Alshareef et al.

BMC Medical Education (2024) 24:907 BMC Medical Education

https://doi.org/10.1186/s12909-024-05894-1

RESEARCH Open Access

The role of emotions in academic

performance of undergraduate medical
students: a narrative review
Nora Alshareef1,2*, Ian Fletcher2 and Sabir Giga2

Abstract
Background This paper is devoted to a narrative review of the literature on emotions and academic performance
in medicine. The review aims to examine the role emotions play in the academic performance of undergraduate
medical students.
Methods Eight electronic databases were used to search the literature from 2013 to 2023, including Academic
Search Ultimate, British Education Index, CINAHL, Education Abstract, ERIC, Medline, APA Psych Articles and APA Psych
Info. Using specific keywords and terms in the databases, 3,285,208 articles were found. After applying the predefined
exclusion and inclusion criteria to include only medical students and academic performance as an outcome, 45
articles remained, and two reviewers assessed the quality of the retrieved literature; 17 articles were selected for the
narrative synthesis.
Result The findings indicate that depression and anxiety are the most frequently reported variables in the reviewed
literature, and they have negative and positive impacts on the academic performance of medical students. The
included literature also reported that a high number of medical students experienced test anxiety during their study,
which affected their academic performance. Positive emotions lead to positive academic outcomes and vice versa.
However, Feelings of shame did not have any effect on the academic performance of medical students.
Discussion The review suggests a significant relationship between emotions and academic performance among
undergraduate medical students. While the evidence may not establish causation, it underscores the importance of
considering emotional factors in understanding student performance. However, reliance on cross-sectional studies
and self-reported data may introduce recall bias. Future research should concentrate on developing anxiety reduction
strategies and enhancing mental well-being to improve academic performance.
Keywords Emotions, Medical students, Academic performance

*Correspondence:
Nora Alshareef
Dr.nourat@gmail.com
1
King Abdulaziz University, Jeddah, Saudi Arabia
2
Lancaster University, Lancaster, UK

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Alshareef et al. BMC Medical Education (2024) 24:907 Page 2 of 17

Introduction According to the literature, 11–40% of medical stu-

Studying medicine is a multi-dimensional process involv- dents suffer from stress, depression, and anxiety due to
ing acquiring medical knowledge, clinical skills, and the intensity of medical school, and these negative emo-
professional attitudes. Previous research has found that tions impact their academic achievement [14, 15]. Severe
emotions play a significant role in this process [1, 2]. Dif- anxiety may impair memory function, decrease concen-
ferent types of emotions are important in an academic tration, lead to a state of hypervigilance, and interfere
context, influencing performance on assessments and with judgment and cognitive function, further affecting
evaluations, reception of feedback, exam scores, and academic performance [16]. However, some studies have
overall satisfaction with the learning experience [3]. In suggested that experiencing some level of anxiety has a
particular, medical students experience a wide range of positive effect and serves as motivation that can improve
emotions due to many emotionally challenging situa- academic performance [16, 17].
tions, such as experiencing a heavy academic workload, Despite the importance of medical students’ emotions
being in the highly competitive field of medicine, retain- and their relation to academic performance, few studies
ing a large amount of information, keeping track of a have been conducted in this area. Most of these stud-
busy schedule, taking difficult exams, and dealing with a ies have focused on the prevalence of specific emotions
fear of failure [4–6].Especially during their clinical years, without correlating with medical students’ academic per-
medical students may experience anxiety when interact- formance. Few systematic reviews have addressed the
ing with patients who are suffering, ill, or dying, and they emotional challenges medical students face. However,
must work with other healthcare professionals. There- there is a lack of comprehensive reviews that discuss the
fore, it is necessary to understand the impact of emotions role of emotions and academic outcomes. Therefore, this
on medical students to improve their academic outcomes review aims to fill this gap by exploring the relationship
[7]. between emotions and the academic performance of
To distinguish the emotions frequently experienced by medical students.
medical students, it is essential to define them. Depres-
sion is defined by enduring emotions of sadness, despair, Aim of the study
and a diminished capacity for enjoyment or engagement This review aims to examine the role emotions play in
in almost all activities [4]. Negative emotions encom- the academic performance of undergraduate medical
pass unpleasant feelings such as anger, fear, sadness, and students.
anxiety, and they frequently cause distress [8]. Anxiety
is a general term that refers to a state of heightened ner- Methods
vousness or worry, which can be triggered by various A systematic literature search examined the role of emo-
factors. Test anxiety, on the other hand, is a specific type tions in medical students’ academic performance. The
of anxiety that arises in the context of taking exams or search adhered to the concepts of a systematic review,
assessments. Test anxiety is characterised by physiologi- following the criteria of Preferred Reporting Items for
cal arousal, negative self-perception, and a fear of failure, Systematic Reviews and Meta-Analyses (PRISMA)
which can significantly impair a student’s ability to per- [18]. Then, narrative synthesise was done to analyse the
form well academically [9, 10]. Shame is a self-conscious retrieved literature and synthesise the results. A system-
emotion that arises from the perception of having failed atic literature search and narrative review provide com-
to meet personal or societal standards. It can lead to feel- plete coverage and flexibility to explore and understand
ings of worthlessness and inadequacy, severely impact- findings. Systematic search assures rigour and reduces
ing a student’s motivation and academic performance bias, while narrative synthesis allows for flexible integra-
[11, 12]. In contrast, positive emotions indicate a state tion and interpretation. This balance improves review
of enjoyable involvement with the surroundings, encom- quality and utility.
passing feelings of happiness, appreciation, satisfaction,
and love [8]. Eligibility criteria
Academic performance generally refers to the out- Inclusion criteria
comes of a student’s learning activities, often measured The study’s scope was confined to January 2013 to
through grades, scores, and other formal assessments. December 2023, focusing exclusively on undergradu-
Academic achievement encompasses a broader range of ate medical students. The research encompassed articles
accomplishments, including mastery of skills, attainment originating within medical schools worldwide, accept-
of knowledge, and the application of learning in practical ing content from all countries. The criteria included only
contexts. While academic performance is often quantifi- full-text articles in English published in peer-reviewed
able, academic achievement includes qualitative aspects journals. Primary research was considered, embracing
of a student’s educational journey [13]. quantitative and mixed-method research. The selected
Alshareef et al. BMC Medical Education (2024) 24:907 Page 3 of 17

studies had to explicitly reference academic performance, were excluded, and the study did not limit itself to a par-
test results, or GPA as key outcomes to address the ticular type of research. Qualitative studies were excluded
research question. from the review because they did not have the quantita-
tive measures required to answer the review’s aim. This
Exclusion criteria review excluded articles on factors impacting academic
The study excluded individuals beyond the undergradu- performance, those analysing nursing students, and gen-
ate medical student demographic, such as students in der differences. The reasons and numbers for excluding
other health fields and junior doctors. There was no articles are shown in Table 1.
imposed age limit for the student participants. The
research specifically focused on articles within medi- Information sources
cal schools, excluding those from alternative settings. It Eight electronic databases were used to search the lit-
solely considered full-text articles in English-language erature. These were the following: Academic Search
peer-reviewed journals. Letters or commentary articles Ultimate, British Education Index, CINAHL, Education
Abstract, ERIC, Medline, APA Psych Articles and APA
Table 1 The reasons and numbers for excluding articles Psych Info. The databases were chosen from several fields
Main reason No. of articles based on relevant topics, including education, academic
Excluding any duplicates and letters and commentary 1592 evaluation and assessment, medical education, psychol-
Other Factors Affecting Academic Performance ogy, mental health, and medical research. Initially, with
Mentoring 3 the help of a subject librarian, the researcher used all the
Emotional intelligence 20 above databases; the databases were searched with spe-
Studying habits 10 cific keywords and terms, and the terms were divided
Testing scales 19 into the following concepts emotions, academic perfor-
Conference papers 3 mance and medical students. Google Scholar, EBSCO-
Gender discrimination 5 host, and the reference list of the retrieved articles were
Environment 13 also used to identify other relevant articles.
Physiological factors (menses, sleep) 22
Motivation 5 Search strategy
Perfectionism 3
This review started with a search of the databases. Eight
Computer use 5
electronic databases were used to search the literature
Grading system 4
from 2013 to 2023. Specific keywords and terms were
Socioeconomic factors 6
used to search the databases, resulting in 3,285,208 arti-
Only exam anxiety 1
cles. After removing duplicates, letters and commentary,
Math course 1
this number was reduced to 1,637 articles. Exclusion and
Smoking 9
inclusion criteria were then applied, resulting in 45 arti-
Depression 7
cles. After two assessors assessed the literature, 17 arti-
Patient safety 1
Stress management 5
cles were selected for the review. The search terms are as
Counselling 1
follows:
Clerkship 1
Keywords: Emotion, anxiety, stress, empathy, test anxi-
Quality of life 12 ety, exam anxiety, test stress, exam stress, depression,
Only Empathy 7 emotional regulation, test scores, academic performance,
OSCE/ Assessment tools 6 grades, GPA, academic achievement, academic success,
Mindfulness 11 test result, assessment, undergraduate medical students
Medication 3 and undergraduate medical education.
Mental health 7 Emotions: TI (Emotion* OR Anxiety OR Stress OR
Communication skills 3 empathy) OR emotion* OR (test anxiety or exam anxi-
Academic Engagement 5 ety or test stress or exam stress) OR (depression) OR
Compassion 1 AB ((Emotion* OR Anxiety OR Stress OR empathy) OR
EEG 1 emotion* OR (test anxiety or exam anxiety or test stress
Neuroimage 2 or exam stress)) (MH “Emotions”) OR (MH “Emotional
Music 3 Regulation”) DE “EMOTIONS”.
Nursing students 20 Academic performance: TI (test scores or academic
Junior doctors 1 performance or grades or GPA) OR (academic achieve-
Not Medical 3 ment or academic performance or academic success)
Primary health care 1 OR (test result* OR assessment*) OR AB (test scores or
Alshareef et al. BMC Medical Education (2024) 24:907 Page 4 of 17

academic performance or grades or GPA) OR (academic (e.g., midterm, final exams), Clinical assessments (e.g.,
achievement or academic performance or academic suc- practical exams, clinical rotations), Overall grade point
cess) OR test result* OR assessment*. average (GPA) or any other relevant indicators of aca-
Medical Students: TI (undergraduate medical students demic achievement.
OR undergraduate medical education) OR AB (under- Data were sought for all outcomes, including all mea-
graduate medical students OR undergraduate medical sures, time points, and analyses within each outcome
education), TI “medical students” OR AB “medical stu- domain. In cases where studies reported multiple mea-
dents” DE “Medical Students”. sures or time points, all relevant data were extracted to
provide a comprehensive overview of academic perfor-
Selection process mance. If a study reported outcomes beyond the pre-
This literature review attempts to gather only peer- defined domains, inclusion criteria were established to
reviewed journal articles published in English on determine whether these additional outcomes would be
undergraduate medical students’ negative and positive included in the review. This involved assessing relevance
emotions and academic performance from January 2013 to the primary research question and alignment with the
to December 2023. Their emotions, including depression, predefined outcome domains.
anxiety, physiological distress, shame, happiness, joy,
and all emotions related to academic performance, were Quality assessment
examined in quantitative research and mixed methods. The quality and risk of bias in included studies were
Moreover, to focus the search, the author specified and assessed using the National Institute of Health’s (NIH)
defined each keyword using advanced search tools, such critical appraisal tool. The tool evaluates studies based on
as subject headings in the case of the Medline database. the following domains: selection bias, performance bias,
The author used ‘MeSH 2023’ as the subject heading, detection bias, attrition bias, reporting bias, and other
then entered the term ‘Emotion’ and chose all the rele- biases. Two independent reviewers assessed the risk of
vant meanings. This method was applied to most of the bias in each included study. Reviewers worked collab-
keywords. oratively to reach a consensus on assessments. Discrep-
Studies were included based on predefined criteria ancies were resolved through discussion and consensus.
related to study design, participants, exposure, outcomes, In cases of persistent disagreement, a third reviewer was
and study types. Two independent reviewers screened consulted.
each record, and the report was retrieved. In the screen- To determine the validity of eligible articles, all the
ing process, reviewers independently assessed each arti- included articles were critically appraised, and all review-
cle against the inclusion criteria, and discrepancies were ers assessed bias. The validity and reliability of the results
resolved through consensus during regular team meet- were assessed by using objective measurement. Each arti-
ings. In cases of persistent disagreement, a third reviewer cle was scored out of 14, with 14 indicating high-quality
was consulted. Endnote library program was used for research and 1 indicating low-quality research. High-
the initial screening phase. This tool was used to identify quality research, according to the NIH (2013), includes
duplicates, facilitated the independent screening of titles a clear and focused research question, defines the study
and abstracts and helped to retrieve the full-text articles. population, features a high participation rate, mentions
The reasons for excluding the articles are presented in inclusion and exclusion criteria, uses clear and specific
Table 1. measurements, reports results in detail, lists the con-
founding factors and lists the implications for the local
Data collection process community. Therefore, an article was scored 14 if it met
Two independent reviewers extracted data from the eli- all criteria of the critical appraisal tool. Based on scor-
gible studies, with any discrepancies resolved through ing, each study was classified into one of three quality
discussion and consensus. If the two primary reviewers categories: good, fair or poor. The poorly rated articles
could not agree, a third reviewer served as an arbitra- mean their findings were unreliable, and they will not
tor. For each included study, the following information be considered, including two articles [16, 19]. Seventeen
was extracted and recorded in a standardised database: articles were chosen after critical appraisal using the NIH
first author name, publication year, study design, sample appraisal tool, as shown in Table 2.
characteristics, details of the emotions exposed, outcome
measures, and results. Effect measures
For each outcome examined in the included studies,
Data items various effect measures were utilised to quantify the rela-
Academic performance as an outcome for medical stu- tionship between emotions and academic performance
dents was defined to include the following: Exam scores among undergraduate medical students. The effect
Alshareef et al. BMC Medical Education (2024) 24:907 Page 5 of 17

Table 2 Study characteristics table

No. Author/year Country Methodology Aim Population Tools Findings Quality
scoring
1 Aboalshamat Saudi Arabia Cross-section To evaluate the (n = 422) 1. Depression 1. Depression 9/14
(2015) Study psychological preclinical Anxiety Stress is the only psy- Good
health of medical medical Scale chological factor
students and and dental 2. General Self- linked to academic
the relationship students Efficacy Scale performance
between psycho- (2nd and 3rd 3-Satisfaction with 2. η2 for the effect
logical health and year) Life Scale of depression on
their academic 3. Students’ aca- academic perfor-
success demic weighted mance is 0.018;
grades this value indicates
that depression
explains 1.8% of
the variance in
academic per-
formance (Small
effect size)
2 Behrens (2019) Chile/South Mixed-method 1. Investigate (n = 55) 1. Achieve- 1. Challeng- 13/14
America study achievement 6th-year ment Emotion ing simulations Good
emotions and medical Questionnaire increase learning,
simulation-based students 2. Observational motivation and
learning ward round as- success in medical
2. Relation- sessment tool students
ship between 3. Focus groups 2. In the
achievement 4. Simulation simulation, some
emotions and students encoun-
medical students’ tered shame,
performance which appeared
3. The effect of to be a potent
emotions on external motivator
learning for learning
However, the
study found non-
significant cor-
relations between
achievement
emotions and
performance
3 Ben-Loubir Morocco Cross-section To investigate (n = 275) 1. Socio-demo- Test anxiety nega- 8/14
(2014) the association Medical graphic scale tively correlates Fair
between test Students 2. Test anxiety with academic
anxiety and aca- scale abilities (r=-0.39)
demic skills. 3. Academic Skills (Large effect size)
Questionnaire
4 Burr and Nebraska/USA Cross-section The relationship (n = 264) 1. Achievement Correlation 8/14
Dallaghan study between achieve- 1st and 2nd- Emotions to academic Fair
(2019) ment emo- year medical 2. The Maslach performance:
tions, burnout, students Burnout Inventory Professional
and academic 3. General Survey efficacy(r = 0.57),
performance? 4. Academic Hope(r = 0.50),
performance pride (r = 0.41),
(final overall anxiety (r = 0.30)
percentage for and
the semester) shame (r =. 40)
Professional
efficacy was the
most significant
factor in academic
performance,
explaining 31.3%
of the variance
Alshareef et al. BMC Medical Education (2024) 24:907 Page 6 of 17

Table 2 (continued)
No. Author/year Country Methodology Aim Population Tools Findings Quality
scoring
5 Del-ben (2013) Brazil Cross-section 1. To assess (n = 85) 1. Beck’s There was no cor- 8/14
academic motiva- 1st-year Anxiety and Beck’s relation between Fair
tion, anxiety, medical Depression academic motiva-
depression and students 2. Social Adjust- tion, anxiety and
social adjustment ment Scale depressive and
among first-year 3. The Academic social adjustment
medical students Motivation Scale with academic
2. Determine 4. GPA achievement
the influence on
their academic
performance
6 Dendle (2018) Australia one-year pro- Examine the (n = 126) 1. Kessler psycho- There was no cor- 9/14
spective cohort impacts of 1st year logical distress relation between Good
study workplace and medical scale the anxiety
study-related students 2. The Gen- and academic
stress factors on eral Health performance
students’ psycho- Questionnaire
logical distress 3. Sources of
and academic workplace stress
performance 4. Academic
during their first scores
clinical year
7 Green (2016) Connecticut/USA Cross-section & 1. Determine (n = 25) 1. Westside test 1. Test anxiety 10/14
RCT the relationship 2nd-year anxiety negatively corre- Good
between test medical 2. USMLE score lated with USMLE
anxiety and per- students be- 3. Medical college step 1 (r= − 0.24)
formance on the fore USLME admission test 2. A test-taking
(USMLE) exam step-1 strategy course
2. Determine relatively reduced
the impact of a anxiety but did
test-taking strate- not increase test
gies course on scores
test anxiety and 3. Anxiety may im-
USMLE scores pair performance
by interfering
with attention to
task-relevant infor-
mation, decreas-
ing the cognitive
resources available
for task processing
8 Hahn (2017) Germany Quantitative To investigate (n = 200) 1. Multiple Choice 1. Anxiety did 5/10
Explorative study the relationship Second-year Vocabulary Intel- not correlate Poor
between anxiety, medical ligence Test with depressive
depression and students 2. State-Trait-Anxi- symptoms or past
academic perfor- ety Inventory or future academic
mance among 3. Beck’s Depres- achievement
medical students sion Inventory II 2. Depression
did not correlate
with academic
performance
Alshareef et al. BMC Medical Education (2024) 24:907 Page 7 of 17

Table 2 (continued)
No. Author/year Country Methodology Aim Population Tools Findings Quality
scoring
9 Hautz Swiss RCT To further (n = 49) Experimental 1. Students train- 9/14
(2017) (Shame) enhance the 4th and 3rd shame scale. Out- ing with a stan- Good
understanding of medical come assessed: dardised patient
state shame students number of lumps experienced more
and its influence correctly docu- shame during
on learning mented during training
final performance 2. Shame does not
assessment, time have any effect on
on task and OSCE OSCE scores
score
10 Hayat (2018) Iran descriptive-cor- The role of (n = 370) 1. Academic 1. Motivation 9/14
relative study medical students’ medical emotions (β = 0.56) and Good
emotions and students Questionnaire positive emotions
motivation in 2. Work prefer- (β = 0.11) increase
their academic ence inventory medical students’
achievement 3. Academic score academic perfor-
mance, explain-
ing 40% of the
variance
2. Negative
emotions: anger,
anxiety, hopeless-
ness, shame, and
boredom, were
found to have a
negative and sig-
nificant correlation
with the academic
achievement of
learners (r=-0.15,
r = 0.24, r = 0.23, r=-
0.215, and r=-0.21)
(small effect)
11 Kausar (2018) Pakistan Cross-section To explore the ef- (n = 79) Medical Student Pre-exam stress 9/14
fect of pre-exam Students of Stressors enhances medical Good
stress levels of final medical Questionnaire students’ academ-
final-year medi- year ic performance
cal students on x2 = 23.52 (p = 0.00)
their academic (W = 0.78 large
performance effect)
12 Kim Korea Cross-section Investigate the (n = 101) 1. Korean Achieve- 1. Test anxiety is 7/14
(2016) effect of test 3rd and 4th ment Emotions moderately associ- Fair
anxiety on OSCE year medical Questionnaire ated with achieve-
among Medical students ment emotions in
students the class, which
are anxiety and
boredom (r = 0.46
and 0.32, p < 0.00)
2-Test anxiety is
not significantly
correlated with
the OSCE scores
(r = 0.09, p = 0.40)
or GPAs (r = 0.09,
p = 0.41)
Alshareef et al. BMC Medical Education (2024) 24:907 Page 8 of 17

Table 2 (continued)
No. Author/year Country Methodology Aim Population Tools Findings Quality
scoring
13 Junaid (2020) Saudi Arabia Analytical Prevalence of (n = 247) 1. Beck Anxiety Anxiety was high 5/14
Cross section anxiety and its medical Inventory and negatively Poor
effect on the students 2. GPA correlated with
academic perfor- academic
mance among performance
medical students mean CGPA = 3.93,
SD = 0.88, p = 0.00
Cohen’s
d = 1.1 (large effect
size)
14 Mihailescu Romania Quantitative Association (n = 254) 1. Zung Self-rating Depression and 9/14
(2016) Cross-section between anxiety 1st and 2nd- Anxiety scale anxiety are nega- Good
and depression year medical 2. Zung Self-rating tively correlated
and academic students Depression Scale with academic
performance 3. GPA performance in
medical students
(rho=-0.14,
p < 0.05), (rho=-
0.19, p < 0.05)
15 Moreira (2018) Portugal Cross-section Prevalence of Total 1. Socio-demo- Depression is 7/14
anxiety and (n = 750) graphic survey associated with Fair
depression in students 2. Hospital Anxiety poor academic
Portuguese (n = 512) and Depression performance but
medical students medical Scale (HADS) is not statistically
compared to students significant. Anxiety
non-medical and (n = 238) negatively signifi-
students nonmedical cantly associated
students with the average
curricular grade
χ2 = 4.49; p < 0.00
(W = 0.76 large
effect size)
16 Nazir et al. Pakistan Cross-section Assess test (n = 680) 1. Test anxiety There is a signifi- 7/14
(2021) anxiety and its medical inventory cant association Fai
influencing fac- students between test anxi-
tors on medical ety and academic
students performance, with
excellent students
exhibiting lower
levels of test anxi-
ety compared to
those with lower
academic grades
OR = 1.47 (95%
CI:1.05, 2.06),
P = 0.02
17 Zalihic (2017) Bosna and Cross section Examine the (n = 100) 1. Anxiety Sensi- Anxiety has a 8/14
Hercegovina impact of anxiety 1stand 5th- tivity Index positive statisti- Fair
sensitivity on the year medical cally significant
success of medi- students on academic
cal students performance
OR = 1.28 (95% CI:
1.16–1.51), p = 0.00

measures commonly reported across the studies included and the statistical analysis conducted in each study. These
prevalence rat, correlation coefficients, and mean dif- measures were used to assess the strength and direction
ferences. The reviewer calculated the effect size for the of the association between emotional factors and aca-
studies that did not report the effect. The choice of effect demic performance.
measure depended on the nature of the outcome variable
Alshareef et al. BMC Medical Education (2024) 24:907 Page 9 of 17

The synthesis method the critical influence of control and value evaluations on
The findings of individual studies were summarised to students’ emotional experiences and academic achieve-
highlight crucial characteristics. Due to the predicted ments [21, 22].
heterogeneity, the synthesis involved pooling effect esti-
mates and using a narrative method. A narrative synthe- Data extraction
sis approach was employed in the synthesis of this review For this step, a data extraction sheet was developed using
to assess and interpret the findings from the included the data extraction template provided by the Cochrane
studies qualitatively. The narrative synthesis involved Handbook. To ensure the review is evidence-based and
a qualitative examination of the content of each study, bias-free, the Cochrane Handbook strongly suggests that
focusing on identifying common themes. This synthesis more than one reviewer review the data. Therefore, the
was employed to categorise and interpret data, allowing main researcher extracted the data from the included
for a nuanced understanding of the synthesis. Themes studies, and another reviewer checked the included,
related to emotions were identified and extracted for excluded and extracted data. Any disagreements were
synthesis. Control-value theory [20] was used as an over- resolved via discussion by a third reviewer. The data
arching theory, providing a qualitative synthesis of the extraction Table 2 identified all study features, including
evidence and contributing to a deeper understanding of the author’s name, the year of publication, the method
the research question. If the retrieved articles include used the aim of the study, the number and description of
populations other than medical, such as dental students participants, data collection tools, and study findings.
or non-medical students, the synthesis will distinguish
between them and summarise the findings of the medical Finalisation of references and study characteristics
students only, highlighting any differences or similarities. PRISMA sheet and the summary of final studies that have
The Control-Value Theory, formulated by Pekrun been used for the review
(2006), is a conceptual framework that illustrates the When the keywords and search terms related to emo-
relationship between emotions and academic achieve- tions, as mentioned above, in the eight databases listed,
ment through two fundamental assessments: control 3,285,208 articles were retrieved. After using advanced
and value. Control pertains to the perceived ability of a search and subject headings, the number of articles
learner to exert influence over their learning activities increased to 3,352,371. Similarly, searching for the sec-
and the results they achieve. Value relates to a student’s ond keyword, ‘academic performance,’ using all the
significance to these actions and results. The theory sug- advanced search tools yielded 8,119,908 articles. Search-
gests that students are prone to experiencing good feel- ing for the third keyword, ‘medical students’, yielded
ings, such as satisfaction and pride when they possess 145,757 articles. All terms were searched in article titles
a strong sense of control and importance towards their and abstracts. After that, the author combined all search
academic assignments. On the other hand, individuals terms by using ‘AND’ and applied the time limit from
are prone to encountering adverse emotions (such as fear 2013 to 2023; the search narrowed to 2,570 articles. After
and embarrassment) when they perceive a lack of control duplicates, letters and commentary were excluded, the
or worth in these particular occupations. These emo- number was reduced to 1,637 articles. After reading the
tions subsequently impact students’ motivation, learning title and abstract to determine relevance to the topic
strategies, and, eventually, their academic achievement. and applying the exclusion and inclusion criteria men-
The relevance of control-value theory in reviewing medi- tioned above, 45 articles remained; after the quality of
cal student emotions and their influence on academic the retrieved literature was assessed by two reviewers, 17
performance is evident for various reasons. This theory articles were selected for the review. The PRISMA flow
offers a complete framework that facilitates comprehend- diagram summarising the same is presented in Fig. 1.
ing the intricate connection between emotions and aca- Additionally, One article by Ansari et al. (2018) was
demic achievement. It considers positive and negative selected for the review; it met most inclusion and exclu-
emotions, providing a comprehensive viewpoint on how sion criteria except that the outcome measure is cogni-
emotions might influence learning and performance. tive function and not academic performance. Therefore,
The relevance of control and value notions is particularly it was excluded from the review. Figure 1 shows the
significant for medical students due to their frequent Prisma flow diagram (2020) of studies identified from the
exposure to high-stakes tests and difficult courses. Gain- databases.
ing insight into the students’ perception of their power
over academic assignments and the importance they Study characteristics
attach to their medical education might aid in identify- Table 2, summarising the characteristics of the included
ing emotional stimuli and devising remedies. Multiple studies, is presented below.
research has confirmed the theory’s assertions, showing
Alshareef et al. BMC Medical Education (2024) 24:907 Page 10 of 17

Fig. 1 Prisma flow diagram (2020)

Findings of the study Population and study setting

Country of the study Regarding population and setting, most of the studies
Many of the studies were conducted in developing coun- focused on all medical students studying in a medical
tries, with the majority being conducted in Europe (n = 4), school setting, from first-year medical students to those
followed by Pakistan (n = 2), then Saudi Arabia (n = 2), and in their final year. One study compared medical students
the United States (n = 2). The rest of the studies were con- with non-medical students; another combined medical
ducted in South America (n = 1), Morocco (n = 1), Brazil students with dental students.
(n = 1), Australia (n = 1), Iran (n = 1), South Korea (n = 1)
and Bosnia and Herzegovina (n = 1). No included studies Study aims
were conducted in the United Kingdom. The study aims varied across the included studies. Seven
studies examined the prevalence of depression and
Study design anxiety among medical students and their relation to
Regarding study design, most of the included articles academic performance. Four studies examined the rela-
used a quantitative methodology, including 12 cross- tionship between test anxiety and academic performance
sectional studies. There were two randomised controlled in medical education. Four studies examined the relation-
trials, one descriptive correlation study, one cohort study, ship between medical students’ emotions and academic
and only one mixed-method study.
Alshareef et al. BMC Medical Education (2024) 24:907 Page 11 of 17

achievements. One study explored the influence of shame academic performance, indicating a significant effect size.
on medical students’ learning. However, Del-Ben (2013) et al. did not provide the sig-
nificant impact of affective changes on academic achieve-
Study quality ment, suggesting trivial effect sizes for these factors.
The studies were assessed for quality using tools created In conclusion, anxiety and depression, both indica-
by the NIH (2013) and then divided into good, fair, and tors of psychological discomfort, are common among
poor based on these results. Nine studies had a high- medical students. There is a link between distress and
quality methodology, seven achieved fair ratings, and poor academic performance results, implying that this
only three achieved poor ratings. The studies that were relationship merits consideration. Table 3 below shows
assigned the poor rating were mainly cross-sectional the specific value of depression and anxiety in retrieved
studies, and the areas of weakness were due to the study articles.
design, low response rate, inadequate reporting of the
methodology and statistics, invalid tools, and unclear Test anxiety
research goals. In this review, four studies examined the relationship
between test anxiety and academic performance in medi-
Outcome measures cal education [27–30]. The studies found high rates of
Most of the outcome measures were heterogenous and test anxiety among medical students, ranging from 52%
self-administered questionnaires; one study used focus [27] to as high as 81.1% [29]. Final-year students tend to
groups and observation ward assessment [23]. All the experience the highest test anxiety [29].
studies used the medical students’ academic grades. Test anxiety has a significant negative correlation with
academic performance measures and grade point average
Results of the study (GPA) [27–29]. Green et al. (2016) found that test anxiety
The prevalence rate of psychological distress in the was moderately negatively correlated with USMLE score
retrieved articles (r= − 0.24, p = 0.00); high test anxiety was associated with
Depression and anxiety are the most common forms of low USMLE scores in the control group, further suggest-
psychological distress examined concerning academic ing that anxiety can adversely affect performance. The
outcomes among medical students. Studies consistently findings that a test-taking strategy course reduced anxi-
show concerningly high rates, with prevalence estimates ety without improving test scores highlight the complex
ranging from 7.3 to 66.4% for anxiety and 3.7–69% for nature of anxiety’s impact on performance.
depression. These findings indicate psychological distress Nazir et al. (2021) found that excellent female medi-
levels characterised as moderate to high based on com- cal students reported significantly lower test anxiety
mon cut-off thresholds have a clear detrimental impact than those with low academic grades, with an odds ratio
on academic achievement [16, 24–26]. of 1.47, indicating that students with higher test anxi-
The studies collectively examine the impact of psy- ety are more likely to have lower academic grades. Kim’s
chological factors on academic performance in medical (2016) research shows moderate correlations between
education contexts, using a range of effect sizes to quan- test anxiety and negative achievement emotions such as
tify their findings. Aboalshamat et al. (2015) identified a anxiety and boredom, but interestingly, this anxiety does
small effect size (η2 = 0.018) for depression’s impact on not significantly affect practical exam scores (OSCE) or
academic performance, suggesting a modest influence. GPAs. However, one study found that examination stress
Mihailescu (2016) found a significant negative correla- enhanced academic performance with a large effect size
tion between levels of depression/anxiety (rho=-0.14, (W = 0.78), with stress levels at 47.4% among their sam-
rho=-0.19), academic performance and GPA among med- ple, suggesting that a certain stress level before exams
ical students. Burr and Beck Dallaghan (2019) reported may be beneficial [30].
professional efficacy explaining 31.3% of the variance in

Table 3 The score of depression and anxiety in the retrieved articles

Author Scale used Depression Anxiety
Abolashamat et al. (2015) Depression Anxiety Stress 69% (high) 66.4% (high)
Burr and Dallaghan (2019) Beck anxiety - 30%
Del-ben et al. (2013) Beck’s anxiety & depression 6.8 (low) 7.3 (mild)
Junaid et al., (2020) Beck anxiety - 49.4% (high)
Moreira et al. (2018) Hospital Anxiety & depression Scale 3.7% (low) 21.5% (high)
Mihailescu et al. (2016) Zung anxiety & depression 29% (low) 41% (low)
Zalihić et al. (2017) Anxiety sensitivity index - 30% (moderate)
Alshareef et al. BMC Medical Education (2024) 24:907 Page 12 of 17

Shame focusing on positive emotions and moderate anxi-

Three papers explored shame’s effect on medical stu- ety. However, no significant relationships were found
dents’ academic achievement [24, 31, 32]. Hayat et al. between positive emotions and the student’s perfor-
(2018) reported that academic feelings, like shame, sig- mance during the simulation [23].
nificantly depend on the academic year. shame was found
to have a slight negative and significant correlation with Discussion
the academic achievement of learners (r=-0.15). One This review aims to investigate the role of emotions in
study found that some medical students felt shame dur- the academic performance of undergraduate medical
ing simulations-based education examinations because students. Meta-analysis cannot be used because of the
they had made incorrect decisions, which decreased their heterogeneity of the data collection tools and different
self-esteem and motivation to learn. However, others research designs [33]. Therefore, narrative synthesis was
who felt shame were motivated to study harder to avoid adopted in this paper. The studies are grouped into four
repeating the same mistakes [23]. categories as follows: (1) The effect of depression and
Hautz (2017) study examined how shame affects medi- anxiety on academic performance, (2) Test anxiety and
cal students’ learning using a randomised controlled trial academic achievement, (3) Shame and academic perfor-
where researchers divided the students into two groups: mance, and (4) Academic performance, emotions and
one group performed a breast examination on manne- medical students. The control-value theory [20], will be
quins and the other group on actual patients. The results used to interpret the findings.
showed that students who performed the clinical exami-
nation on actual patients experienced significantly higher The effect of depression and anxiety on academic
levels of shame but performed better in examinations performance
than in the mannequin group. In the final assessments According to the retrieved research, depression and anxi-
on standardised patients, both groups performed equally ety can have both a negative and a positive impact on
well. Therefore, shame decreased with more clinical prac- the academic performance of medical students. Severe
tice, but shame did not have significant statistics related anxiety may impair memory function, decrease concen-
to learning or performance. Similarly, Burr and Dal- tration, lead to a state of hypervigilance, interfere with
laghan (2019) reported that the shame level of medical judgment and cognitive function, and further affect
students was (40%) but had no association with academic academic performance [4]. Most of the good-quality
performance. retrieved articles found that anxiety and depression
were associated with low academic performance [16,
Academic performance, emotions and medical students 24–26]. Moreira (2018) and Mihailescu (2016) found
Three articles discussed medical students’ emotions and that higher depression levels were associated with more
academic performance [23, 24, 32]. Burr and Dallaghan failed courses and a lower GPA. However, they did not
(2019) examine the relationship between academic suc- find any association between anxiety level and academic
cess and emotions in medical students, such as pride, performance.
hope, worry, and shame. It emphasises the links between By contrast, some studies have suggested that experi-
academic accomplishment and professional efficacy, as encing some level of anxiety reinforces students’ moti-
well as hope, pride, worry, and shame. Professional effi- vation to improve their academic performance [16, 34].
cacy was the most significant factor linked to academic Zalihic et al. (2017) conducted a study to investigate anxi-
performance, explaining 31.3% of the variance. The ety sensitivity about academic success and noticed a posi-
importance of emotions on understanding, processing of tive relationship between anxiety level and high academic
data, recall of memories, and cognitive burden is empha- scores; they justified this because when medical stu-
sised throughout the research. To improve academic dents feel anxious, they tend to prepare and study more,
achievement, efforts should be made to increase student and they desire to achieve better scores and fulfil social
self-efficacy. expectations. Similarly, another study found anxiety has
Hayat et al. (2018) found that positive emotions and a negative impact on academic performance when exces-
intrinsic motivation are highly connected with academic sive and a positive effect when manageable, in which case
achievement, although emotions fluctuate between edu- it encourages medical students and motivates them to
cational levels but not between genders. The correlations achieve higher scores [35].
between negative emotions and academic achievement, In the broader literature, the impact of anxiety on aca-
ranging from − 0.15 to -0.24 for different emotions, sug- demic performance has contradictory research findings.
gest small but statistically significant adverse effects. While some studies suggest that having some level of
Behren et al.‘s (2019) mixed-method study found that anxiety can boost students’ motivation to improve their
students felt various emotions during the simulation, academic performance, other research has shown that
Alshareef et al. BMC Medical Education (2024) 24:907 Page 13 of 17

anxiety has a negative impact on their academic success study examined the effects of test anxiety on working
[36, 37]. In the cultural context, education and anxiety memory capacity and found that test anxiety negatively
attitudes differ widely across cultures. High academic correlated with academic performance [44]. Therefore,
pressure and societal expectations might worsen anxi- the evidence from Song’s study suggests a small but sig-
ety in many East Asian societies. Education is highly val- nificant effect of anxiety on working memory capacity.
ued in these societies, frequently leading to significant However, another cross-sectional study revealed that test
academic stress. This pressure encompasses attaining anxiety in medical students had no significant effect on
high academic marks and outperformance in competi- exam performance [45]. The complexities of this rela-
tive examinations. The academic demands exerted on tionship necessitate additional investigation. Since the
students can result in heightened levels of anxiety. The retrieved articles are from different countries, it is critical
apprehension of not meeting expectations can lead to to recognise the possible impact of cultural differences
considerable psychological distress and anxiety, which on the impact of test anxiety. Cultural factors such as dif-
can appear in their physical and mental health and aca- ferent educational systems, assessment tools and societal
demic achievement [38, 39]. expectations may lead to variances in test anxiety expe-
rience and expression across diverse communities [46,
Test anxiety and academic achievement 47]. Culture has a substantial impact on how test anxi-
The majority of the studies reviewed confirm that test ety is expressed and evaluated. Research suggests that the
anxiety negatively affects academic performance [27– degree and manifestations of test anxiety differ among
29]. Several studies have found a significant correla- different cultural settings, emphasising the importance of
tion between test anxiety and academic achievement, using culturally validated methods to evaluate test anxi-
indicating that higher levels of test anxiety are associ- ety accurately. A study conducted by Lowe (2019) with
ated with lower exam scores and lower academic per- Canadian and U.S. college students demonstrated cul-
formance [40, 41]. For example, Green et al. (2016) RCT tural variations in the factors contributing to test anxiety.
study found that test anxiety has a moderately significant Canadian students exhibited elevated levels of physiologi-
negative correlation with the USMLE score. They found cal hyperarousal, but U.S. students had more pronounced
that medical students who took the test-taking strategy cognitive interference. These variations indicate that the
course had lower levels of test anxiety than the control cultural environment has an influence on how students
group, and their test anxiety scores after the exam had perceive and respond to test anxiety, resulting in differ-
improved from the baseline. Although their test anxiety ing effects on their academic performance in different
improved after taking the course, there was no signifi- cultures. Furthermore, scholars highlight the significance
cant difference in the exam scores between students who of carrying out meticulous instruments to assess test
had and had not taken the course. Therefore, the inter- anxiety, which are comparable among diverse cultural
vention they used was not effective. According to the cohorts. This technique guarantees that the explanations
control-value theory, this intervention can be improved of test scores are reliable and can be compared across
if they design an emotionally effective learning environ- different populations. Hence, it is imperative to com-
ment, have a straightforward instructional design, foster prehend and tackle cultural disparities in order to create
self-regulation of negative emotions, and teach students efficient interventions and assistance for students who
emotion-oriented regulation [22]. encounter test anxiety in diverse cultural environments.
Additionally, according to this theory, students who Therefore, there is a need for further studies to examine
perceive exams as difficult are more likely to experi- the level of test anxiety and cultural context.
ence test anxiety because test anxiety results from a stu-
dent’s negative appraisal of the task and outcome values, Shame and academic performance
leading to a reduction in their performance. This aligns The review examined three studies that discuss the
with Kim’s (2016) study, which found that students who impact of feelings of shame on academic performance
believed that the OSCE was a problematic exam experi- [23, 24, 48]. Generally, shame is considered a negative
enced test anxiety more than other students [9, 22, 42]. emotion which involves self-reflection and self-evalua-
In the wider literature, a meta-analysis review by von tion, and it leads to rumination and self-condemnation
der Embse (2018) found a medium significant negative [49]. Intimate examinations conducted by medical stu-
correlation (r=-0.24) between test anxiety and test perfor- dents can induce feelings of shame, affecting their abil-
mance in undergraduate educational settings [43] . Also, ity to communicate with patients and their clinical
they found a small significant negative correlation (r=- decisions. Shame can increase the avoidance of intimate
0.17) between test anxiety and GPA. This indicates that physical examinations and also encourage clinical prac-
higher levels of test anxiety are associated with lower test tice [23, 24, 48].
performance. Moreover, Song et al. (2021) experimental
Alshareef et al. BMC Medical Education (2024) 24:907 Page 14 of 17

One study found that some medical students felt hampered their decision-making process, and negatively
shame during simulations-based education examina- affected their self-esteem, which is consistent with the
tions because they had made incorrect decisions, which academic achievement emotions literature where nega-
decreased their self-esteem and motivation to learn. tive emotions are associated with poor intrinsic motiva-
However, others who felt shame were motivated to study tion and reduced the ability to learn [3].
harder to avoid repeating the same mistakes [23]. Shame The study also emphasises that mild anxiety can have
decreased with more clinical practice, but shame did positive effects, corroborated by Gregor (2005), which
not affect their learning or performance [48]. The litera- posits that moderate degrees of anxiety can improve
ture on how shame affects medical students’ learning is performance. The author suggests that an ideal state of
inconclusive [31]. arousal (which may be experienced as anxiety) enhances
In the broader literature, shame is considered maladap- performance. Mild anxiety is commonly seen as a type
tive, leading to dysfunctional behaviour, encouraging of psychological stimulation that readies the body for
withdrawal and avoidance of events and inhibiting social upcoming challenges, frequently referred to as a “fight
interaction. However, few studies have been conducted or flight” response. Within the realm of academic per-
on shame in the medical field. Therefore, more research formance, this state of heightened arousal can enhance
is needed to investigate the role of shame in medical concentration and optimise cognitive functions such
students’ academic performance [49]. In the literature, as memory, problem-solving skills, and overall perfor-
there are several solutions that can be used to tackle the mance. However, once the ideal point is surpassed, any
problem of shame in medical education; it is necessary additional increase in arousal can result in a decline in
to establish nurturing learning settings that encourage performance [53]. This is additionally supported by Cas-
students to openly discuss their problems and mistakes sady and Johnson (2002), who discovered that a spe-
without the worry of facing severe criticism. This can be cific level of anxiety can motivate students to engage in
accomplished by encouraging medical students to par- more comprehensive preparation, hence enhancing their
ticipate in reflective practice, facilitating the processing performance.
of their emotions, and enabling them to derive valu- The reviewed research reveals a positive correlation
able insights from their experiences, all while avoiding between positive emotions and academic performance
excessive self-blame [50]. Offering robust mentorship and a negative correlation between negative emotions
and support mechanisms can assist students in effec- and academic performance. These findings align with the
tively managing the difficulties associated with intimate control–value theory [8, 22], which suggests that positive
examinations. Teaching staff have the ability to demon- emotions facilitate learning through mediating factors,
strate proper behaviours and provide valuable feedback including cognitive learning strategies such as strate-
and effective mentoring [51]. Training and workshops gic thinking, critical thinking and problem-solving and
that specifically target communication skills and the han- metacognitive learning strategies such as monitoring,
dling of sensitive situations can effectively equip students regulating, and planning students’ intrinsic and extrin-
to handle intimate tests, hence decreasing the chances sic motivation. Additionally, several studies found that
of them avoiding such examinations due to feelings of extrinsic motivation from the educational environment
shame [52]. and the application of cognitive and emotional strategies
improve students’ ability to learn and, consequently, their
Academic performance, emotions and medical students academic performance [23, 24, 32]. By contrast, negative
The literature review focused on three studies that exam- emotions negatively affect academic performance. This is
ined the relationship between emotions and the academic because negative emotions reduce students’ motivation,
achievements of medical students [23, 24, 32]. concentration, and ability to process information [23, 24,
Behren et al. (2019) mixed-method study on the 32].
achievement emotions of medical students during simu-
lations found that placing students in challenging clini- Limitations of the study
cal cases that they can handle raises positive emotions. This review aims to thoroughly investigate the relation-
Students perceived these challenges as a positive drive ship between emotions and academic performance in
for learning and mild anxiety was considered beneficial. undergraduate medical students, but it has inherent
However, the study also found non-significant correla- limitations. Overall, the methodological quality of the
tions between emotions and performance during the retrieved studies is primarily good and fair. Poor-quality
simulation, indicating a complex relationship between research was excluded from the synthesis. The good-
emotions and academic performance. The results quality papers demonstrated strengths in sampling tech-
revealed that feelings of frustration were perceived to niques, data analysis, collection and reporting. However,
reduce students’ interest and motivation for studying, most of the retrieved articles used cross-section studies,
Alshareef et al. BMC Medical Education (2024) 24:907 Page 15 of 17

and the drawback of this is a need for a more causal rela- provide effective solutions for managing test anxiety. This
tionship, which is a limitation in the design of cross- gap highlights the need for practical solutions informed
sectional studies. Furthermore, given the reliance on by Pekrun’s Control-Value Theory. Ideally, a longitudinal
self-reported data, there were concerns about potential study measuring test anxiety and exam scores over time
recall bias. These methodological difficulties were noted would be the most appropriate approach. it is also neces-
in most of the examined research. When contemplating sary to explore cultural differences to develop more effec-
the implications for practice and future study, the impact tive solutions and support systems tailored to specific
of these limitations on the validity of the data should be cultural contexts.
acknowledged. The impact of shame on academic performance in
The limitation of the review process and the inclusion medical students was inconclusive. Shame is a negative
criteria restricted the study to articles published from emotion that has an intricate influence on learning out-
January 2013 to December 2023, potentially overlook- comes. The inadequacy of current literature emphasises
ing relevant research conducted beyond this timeframe. the imperative for additional research to unravel the
Additionally, the exclusive focus on undergraduate medi- nuanced role of shame in the academic journeys of medi-
cal students may constrain the applicability of findings to cal students.
other health fields or educational levels. Overall, emotions play a crucial role in shaping
Moreover, excluding articles in non-English language students’ academic performance, and research has
and those not published in peer-reviewed journals intro- attempted to find solutions to improve medical stu-
duces potential language and publication biases. Reli- dents’ learning experiences; thus, it is recommended that
ance on electronic databases and specific keywords may medical schools revise their curricula and consider using
inadvertently omit studies using different terms or index- simulation-based learning in their instructional designs
ing. While the search strategy is meticulous, it might not to enhance learning and improve students’ emotions.
cover every relevant study due to indexing and database Also, studies have suggested using academic coaching to
coverage variations. However, the two assessors’ involve- help students achieve their goals, change their learning
ment in study screening, selection, data extraction, and styles, and apply self-testing and simple rehearsal of the
quality assessment improved the robustness of the review material. Moreover, the study recommended to improve
and ensured that it included all the relevant research. medical students’ critical thinking and autonomy and
In conclusion, these limitations highlight the need for changing teaching styles to support students better.
careful interpretation of the study’s findings and stress
the importance of future research addressing these con- Supplementary Information
straints to offer a more comprehensive understanding The online version contains supplementary material available at https://doi.
org/10.1186/s12909-024-05894-1.
of the nuanced relationship between emotions and aca-
demic performance in undergraduate medical education. Supplementary Material 1

Conclusion and future research Acknowledgements

The review exposes the widespread prevalence of depres- I would like to thank Lancaster university library for helping me to search
sion, anxiety and test anxiety within the medical student the literature and to find the appropriate databases and thanks to Lancaster
university to prove access to several softwares.
population. The impact on academic performance is
intricate, showcasing evidence of adverse and favourable Author contributions
relationships. Addressing the mental health challenges of NA made substantial contributions throughout the systematic review
process and was actively involved in writing and revising the manuscript.
medical students necessitates tailored interventions for NA’s responsible for the design of the study, through the acquisition, analysis,
enhancing mental well-being in medical education. Fur- and interpretation of data, to the drafting and substantive revision of the
thermore, it is crucial to create practical strategies con- manuscript. NA has approved the submitted version and is personally
accountable for her contributions, ensuring the accuracy and integrity of
sidering the complex elements of overcoming test anxiety. the work. IF was instrumental in screening the literature, extracting data,
Future research should prioritise the advancement of and conducting the quality assessment of the included studies. Additionally,
anxiety reduction strategies to enhance academic perfor- IF played a crucial role in revising the results and discussion sections of the
manuscript, ensuring that the interpretation of data was both accurate
mance, focusing on the control-value theory’s emphasis and insightful. IF has approved the submitted version and has agreed to
on creating an emotionally supportive learning environ- be personally accountable for his contributions, particularly in terms of the
ment. Additionally, Test anxiety is very common among accuracy and integrity of the parts of the work he was directly involved in.
SG contributed significantly to the selection of papers and data extraction,
medical students, but the literature has not conclusively demonstrating critical expertise in resolving disagreements among authors.
determined its actual effect on academic performance. SG’s involvement was crucial in revising the entire content of the manuscript,
Therefore, there is a clear need for a study that exam- enhancing its coherence and alignment with the study’s objectives. SG has
also approved the submitted version and is personally accountable for his
ines the relationship between test anxiety and academic contributions, committed to upholding the integrity of the entire work.
performance. Moreover, the retrieved literature did not
Alshareef et al. BMC Medical Education (2024) 24:907 Page 16 of 17

Funding 18. Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD et al.
No funding. The PRISMA 2020 statement: an updated guideline for reporting systematic
reviews. BMJ. 2021;372.
Data availability 19. Hahn H, Kropp P, Kirschstein T, Rücker G, Müller-Hilke B. Test anxiety in
all included articles are mentioned in the manuscript, The quality assessment medical school is unrelated to academic performance but correlates with an
of included articles are located in the supplementary materials file no. 1. effort/reward imbalance. PLoS ONE. 2017;12(2):1–13.
20. Pekrun R. The control-value theory of achievement emotions: assumptions,
corollaries, and Implications for Educational Research and Practice. Educa-
Declarations tional Psychol Rev. 2006;18(4):315–41.
21. Graesser AC. Emotions are the experiential glue of learning environments in
Ethics approval and consent to participate the 21st century. Learn Instruction. 2019.
Not applicable. 22. Pekrun R, Perry RP. Control-value theory of achievement emotions. Interna-
tional handbook of emotions in education: Routledge; 2014. pp. 120 – 41.
Consent for publication 23. Behrens CC, Dolmans DH, Gormley GJ, Driessen EW. Exploring undergraduate
Consent of publication was obtained from the other authors. students achievement emotions during ward round simulation: a mixed-
method study. BMC Med Educ. 2019;19(1):316.
Competing interests 24. Burr J, Beck-Dallaghan GL. The relationship of emotions and Burnout to Medi-
The authors declare no competing interests. cal Students’ academic performance. Teach Learn Med. 2019;31(5):479–86.
25. Zalihić A, Mešukić S, Sušac B, Knezović K, Martinac M. Anxiety sensitivity as
Received: 8 March 2024 / Accepted: 12 August 2024 a predictor of academic success of medical students at the University of
Mostar. Psychiatria Danubina. 2017;29(Suppl 4):851–4.
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