December 6, 2021

Test Anxiety and Academic Performance

by Arlesha N. Armstrong, Pharm.D., PGY-1 Pharmacy Practice Resident, Magnolia Regional Health Center

American educator Booker T. Washington once said that “Success is to be measured not so much by the position that one has reached in life as by the obstacles which he has overcome”. One obstacle that many students at all levels of formal schooling find difficult to overcome is test anxiety. It is often silent and yet incredibly loud. The first and most important step is recognizing test anxiety and the effects it can have on a student and their future. Test anxiety encompasses more than just being “worried about the test” or “hoping to get a good grade”. For some students, the level of anxiety negatively impacts performance and can become unbearable. Test anxiety encompasses two broad domains: emotionality (physiological components such as perspiration and headaches) and worry (psychological components such as heightened sense of threat, increased distraction, and motivational disturbances)1. Test anxiety is something that should be taken seriously and acted on. 

So how can educators notice the signs? The emotional symptoms in students might not be readily apparent, but the physical symptoms might be seen with close observation. Watching students and how they behave during “normal” classroom days compared to exam days may reveal subtle indications of their level of anxiety. Is the student quieter or more talkative than normal? Are they excessively sweating or noticeably breathing? Is the student shaking their leg, twitching, scratching and tapping, or pulling on clothes or hair? Although these can be normal behaviors, noticing differences in students’ behaviors surrounding exams can lead to conversations with them.

Text anxiety is surprisingly common.  Between 15 and 40% of students report experiencing some level of anxiety during examinations and other forms of assessment.3  Some students may have been told that they are overly dramatic or that they worry too much.  That they should learn to relax a little. After a while, the student may begin to think that this is just the way that they are and will have to just “live with it.” Although anxiety disorders are highly treatable, according to the Anxiety and Depression Association, only about one-third of people suffering from anxiety receive treatment. It is not a part of life. it is not a rite of passage.  It can be treated but far too often it’s not.

Physical Symptoms:

Emotional Symptoms:

·       Excessive sweating

·       Nausea, vomiting, or diarrhea

·       Stomach pain or “butterflies”

·       Rapid heartbeat

·       Shortness of breath

·       Headaches, Lightheaded or Faint

·       Restless or fidgety

·       Self-doubt

·       Fear

·       Stress

·       Hopelessness

·       Inadequacy

·       Anger

·       Nervousness

Test anxiety can have unfortunate detrimental effects on a student that leads to negative impacts on their performance. Anxiety can cause the student to procrastinate, reduce their ability to focus long enough to study, and lead to feelings of paralysis because they feel so overwhelmed. In some cases, the student might even become physically sick and cannot make it through the exam. These symptoms don’t just impact young children but can impact older students as well. Indeed, as a student advances in their education, the stressors can really add up.  Or it can be due to unresolved testing anxiety carried from childhood.

According to a study evaluating health professional students, there was a significantly positive correlation between test anxiety and procrastination on school-related work.2 Not surprisingly, students with test anxiety tend to have lower scores on standardized tests and lower GPAs.3 Unfortunately, many decisions such as college admission, scholarships, and career opportunities are influenced by test scores.3 Thus, those with test anxiety are the ones who suffer the most because there is no way to adjust for test anxiety. Until we move past standardized testing, we need to help students address and overcome test anxiety so they can achieve their full potential.  It’s true that academic performance is influenced by many factors, but teachers should always strive to identify and address the obstacles that hinder their performance. Address text anxiety may not only lead to improvement in the students’ test performance but it may also to improvements in the student’s sense of wellbeing and life satisfaction.

So how can you help students who are struggling with test anxiety? Here are some things that students and educators can do:

Advice for Students:

Advice for Educators:

·  Preparation

·  Develop a routine

·  Adequate sleep and rest

·  Decrease caffeine

·  Eat balanced meals

·  Exercise

·  Talk to the instructor

·  Learn relaxation techniques

·  Get a tutor

·  Seek counseling and support

·  Ask for accommodations

·  Teach and provide opportunities to engage in breathing exercises

·  Provide practice exams

·  Offer comprehensive review

·  Set clear expectations

·  Stagger test schedules

·  Refrain from time limits (when possible)

·  Try different exam formats and styles

·  Provide accommodations if necessary

·  Offer encouragement

The first step in helping students with test anxiety is recognizing its validity and legitimacy. Helping them realize their triggers and what induces anxiety can help a student learn how to address anxious thoughts. One way this can be done is by having the counselors come to do a general presentation about anxiety (including test anxiety) — that way every student gets the information but no student is singled out. This opens the door for a student to come forward in private. Every teacher should destigmatize anxiety and encourage students to seek counseling, engage in some form of cognitive therapy, and (when needed) take medication. This is not to say that even when a student receives therapy that anxiety will never be there. But therapy can help students take positive action, rather than letting anxiety have a hold and control over them.

Helen Keller once said “Be of good cheer. Do not think of today’s failures, but of the success that may come tomorrow. You have set yourself a difficult task, but you will succeed if you persevere, and you will find a joy in overcoming obstacles.” Addressing and overcoming anxiety is difficult to do. No one wakes up each day and chooses to have anxiety. However, addressing test anxiety can arm a student with new coping skills that can help in many other life situations.  It can really improve a student’s academic performance and quality of life.



  1. Pate AN, Neely S, Malcolm DR, et al. Multisite study assessing the effect of cognitive test anxiety on academic and standardized test performance. Am J Pharm Educ. 2021; 85(1): Article 8041.
  2. Sarvenaz R, Seyyed MA, and Alireza K. Investigating the relationship of test anxiety and time management with academic procrastination in students of health professions. Education Research International 2021; Article 1378774
  3. Myers S, Davis S, and Chan JCK. Does expressive writing or an instructional intervention reduce the impacts of test anxiety in a college classroom? Research 2021; 6:44.
  4. Harris H and Coy D. Helping students cope with test anxiety. ERIC Digest 2003.

The Importance of Self-Assessment

by Taylor Hayes, PharmD, PGY1 Pharmacy Practice Resident, Baptist Memorial Hospital – Golden Triangle

Self-assessment is a practice that encourages students to reflect on their learning or performance so that they can identify strengths and weaknesses and make improvements. Teaching a student to effectively engage in self-assessment brings to mind the parable “If you give a man a fish, you can feed him for a day. However if you teach a man to fish, you feed him for a lifetime”.1Teaching self-assessment helps students to become more autonomous in their learning by being able to self-identify what went right or wrong. From this, students can tailor their learning habits, strategies, and materials so that have a positive effect on their performance.

Self-assessment can come in many forms – from students scoring their own projects using a rubric, reflective assignments, and exam wrappers. Exam wrappers are designed to make students look beyond their score of the exam and take a deeper dive.  An exam wrapper asks students probing questions about the exam and the student’s preparation. Some example questions of the exam wrapper include how much time the student spent preparing for the exam, the part of the exam that the student believes they did not perform the best on, and what the student believes the teachers can do to help in their preparation for the next exam.2 Having students ponder on these questions prompts self-reflection and gets them to consider ways they might better prepare for the next exam.

Self-assessment is a key element of metacognition, the mental processes where one develops awareness of the processes one uses when learning new material or problem-solving. Metacognition makes students more conscious of their thinking and how their cognitive strategies help them succeed. Being self-aware of one’s performance helps students take ownership of their learning.3,4

However, self-assessment is often subjective and students often struggle with identifying the areas where they need to make improvements. These students are unconscious in their shortcomings and may not realize the need for adjustments (or how to make adjustments). A preceptor once asked for me to place myself into a category – unconsciously incompetent, consciously incompetent, consciously competent, or unconsciously competent. These categories are known as the four stages of competency. When you are unconsciously incompetent, you are unaware of a knowledge gap. When you are consciously incompetent, you are aware of a knowledge gap and recognize the importance of filling this gap. For those who are consciously competent, they know the information but they need to put forth conscious effort to recall the information or perform the task. Finally, unconsciously competent refers to knowing the information and being able to easily perform the skill without much conscious effort or thought.6 It is hard for students that are unconsciously incompetent to be aware of what they do not know.  Thus, continually practicing self-assessment can help the learner develop the skills needed to identify areas that need improvement. Self-assessment can, at first, be facilitated by teachers giving students feedback on their performance and then asking the students to reflect on how they think they performed (or vice versa). This helps students gain a sense of direction on the things they can improve, while also prompting them to independently think about how they can improve.

Source: The Four Stages of Competence [Internet]. Timothy S. Bates. 2014. Available from:

One study looked at the impact of self-assessment on academic performance in students. Eighty-nine students took a test and then self-assessed their performance by grading their exams under the supervision of a teacher. Following this, the teachers also graded the test and provided feedback to the students. A second test was given on the same topic and was graded solely by the teachers. From this, the two scores from both the student-graded test and the teacher-graded test were then calculated. The study found that 74% of students scored higher on the second test. This helped to show that after the students had self-assessed their own performance, they were able to identify the areas of shortcomings in order to improve on them for the next exam.

This same study, however, also showed some of the pitfalls that may occur with self-assessments. An analysis of the first student-graded test was performed to assess the difference in scoring between the student’s score versus the teacher’s score.  The majority of the students (74%) gave themselves significantly higher scores than what the teacher had given them. This highlights that self-assessment is subjective, and that being able to accurately assess one’s performance is difficult for some students. Ways to combat this include giving students a rubric to follow, showing an example of good performance and comparing it to a not-so-good performance, or grading a paper together as a group. In the study, the student’s and teachers’ perceptions about the self-assessment process were gathered using questionnaires. The teachers believed that having the students perform the self-assessment was effective in promoting student self-learning. The students found the process beneficial but time-consuming. While as teachers we can never give back time, we can reiterate the importance of the task as a worthwhile investment of time. Reminding the students that self-assessment will help them in future learning and performances will help the student understand why the self-assessment activity is being done. The authors of the study concluded that self-assessment can serve to increase the motivation for students to both want to perform better and help develop self-directed learning skills.6

It might be beneficial for students to develop a list of their “successes” and “failures” in order to reflect on them. When were times they were disappointed in their performance, and how could they avoid these same disappointments from happening in the future? When was a time they were proud of their work, and what were the steps they took in order for this to happen? If other people have provided feedback on the student’s performance, it might be beneficial for them to reflect on this in their self-assessment as well. The student needs to really reflect and narrate on their experience to improve from it, rather than just regurgitate a list. Of course, it’s important to remember when writing a self-assessment that there is always room for improvement. Self-assessment isn’t remediation, only for those who are performing poorly.  Even when a student is performing well, there are still things to learn from that experience that can benefit the student in future exams and experiences.7,8


  1. Loveless B. Helping students thrive by using self-assessment [Internet]. Education Corner.
  2. Lovett M. Exam Wrappers [Internet]. Eberly Center - Carnegie Mellon University.
  3. Mcdaniel R. Metacognition [Internet]. Vanderbilt University. 1970.
  4. Burch N. The Four Stages of Competence [Internet]. Mercer County Community College.
  5. Assessment Resource Centre [Internet]. Centre of Enhancement for Teaching and Learning.
  6. Hertzberg K. How to Write a Self-Evaluation [Internet]. Grammarly; 2020.
  7. How to write a performance evaluation self-assessment [Internet]. Business News Daily.

December 2, 2021

Cameras on! Requiring Cameras “on” in the Virtual Classroom

by Sydney Kennedy, PharmD, PGY1 Pharmacy Practice Resident, University of Mississippi Medical Center

The Covid-19 pandemic forced employees of many industries into remote work, most often from home. Likewise, students were forced to rapidly transition to remote learning.  The rapid transition from in-person to remote instruction posed challenges to both learners and educators. From an educator’s standpoint, requiring the use of cameras during remote instruction most closely approximates the face-to-face interaction that occurs in an in-person classroom.  The assumption is that interacting “face-to-face” will increase student participation, but is this true? There is controversy about whether requiring cameras to be “on” during meetings and classes improves the quality of the meeting or the instruction. The lay press reports how students and workers are feeling drained after attending face-to-face virtual meetings.  Some call this phenomenon “Zoom fatigue.” The impact on students who have been, by necessity, forced to learn in a virtual environment has not been studied. There may be consequences of the virtual environment caused by prolonged video conferencing.  Just because you ‘can’ use video cameras does not necessarily mean that using video leads to better outcomes.

A recent study entitled “The Fatiguing Effects of Camera Use in Virtual Meetings: A Within-Person Field Experiment” reveals the negative impact that a “camera’s on” policy might have. This was a four-week field experiment.  The authors hypothesized that virtual meetings would be more fatiguing for women and those who were newer members of the organization.  The study was performed to gather insights about best practices for virtual meetings. The study involved 103 employees that were largely female (56.3%) who had been with the organization, on average, for about three years. The participants were randomly assigned to the camera study condition, “on” or “off.” The camera “on” or “off” condition was the independent variable, and all participants were given a survey instrument that included questions about how they felt during the meeting. Fatigue was significantly greater in the camera “on” group (p < 0.001). Camera use also negatively effected engagement (p < 0.001). This was assessed by participant ratings on the survey after each meeting to the question, “in meetings today, when I had something to say, I felt like I had a voice.” The association between camera use and fatigue was stronger for women than men (p < 0.001). Additionally, there was a positive relationship between camera use and fatigue among those employees with the shortest tenure with the organization (p < 0.001). Overall, these results suggest that camera use is particularly fatiguing for women and newer employees.

The results of this study align with the theory that virtual meeting participants feel that they need to actively manage impressions when their cameras are on.  When the participants’ are on camera, they experience a “self-presentation” effect that causes fatigue. Thus, encouraging (or requiring) employees or students to turn cameras on may be harmful and actually hinder engagement. 

To date, there are no studies that have evaluated whether different camera angles would be less fatiguing by being able to give the learner the ability to minimize the self-presentation effects. Self-presentation may be fatiguing due to pressure to “look” competent while maintaining societal appearance standards. There are limitations to these findings, however, such as not being able to evaluate the long-term effects of virtual meetings over time and whether the size of the virtual meetings contributes to these effects.

While this study evaluated people in an employment context, I believe the results can be extrapolated to the virtual classroom. Similar to students, employees are being evaluated on performance and engagement in discussions. There may be additional reasons contributing to fatigue in the virtual classroom. The amount of close-up eye contact with the instructor and other students is not a natural distance when compared to in-person classrooms. Furthermore, students may be spending a lot of time acknowledging self (e.g., looking at themselves) rather than the educator — a phenomenon that does not occur during in-person classes. Additionally, the frame of the camera is small and limits normal mobility.  This can be physically straining. Lastly, the cognitive load is higher in a video environment because it’s more challenging to pick up on nonverbal cues and therefore work much harder to send and receive signals. 

There have been several proposed solutions to these problems. It may be beneficial to reduce the size of the window on the monitor to reduce the student’s face size. For those who use laptop computers, external keyboards can increase the distance between the learner and the video monitor. It has also could be suggested to build in camera “off” time spaced throughout the day to give the students nonverbal rest. 

Admittedly, this topic is controversial.  But the results of this study provide some evidence that requiring “cameras on” during video conferencing may not always be beneficial and may contribute to a negative learning environment. Clearly, we need to learn more about the effects of cameras on student learning and performance! However, educators should be cognizant of some of the negative consequences of “cameras on” in their virtual classrooms.


  1. Shockley KM, Gabriel AS, Robertson D, et al. The fatiguing effects of camera use in virtual meetings: A within-person field experiment. J Appl Psychol. 2021 Aug;106(8):1137-1155.
  2. Ramachandran V. Stanford researchers identify four causes for ‘Zoom fatigue’ and their simple fixes.. Stanford News 2021. Accessed November 2021.