regulate their routes for essential oils include ingestion, direct or indirect inhala-
own learning and to master academic activities determine their aspi- tion, and topical application via oral, rectal, vaginal, or transdermal
rations, level of motivation, and academic accomplishments” (p. absorption. This study employed direct inhalation and topical appli-
117). Other studies have supported the role that self-efficacy plays cation via transdermal absorption.
in academic performance. Researchers have noted that higher self-ef-
ficacy can positively influence academic outcomes (Komarraju & Lavender Oil and Test Anxiety
Nadler, 2013; Onyeizugbo, 2010). Lavendula angustifolia, or true lavender, is most commonly used
Furthermore, self-efficacy may influence student retention rates. for its calming properties. Lavender oil (LO) has strong effects on
Nursing students suffer a disproportionately high rate of attrition. alpha and theta brain wave activity, which are linked to increased re-
As noted, baccalaureate nursing programs lose about 50% of their laxation. Sayorwan et al. (2012) demonstrated that participants who
enrollees, and associate degree nursing programs are nearly as high inhaled LO had greater increases in alpha 1, alpha 2, and theta
at 47% attrition (Harris et al., 2014). According to Harvey and brainwave activity on electroencephalogram (EEG) readings, com-
McMurray (1994), lower academic self-efficacy scores correlate pared with those who inhaled a control of almond oil. In addition to
with higher nursing school attrition rates. the EEG changes, this study also found decreased autonomic
 J. Farner et al. / Teaching and Learning in Nursing 14 (2019) 225–230 227

indicators of stress, such as blood pressure, heart rate, and skin tem- progress toward adaptation. They include physiological function,
perature, and increased participant report of positive emotional state, self-concept, role function, and interdependence.
compared with C groups (Sayorwan et al., 2012). The culmination of these steps leads to the output, which is the
LO is effective for treating many types of anxiety, including test human response to stimuli. Humans can have an adaptive response
anxiety. One study showed that students who were exposed to either or an ineffective response. These responses are fed back to become
LO or orange via inhalation for 60 seconds prior to examinations part of the person's baseline adaptation level, and the process repeats
demonstrated decreases in both subjective and objective measures itself.
of anxiety, but no differences were found between the two groups The input or external stimulus in this study is examination stress,
(Bakhsha, Yousefi, Aryaee, Jafari, & Derakhshanpoor, 2016). Another whereas the output is test anxiety. Although this study focused on
study found that while LO decreased anxiety in graduate nursing stu- utilizing aromatherapy and HM to address the cognators in the con-
dents, it also decreased attention (McCaffrey et al., 2009). trol process, the physiological response to reduced anxiety could
Other studies have looked at the effect of inhaled LO on anxiety also affect the regulators. However, biometrics were not measured
and examination scores. Kutlu et al. (2008) exposed nursing students in this study. Self-efficacy is an adaptive mode that falls in the effector
to the scent of lavender for 15 minutes prior to their examinations. group of self-concept. High self-efficacy would contribute toward ad-
Compared with a C group, those exposed to lavender reported signif- aptation or decreased test anxiety. This study measured only the
icantly less anxiety. They also had higher mean examination scores, changes in self-efficacy and test anxiety related to aromatherapy
but not significantly more so than the C group. Kavurmaci et al. and HM. It did not explore the relationship between self-efficacy
(2015) exposed randomly selected nursing students to LO via inhala- and test anxiety statistically.
tion method during an academic examination. Compared with the C
group who received no intervention, the students exposed to LO Design and Methodology
scored significantly lower on measures of anxiety. This study found
no differences in examination scores between the C and the interven- The pilot study used a randomized quasi-experimental design to
tion groups. evaluate the effects of two interventions (AHM and unscented HM)
on test anxiety and self-efficacy. Both interventions have demon-
strated success in treating test anxiety. The study was funded by
Rosemary Oil and Test Anxiety
the Alpha Psi Chapter of Sigma Theta Tau International. The institu-
Rosemary oil (RO; Rosmarinus officinalis) is thought to have stim-
tional review board reviewed and approved the research protocol.
ulating properties. Inhalation of this oil decreases blood flow and in-
crease systolic blood pressure (Lis-Balchin, 2006). Although RO is a
Sample
stimulant, it is effective for addressing anxiety, including test anxiety.
Morris, Birtwistle, and Toms (1995) conducted a study with the aim
The adaptive beings targeted for the intervention were under-
of measuring the effects of geranium essential oils on state and trait
graduate nursing students at a large urban university in the midwest-
anxiety in undergraduate students. In this study, rosemary was the
ern United States. A convenience sample of senior-level students
active control, with the assumption that it would have no greater ef-
enrolled in an accelerated baccalaureate nursing program was se-
fect on anxiety than steam inhalation. However, students who in-
lected from a critical care nursing course. One week prior to their
haled rosemary essential oils also showed a reduction of anxiety.
written midterm examinations, the research team introduced the in-
Inhalation of RO also affects physiological biomarkers of anxiety.
tervention to the students.
Like LO, inhalation of RO decreased salivary cortisol levels (Atsumi
Twenty-one students signed consents immediately following the
& Tonosaki, 2007). McCaffrey et al. (2009) studied the differences be-
announcement and explanation of the intervention. On the day of the
tween the effects of LO and RO inhalation on test anxiety scores and
intervention, the team randomly assigned the participants to one of
physiological markers of anxiety in nursing students. They found
three cognator groups: an AHM group (n = 4), an unscented HM
that both LO and RO decreased test anxiety scores and heart rate
group (n = 4), and a C group that received no intervention (n = 6).
more than controls when inhaled just prior to examinations. Most
Participants were assigned to their respective groups using random
studies examining the effects of rosemary essential oil on anxiety
number selection. Participants in the AHM group self-selected either
show a reduction in anxiety measures, but participants in one study
LO or RO for their HM. All four of those in the AHM group selected LO
reported increased feelings of tension, unease, and nervousness
for their intervention.
(Burnett, Solterbeck, & Strapp, 2004). Because rosemary is a stimulat-
ing scent, those who inhaled this essential oil in this study may have
Instruments
been overly aroused.
Two instruments were determined to be well-suited for this
Conceptual Framework study. The Westside Test Anxiety Scale (WTAS) was selected to mea-
sure participants' pre- and postintervention test anxiety. This tool is a
The Roy adaptation model guided the study. First published by 10-item, 5-point Likert scale designed to measure anxiety impair-
Sister Calista Roy in 1970, the theory posits that humans are adaptive ments related to test taking. It has an alpha of .78 and a split half re-
beings whose internal and external processes guide their ability to liability of .77, a validity coefficient of .51 (Driscoll et al., 2009;
adapt to input (Roy, 1988). Input includes either internal or external Onyeizugbo, 2010). This tool has been used to measure test anxiety
stimuli along with the person's initial adaptation level, the person's in many different studies, including research on undergraduate nurs-
baseline ability to deal with stimuli. ing students, pharmacy students, and students undertaking board ex-
Humans also utilize control processes to help adapt to new stim- aminations (Afzal, Afzal, Siddique, & Naqvi, 2012; Driscoll et al., 2009;
uli. These coping mechanisms are regulators and cognators. Regula- Evans, Ramsey, & Driscoll, 2010; Larson et al., 2011; Mary, Marslin,
tors are coping mechanisms that address physical needs, such as Franklin, & Sheeba, 2014; Nograles et al., 2015; Onyeizugbo, 2010;
heart rate and blood pressure. Cognators, in turn, address cognitive Rajiah & Saravanan, 2014).
and affective needs. The General Self-Efficacy Scale (GSES) was chosen to measure
The model includes four adaptation modes known as effectors. Ef- pre- and postintervention self-efficacy. This is a 10-item, 4-point
fectors are groups of responses that contribute to or inhibit the Likert scale that has been used worldwide. It was originally
228 J. Farner et al. / Teaching and Learning in Nursing 14 (2019) 225–230

constructed in 1982 and found to have reliability coefficients of .86 Results

and .71, with construct validity demonstrated for all sections of the
tool (Sherer et al., 1982). It has since been demonstrated to have a re- Of the 21 subjects recruited, only 14 participated on the day of the
liability coefficient ranging from .76 to .90 in samples from 23 differ- intervention. All 14 participants were female and reported English as
ent nations, and stability coefficients have ranged from .47 to .75 in their primary language. All but one of the students identified as Cau-
longitudinal studies (Luszczynska, Scholz, & Schwarzer, 2005). This casian/White (n = 13; Asian, n = 1). The majority of the students
tool has successfully measured self-efficacy in nursing students in a were between 26 and 40 years of age (n = 10), two students were
number of studies (Gore, 2006; Peterson-Graziose, Bryer, & between 18 and 25 years old, and two others were 41–55 years old.
Nikolaidou, 2013; Taylor & Reyes, 2012). Almost all of the students had at least a prior bachelor's degree
(bachelor's degree, n = 12; master's degree, n = 1; trade school, n
Data Collection Process = 1). Finally, most of the participants (n = 10) reported that they
had tried some form of complementary or alternative medicine
To determine the students' initial adaptation levels, the partici- (CAM) at least once but did not regularly utilize those types of
pants were asked to complete the WTAS and GSES before and after
their cognator group assignments. The initial scores from these scales
provided the participants' baseline levels of test anxiety and self-effi-
Table 1
cacy. Each participant also completed a demographic questionnaire. Demographics
Immediately following the intervention, participants completed an-
other WTAS and GSES to determine if the cognator effect on the Group Group Group
1⁎ 2┴ 3◆
self-concept effectors had led to adaptation. Less than 5 minutes
passed between the time the intervention was completed and the N % N % N %
time participants began filling out the posttests. Those participants Age
who received no intervention were asked to complete the posttests 18–25 years 0 0 1 7.1 1 7.1
prior to leaving their designated room (at least 10 minutes after 26–40 years 5 35.7 2 14.3 3 21.4
41–55 years 1 7.1 1 7.1 0 0
arriving). ≥ 56 years 0 0 0 0 0 0

Procedure Gender
Male 0 0 0 0 0 0
Female 6 42.9 4 28.6 4 28.6
The researcher team provided the massages. All team members
received training in how to give an HM based on a standardized, ev- Language
English 6 42.9 4 28.6 4 28.6
idence-based HM protocol. Training included a video demonstration Spanish 0 0 0 0 0 0
showing a professional massage therapist providing the massage to Mandarin 0 0 0 0 0 0
a volunteer, face-to-face instruction, and written step-by-step in- Arabic 0 0 0 0 0 0
structions. Prior to the intervention, a member of the research team Other 0 0 0 0 0 0
blended each of the essential oils with an unscented carrier oil, Education
using four drops of essential oil per each 5 ml of carrier oil. Carrier High school diploma/equivalent 0 0 0 0 0 0
oils are used to decrease the risk of potential skin irritation from the Trade school/certificate 0 0 1 7.1 0 0
Associates degree 0 0 0 0 0 0
volatile essential oils. Jojoba oil was selected as the carrier oil because
Bachelor's degree 6 42.9 3 21.4 3 21.4
it has little fragrance and a low risk for causing sensitivity or allergic Master's degree or higher 0 0 0 0 1 7.1
reactions.
Race
Students arrived on campus 60 minutes before their midterm ex-
Caucasian/White 5 35.7 4 28.6 4 28.6
amination on the day of the intervention. After ensuring that in- Black 0 0 0 0 0 0
formed consent had been obtained, the students were randomly Asian 1 7.1
assigned to receive AHM, HM with unscented jojoba oil, or no inter- Native American/Native Alaskan/Pacific 0 0 0 0 0 0
vention (C) within the 60 minutes just prior to their written midterm Islander
Arab 0 0 0 0 0 0
examinations. Participants assigned to the AHM group briefly inhaled Hispanic 0 0 0 0 0 0
the scents of lavender essential oil and rosemary essential oil; they Multiracial 0 0 0 0 0 0
were then asked to decide which scent they would prefer for their Other 0 0 0 0 0 0
HMs. Marital status
After completing their initial demographic, WTAS, and GSES ques- Single 0 0 4 28.6 1 7.1
tionnaires, participants moved to their designated room for their Married 4 28.6 0 0 2 14.3
assigned cognator group. Separate rooms for each group were used, Divorced 0 0 0 0 0 0
Separated 0 0 0 0 0 0
including one each for the LO and RO HMs, as well as for the un-
Widowed 0 0 0 0 0 0
scented HMs. After participants washed their hands, those in the Committed relationship 2 14.3 0 0 1 7.1
AHM and HM groups received their 10-minute HM, 5 minutes per
CAM use
hand. Participants who received no intervention sat in a room for at
Never used 1 7.1 4 28.6 2 14.3
least 10 minutes and engaged in activities they normally would Use occasionally 5 35.7 0 0 1 7.1
prior to an examination. Use regularly 0 0 0 0 1 7.1
After having their designated cognators applied, the participants Use exclusively 0 0 0 0 0 0
completed postintervention WTAS and GSES questionnaires. Infor- Allergies
mation from the demographic forms was synthesized using descrip- Yes 0 0 0 0 0 0
tive statistics. The results from the pre- and postintervention No 6 42.9 4 28.6 4 28.6
questionnaires were compared using repeated measures analysis of ⁎ Group 1: No intervention (C) group.
┴
variance (ANOVA) to determine if participants had differing adapta- Group 2: Unscented HM group.
◆
tion in the form of decreased test anxiety and increased self-efficacy. Group 3: AHM group.
 J. Farner et al. / Teaching and Learning in Nursing 14 (2019) 225–230 229

Table 2 Table 4
Repeated measures ANOVA for WTAS Mean differences in test anxiety and self-efficacy

Source WTAS Type III df Mean square F Sig. Percentage change in means
Sum of squares
C HM AHM
WTAS Linear 28.894 1 28.894 10.153 .010
WTAS −1.76% −8.63% −12.4%
WTAS * Group Linear 13.003 2 6.502 2.285 .152
GSES 0.52% −3.03% 5.93%
Error (WTAS) Linear 28.458 10 2.846

therapies. Three students had never used any CAM therapies, and one before their examination and provided no reminder in between the
reported that she regularly used some type of CAM therapies (Table time of the first announcement and the implementation of the inter-
1). vention. Because no students expressed interest in receiving an HM
Significant improvements between baseline and postintervention with RO, that oil could be dropped from the study, freeing up the re-
WTAS scores were found across all groups (p = .010). No differences search team to expedite the number of HMs that they are able to
were found between the groups, which was likely because of the complete.
small sample size (Table 2). No differences in the GSES scores were A larger sample size would be necessary to determine significance
noted overall or between the cognator groups (Table 3). The partici- in any subsequent investigations on this topic. Although no signifi-
pants' baseline self-efficacy scores were higher than expected, but cant changes were found, trends in data may help identify interven-
this was not explored further. tions to decrease test anxiety and self-efficacy. Given the relatively
Although no differences were found between the groups, the low risk of adverse reaction to AHM, nursing faculty can feel comfort-
trend in the percentage change from the means could indicate that able recommending this intervention to students with high levels of
some of the students demonstrated adaptive responses in test anxi- test anxiety as something that may be beneficial to them before ex-
ety and bolstered their self-efficacy effector after receiving AHM. Stu- aminations. Interventions that could decrease test anxiety and in-
dents who participated in the AHM group saw a 12.4% decrease in crease self-efficacy in nursing students have the potential to
test anxiety, compared with only a 1.76% decrease in the group who improve nursing student academic outcomes and retention rates.
received no intervention (Table 4). Similarly, the AHM group noted However, future inquiry would need to critically explore the discrep-
a higher percentage change from the mean (5.93%) than both the ancy between expressed interest and actual participation. This study
HM and C groups (−3.03% and 0.52%, respectively) in self-efficacy. lays the groundwork for others like it in the future.

Conclusions
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