Anxiety can create a significant barrier to learning for nursing students who are performing simulations and can decrease self-efficacy for subsequent simulation experiences (Moscaritolo, 2009). Anxiety-reducing methods have been shown to be effective in overcoming symptoms associated with performing simulations (Gosselin, Holland, Mulcahy, Williamson, & Widacki, 2016; Holland, Mountain, & Gosselin, 2017). The use of techniques such as yoga, tai-chi, and qigong can reduce stress, depression, and anxiety while increasing self-efficacy (Chan et al., 2013). Guided by Bandura’s (1986) social cognitive theory, this study examined tai-chi as an anxiety-reducing method to increase self-efficacy and improve performance among nursing students during a patient care simulation.
Institutional review board approval was obtained for the study, which used a randomized control group pretest-posttest design. Participants were exposed to the same clinical simulation scenarios and evaluation with 63 participants randomly assigned to a control (n = 31) or treatment condition group (n = 32). Inclusion criteria included enrollment in the second adult health course of the program. Exclusion criteria included students reporting medication use affecting heart rate or a preexisting anxiety disorder.
A priori power analysis for analysis of variance (ANOVA) with an alpha of .05, power of .95, and φφ = .50 required a sample of 54; 63 nursing students enrolled in the study and completed the investigation (response rate 88.7 percent). Participants (Mage = 22.68, SD = 3.15) were predominantly female (n = 59, 93.6 percent) and Caucasian (n = 53, 84.1 percent); five were Asian (7.9 percent). The majority were enrolled in a traditional BSN program (n = 48, 76.2 percent); 15 students were enrolled in an accelerated second-degree program.
Outcome variables assessed were anxiety, self-efficacy, and performance. Anxiety was assessed by the State-Trait Inventory for Cognitive and Somatic Anxiety (STICSA; Ree, MacLeod, French, & Locke, 2000). Cognitive and somatic anxiety are considered subcomponents of anxiety; cognitive pertains to the mental component and is characterized by negative expectations about success or self-evaluation, worries about performance, images of failure, and disrupted attention (Martens, Vealy, & Burton, 1990). The STICSA is a validated measure with good internal consistency that assesses how respondents feel at the time of the assessment (state-anxiety) and how they feel in general (trait-anxiety; Ree et al., 2000). It has good convergent validity (r = .65) when compared with scores on the State-Trait Anxiety Inventory and also exhibits good internal consistencies (alphas ≥ .92; Roberts, Hart, & Eastwood, 2016). Each scale consists of 21 self-report questions on a 4-point Likert scale (1 = not at all, 4 = very much so).
Self-efficacy was measured by the 12-item modified version of the General Self-Efficacy Scale (GSES; Schwarzer & Jerusalem, 1995); questions are measured on a 4-point scale and were adapted to assess confidence of students’ clinical skills, with “the student” in place of “I can” as stated on the GSES. For this study, the newly adapted scale was named the Nursing Simulation Performance Scale (NSPS) and used to assess clinical performance in areas such as patient monitoring, communication, and assessment. The NSPS and GSES measures were subject to content validation with a resulting content validity ratio of .97 for the NSPS and .94 for the GSES. The stepped-up consistency version for determining intraclass correlation coefficients was conducted across three faculty raters; total mean scores across five ratings from each evaluator resulted in an intraclass correlation coefficient of .92 for the NSPS and .95 for the GSES. The 95 percent confidence interval ranged from .87 to .97 (NSPS) and .84 to .99 (GSES), suggesting good reliability across raters (Lawshe, 1975). Cronbach’s coefficient alphas were .89 for the NSPS and .78 for the GSES. Permissions were granted for use of the study assessments.
Students were randomly assigned into the two groups. Anxiety and self-efficacy data were collected 35 minutes prior to simulation. Two instructors assessed each student’s performance during the simulation using the NSPS, blind to the treatment condition. Following a preconference, students were escorted to a room where responses from the STICSA and the GSES were collected. The control group was instructed to prepare for a 30-minute period as they normally would following a preconference briefing. The experimental group participated in 30 minutes of tai-chi movements guided by a YouTube video displayed on a monitor. Participants mimicked the movements to the best of their ability and were guided through 11 segments that included slow, rhythmic movements while practicing controlled breathing. Following the intervention or control, students participated individually in a 30-minute simulation experience. They completed the posttest immediately following the simulation and participated in a debriefing lasting approximately 30 minutes.
Posttest differences on mean scores were examined using ANOVA tests with condition (control vs. movement) as the grouping variable and anxiety outcomes, self-efficacy, and simulation performance as the dependent variables. No initial group differences were seen on the dependent variables. All data met parametric statistical testing assumptions. Individual ANOVA tests were conducted to provide conceptual clarity in evaluating differences on the dependent variables.
Results of the first ANOVA to evaluate intervention effectiveness on state cognitive anxiety were not significant, F(1, 61) = 0.24, p = .625, d = 0.12. For univariate within-subject comparisons, the Bonferroni correction was applied to adjust for a potentially inflated alpha-wise error rate resulting in an adjusted alpha of .05/4 = .0125. Results revealed no group differences in the control condition (p = .021); significantly lower cognitive anxiety was observed from pretest (M = 16.75, SD = 5.70) to posttest (M = 13.94, SD = 4.52) in the movement group, t(1, 31) = 4.66, p < .000, d = 0.87. Results of the second ANOVA to assess the effectiveness of movement on state somatic anxiety were significant, F(1, 61) = 6.40, p = .014, d = 0.65. After applying the Bonferroni correction, within-subject comparisons revealed no group differences in the control condition (p = .018). The experimental group had significantly lower mean somatic anxiety scores (M = 17.94, SD = 4.17) than the control group (M = 12.44, SD = 1.97) at posttest, t(1, 31) = 8.11, p < .000, d = 1.74. The ANOVA to evaluate posttest between-group differences on self-efficacy was not significant, F(1, 61) = 1.75, p = .191, d = 0.34. No within-group differences were observed in the control group (p = .085). The experimental group had significantly higher self-efficacy scores from pretest (M = 39.09, SD = 4.48) to posttest (M = 40.06, SD = 4.63), t(1, 31) = 6.11, p < .000, d = 1.09. Results of the ANOVA to assess the effectiveness of movement on performance were significant, F(1, 61) = 12.40, p = .001, d = .90. Comparisons revealed no group performance differences in the control condition from pretest to posttest (p = .354). Higher mean performance scores were observed pretest (M = 42.66, SD = 3.75) to posttest (M = 44.63, SD = 4.19) in the movement condition, t(1, 31) = 10.20, p < .000, d = 1.96.
The study findings are consistent with previous research related to movement-based techniques to reduce anxiety, improve self-efficacy, and performance. Previous studies support the use of yoga, tai-chi, and qigong to reduce stress, depression, and anxiety while increasing self-efficacy (Chan et al., 2013). Techniques such as listening to music or autogenic training have also been shown to reduce anxiety and improve performance in nursing simulation (Gosselin et al., 2016; Holland et al., 2017). The experimental group in this study experienced a decrease in cognitive and somatic anxiety after performing tai-chi and also experienced improved self-efficacy and performance. Nurse educators can employ tai-chi as an anxiety-reducing technique to enhance learning in simulation as an effective way to better prepare students for clinical practice (Victor, Ruppert, & Ballasy, 2017). This study supports the use of tai-chi as an effective and cost-efficient anxiety-reducing method in nursing simulation. Limitations include a single site with a small sample size. Future studies focusing on the use of alternative movement interventions to reduce anxiety are needed.
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