Anxiety and Acceptance of the Objective Structured Clinical Examination (OSCE) in Nursing Students: A Cross-Sectional Study

1. Introduction

The Objective Structured Clinical Examination (OSCE) is defined as an assessment in which students demonstrate their competence across a range of simulated clinical scenarios [1]. This tool is specifically designed to evaluate targeted clinical skills and is typically organized as a circuit of multiple stations. At each station, participants are required to display a particular skill set or combination of competencies, alongside the relevant theoretical knowledge [2].

Beyond technical abilities, the OSCE also assesses students’ confidence, preparedness, clinical skills, and psychosocial competencies, encompassing both motor and interpersonal abilities. Monitoring these domains is essential for tracking professional development. Notably, this evaluation method has been shown to enhance student performance and confidence, while also increasing engagement among clinical educators [3]. Originally developed in the United Kingdom, the OSCE was rapidly adopted by medical schools throughout Western countries. By the 1990s, its use was widespread in North America, Canada, Australia, and other regions, with Canada instituting it as a requirement for national licensure examinations. Over time, its application has expanded to additional health professions, including radiology, physiotherapy, and nursing [4].

Given that nurses’ clinical competence has a direct impact on patient outcomes and the overall quality of healthcare, accurate assessment of nursing students’ clinical abilities during training is imperative [5]. Miller’s framework for clinical competence (1990) outlines four progressive levels of assessment: the initial two focus on cognitive aspects, evaluating theoretical knowledge (“knows”) and its application (“knows how”), while the latter two assess performance—first in controlled settings (“shows how”), and ultimately in real clinical environments (“does”) [6].

The OSCE offers several advantages as an assessment tool in nursing education. It enables the evaluation of essential skills such as communication, clinical assessment, information processing, documentation, clinical reasoning and judgment, and decision-making [2]. Furthermore, it has been formally recognized as a standard method of evaluation by most faculties of nursing and midwifery [3]. The OSCE also contributes to bridging the gap between theoretical instruction and clinical practice, with evidence indicating strong support for its inclusion in nursing curricula from both students and educators [7]. In the biomedical sciences, including nursing, simulation-based education is increasingly utilized as a means of both teaching and assessment. This approach allows students to practice and refine their skills within a safe, controlled environment that closely mirrors real-life clinical situations [8].

Despite these strengths, the practical implementation of OSCEs within nursing curricula is often insufficiently addressed [9]. Studies have identified that unfamiliarity with the OSCE format and structure is a significant contributor to heightened anxiety and stress among nursing students. Key academic stressors include exam preparation, the examination process itself, and anxiety related to assessment. Excessive or unnecessary stress can disrupt essential cognitive processes, ultimately impairing student performance [10]. Although nursing students recognize the importance of the clinical experience gained through OSCEs, they frequently report feelings of anxiety, lack of control, and pressure during the examination [3]. In light of these considerations, the present study aims to examine both anxiety levels and acceptance of the OSCE among nursing students.

2. Materials and Methods

2.1. Study Design

A cross-sectional, descriptive observational study was conducted in accordance with the STROBE reporting guidelines [11].

2.2. Setting and Participants

The study took place at the University of Almería (Spain) between October 2024 and May 2025. Eligible participants were undergraduate nursing students enrolled at the University of Almería. A convenience sample was recruited based on the following inclusion criteria: enrollment in the nursing program at the University of Almería, current or previous completion of the Emergency Care course, and provision of informed consent via the attached form. Students were excluded if they were international students (due to potential language barriers) or had a prior diagnosis of an anxiety disorder.

2.3. Variables and Instruments

Sociodemographic variables collected included age, sex, year of study, prior experience with the OSCE, and the year in which the student first completed an OSCE during their nursing studies.

The primary variables of interest were anxiety and students’ perceptions and acceptance of the OSCE as an assessment tool. Data were collected using two instruments:

• The Three-Factor Anxiety Inventory (TFAI) [12], a 25-item scale measuring anxiety across three dimensions: cognitive anxiety (worry and self-focus), physiological anxiety (autonomic hyperactivity and somatic tension), and the regulatory dimension of anxiety (perceived control). Responses were recorded on a five-point Likert scale (1 = strongly disagree to 5 = strongly agree). Cronbach’s alpha coefficients were 0.86 for cognitive anxiety, 0.75 for physiological anxiety, and 0.85 for the regulatory dimension.
• The OSCE Perceptions and Acceptance Questionnaire [13], adapted from a validated instrument [14], comprises 14 items assessing students’ perceptions of the OSCE as an evaluation method, divided into two sections: the first addresses students’ experiences with the OSCE, and the second assesses content evaluation. Responses were also recorded on a five-point Likert scale (1 = strongly disagree to 5 = strongly agree). The Cronbach’s alpha for this instrument was 0.81.

2.4. Procedure

Data collection was conducted via an online, self-administered questionnaire created using Google Forms, with an estimated completion time of 10–15 minutes. The questionnaire consisted of four sections: informed consent, sociodemographic variables, the TFAI scale, and the OSCE Perceptions and Acceptance Questionnaire.

To recruit participants, faculty members teaching the Emergency Care course were contacted and provided students with a QR code to access the questionnaire after the theoretical exam. Additionally, class representatives for third-year students and fourth-year nursing students were approached to distribute the questionnaire through online student groups. Responses were stored in a secure cloud database, accessible only to the research team.

2.5. Ethical Considerations

This study was reviewed and approved by the Institutional Review Board (Registration No. EFM 388.25). All participants were fully informed about the purpose of the study, the confidential and anonymous handling of their data, and provided written informed consent prior to participation. All participants in the study signed informed consent. The study was carried out in accordance with the Declaration of Helsinki of the World Medical Association.

2.6. Data Analysis

Data were analyzed using SPSS version 29. Descriptive statistics were calculated for demographic variables: measures of central tendency and dispersion for quantitative variables, and frequencies and percentages for qualitative variables. Non-parametric tests (Mann-Whitney U test for group comparisons and Spearman’s correlation) were used to analyze the data. A 95% confidence interval was established, and p-values less than 0.05 were considered statistically significant.

3. Results

3.1. Sample Sociodemographic Characteristics

A total of 105 nursing students participated in the study. The majority were female (n = 85, 81%), most were in their third year of the nursing program (n = 81, 77.1%), and nearly all reported previous experience with the OSCE (n = 98, 93.3%). For almost half of the students, their first OSCE took place during the first year of their studies (n = 50, 47.6%). The mean age of participants was 23.75 years (SD = 6.49), with ages ranging from 19 to 56 years. Detailed characteristics of the sample are presented in Table 1.

3.2. Evaluation of Students’ Perceptions and Acceptance of the OSCE

Table 2 presents the mean scores for the 15 items comprising the questionnaire assessing students’ perceptions and acceptance of the OSCE. The item with the highest mean score was related to the perception of the OSCE as an intimidating evaluation method (mean = 4.02; SD = 1.06). Conversely, the item indicating that the OSCE was considered less stressful than other types of examinations received the lowest mean score (mean = 1.85; SD = 1.10).

No significant differences were found when comparing perceptions and acceptance of the OSCE by sex (p > 0.05). However, differences emerged between students according to academic year for 4 out of the 15 questionnaire items. Specifically, third-year students rated the OSCE as a more practical and useful experience (U = 648.50, p = .01, Z = -2.57), found the instructions clearer (U = 661.50, p = .01, Z = -2.45), perceived greater opportunities to learn from real-life scenarios (U = 608.00, p < 0.05, Z = -2.89), and felt more challenged to think critically (U = 699.50, p = .03, Z = -2.16). Examination of mean scores indicated that third-year students had a more positive perception of the OSCE compared to fourth-year students, as detailed in Table 3.

3.2. Three-Factor Anxiety Inventory (TFAI)

Table 4 displays the mean scores for each item and for the dimensions comprising the TFAI scale. The cognitive anxiety dimension recorded the highest mean score, with an average of 4.06 (SD = 0.60). The item with the highest individual score also belonged to the cognitive anxiety dimension: “I worry about making mistakes,” which had a mean of 4.51 (SD = 0.73). The item with the lowest mean score was “I stop to think about how I might fail to impress important people,” with a mean of 3.22 (SD = 1.31).

3.2.1. Cognitive Anxiety Dimension

Significant differences were observed by sex (p < 0.05), as shown in Table 5. Female students reported greater concern than males about making mistakes (M = 4.61; SD = 0.73) and the consequences of failure (M = 4.26; SD = 0.98). They were also more aware of the possibility of disappointing important people compared to their male counterparts (M = 3.75; SD = 1.20).

3.2.2. Physiological Anxiety Dimension

Significant differences were also found by sex (U = 583.50, p = .02, Z = -2.26), with female students more likely to feel easily fatigued (M = 3.88; SD = 1.26) than males (M = 3.15; SD = 1.38). Regarding academic year (U = 698.50, p = .03, Z = -2.14), third-year students reported greater mouth dryness when facing the OSCE (M = 3.60; SD = 1.31) compared to fourth-year students (M = 2.88; SD = 1.51).

3.2.3. Anxiety Regulatory Dimension

No significant differences were found regarding academic year, prior OSCE experience, age, or the year in which students first completed an OSCE. However, significant differences were observed by sex (U = 591.00; p = .02, Z = -2.24), with male students expressing greater confidence in their ability to perform (M = 4.15; SD = 0.87) compared to female students (M = 3.68; SD = 0.84).

3.3. Correlations

The results of the Spearman correlation analyses between perceptions and acceptance of the OSCE and anxiety levels measured by the TFAI scale revealed significant associations, as shown in Table 6. The perception of the OSCE as less stressful than other exams showed a positive and significant correlation with the regulatory dimension of anxiety (rho = .215, p = .028). Likewise, considering the OSCE as an intimidating method was significantly associated with higher levels of physiological anxiety (rho = .313, p = .001). On the other hand, positive and significant correlations were observed between the perception of realism in the presented cases and anxiety regulation (rho = .248, p = .011), as well as with the perception that the OSCE helped identify areas for improvement (rho = .284, p = .003). Moreover, even stronger correlations were found with the perception that the tasks reflected acquired competencies (rho = .345, p < .001) and with the feeling of competence in performing practiced skills (rho = .474, p < .001), both with the regulatory dimension of anxiety. These findings suggest that a more positive and realistic perception of the OSCE is related to students’ improved ability to regulate their anxiety.

4. Discussion

The aim of this study was to assess anxiety and acceptance of the Objective Structured Clinical Examination (OSCE) among nursing students. The findings revealed significant differences in anxiety levels as measured by the TFAI scale. In the cognitive anxiety dimension, female students reported greater concern than males regarding making mistakes and the consequences of failure, as well as heightened awareness of the possibility of disappointing important individuals. In the physiological anxiety dimension, women were more likely to report feeling easily fatigued compared to men. Regarding academic year, third-year students experienced greater mouth dryness when facing the OSCE than fourth-year students. In contrast, for the anxiety regulatory dimension, male students expressed greater confidence in their ability to perform compared to female students. Additionally, third-year students evaluated the OSCE more positively than fourth-year students in terms of perceptions and acceptance.

These results are consistent with previous research indicating that anxiety is a common experience for nursing students facing the OSCE, with gender differences frequently observed. Various studies using different anxiety measurement tools have reported similar trends: for example, the Test Anxiety Inventory (TAI) found significant differences in emotionality subscales between women and men, and the State-Trait Anxiety Inventory (STAI) also showed higher state anxiety in women [15]. However, some studies have reported higher anxiety levels among male students [16]. Moderate to high anxiety scores are common, and many students perceive the OSCE as a stressful and anxiety-inducing assessment, often due to time constraints, lack of preparation time, and the pressure of being observed by examiners [17].

Physiological symptoms, such as fatigue and increased heart rate, have also been documented in the context of OSCEs and other high-stakes exams, highlighting the physiological impact of exam-related stress [18]. Confidence has been shown to have a calming effect and is associated with improved self-perceived performance, which aligns with the finding that male students reported greater self-efficacy in this study [19].

Given the prevalence of anxiety associated with the OSCE, several studies have explored interventions to mitigate its impact. Techniques such as relaxation training, deep breathing exercises, and coaching workshops have been found to be beneficial in reducing pre-exam anxiety and improving students’ preparation and confidence, even if not always resulting in statistically significant reductions in anxiety scores [20,21].

4.1. Limitations and Future Directions

The main limitations of this study include the relatively small and predominantly third-year sample, which may affect the generalizability of the findings. Expanding the sample to include students from other universities and academic years would provide a broader perspective. Additionally, external variables such as social support, baseline emotional state, and individual coping styles were not controlled and may influence anxiety levels.

Future research should investigate pedagogical and psychological strategies—such as preparatory simulations, mindfulness practices, and coping skills training—to reduce OSCE-related anxiety. Developing standardized protocols for the implementation of OSCEs at the university level could help establish consistent structures, better preparing students and potentially reducing anxiety during these assessments.

5. Conclusions

Students generally value the OSCE as a useful, realistic, and representative tool for assessing acquired competencies. However, it is also perceived as an intimidating and stressful evaluation method, with significant differences observed according to sex, academic year, and anxiety dimensions. These findings highlight the importance of implementing targeted support strategies to help mitigate student anxiety and promote a more positive assessment experience ensuring the educational effectiveness of the OSCE.