European Journal of Dental Education ISSN 1396-5883

Is the OSCE more stressful? Examination anxiety and its

consequences in different assessment methods in
dental education
H. S. Brand1,2 and M. Schoonheim-Klein3
1
Department of Basic Dental Sciences,
2
Department of Oral and Maxillofacial Surgery,
3
Department of Periodontology, Academic Centre for Dentistry Amsterdam (ACTA), Amsterdam, The Netherlands

Keywords Abstract
clinical curriculum, dental education; OSCE;
stress; state-trait anxiety; undergraduate Objective: To measure the levels of anxiety, self-perception of preparation and expec-
students. tation for success induced by an objective structured clinical examination (OSCE), a
written examination and a preclinical preparation test, and to examine the effects of
Correspondence the three predictive variables on the outcome of the assessments.
H. S. Brand
Department of Basic Dental Sciences,
Room A-220
Materials and methods: Test anxiety was measured with Spielberger’s state anxiety
Academic Centre for Dentistry Amsterdam inventory. Preparation for the assessment and expectation to succeed were quantified
(ACTA) with 4-point Likert scales. The questionnaire was completed during an OSCE, a written
Vrije Universiteit and Universiteit van examination, a preclinical crown and bridge preparation test and a non-examination
Amsterdam situation.
Van der Boechorststraat 7
1081 BT Amsterdam
Results: The OSCE was a most anxiety-provoking assessment method and students
The Netherlands
prepared more for the OSCE than for the other examinations. The expectation to suc-
Tel: +31 (0) 20 444 8673
ceed was also higher for the OSCE. State anxiety during the OSCE was associated with
Fax: + 31 (0) 20 444 8685
e-mail: hs.brand@vumc.nl
the level of preparation but not with scores obtained. The state anxiety during a writ-
ten examination showed a positive relation with the scores obtained, but not with
Accepted: 21 November 2008 preparation or expectation to succeed. During the preclinical test, state anxiety showed
a positive association with the preparation and expectation to succeed, but not with
doi:10.1111/j.1600-0579.2008.00554.x the scores for this test.
No significant gender effects were observed for the state anxiety, level of preparation
or the expectation to pass the examination. In the written examination female students
scored significantly higher than male students. Such a gender effect was not found for
the scores of the OSCE or the preclinical test.

Conclusion: State anxiety was elevated during all three assessment methods. However,
anxiety was not predictive of performance outcome in the OSCE, written examination
or preclinical preparation test.

State anxiety is defined as an unpleasant arousal in the face

Introduction
Examinations have an important role in evaluating students’
learning outcomes and their mastery of a subject. Passing or
failing an examination can have strong consequences for the
student’s career. Therefore, it is not surprising that interna-
tional studies consistently show that dental students report
examinations and grades among the highest ranking stressors
in dental school (1–7).
of threatening demands or dangers (8). A high level of test anx-
iety may interfere with optimal learning, resulting in a poorer
achievement of students during assessments (9–12). This has
also been reported for dental students. Those with the highest
level of self-reported stress tend to achieve lower grades than
dental students with lower stress levels (13). Perception of
higher levels of stress after the examination was marginally
associated with poorer marks for that examination (5).

Eur J Dent Educ 13 (2009) 147–153 ª 2009 The Authors. Journal compilation ª 2009 Blackwell Munksgaard 147
Examination anxiety in dental education
Measurement instruments for stress used in studies differ
considerably. Some studies used physiological parameters such
as salivary markers, whereas others used a single question on
the level of perceived stress or questionnaires on self-perceived
stress (1–7, 14). The Spielberger State-Trait Anxiety Inventory
is an internationally validated questionnaire for levels of test
anxiety (15). A recent review found the reliability of this ques-
tionnaire acceptable, both with regard to internal consistency
and test–retest reliability (16).
Several dental schools have incorporated the objective struc-
tured clinical examination (OSCE) in their curricula to assess
the clinical competence of dental students (17–21). During the
OSCE, the students rotate through a series of stations in which
they are required to perform a variety of clinical tasks during a
pre-specified period of time (22).
There are indications that OSCEs may induce higher levels
of stress than other forms of assessment. In medical students,
as well as radiology and nursing students, the majority indicates
that they consider an OSCE more stressful than other examina-
tions like a written examination or a staged clinical assessment.
(23–25). Whether an OSCE also causes more stress in dental
students than other examinations is unknown, although there
are anecdotic reports that some dental students suffer from
shaking hands, quivering voices and/or increased blood pres-
sure during an OSCE (21, 26). Therefore, the aim of the cur-
rent study was to examine whether the level of stress of dental
students induced by an OSCE is higher than by a written
examination and a preclinical crown and bridge preparation. A
further goal of this study was to determine whether self-
reported anxiety levels were related to preparation for the
examination and scores achieved. Finally, as several studies
reported sex differences for state anxiety in students (e.g. 27–
29), we were also interested in potential gender differences.
Methods
The study sample comprised third-year dental students of a
Dutch dental school. The students were under no obligation to
participate in this research and their participation was volun-
tary. Although students were invited to provide their registra-
tion number, so that anxiety levels could be linked to gender
and marks achieved, they also had the option of completing
the questionnaire anonymously.
Test anxiety was measured with the state scale of the State-
Trait Anxiety Inventory (15). This widely used, well-validated
TABLE 1. Characteristics of the different assessment methods
OSCE
Time (min) 16 · 5
Potential range of scores 0–160
Range of scores obtained 89–141
Direct supervision Yes
during assessment
History experience with format Second-year
dental school
Consequences of failing Study delay
148 Eur J Dent Educ 13 (2009) 147–153 ª 2009 The Authors. Journal compilation ª 2009 Blackwell Munksgaard
Brand & Schoonheim-Klein
questionnaire consists of 20 statements (e.g. ‘I am tense’), to
which respondents indicate their level of agreement on a
4-point scale regarding how they feel at the given moment
(1 = not at all, 2 = somewhat, 3 = moderately so, 4 = very
much so). The potential scores range from 20 to 80, with high
scores representing high levels of anxiety. Two similar 4-point
statements were added to the questionnaire, and the students
were asked to indicate their preparation for the assessment (‘I
prepared myself well for the test’) and their expectation to
succeed (‘I think I will pass the test’).
The questionnaire was distributed to participating dental
students in four test situations (Table 1):
1 At a rest station in an OSCE (survey station) that interca-
lated among the other clinical skills stations. The OSCE,
described in detail earlier (17) consisted of 16 stations of 5 min
each and assessed the clinical competence after an integrated
dental course. As 10 points could be obtained for each station,
the maximum score for the OSCE is 160.
2 A written test in endodontics. During this examination the
students were required to answer 20 short essay-type questions
within maximally 90 min. The scores for this examination
range from 1 to 10.
3 A preclinical crown and bridge preparation test of maxi-
mally two times 3 h. Scores are expressed from 0 to 2
(0 = failed both parts of the test; 1 = passed one part of the
test; 2 = passed both parts).
4 A Basic Life Support course of 3 h, for which the students
did not have to prepare. As the students knew beforehand that
the course did not include an assessment, the obtained values
were considered to represent non-assessment baseline anxiety
levels.
Due to the voluntary base of our study and the fact that not
all students participated in each test condition, the number of
completed surveys differs between the test situations.
Statistical analyses
Data are presented as mean ± SD and were analysed using the
statistical software package SPSS version 12.0 (SPSS Inc., Chi-
cago, IL, USA). The self-reported levels of anxiety, preparation
and expectation at the different test conditions were compared
with Kruskal–Wallis tests, followed by Mann–Whitney tests as
post hoc procedure. Relations between variables were explored
with Spearman’s rank order coefficient and gender differences
were analysed with Mann–Whitney tests. Subsequently, the
Written Crown and bridge Baseline
examination preparation (BLS-course)
90 2 · 180 180
1–10 0–2 –
1–9 0–2 –
No No –
First-year high school Third-year dental school Second-year
dental school
None Study delay None
Brand & Schoonheim-Klein Examination anxiety in dental education

students were classified into tertiles according to level of their TABLE 3. Nonparametric correlations between state anxiety score, level
state anxiety (‘low’, ‘medium’ and ‘high’), and the level of self- of preparation, expectation to succeed and scores obtained during an
reported preparation, the expectation to succeed and the OSCE (Spearman’s rank order coefficient)
obtained results of the three groups were compared with a
Level of Expectation Scores
Kruskal–Wallis procedure. For all statistical tests, P < 0.05 was
preparation to succeed obtained
accepted as statistically significant.
State anxiety 0.271 )0.169 0.138
P = 0.011 P = 0.117 P = 0.226
Results (n = 87) (n = 87) (n = 79)
Table 2 shows that all assessment methods induced a significant Level of preparation 0.363 0.329
increase in state anxiety compared to baseline levels, with the P = 0.001 P = 0.020
highest anxiety levels reported during an OSCE. Differences in (n = 88) (n = 78)
preparation for the three assessments as well as in the expecta- Expectation to succeed 0.340
tion to pass the tests were also observed. The students reported P = 0.002
(n = 78)
preparing themselves better for the OSCE than for both the
written examination and the preclinical preparation test. Their The values in italics represent the P values of the correlations, with the
expectation to pass the test was also significantly higher for the bold ones indicating significant P values (P < 0.05).
OSCE than for both other assessment methods. The level of
state anxiety, preparedness and expectation to succeed of TABLE 4. Nonparametric correlations between state anxiety score, level
students that provided their registration number did not differ of preparation, expectation to succeed and scores obtained during a
significantly from the anonymously participating students. written examination (Spearman’s rank order coefficient)
The state anxiety during the OSCE showed an association
Level of Expectation Scores
with the level of preparation, with individuals with a high anxi-
preparation to succeed obtained
ety level reporting more preparation (Table 3). The scores
obtained for the OSCE did not correlate with the state anxiety State anxiety 0.205 0.207 0.325
during the OSCE. However, the level of state anxiety during a P = 0.204 P = 0.199 P = 0.044
written examination showed a positive correlation with the (n = 40) (n = 40) (n = 39)
scores obtained, with students with higher anxiety levels having Level of preparation 0.668 0.479
better grades (Table 4). The state anxiety for the written exami- P < 0.0005 P = 0.002
nation was not associated with preparation or the expectation (n = 40) (n = 39)
to succeed. The state anxiety during the preclinical crown and Expectation to succeed 0.609
bridge preparation showed a positive correlation with the prep- P < 0.0005
aration and expectation to succeed. Students with high anxiety (n = 39)
levels reported more preparation and had higher expectations
The values in italics represent the P values of the correlations, with the
to succeed. State anxiety did not correlate with the scores for bold ones indicating significant P values (P < 0.05).
this test (Table 5).
For all three types of assessment, the level of preparation preparation for both the OSCE and crown and bridge prepara-
showed a positive correlation with the expectation to succeed tion was the highest in subjects with ‘high’ state anxiety. The
and the scores obtained. Students who reported a high level of expectation to succeed for the crown and bridge preparation
preparation expressed more expectations to succeed and was also the highest in students with ‘high’ state anxiety.
obtained better results (Tables 3–5). For each assessment, a No significant gender effects were observed for the state anx-
high expectation to succeed was associated with higher scores iety, level of preparation or the expectation to pass the exami-
obtained (Tables 3–5). nation (Table 7). However, the average grades of female
When students were classified into tertiles according to their students for the written examination were significantly higher
level of state anxiety, no curvilinear relationship was observed than those of male students. Such a gender effect was not
with the level of self-reported preparation, expectation to found for the scores of the OSCE or the preclinical crown and
succeed or obtained results (Table 6). In contrast, the level of bridge test.

TABLE 2. Mean ± SD state anxiety scores, levels

of preparation and expectation to succeed for State anxiety Preparation Expectation
three different assessment methods and at Assessment method (range 20–80) (range 1–4) (range 1–4)
baseline Baseline, n = 40 33.98 ± 6.51 n.a. n.a.
OSCE, n = 89 54.06 ± 12.551 3.02 ± 0.71 2.28 ± 0.66
Written, n = 40 41.55 ± 9.591,2 1.73 ± 0.722 1.75 ± 0.772
Crown and bridge, n = 61 40.24 ± 8.561,2 2.21 ± 0.842 1.87 ± 0.672
Kruskal–Wallis P < 0.0005 P < 0.0005 P < 0.005
1
P < 0.05 vs. baseline.
2
P < 0.05 vs. OSCE (Mann–Whitney).

Eur J Dent Educ 13 (2009) 147–153 ª 2009 The Authors. Journal compilation ª 2009 Blackwell Munksgaard 149
Examination anxiety in dental education Brand & Schoonheim-Klein

TABLE 5. Nonparametric correlations between state anxiety score, level TABLE 7. Mean state anxiety scores, levels of preparation, expectation to
of preparation, expectation to succeed and scores obtained during a pre- succeed and scores obtained for three different assessment methods,
clinical crown and bridge preparation (Spearman’s rank order coefficient) stratified according to gender

Level of Expectation Scores Male Female

preparation to succeed obtained
Baseline
State anxiety 0.384 0.451 0.136 State anxiety (20–80) 32.92 ± 6.63 (24) 33.06 ± 6.53 (16)
P = 0.002 P < 0.0005 P = 0.295 OSCE
(n = 61) (n = 61) (n = 61) State anxiety (20–80) 51.14 ± 10.73 (29) 54.59 ± 13.88 (49)
Level of preparation 0.683 0.300 Preparation (1–4) 2.83 ± 0.54 (29) 3.04 ± 0.77 (48)
P < 0.0005 P = 0.019 Expectation (1–4) 2.33 ± 0.61 (30) 2.21 ± 0.72 (47)
(n = 61) (n = 61) Scores (0–160) 114.5 ± 11.2 (51) 117.7 ± 10.2 (82)
Expectation to succeed 0.395 Written examination
P = 0.002 State anxiety (20–80) 43.75 ± 9.18 (24) 37.87 ± 9.72 (15)
(n = 61) Preparation (1–4) 1.71 ± 0.62 (24) 1.73 ± 0.88 (15)
Expectation (1–4) 1.83 ± 0.76 (24) 1.60 ± 0.83 (15)
The values in italics represent the P values of the correlations, with the Scores (1–10) 5.00 ± 2.04 (35) 6.02 ± 1.69 (42)1
bold ones indicating significant P values (P < 0.05). Crown and bridge preparation
State anxiety (20–80) 40.09 ± 9.54 (34) 40.11 ± 7.24 (26)
Preparation (1–4) 2.21 ± 0.81 (34) 2.19 ± 0.89 (26)
Discussion Expectation (1–4) 1.85 ± 0.66 (34) 1.85 ± 0.67 (26)
Scores (0–2) 0.29 ± 0.44 (34) 0.38 ± 0.50 (26)
Examinations and assessment procedures have the potential to
be anxiety provoking and stressful for dental students (1–7). Values within parentheses indicate number of subjects. OSCE, objective
The current study explored the state anxiety of dental students structured clinical examination.
1
during three different types of examinations: an OSCE, a writ- Mann–Whitney test < 0.05.
ten examination and a preclinical crown and bridge prepara-
tion. In the control condition, the dental students in our study students studying for other health professions (23–25, 30).
reported state anxiety levels comparable with baseline popula- A possible explanation is that a written examination is
tion norms (14, 15). undertaken in relative anonymity, whereas the constant moni-
Although each type of assessment evoked an increased level toring and observation during an OSCE may increase anxiety
of state anxiety (Table 2), significant differences were observed levels (21, 25, 30, 31). The timed, interactive aspects of the
between the three assessment methods. The mean state anxiety OSCE may also create high levels of student anxiety (21). It has
levels of dental students during the OSCE and written examina- been shown that students in a timed examination did not per-
tion (Table 2) are comparable with previously reported state form as well as their counterparts without time limit (10).
anxiety levels of radiology students during these two types of However, Schoonheim-Klein et al. (19) showed that more time
examinations (59.2 and 47.4 respectively) (25). The observation per station did not improve student’s performance. In our
that the dental students find the OSCE much more stressful study, failing the OSCE or the crown and bridge preparation
than a written examination is in agreement with studies among has negative consequences for the study progress of the dental

TABLE 6. Mean ± SD levels of preparation, expectation to succeed and scores obtained for three different assessment methods. The subjects were
classified according to state anxiety into ‘low’, ‘medium’ and ‘high’

Level of state anxiety

Low Medium High Kruskal–Wallis

OSCE
Preparation 2.79 ± 0.73 (29) 2.96 ± 0.65 (28) 3.29 ± 0.69 (30) P = 0.025
Expectation 2.31 ± 0.71 (29) 2.43 ± 0.57 (28) 2.13 ± 0.68 (30) P = 0.255
Scores 113.0 ± 12.7 (28) 119.7 ± 10.2 (26) 117.1 ± 10.4 (25) P = 0.133
Written examination
Preparation 1.46 ± 0.52 (13) 1.77 ± 0.73 (13) 1.93 ± 0.83 (14) P = 0.277
Expectation 1.54 ± 0.66 (13) 1.77 ± 0.93 (13) 1.93 ± 0.73 (14) P = 0.368
Scores 4.15 ± 1.46 (13) 5.33 ± 2.43 (12) 5.64 ± 1.95 (14) P = 0.074
Crown and bridge preparation
Preparation 1.75 ± 0.55 (20) 2.37 ± 1.01 (19) 2.50 ± 0.74 (22) P = 0.008
Expectation 1.45 ± 0.51 (20) 1.95 ± 0.62 (19) 2.18 ± 0.66 (22) P = 0.001
Scores 0.20 ± 0.41 (20) 0.47 ± 0.51 (19) 0.41 ± 0.59 (22) P = 0.204

Values within parentheses indicate number of subjects. OSCE, objective structured clinical examination.
The values in italics represent the P values of the correlations, with the bold ones indicating significant P values (P < 0.05).

150 Eur J Dent Educ 13 (2009) 147–153 ª 2009 The Authors. Journal compilation ª 2009 Blackwell Munksgaard
Brand & Schoonheim-Klein
students (Table 1). Despite the similar consequences, the anxi-
ety-inducing level of the OSCE is much higher (Table 2).
The written examination is a traditional method of assess-
ment in the academic environment. Although selection to our
dental school is not based on performance on written tests, the
students are familiar with this assessment format since their
first year at high school. It has been suggested that the
relatively new character of the OSCE (Table 1) could play an
important role in the associated anxiety (24, 25) and more
experience might reduce levels of stress (32). However, in our
study the participating dental students already performed in an
OSCE during their previous, second year. The dental students
had even less experience with the crown and bridge examina-
tion (Table 1) which nevertheless induced significantly lower
level of state anxiety (Table 2). In medical students the percent-
age of students regarding the OSCE as highly stressful did not
decrease with increasing experience (33). So it seems unlikely
that more experience will decrease state anxiety levels of dental
students during an OSCE. Finally, it must be acknowledged
that maybe the different content of the material tested in the
assessments rather than the assessment methods themselves
provoked different levels of state anxiety (25).
It is a matter of debate as to whether stress is functional, lead-
ing to better learning, or dysfunctional, with reduced learning
resulting in poor performance (9, 34, 35). In our study, we
found a significant positive relationship between the level of
state anxiety during a written examination and the scores
obtained for this type of assessment (Table 4). For the other two
types of examination, no relation between state anxiety and out-
come was observed. Previous studies reported weak negative
relationships between state anxiety of dental students and their
grades (36, 37). Among first-year dental students, a statistically
significant negative relationship between state anxiety and grade
points was observed for only three of the 48 courses investi-
gated, while for one course even a significant positive relation-
ship was found (13). During a written test in paediatric
dentistry, a near-significant negative correlation between level of
stress and test scores was observed (P = 0.07) (5). In two recent
studies among medical trainees, anxiety scores were not signifi-
cantly correlated with performance scores (11, 31, 38).
The Yerkes–Dodson law indicates that some degree of state
anxiety enhances performance, but only up to a certain point.
High levels of anxiety may retard performance, which results in
an inverted U-shaped relationship between state anxiety and
performance (39). However, when our students were stratified
into tertiles according to their state anxiety, no significant dif-
ferences were observed in performance for any of the three
assessment types. Taken together, these results suggest that
there is no relationship between state anxiety during examina-
tions and test performance or that this relationship is only very
mild (13).
Dental students spend much more time preparing for the
OSCE than for the other two types of assessment (Table 2).
This could support the claim that participation in an OSCE
can enhance students’ learning (40).
The level of preparation for the OSCE was significantly
related to the scores obtained (Table 3). In second-year medical
students, OSCE performance was also positively related to
study time (41). Dental students showed no gender difference
Eur J Dent Educ 13 (2009) 147–153 ª 2009 The Authors. Journal compilation ª 2009 Blackwell Munksgaard
Examination anxiety in dental education
for the level of preparation for the OSCE (Table 7), which also
has been reported for medical students (41).
Men and women did not differ in their state anxiety scores
during each type of examination (Table 7). This seems remark-
able as several studies reported that female dental students per-
ceive examinations and grades more stressful than males (1, 4,
42, 43). However, other studies also failed to support this find-
ing (6, 7). A possible explanation for these conflicting results
may be that cultural and social differences between the
conducted studies may have an influence on potential gender
differences in perceived stress.
There were no significant gender differences in OSCE perfor-
mance observed. In a previous study, female dental students
outperformed their male counterparts in a summative peri-
odontal OSCE (18). In the UK, female medical students also
performed better in a summative OSCE (44, 45). In a formative
OSCE, however, no significant differences in OSCE perfor-
mance related to gender were observed. The type of test-station
may also be an important factor for gender-related differences
in OSCE performance. In a nine-station OSCE, female students
outperformed male students only significantly in specific
stations (19).
Although the increase in anxiety level induced by the assess-
ments showed no significant relation to the performance of the
students, dental staff should not underestimate the anxiety-pro-
voking potential of the different types of assessment. A recent
study showed that psychological stress in undergraduate dental
students has effects on burnout and mental health (46).
This study has some limitations. As the dental students were
recruited on a voluntary basis, not all students participated in
each test condition, and only a small number of students com-
pleted all four test situations. It has been suggested that high
anxious students may be less willing to participate in this type
of studies (11). Although we cannot exclude this possibility,
gender and/or examination grades of the non-participating or
anonymously participating students did not differ significantly
from the students that provided their registration number.
The three assessment methods differ considerably in the
potential range of results. For the OSCE and the written exami-
nation, the potential as well as the obtained results show a rela-
tively large range (Table 1). However, the result of the crown
and bridge preparation has only a 3-point range. The same
applies to the questions regarding self-reported preparation or
expectation to succeed, each having a 4-point range. These
restrictions in range could potentially lead to attenuation on
measures of association.
Another potential limitation is that test anxiety levels were
measured at a rest station of the OSCE, which induces the pos-
sibility of changes in anxiety level during the examination, e.g.
a student who answered the questionnaire after performing a
few stations may differ in perceived stress from a student that
had finished most or all of the stations. In medical students,
however, no such interaction between anxiety level and place-
ment in the OSCE has been found (47).
In summary, this study demonstrated that state anxiety was
elevated in dental students during three assessment methods:
OSCE, written examination or preclinical preparation test. The
OSCE provoked more anxiety than other formats of assess-
ments. However, anxiety was not predictive of performance
151
Examination anxiety in dental education
outcomes in contrast to preparation and expectation to
succeed, which were good predictors of the outcome scores.
Acknowledgements
The authors would like to thank Denise van Diermen and
Merel Rooijakkers for their assistance in collecting the data and
all the dental students who took part in this study.
References
1 Al-Omari WM. Perceived sources of stress within a dental educa-
tional environment. J Contemp Dent Pract 2005: 6: 64–74.
2 Grandy TG, Westerman GH, Combs CE, et al. Perceptions of stress
among third/year dental students. J Dent Educ 1989: 53: 718–721.
3 Muirhead V, Locker D. Canadian dental students’ perceptions of
stress. J Can Dent Assoc 2007: 72: 323–323e.
4 Naidu RS, Adams JS, Simeon D, et al. Sources of stress and psycho-
logical disturbance among dental students in the West Indies.
J Dent Educ 2002: 66: 1021–1030.
5 Ng V, Koh D, Mok BYY, et al. Salivary biomarkers associated with
academic assessment stress among dental undergraduates. J Dent
Educ 2003: 67: 1091–1094.
6 Yap AU, Bhole S, Teo CS. A cross-cultural comparison of perceived
sources of stress in the dental school environment. J Dent Educ
1996: 60: 446–451.
7 Westerman GH, Grandy TG, Ocanto RA, et al. Perceived sources of
stress in the dental environment. J Dent Educ 1993: 57: 225–231.
8 Lazarus RS. Emotion and adaptation. London: Oxford University
Press, 1991.
9 Sanders AE, Lushington K. Effect of perceived stress on student
performance in dental school. J Dent Educ 2002: 66: 75–81.
10 Onwuegbuzie AJ, Daley CE. The relative contributions of examina-
tion-taking coping strategies and study coping strategies to test
anxiety; a concurrent analysis. Cognit Ther Res 1996: 20: 287–303.
11 Reteguiz J-A. Relationship between anxiety and standardized patient
test performance in the medicine clerkship. J Gen Intern Med 2006:
21: 415–418.
12 Phillips A. Reducing nursing students’ anxiety level and increasing
retention of materials. J Nurs Educ 1998: 27: 35–41.
13 Westerman GH, Grandy TG, Lupo JV, Mitchell RE. Relationship of
stress and performance among first-year dental students. J Dent
Educ 1986: 50: 264–267.
14 Bosch JA, Brand HS, Ligtenberg AJM, et al. Psychological stress as a
determinant of protein levels and salivary-induced aggregation of
Streptococcus gordonii in human whole saliva. Psychosom Med 1996:
58: 374–382.
15 Spielberger CD, Lushene G, Vagg P, et al. Manual for the State-
Trait Anxiety Inventory. Palo Alto, CA: Consulting Psychologist
Press, 1983.
16 Barnes LLB, Harp D, Yong WS. Reliability Generalization of Scores
on the Spielberger State-Trait Anxiety Inventory. Educ Psychol
Meas 2002: 62: 603–618.
17 Schoonheim-Klein M, Walmsley AD, Habets L, et al. An implemen-
tation strategy for introducing an OSCE into a dental school. Eur J
Dent Educ 2005: 9: 143–149.
18 Schoonheim-Klein ME, Habets LLMH, Aartman IHA, et al. Imple-
menting an objective structured clinical examination (OSCE) in
dental education: effects on students’ learning strategies. Eur J Dent
Educ 2006: 10: 226–235.
19 Schoonheim-Klein ME, Hoogstraten J, Habets L, et al. Language
background and OSCE performance: a study of potential bias. Eur J
Dent Educ 2007: 11: 222–229.
152 Eur J Dent Educ 13 (2009) 147–153 ª 2009 The Authors. Journal compilation ª 2009 Blackwell Munksgaard
Brand & Schoonheim-Klein
20 Brown G, Manogue M, Martin M. The validity and reliability of an
OSCE in dentistry. Eur Dent Educ 1999: 3: 117–125.
21 Zartman RR, McWhorter AG, Seale S, et al. Using OSCE-based
evaluation: curricular impact over time. J Dent Educ 2002: 66:
1323–1330.
22 Harden R, Stevenson M, Wilson Downie W, et al. Assessment of
clinical competence using objective structured examination. Br Med
J 1975: 1: 447–451.
23 Brosnan M, Evans W, Brosnan E, et al. Implementing objective
structured clinical skills evaluation (OSCE) in nurse registration
programmes in a centre in Ireland: a utilisation focused evaluation.
Nurse Educ Today 2006: 26: 115–122.
24 Furlong E, Fox P, Lavin M, et al. Oncology nursing students’ views
of a modified OSCE. Eur J Oncol Nurs 2005: 9: 351–359.
25 Marshall G, Jones N. A pilot study into anxiety induced by various
assessment methods. Radiography 2003: 9: 185–191.
26 Brand HS, Lie SHAJJ, van Diermen DE. 2006. Blood pressure and
heart rate of dental students undergoing an OSCE. Proceedings of
the ABSTD, Dublin, Ireland, September 11–13, p. 25.
27 McCann SJ, Stewin LL, Short RH. Sex differences, social desirabil-
ity, masculinity and the tendency to worry. J Genet Psychol 1991:
152: 295–301.
28 McCleary R, Zucker EL. Higher trait- and state-anxiety in female law
students than male law students. Psychol Rep 1991: 68: 1075–1078.
29 Carillo E, Moya-Albiol L, Gonzalez-Bono E, et al. Gender differ-
ences in cardiovascular and electrodermal responses to public
speaking task: the role of anxiety and mood states. Int J Psycho-
physiol 2001: 42: 253–264.
30 Sarid O, Anson O, Bentov Y. Students’ reactions to three typical
examinations in health sciences. Adv Health Sci Educ 2005: 10:
291–302.
31 Anderson M, Stickley T. Finding reality: the use of objective struc-
ture clinical examination (OSCE) in the assessment of mental
health nursing students interpersonal skills. Nurse Educ Pract 2002:
2: 160–168.
32 LeBlanc VR, Bandiera GW. The effects of examination stress on the
performance of emergency medicine residents. Med Educ 2007: 41:
556–564.
33 Troncon LE. Clinical skills assessment: limitations to the introduc-
tion of an ‘‘OSCE’’ (objective structured clinical examination) in a
traditional Brazilian medical school. Sao Paulo Med J 2004: 112:
12–17.
34 Clarke M. The constructs ‘stress’ and ‘coping’ as a rationale for
nursing activities. J Adv Nurs 1984: 9: 267–275.
35 Frierson HT, Hoban D. Effects of test anxiety on performances
in the NBME part 1 examination. J Med Educ 1987: 62:
431–433.
36 Cecchini JJ, Friedman N. First-year dental students: relationship
between stress and performance. Int J Psychosom 1987: 34: 17–19.
37 Fredericks MA, Mundy P. Relations between social class, stress-
anxiety responses, academic achievement, and professional attitudes
of dental students. J Dent Educ 1969: 33: 377–384.
38 Chapell MS, Blanding B, Silverstein ME, et al. Test anxiety and
academic performance in undergraduate and graduate students.
J Educ Psychol 2005: 97: 268–274.
39 Yerkes RM, Dodson JD. The relation of strength of stimulus to rapid-
ity of habit-formation. J Comp Neurol Psychol 1908: 18: 459–482.
40 Shumway JM, Harden RM. AMEE guide No. 25: the assessment of
learning for the competent and reflective physician. Med Teach
2003: 25: 569–584.
41 Mavis BE. Does studying for an objective structured clinical
examination make a difference? Med Educ 2000: 34: 808–812.
42 Lloyd C, Musser LA. Stress in dental students. J Am Coll Dent
1985: 52: 11–19.
Brand & Schoonheim-Klein
43 Lloyd C, Musser LA. Psychiatric symptoms in dental students.
J Nerv Ment Dis 1989: 177: 61–69.
44 Haq I, Higham J, Morris R, et al. Effect of ethnicity and gender on
performance in undergraduate medical examinations. Med Educ
2005: 39: 1126–1128.
45 Wiskin CM, Allan TF, Skelton JR. Gender as a variable in the
assessment of final year degree-level communication skills. Med
Educ 2004: 38: 129–137.
Eur J Dent Educ 13 (2009) 147–153 ª 2009 The Authors. Journal compilation ª 2009 Blackwell Munksgaard
Examination anxiety in dental education
46 Gorter R, Freeman R, Hammen S, et al. Psychologi-
cal stress and health in undergraduate dental students:
fifth year outcomes compared with first year baseline results
from five European dental schools. Eur J Dent Educ 2008: 12:
61–68.
47 Allen R, Heard J, Savidge M, et al. Surveying students’
attitudes during the OSCE. Adv Health Sci Educ 1998: 3:
197–206.
153