Impact of Inquiry-Based Stress Reduction Intervention on Pharmacy Students’ Test Anxiety

Abstract

Test anxiety is a significant issue among pharmacy students, potentially affecting their academic performance and well-being. This study aimed to evaluate the effectiveness of an Inquiry-Based Stress Reduction (IBSR) intervention in reducing test anxiety. Pharmacy students enrolled in a didactic course were randomized into an IBSR intervention group or a control group. Both groups attended a 1.5 h seminar; the intervention group learned the IBSR technique, while the control group received instruction on an unrelated topic (emotional intelligence). The intervention group also submitted weekly self-reflections on applying IBSR to exam-related anxiety. Anxiety levels were measured using the State-Trait Anxiety Inventory (STAI) at the start of two major exams. Descriptive data were collected and STAI results were analyzed via independent t-tests. Among the 86 participants, the average baseline STAI score indicated moderate–severe anxiety (51/80). No significant differences were found in anxiety scores between the groups before exam 2 (p = 0.99) and exam 3 (p = 0.60). However, 67% of the intervention group found IBSR helpful, 58% changed their test-taking approach, and 61% altered their self-perception. While IBSR did not significantly reduce pre-exam anxiety levels, it was perceived as beneficial by many students. Future research should explore additional strategies for managing test anxiety in this population.

1. Introduction

Test anxiety, defined as the physiological and emotional responses from anxiety that can result in academic consequences for students if not addressed [1], affects 20% to 40% of university students [2]. Test anxiety can impair learning, cognition, academic performance, self-efficacy, and problem-solving [3]. Effective interventions for test anxiety in the general population include focused breathing exercises, expressive writing [4], cognitive reappraisal and mindfulness-based stress reduction through breathing exercises [5], and psychoeducation [5,6]. Mindful breathing was also shown to increase positive thoughts [5].

Health science graduate students report higher anxiety levels than the general population but are less likely to seek treatment due to cultural and logistic barriers [7]. While nursing and medical students have been the focus of many studies on test anxiety interventions [1,2,8,9,10,11], there is limited research on pharmacy students [6]. One study, focused on test anxiety in pharmacy students, implemented psychoeducation, relaxation therapy, and systematic desensitization: these interventions significantly reduced test anxiety, psychological distress, and amotivation [6]. Another study conducted with pharmacy students used music as an intervention, concluding that both actively playing music and passively listening to music prior to an exam decreased test anxiety levels [12]. Guided yoga and meditation sessions, conducted weekly for one hour over six weeks preceding final examinations, significantly decreased anxiety and stress levels while significantly increasing mindfulness in pharmacy students [13]. Of particular interest to this study, there is a notable gap in the literature, as no research to date has explored the use of inquiry-based stress reduction (IBSR) as a strategy to reduce test anxiety among pharmacy students.

IBSR is based on a method of self-assessment, coined “The Work”, that was developed in 1986 by American author and speaker Byron Katie [14]. The process begins with identifying a source of stress and applying four specific questions and their respective turnarounds. Turnarounds are used to challenge the individual’s perception of their stressor or situation and, ultimately, their broader self-perspective [14]. For example, Katie suggests that the turnarounds for the statement “Paul doesn’t listen to me” could be “I don’t listen to myself” and/or “I don’t listen to Paul” [14,15]. These questions and turnarounds aim to raise self-awareness of one’s problems and reduce emotional distress by encouraging individuals to reconsider their thoughts by turning inward. IBSR is the clinical implementation of this mindfulness process, adapted to be used in a clinical setting while maintaining the personal aspect of “The Work” [15].

IBSR shares similarities with cognitive behavioral therapy (CBT), a well-established and effective psychological treatment used in conditions such as depression, anxiety disorders, and substance abuse disorders. Both CBT and IBSR address individual cognitive distortions and aim to reconstruct one’s perspective by prompting internal rather than external actions [7]. The potential of IBSR has been observed in other studies assessing a wide range of applications, all of which have concluded favorable results for IBSR usage. Several studies have compared the utilization of IBSR to that of standard CBT treatment in psychosocial parameters such as depression, chronic stress, trait anxiety [16], and general mental health [15]. Studies within academia support IBSR usage for test anxiety in university students [17], academic self-efficacy and subsequent procrastination towards the end of an academic term [18], as well as teacher burnout both before and during the COVID-19 pandemic [19,20]. However, despite its potential, there is lack of research evaluating IBSR in pharmacy students specifically. Given the unique stressors pharmacy students face, further studies are needed to evaluate the effectiveness and optimal utilization of IBSR in this population. Exploring IBSR’s long-term impact on academic performance, mental health, and overall well-being can also contribute to broader discussions about effective stress management interventions in health sciences education.

First-year pharmacy students were chosen for this study because they often face heightened anxiety as they transition into a rigorous professional program with high academic demands. This population provides a valuable opportunity to evaluate the early implementation of stress-reduction interventions, which could potentially enhance their coping strategies throughout their academic journey. Given the prevalence of test anxiety among students and the potential benefits of interventions like IBSR, it is essential to employ reliable tools to measure anxiety levels accurately. The State-Trait Anxiety Inventory (STAI) is validated and widely recognized self-report tool for assessing both transient (STATE) and enduring (TRAIT) anxiety, making it a valuable resource in health-related and academic research, particularly for evaluating interventions aimed at reducing test-related anxiety [21]. STATE anxiety, which reflects a person’s immediate feelings of apprehension in a specific situation, rather than TRAIT anxiety, which represents a more stable, personality-related characteristic can be influenced in a short amount of time [21]. The original 20-item STATE scale of the STAI can be burdensome for participants, particularly in time-sensitive or high-stress situations [21]. To address this, a validated short form of the STATE scale has been developed, allowing researchers to efficiently capture immediate anxiety levels while minimizing participant fatigue. With this tool, the objectives of this study were the following:

(1) Evaluate the effectiveness of the IBSR technique in reducing “state” anxiety levels among first-year pharmacy students prior to taking an exam as measured by comparing State-Trait Anxiety Inventory (STAI) scores between the IBSR intervention group and the control group.

(2) Assess students’ attitudes and perceptions regarding their experience learning and applying the IBSR technique.

2. Materials and Methods

This study was approved by the institutional review board at the University of the Pacific (UOP). All first-year students enrolled in the summer 2021 Integrated Sciences- Endocrine Disorders course within the School of Pharmacy were eligible to participate in the study. The study was introduced to all students during class. Students had the option to participate in the study to obtain an incentive of 2 extra credit points on one of the course exams. Informed consent was distributed via an electronic Google Form (Google, Menlo Park, CA, USA).

Stratified randomization was applied using grade point average (GPA) and self-reported test anxiety level to place participants into one of two study arms: the IBSR intervention group and the control group. This randomization method was used to prevent a type 1 error that could be seen with one group having higher average stress or lower average GPA which could influence results, this is especially useful in smaller sample sizes. This pre/post-test study design involved participants completing the STAI and a survey including attitude and perception questions. The STAI is a validated self-report assessment to measure state anxiety, present circumstance, and trait anxiety, personality characteristic [21].

The intervention group attended an IBSR seminar delivered by the primary investigators for a total of 1.5 h via Zoom audiovisual teleconferencing (Zoom Video Communications, San Jose, CA). The seminar provided an introduction to the IBSR technique and guided students through its application, with several examples of the reflection tool, to managing stress and anxiety as it relates to taking an exam. The control group attended a separate 1.5 h seminar regarding emotional intelligence, an unrelated subject to the study intervention and test anxiety. Following the seminar and leading up to their exams, the intervention group individually submitted a total of 4 self-reflections using and applying the IBSR technique to address stress caused by upcoming exams. The inclusion of both an intervention group and a control group were essential to determine the specific impact of the IBSR technique on state anxiety, allowing for a more robust comparison of its efficacy against standard practices.

All participants completed the STAI, the “state” short form, prior to the course exam #2 and exam #3. The short form STAI used consisted of 10 questions to assess their anxiety moments prior to their exam. The short form was utilized to minimize survey fatigue and focus the intervention on their immediate state prior to the exam. Following the completion of exam #3, a post-survey was administered to both groups. The survey included questions regarding the participants’ experience with the IBSR intervention and their agreement with statements related to the technique’s efficacy. The participants responded to the survey items using a Likert scale ranging from 1 to 5 (1 = Strongly Disagree, 2 = Disagree, 3 = Undecided, 4 = Agree, 5 = Strongly Agree).

All data were collected via Google Forms then de-identified and analyzed by investigators via a shared password protected Google Sheet (Google, Menlo Park, CA, USA).

Table 1. Timeline of research activities.

Week #	Participant Activities (Duration)
Week 1	Call for participants: Study Introduction/Informed Consent (5 min) All students who opt in submit GPA and self-perceived test anxiety
Week 2	Enrolled students randomized to either intervention or control group based on GPA and self-perceived test anxiety. Students completed pre-survey (demographics, attitudes, perceptions), Pre-TRAIT, Pre-STAI
Week 3	Intervention group: IBSR Seminar (1.5 h) First Reflection submitted on Canvas Control group: Emotional Intelligence Seminar (1.5 h)
Week 4	Weekly Reflection on Canvas
Week 5	Exam #2 STATE anxiety scale completed as first 10 questions of exam (5 min)
Week 6	Weekly Reflection on Canvas
Week 7	Weekly Reflection on Canvas
Week 8	Exam #3 STATE anxiety completed as first 10 questions of exam (5 min) Post-survey

Abbreviations: GPA—grade point average; STAI—state-trait anxiety inventory; IBSR—inquiry-based stress reduction.

represents the timeline of activities required by the intervention and control groups. Descriptive statistics summarized participant demographic information and post-survey results for the intervention group. The average STAI scores were calculated for all participants to assess the overall level of test anxiety. Independent t-tests were conducted to compare state anxiety scores between the intervention and control groups at specific time points (before Exam #2 and Exam #3), with significance set at p < 0.05. This approach was selected because each exam assessed different material, independent t-tests allowed a focus on discrete comparisons that align with the variability in exam content.

3. Results

A total of 95 pharmacy students enrolled in the study and were divided into the intervention group (n = 46) and control group (n = 49). The demographics of the study participants are included in

Table 2. Summarized demographics of participants from pre-survey.

	Control% (n = 49)	Intervention% (n = 46)	Total% (n = 95)
Age Range
18–24 years old	71 (35)	80 (37)	75 (72)
25–29 years old	20 (10)	13 (6)	16 (16)
30–44 years old	8 (4)	6 (3)	7 (7)
Gender
Male	32 (16)	17 (8)	25 (24)
Female	65 (32)	80 (37)	72 (69)
Other/Prefer not to say	2 (1)	2 (1)	2 (2)
Ethnicity
White	10 (5)	9 (4)	9 (9)
Hispanic or Latino	8 (4)	4 (2)	6 (6)
Black or African American	0	2 (1)	1
Asian or Pacific Islander	78 (38)	78 (36)	78 (74)
Multi-racial	2 (1)	4 (2)	3 (3)
Other/Prefer not to say	2 (1)	2 (1)	2 (2)
Mean GPA (SD)	3.21 (0.53)	3.21 (0.54)	3.21 (0.53)

. A total of 86 students completed the study with 9 students lost to follow up.

Objective 1: Effectiveness of IBSR Technique in Reducing “STATE” Anxiety Levels Prior to Exams

The average STAI score for all participants indicated a moderate–severe level of anxiety (M = 51 out of 80 points). Independent t-tests comparing the state anxiety scores between the intervention and control groups were conducted. The participants’ state anxiety scores were measured and compared between the intervention and control groups before Exam #2 (p = 0.99) and Exam #3 (p = 0.60) using the STAI. Statistical analysis revealed no significant difference in anxiety levels between the intervention and control group. The results are indicated in

Table 3. Student reported STAI “STATE“ score prior to exams.

Exam	Control Group (Mean)	Intervention Group (Mean)	t-Statistic	p-Value	95% CI
Exam 2	30.143	30.721	−0.418	0.677	−3.330, 2.174
Exam 3	27.524	26.302	0.864	0.390	−1.591, 4.034

.

Objective 2: Student’s Attitudes and Perceptions Using the IBSR Technique

Post-survey questions were administered to the intervention group to gain their insight on the IBSR technique. Students were asked five questions related to their experience using the IBSR technique using a 5-point Likert scale (1 = “Strongly Disagree”, 2 = “Disagree”, 3 = “Undecided”, 4 = “Agree”, 5 = “Strongly Agree”). For analysis, the responses were collapsed into two categories: Percent Disagreed (1, 2) and Percent Agreed (4, 5).

Table 4. Post-survey responses from intervention group.

Question	N	Mean	SD	Percent Agreed	Percent Disagreed
1. I will use the IBSR technique in the future	33	3.50	1.05	58.82	20.59
2. I found the IBSR technique to be helpful	33	3.68	0.95	67.65	11.77
3. Learning the IBSR technique will change how I approach test taking	33	3.44	0.99	58.82	20.59
4. Learning about IBSR has helped me to think differently about how I see myself	33	3.62	1.07	61.77	17.65
5. I was able to apply the IBSR technique to other aspects of my life besides test anxiety	34	3.24	1.15	42.42	27.27

provides descriptive statistics for the five pre-determined post-survey intervention questions.

4. Discussion

Test anxiety is a significant issue among pharmacy students, potentially affecting their academic performance and well-being [3,6]. The average STAI score of 51 out of 80 points suggests a considerable level, moderate to severe baseline, of anxiety observed in our participants. This finding aligns with the existing literature indicating that pharmacy students often face high levels of stress and anxiety due to the demanding academic environment and the substantial emphasis placed on examinations [3].

The STAI state anxiety scores revealed no significant difference between the intervention and control groups’ state anxiety scores prior to Exam #2 (p = 0.99) and Exam #3 (p = 0.60). This suggests that both groups exhibited similar levels of anxiety before facing the exams. Although the STAI scores did not detect a measurable difference between the intervention and control group, the post-survey results underscore the potential benefits of the IBSR technique.

Notably, 67% of participants in the intervention group reported finding the technique helpful. Additionally, 58% indicated that learning the IBSR technique altered their approach to test taking, and 61% reported a positive change in their self-perception. Furthermore, 42% of participants reported they were able to apply the IBSR technique to other aspects of their lives, showing that technique may provide benefits beyond test-taking [15]. The IBSR technique’s emphasis on self-inquiry, self-reflection, and stress reduction strategies may have helped students develop a more positive mindset and a healthier approach to managing academic stress and cultivate resilience [14].

These findings suggest that while immediate reductions in state anxiety were not evident, IBSR may provide effective coping mechanisms and strategies for managing stress and test anxiety. Given the short duration of the study, changes in TRAIT anxiety were not assessed, as such shifts typically require a longer timeframe. Perhaps the IBSR technique holds even greater potential in the long-term and these findings warrant further exploration [15,16,17,20].

Once the students attended the seminar and were taught how to utilize IBSR, students were able to practice the intervention on their own time without facilitation. There may have been variation on the frequency in which the IBSR technique was used by participants and differences in engagement with the intervention. This highlights the need for individualized approaches and ongoing support to ensure sustained engagement and the application of stress reduction techniques.

It is important to note some of the limitations of this study. The small sample size may have limited the statistical power to detect significant differences. Individual factors such as personal motivation, learning style and prior experiences with stress management could influence the effectiveness of the IBSR technique [14]. Additionally, the self-reported and subjective nature of the anxiety measurements introduces the possibility of response biases. The use of more objective measures like heart rate or blood pressure could be explored in the future to provide a more comprehensive assessment of anxiety levels.

The study’s generalizability is limited by its specific institutional context and specific population of pharmacy students. The small sample size may have reduced the ability to detect significant differences. The short duration and follow up period of the study limits the ability to establish causal relationships between the IBSR technique and changes in test anxiety. In addition, placement of STATE questions at the beginning of each exam elicited mixed responses from students as some found that it allowed them to be mindful going to the exam while others found it distracting from the exam. It is to be noted that the third exam was closer to the final exams period, therefore students’ stress levels may have been elevated, impacting the findings. Variability in engagement with the intervention, as students practiced the technique independently after the seminar, may have also impacted findings.

The independent t-tests used in this study were chosen to account for the unique content of each exam, avoiding the extrapolation of trends that might arise if exams were treated as equivalent. While this approach was deemed appropriate for the study design by the authors, it limited the ability to analyze overarching trends. Future research could explore alternative statistical methods to examine broader patterns, provide qualitative analysis of reflections or evaluate individual student improvement to discover how to better target this intervention to students. Future research should aim to replicate these findings with larger sample sizes and diverse student populations to enhance generalizability. Students’ individual variables such as potential learning disabilities or high baseline anxiety need to be considered and possibly targeted for tailored interventions. Long-term follow-up assessments could provide insights into the sustained effectiveness with consistent use of the IBSR technique and its impact on academic performance and well-being over time. Additionally, exploring the integration of the IBSR technique within the curriculum or as part of support services for pharmacy students may further enhance its accessibility and effectiveness. By addressing these limitations and building on current findings, future research can expand our understanding of IBSR and its role in supporting students’ mental health in high-pressure academic environments.

5. Conclusions

The study found a high prevalence of anxiety amongst the pharmacy student population. While no significant differences in state anxiety scores were observed between the intervention and control groups, the results of this study suggest that the Inquiry-Based Stress Reduction (IBSR) technique may positively impact pharmacy students’ test-taking strategies and self-perception. Further research is needed to validate these findings and explore best practices for the implementation of the IBSR technique and utilization of other stress management tools and techniques to support pharmacy students’ mental health and academic success.