INTRODUCTION:

The environment we live in is dynamic and difficult on all levels such as physically, psychologically, emotionally, socially, and morally. We have effective mechanisms in place to deal with everyday stress. Normal adaptive mechanisms can sometimes become over-activated and, as a result, maladaptive. Anxiety is a common side effect of such over-activation. Anxiety presents itself in life endeavors in the shape of anxieties and restlessness as an emotional component of human beings. Every day, people are plagued by strong emotions as a result of life's constant challenges, which each individual seeks to solve.¹

Anxiety, according to Barlow (2002), is a negative mood state marked by somatic signs of physical tension and fear of the future. It is a mental health issue with physical, emotional, cognitive, and behavioral components. Anxiety is a word for a variety of conditions that produce anxiety, insomnia, apprehension, and concern. These illnesses have an impact on how we feel and think, and they can cause physical symptoms. Mild anxiety is undefined and unsettling, however severe anxiety can be crippling and have a significant influence on daily living.²

When an individual suffers apprehension and uneasiness before during and after a specific exam, this is referred to as test anxiety. This universal human emotion has both promoting and inhibiting impacts on the learning process. While an average level of anxiety might be beneficial to kids, if they are overwhelmed by it, their performance will suffer people can profit from a reasonable level of anxiety because it motivates them to work hard and be accountable for their responsibilities, resulting in a more sustainable and prosperous life.³

NEED FOR THE STUDY:

Test anxiety is a prevalent health condition among medical students around the world. The prevalence of troublesome test anxiety among undergraduate medical students ranges from 25 to 40%, and it has a negative impact on academic achievement and success. However, there is a scarcity of evidence on the prevalence of test anxiety among medical students.⁴

Medical students are exposed to stress throughout their education. According to reports, 60% of students experience anxiety and despair during their academic careers. Exam anxiety is the most common cause of anxiety. Students with significant test anxiety have been found to do worse academically than those with minimal test anxiety.⁵

PROBLEM STATEMENT:

A Quasi Experimental Study to Assess the Effectiveness of Cognitive Behavior Therapy on Test Anxiety Among Students Studying at Selected Nursing Institutes of Punjab (2021-2023).

OBJECTIVES:

1. To assess and compare the pre-test and post-test level of test anxiety score among nursing students in experimental and control group.

2. To develop and implement cognitive behavior therapy among nursing students.

3. To determine the effectiveness of cognitive behavior therapy on the level of test anxiety in terms of pre-test and post-test scores comparison between experimental and control group.

4. To find out the association between post-test level of test anxiety in experimental and control group with their selected socio-demographic variables.

Hypotheses:

The study aims to test the following hypothesis. All the hypotheses will be tested at 0.05 level of significance.

H1: There is significant difference observed in post test scores of test anxiety among nursing students between the experimental group and control group.

H2: There is significant difference observed in pre-test and post-test scores of test anxiety score among nursing students within the experimental group.

Assumptions:

· Test anxiety may have impact on student’s health.

· Maladjustments may have impact on student’s health.

· Test anxiety is a measurable phenomenon.

· Test anxiety can be reduced by effective cognitive behavioral therapy interventions.

OPERATIONAL DEFINITIONS:

1. Test Anxiety: It refers to the experience of feeling an intense moment of fear before exams or assessment. This is measured in terms of scores obtained by nursing students on Test Anxiety Questionnaire by Nist and Diehl.

2. Cognitive Behavior Therapy: It refers to the structured therapy that is developed by the researcher for nursing students. It includes 7 sessions that intended to reduce test anxiety such as Cognitive reconstructing / reframing, Relaxation techniques, mindfulness and deep breathing.

REVIEW OF LITERATURE:

Jereyard K.G Maria and Bhuvneshwari U.L. (2020) conducted a study on the level of test anxiety experienced by higher secondary students and effect of psychological intervention in Coimbatore Tamil Nadu. A total of 160 students (92 boys and 68 girls). Nist and Diehl Questionnaire was administered as pretest and posttest. The results showed that 49% of sample experienced moderate anxiety and 51% experienced mild anxiety and 3% experienced severe anxiety. At the end findings revealed that test anxiety was reduced due to intervention.⁶

Binandeh G. and Koozekonan J Sahebi. (2022) conducted a study on the effect of cognitive behavior therapy on reducing anxiety in high school students in Shabestar city. The study was conducted on 50 female students of 2^nd year. Sarason‘s 37 questionnaire was used to collect the data. Pre-test post-test were taken. Alpha test was performed to see the difference in mean for variance analysis. The result showed that the level of confidence was (p<0.005) which was higher and difference (-10.415) with significant (p<0.005) between test anxiety management training group and control group after intervention. Therefore, the null hypothesis is rejected and the research hypothesis is confirmed that cognitive behavioral group training is effective in reducing test anxiety.⁷

Lethika K and N.V Amudha (2022) conducted a study on the efficacy of cognitive behavior therapy in managing test anxiety and in enhancing achievement motivation among female nursing students in Kozhikode Kerala. The pre test post test design was adopted for 40 student sample. Test anxiety scale developed by Sharma V.P. (2000) were used and 7-day session of CBT were given to the students by using different techniques. The results showed that mean value 60.80 with standard deviation 6.17 after the sessions and showed clear difference in the scores i.e. test anxiety has been reduced among students. The Repeated Measure ANOVA for test anxiety and achievement motivation results revealed that significant differences were observed in all three phases (before, after, and follow-up). Conclusion Cognitive behaviour therapy was found to be effective in reducing test anxiety and enhancing achievement motivation among nursing students.⁸

MATERIAL AND METHODS:

Research Approach: A Quantitative Research Approach

Research Design: The research design was Non-equivalent pre-test post-test control group design

Research Setting: The present study was conducted in two selected Nursing Institutions of Punjab.

Target Population: Undergraduate students were the target population for this study.

Sample Size: 130 (65 in each group).

Sampling Technique: The sample was selected by simple random sampling from BSc. (N)3^rd year and BSc.(N) 4^th year students.

Selection And Description of Tools:

The Standardized Questionnaire was selected to assess the test anxiety among nursing students. Review of Literature from journals and internet, experts’ opinions and investigators own experiencein the area provided foundation for the construction of tool. A proposed draft was prepared which included - Socio Demographic Profile Sheet with 5 items, Test Profile Sheet with 4 items and Nist and Diehl Questionnaire Scale.

Description of the Tool: Tools consisted of 3 sections given below:

Section 1: Socio-Demographic Profile Sheet

This tool consisted of 5 items such as Age, Course of study, Class, Residence during course of study, Previous Education Board.

Section 2: Test Profile Sheet

This tool consists of 4 items such as utilization of leisure time, self-study hours per day, frequency of test per week, giving test regularly on time.

Section 3: Nist and Diehl Questionnaire Scale:

It is a 5- point Likert Scale with 10 items. Response scale ranges from never to always (1 to 5). Higher scores reflect unhealthy level of test anxiety and low score reflects healthy to keep you focused.

Table 1: Scoring Interpretation of Level of Test Anxiety

Level of test anxiety	Score
Unhealthy level of test anxiety	36 -50
Moderate test anxiety	20 -35
No test anxiety	10 – 19
Maximum score = 50	Minimum score = 10

Pilot Study:

The pilot study was carried out as Saraswati Nursing Institute Dhianpura, Kurali Punjab on BSc.(N) 3^rd semester on 10 students. Permission was received from concerned authorities. Assurance was given about maintaining confidentiality of the responses given by them. Nist and Diehl Questionnaire were used for assessing test anxiety to collect the data from students.

Data Collection Procedure:

The study's final data was collected at Saraswati Nursing Institute, Dhianpura and Rayat Bahra College of Nursing, Kharar, Punjab. The investigator acquired written confirmation from the authorities of colleges. The data was collected in the month of March (15^th March 2023 to 22th March 2023). A total of 130 subjects by using simple random lottery method 65 in experimental group and 65 in control group were undertaken to conduct a study based on sample selection criteria. The study participants were assured of maintenance of confidentiality and anonymity of the data or information gathered.

On day 1 pre-test was conducted for both the groups and duration of 15-20 minutes by self-reporting technique. After pre–test, Cognitive Behavior Therapy was administered to the experimental group in 7 sessions for 7 days. Each session was for the duration of 60 minutes approximately. No intervention was given to control group. On 8^th day, post-test same as of pre- test conducted for both groups to evaluate the effectiveness of Cognitive Behavior Therapy on subjects.

Plan For Data Analysis:

The data were analyzed according to the objectives and hypothesis established for the research study, By Utilizing both descriptive and inferential statistics, the data have been examined.

RESULTS:

Table 2: Frequency and Percentage distribution of study subjects as per their selected socio – demographic variables N=130

VARIABLES		Experimental n =65 F (%)	Control n=65 F (%)	chi² value	p-value
Age (in years)	18-20	30(46%)	8(12%)	2.696	0.101^NS
Age (in years)	21-23	35(54%)	57(88%)	2.696	0.101^NS
Course of the study Class	B. Sc. Nursing	65(100%)	65(100%)		NA
	B. Sc Third Year	27(42%)	30(46%)	0.087	0.768^NS
	B. Sc Fourth Year	38(58%)	34(52%0	0.087	0.768^NS
Residence during course of study	Day Scholar	11(17%)	44(68%)	0.602	0.438^NS
Residence during course of study	Hostler	54(83%)	21(32%)	0.602	0.438^NS
Previous education board	ICSE	00	00	5.414	0.144^NS
	CBSE	11(17%)	30(46%)
	PSEB	12(18%)	11(17%)
	HPSEB	23(35%)	6(9%)
	Others	19(29%)	18(28%)
Utilization of leisure time	Self study	10(15%)	7(11%)	2.371	0.668^NS
	Mobile usage	28(43%)	33(51%)
	Gossiping	07(11%)	01(2%)
	Playing outdoor games	11(17%)	15(23%)
	Others	9(14%)	9(14%)
Self-study hours per day	≤1 hour	10(15%)	35(54%)	0.944	0.624^NS
	2-3 hours	50(77%)	25(38%)
	>3 hours	05(8%)	05(8%)
Frequency of test per week	Once a week	3(5%)	18(28%)	6.208	0.045*
	Twice a week	51(78%)	29(45%)
	Twice a week	11(17%)	18(28%)
Giving test regularly on scheduled time	Yes	47(72%)	37(57%)	1.205	0.548^NS
	No	02(3%)	08(12%)
	Sometimes	16(25%)	20(31%)

*= Significant; NS = non-significant

Table 4: Comparison between Mean Pre-test and Post-test of Test Anxiety score among students in Experimental and Control group.

N=130

		Test Anxiety Score			Paired t Test
		Pretest	Posttest		Paired t Test
Group	N	Mean ± SD	Mean ± SD		Mean difference	df	t	Result
Experimental Group	65	28.72 ± 5.017	15.29 ± 2.441		13.43	64	18.246	p value<0.001 Significant
Control Group	65	29.76 ± 4.589	29.91 ± 4.520		-0.15	64	1.915	P value=0.06 NS
Unpaired t- test	Df	128	Df	128
	T	1.241	T	22.938
	Result	p value =0.217NS	Result	p value = 0.001 significant

Table 5: Association of post test score of test anxiety among students in experimental group with their selected socio-demographic variables N=65

Variables		Test Anxiety Score
		Below median	Above median	df	Chi² value	p Value
Age (in years)	18-20	16	14	1	.023	.878^NS
	21-23	18	17
Class	B. Sc Third Year	14	13	1	.004	.951^NS
	B. Sc Fourth Year	20	18
Residence during course of study	Day Scholar	05	06	1	1.427	.490^NS
	Hostler	29	25
Previous education board	CBSE	08	03	3	2.569	.463^NS
	PSEB	05	07
	HPPSEB	12	11
	Others	09	10
Utilization of leisure time	Self study	07	03	4	5.771	.217^NS
	Mobile usage	11	17
	Gossiping	03	04
	Playing outdoor games	06	05
	Others	07	02
Self-study hours per day	≤1 hour	04	06	2	.783	.676^NS
	2-3 hours	27	23
	>3 hours	03	02
Frequency of test per week	Once a week	02	01	2	1.506	.471^NS
	Twice a week	28	23
	Twice a week	04	07
Giving test regularly on scheduled time	Yes	24	23	2	1.887	.389^NS
	No	02	0
	Sometimes	08	08

Table 6: Association of post test score of test anxiety among students in control group with their selected socio-demographic variables

N=65

Variables		Test Anxiety Score
		Below median	Above median	Df	Chi²value	p Value
Age (in years)	18-20	03	05	1	.820	.371^NS
	21-23	31	26
Class	B. Sc Third Year	11	20	2	7.246	.027^*
	B. Sc Fourth Year	23	11
Residence during course of study	Day Scholar	24	20	1	.273	.601^NS
	Hostler	10	11
Previous education board	CBSE	16	14	3	4.277	.233^NS
	PSEB	03	08
	HPPSEB	03	03
	Others	12	16
Utilization of leisure time	Self study	01	06	4	12.879	.012^*
	Mobile usage	24	09
	Gossiping	0	01
	Playing outdoor Games	06	09
	Others	03	06
Self-study hours per day	≤1 hour	19	16	2	.359	.836^NS
	2-3 hours	12	13
	>3 hours	03	02
Frequency of test per week	Once a week	11	07	2	1.954	.376^NS
	Twice a week	16	13
	Twice a week	03	02
Giving test regularly on scheduled time	Yes	18	19	2	.590	.745^NS
	No	05	03
	Sometimes	11	09

Table 6: depicts the association of post test score of test anxiety in control group. Based on chi square test, there was a statistically significant association has been found with class and utilization of leisure time whereas age in years, residence during course of study, previous education board, self-study hours per day, frequency of test per week and giving test regularly on scheduled time were not significantly associated i.e. (p<0.05).

CONCLUSION:

It cannot be argued that test anxiety will persist as long as exams are given, however, the issue of test anxiety cannot be disregarded. In light of cognitive restructuring of nursing students, experiencing anxiety before and during test, research to determine effective cognitive behavioral therapy to cope with test anxiety is essential.

As per findings of the present study, Cognitive Behavior Therapy was valuable psychotherapy in reducing test anxiety among nursing students.

Based on obtained results, it is suggested that short term test anxiety reducing strategies like cognitive behavior therapy needs to be incorporated by nursing teachers and psychiatric nurses for test anxiety and student well-being.

DISCUSSION:

Setyowati A, Rayaginamsih F, Fahriza I (2019)³³ conducted a study on behavioral cognitive counselling for reducing test anxiety among university students. The post scores highlighted that 60.91% students had low level of test anxiety and 30.09% students possessed moderate anxiety. Result revealed that cognitive counselling was effective to reduce test anxiety among university students.⁹

The result of study supported by Nikpour G, Kargozar A, Ghribzadeh S (2021)¹² significant difference in mean pre and post test scores of experimental group and control groups were 32.73±5.67 and 32.07±5.75 respectively whereas in post-test the mean and standard deviation were 45.53±6.80 and 32.20±5.80 in experimental group and control group respectively.¹⁰

A similar study was conducted by Zheng G, Zhang Q, Ran G (2023)⁴⁵ showed association of test anxiety with variables like academic stress, emotional self-efficacy, preantral expectations.¹¹

ACKNOWLEDGEMENT:

I appreciate contribution of all my teachers, family members and my friends for their continuous moral support and cooperation.

“All may not be mentioned, but none is forgotten from the heart” With heart felt and everlasting gratitude.”

ETHICAL CONSIDERATION:

Ethical clearance was obtained from Institutional Ethical committee and BFUHS, Faridkot. Written permissions were obtained from the principal of Saraswati Nursing Institute, Dhianpura, Roopnagar and Rayat Bahra College of Nursing, Kharar. All participants were informed that their participation in the study is voluntary and they can refuse to participate and can withdraw from the study at any time. Throughout the duration of the research, information's confidentiality and anonymity were upheld.

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6. Jereyard.K, Bhuvaneshwari.L: Test Anxiety In Higher Secondary Students, Indian Journal of Applied Research. Available from: https://www.worldwidejournals.com/indian-journal-of-applied- research-(IJAR)/article/test-anxiety-in-higher-secondary-students. March 17.2023.

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9. Setyowati A, Irfan F. study on cognitive behavioral therapy - Google Search[Internet].[cited2023Mar17].Availablefrom: https://www.google.com/search?q=setyowati+aprilia+%2C+irfan+fahi za+study+on+cognitive+behavioral+therapy.

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11. Zheng G, Zhang Q, Ran G. The association between academic stress and test anxiety in college students: The mediating role of regulatory emotional self-efficacy and the moderating role of parental expectations. Front Psychol [Internet]. 2023 [cited 2023 May 13]; 14. Available from: https://www.frontiersin.org/articles/10.3389/fpsyg. 2023.1008679.

Received on 27.03.2026 Revised on 09.05.2026

Accepted on 17.06.2026 Published on 27.07.2026

Available online from August 01, 2026

Asian J. Nursing Education and Research. 2026;16(3):166-172.

DOI: 10.52711/2349-2996.2026.00034

This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. Creative Commons License.

Test anxiety level (score)	Experimental group n=65		Control groupn=65
Test anxiety level (score)	Pre test n (%)	Post test n (%)	Pre test n (%)	Post test n (%)
Unhealthy level (36-50)	07(10.8%)	00	06(9.2%)	06(9.2%)
Moderate level (20-35)	57(87.7%)	03(4.6%)	59(90.8%)	59(90.8%)
No test anxiety (10-19)	1(1.5%)	62(95.4%)	00	00