Mathematics Anxiety and Undergraduate Nursing Students: A Mixed Methods Study

Abstract

ABSTRACT

Background

Sound mathematical skills are paramount for effective nursing practice and patient safety.

Objectives

To explore the factors that influence nursing student anxiety when engaging with mathematics‐related activities in nursing education.

Design

A concurrent mixed methods employing cross‐sectional online survey and focus group interviews.

Setting

One undergraduate nursing course at an Australian university.

Participants

Bachelor of Nursing students from across academic years.

Methods

An online survey comprising closed‐ and open‐ended questions to assess mathematics anxiety and self‐efficacy and associated factors affecting its application to practice. Focus group interviews to explore anxieties related to mathematics and students' approaches to nursing mathematics. Quantitative data were analysed using descriptive statistics and qualitative data using inductive content analysis.

Results

A total of 202 nursing students commenced the survey, of which 135 were fully completed, while 17 students participated in focus groups. Less than half were school leavers. Around three‐quarters reported some level of fear of mathematics, while many lacked confidence, fear of making errors and/or harming patients and negative childhood experiences of mathematics. Survey items demonstrated extensive variation in perceptions.

Conclusions

The complexity and diversity of anxieties presents key challenges for nurse academics seeking to educate competent, safe students. Teaching approaches should be varied and consideration of having specialist mathematics teachers and learning psychologists on teaching teams to ensure student success.

Reporting Method

This study is reported using Mixed Methods Reporting in Rehabilitation & Health Sciences (MMR‐RHS).

Patient or Public Contribution

No patient or public contribution.

Introduction

Medication management is a fundamental role for nurses and many other health professionals, and it is widely recognised that underpinning associated patient safety is mathematic accuracy (Moloney, Kingston, and Doody 2020). Furthermore, mathematics skills are also important for other nursing tasks including management of medical equipment and recognising and responding to numerical trends in vital signs observations. Sound numeracy skills have been closely linked to increasing efficiency and reducing errors in the clinical context and are crucial given that medication administration alone comprises a large component of nurses' work (Schneidereith 2021; Schneidereth and Barr 2023).

Nurse academics play important roles in preparing students for safe clinical practice, an environment where calculation errors can have fatal consequences. However, for decades, the nursing literature has identified associated challenges and approaches to teaching this content, along with the concept of mathematics anxiety impacting on student learning (McKenna et al. 2022). Furthermore, mathematical competency is not necessarily mandated for entry into preregistration nursing courses and prior mathematics education may be limited (Minty-Walker et al. 2021), so academics may be required to teach fundamental, as well as applied, skills (Bagnasco et al. 2016). Yet, what and how mathematics education is influenced is unclear.

Background

Much has been written about numeracy challenges for nursing students and their educators. In an Italian study, Bagnasco et al. (2016) identified that many undergraduate students in their sample had difficulties with basic mathematics including fractions, percentages, division and multiplication. Similarly, an Australian study identified that nursing students made fundamental conceptual, arithmetic and computational calculation errors (Eastwood et al. 2011). This situation is compounded by different approaches to teaching medication mathematics. Numeracy education in reportedly delivered in various ways including in the classroom with problem-solving case studies or calculation-based activities and simulated laboratory-based scenarios (O'Reilly et al. 2020). In the simulated laboratory and when nursing students are on professional practice placements, they face added complexity of integrating learnt psychomotor skills along with numeracy skills (Zahara-Such 2013). Yet, in a survey of prelicensure education providers in the United States, Schneidereith and Barr (2023) identified little consistency in how medication dosage calculations were taught across programs. For example, only 22.8% of programmes were found to include hands-on application of skills in clinical skill laboratory sessions.

Diversity in cohorts of nursing students further contributes to variation in mathematics preparation for applied approaches required in nursing, impacting on overall capability. Notably, nursing cohorts are predominantly female and comprise large numbers of mature age entry students who enter via a range of pathway programmes. In addition, in some countries, mathematics is not a required prerequisite (Minty-Walker et al. 2021) meaning some students will be better prepared than others. In an Australian study, Gregory et al. (2019) assessed 715 undergraduate nursing students' mathematics self-efficacy prior to, and at 6 and 7 weeks following, instruction. At baseline, they identified that males and students with mathematics education in the final year of secondary school had the highest mathematics scores. Given that nursing is predominantly female and cohorts comprise many mature-aged students, this is a potential issue.

Mathematics anxiety has been widely identified as an inhibitor to mastery of medication calculations in nursing students; however, most studies are small and single site (McKenna et al. 2022). While several definitions have been used to describe mathematics anxiety, Suárez-Pellicioni et al. (2016, p. 4) suggest they all have the commonality ‘that for some people dealing with numbers of math-related situations evokes an emotional response that disrupts their performance’. It has been identified as increasingly prevalent with age (Skagerlund et al. 2019), in females and in people with lower self-awareness (Khasawneh, Gosling, and Williams 2021). In a British study involving second-year nursing students, McMullan, Jones, and Lea (2012) identified strong relationships between anxiety, self-efficacy and ability in drug calculation ability, with overall numerical ability playing the strongest role in anxiety. Motivation and confidence have also been found to correlate in numeracy performance and mathematics anxiety in nursing students (Thompson et al. 2015). While previous studies have alluded to reasons for mathematics anxiety in nursing students, and a need for more research identified (Eastwood et al. 2011; Hunn and Slaven 2023), few have extended upon this important concept. Hence, this study sought to use a mixed methods approach to answer the question: What factors influence nursing student anxiety when engaging with mathematics related activities in nursing education?

Methods

This study employed a concurrent mixed methods design comprising a survey (quantitative) and focus groups (qualitative) with Bachelor of Nursing students from one Australian university. The research team comprised experienced nurse academics and researchers, some of whom taught the mathematics component of the curriculum. The three-year degree has been offered at the university since the 1980s, and students are spread across five campuses, both urban and regional, and are culturally diverse. In the programme, mathematics for nursing is introduced in first year and embedded across subsequent years. Mixed methods facilitated both measurements and understanding experiences.

The online survey sought to assess mathematics anxiety and self-efficacy and associated factors affecting its application to practice among nursing students. The questionnaire comprised demographic data, Mathematics Anxiety Scale (MAS), Mathematics Self-Efficacy Scale (MSES) and two key open-ended questions related to fear and challenge around mathematics. The Mathematics Self-Efficacy Scale (MSES) was developed by Betz and Hackett (1983) to measure confidence in doing mathematics. The complete scale consists of 52 items in three subscales: (1) Mathematics Tasks Subscale, (2) Mathematics Courses Subscale and (3) Mathematics Problems Subscale. Only the first subscale was used in our study as it was appropriate to our student population and research aim. The second subscale relates to students undertaking higher studies in mathematics and the third involves solving mathematical problems, which were not relevant to our study. The employed subscale responses are from 1 ‘no confidence at all’ to 10 ‘completely confident’. Betz and Hackett (1983) reported a Cronbach reliability coefficient alpha of 0.92 for this subscale. The 10-item Mathematics Anxiety Scale (MAS) was developed by Betz (1978) as an adaptation of the anxiety subscale of the Fennema–Sherman Attitudes Scales (Fennema and Sherman 1976) to assess mathematics anxiety in university students. It rates statements on a scale from 1 strongly disagree to 5 strongly agree. Hackett and Betz (1989) reported Cronbach alpha values ranging from 0.86 to 0.90. Purposive sampling was employed to recruit potential participants, and given the mixed methods nature of the study, sample size calculation was not performed. Data were entered into IBM SPSS (Version 28) and analysed using descriptive statistics.

A descriptive qualitative approach was employed for the qualitative component. Eight focus groups were conducted in October and November 2022 with a total of 17 students guided by an interview schedule developed by the research team (Table 1). As the study was conducted during the COVID-19 pandemic, these were conducted online via Zoom. Students were predominantly female (n = 13) and ages ranged from 20 to 59 years (mean = 33.4; median = 30). Four (23.5%) were in the first year of the degree, nine were in second (52.9%), three (17.6%) were in third, and one (5.9%) was a fourth-year double-degree student. Students were invited to participate via email from a research team member not directly involved in their teaching who also conducted the interviews. Focus groups ranged from 30 to 45 min in duration and were transcribed for analysis. Interviews and open-ended questions were manually analysed together using inductive content analysis informed by Elo and Kyngäs (2008), whereby data were coded individually, categories created and abstraction applied. Analysis was conducted by one team member and confirmed by other team members.

TABLE 1 Interview guide.

Questions

Do you experience any anxiety when having to complete a maths question? If so, can you tell me about it?

How does your approach to maths problems influence how you do medication calculations?

Can you tell me about how you approach doing medication calculations? Does this differ between classroom and clinical?

How does completing medication calculations in class (labs and sims) differ to during clinical placement?

Can you give an example of where you experienced anxiety when completing medication calculations while on clinical placement?

How have you managed any anxiety around medication calculations and administering medications?

Can you suggest strategies that lecturers or nurses could use to increase your confidence around medication calculations?

Prior to commencing data collection, ethics approval was obtained from the La Trobe University Human Research Ethics Committee (Approval No. HEC22116) on 14 July 2022. All enrolled students were eligible to participate, and there were no exclusion criteria applied. Purposive sampling was employed to recruit student participants. An invitation email was sent to students via the university learning management system containing written information about participation and a link to the online survey. The survey contained information about the focus groups and invitation to participate with separate notification to the research team. The initial invitation was sent in August 2022, with follow-up reminders in September and October 2022.

For the survey, participants indicated consent prior to answering questions, while written informed consent was obtained prior to commencing focus groups. These interviews were conducted by a research assistant not previously known to students. Data are stored on the university's secure research platform and only available to some research team members. Data are reported de-identified to protect participants. The study is reported in line with Mixed Methods Reporting in Rehabilitation & Health Sciences (MMR-RHS) (Tovin and Wormley 2023).

Results

In total, 202 students commenced the survey, of which 135 were fully completed. Missing values were removed from analysis. Of those students who identified their gender, most were female (n = 118; 90.77%) in line with the broader nursing population. Of the 129 who provided country of birth, most (n = 96; 74.42%) identified Australia, with 7 (5.43%) born in India, 3 (3.88%) in the Philippines, and the remainder spread across 15 other countries. The majority (n = 59; 45.74%) were second-year students, and most (n = 88; 68.22%) did not have school aged children at home. In total, 49 (38.28%) had entered the course as school leavers, while the remaining 79 (61.72%) entered via other pathways. A majority (n = 72; 56.25%) reported having completed mathematics at Year 12 (final year of secondary school). Overwhelmingly, 99.22% (n = 127) recognised mathematics as having some level of importance in nursing, but 75.97% (n = 98) reported some level of fear of mathematics (Table 2).

TABLE 2 Demographic data.

	Characteristics	N (%)
Gender	Male	11 (8.46)
Female	118 (90.77)
Non-binary	1 (0.77)
Country of birth	Australia	96 (74.42)
India	7 (5.43)
Philippines	3 (3.88)
Burundi, China, Italy, Poland, United States	2 (1.1) each
Croatia, Fiji, Germany, Nepal, Netherlands, New Zealand, Pakistan, Saudi Arabia, United Kingdom, Zimbabwe	1 (0.5) each
Level/Year in bachelor of nursing degree course	First year	39 (30.23)
Second year	59 (45.74)
Third year	28 (21.71)
Fourth year	3 (2.33)
School aged children at home	Yes	41 (31.78)
No	88 (68.22)
Entered the course as a school leaver	Yes	49 (38.28)
No, as enrolled nurse	29 (22.66)
No, via graduate entry pathway	18 (14.06)
No, other	32 (25.0)
Highest level of education prior to entering your bachelor of nursing	Completed Year 12 (final year high school)	63 (48.84)
Certificate IV (vocational)	8 (6.2)
Diploma	38 (29.46)
Bachelor degree	12 (9.3)
Masters	7 (5.43)
Doctorate	1 (0.78)
Highest level of mathematics education completed prior to entering your Bachelor of Nursing	Year 10	8 (6.25)
Year 11	15 (11.72)
Year 12	72 (56.25)
Diploma	21 (16.41)
Bachelor	9 (7.03)
Other	3 (2.34)
How important do you feel mathematics is in nursing practice?	Not at all important	1 (0.78)
Somewhat important	18 (14.06)
Very important	70 (54.69)
Extremely important	39 (30.47)
Do you fear mathematics?	Not at all	31 (24.03)
A little	59 (45.74)
Somewhat	22 (17.05)
A lot	17 (13.18)

Table 3 provides data from the Mathematics Self-Efficacy Scale (MSES) regarding perceptions and attitudes towards performing mathematics. Overall, commonly encountered activities were viewed positively and indicate ability of the cohort to utilise everyday mathematics. Notably, however, standard deviations on all items indicate great variability across the sample; hence, medians were also calculated.

TABLE 3 Perceptions and attitudes towards performing mathematics (Mathematics Self-Efficacy Scale [MSES]).

Task statement	N	Mean	Median	SD
Add two large numbers (e.g., 5739 + 62,543) in your head	146	5.15	5.00	2.69
Determine the amount of GST on a clothing purchase	144	5.07	5.00	2.92
Figure how much material to buy in order to make curtains	145	6.35	7.00	2.56
Determine how much interest you will end up paying on a $675 loan over 2 years at 14.75% interest	143	4.22	3.00	2.89
Use a scientific calculator	145	6.61	7.00	2.71
Compute your car's fuel km	142	6.04	6.00	2.65
Calculate recipe quantities for a dinner for 41 when the original recipe is for 12 people	142	7.26	8.00	2.52
Balance your savings account without a mistake	142	6.68	7.00	2.49
Understand how much interest you will earn on your saving account in 6 months, and how that interest is computed	142	5.20	5.00	2.63
Figure out how long it will take from city A to city B driving 110 kph	140	6.59	7.00	2.64
Set up a monthly budget for yourself	141	7.81	8.00	2.21
Compute your income taxes for the year	141	5.50	5.00	2.61
Understand a graph accompanying an article on business profits	138	6.14	6.50	2.59
Figure out how much you would save if there is a 15% markdown on an item you wish to buy	140	7.53	8.00	2.52
Estimate your grocery bill in your head as you pick items	141	7.31	8.00	2.30
Figure out which of two summer jobs is the better offer; one with a higher salary but no benefits, the other with a lower salary plus room, board and travel expenses	140	7.66	8.00	2.13
Figure out the tip on your part of a dinner bill split eight ways	141	7.01	8.00	2.72
Figure out how much wood you need in order to build a set of bookshelves	138	6.09	6.50	2.62

Table 4 presents the findings of the Mathematics Anxiety Scale (MAS). Findings suggest that students would value more classroom opportunities to engage in mathematics and that they experienced tension when undertaking mathematics testing. Again however, standard deviations indicate variability across the sample on all items. Again, because of this, medians were also calculated.

TABLE 4 Thoughts and feelings regarding mathematics (Mathematics Anxiety Scale [MAS]).

Statement	N	Mean	Median	SD
It would not bother me at all to take more maths classes	137	3.47	4.00	1.09
I have usually been at ease during maths tests	136	2.70	3.00	1.18
I have usually been at ease during maths lessons	136	3.07	3.00	1.11
I usually don't worry about my ability to solve maths problems	136	2.75	3.00	1.13
I almost never get tense while taking maths tests	137	2.36	2.00	1.13
Mathematics makes me feel uneasy and confused	137	3.12	3.00	1.11
I get really tense during maths tests	137	3.28	3.00	1.20
My mind goes blank and I am unable to think clearly when doing mathematics	137	2.99	3.00	1.15
Mathematics makes me feel uncomfortable and nervous	137	2.99	3.00	1.14
I get a sinking feeling when I think of trying maths problems	137	2.87	3.00	1.21

Four themes were constructed from focus group interviews and open-ended survey questions: Roots and Catalysts of Mathematics Anxiety, Navigating Mathematics Education, Unravelling the Medication Mathematics Maze, and Enhancing Mathematics Education, with sub-themes.

Roots and Catalysts of Mathematics Anxiety

This theme highlighted a myriad of triggers for mathematics anxiety and its pronounced effect in clinical practice settings. Anxiety revealed stemmed from diverse sources, including complexity of mathematical concepts, fear of consequences from clinical errors, lack of confidence, stress and cognitive overload, and societal pressures.

Navigating Mathematical Complexities and Clinical Precision

Representing many survey responses (Table 5), students expressed challenges in understanding and applying mathematical concepts such as conversions, formulas and equations.

Calculating mathematics is okay for me but remembering the formula is the more difficult part of it.

TABLE 5 Content analysis of open-ended questions.

	N	%
If you are fearful of mathematics, why do you think that is the case?	78
Codes
Lack confidence in own skills	29	37.2
Making errors	24	30.8
Negative childhood experience/preparation	15	19.2
Causing patient harm	12	15.4
Feeling pressured or overwhelmed	11	14.1
Complexity of the task	5	6.4
Remembering formulae	4	5.1
Applying to real-world situations	3	3.8
Need for 100% accuracy	1	1.3
Underlying learning disability	1	1.3
What challenges have you encountered with mathematics in your degree to date?	115
Codes
No issues to date	20	17.4
Own fears/abilities	17	14.8
Medication calculations	13	11.3
Intravenous calculations	12	10.4
Remembering formulae	10	8.7
Teaching-related issues	5	4.3
Mental mathematics/Needing calculator	3	2.6
Fractions	3	2.6
Volumes/Dilutions	3	2.6
Complex medications, e.g., heparin	2	1.7
Conversions	2	1.7
Vital signs calculations	2	1.7
Algebra	1	0.9
Body weight calculations	1	0.9
100% pass rate	1	0.9
Decimals	1	0.9
Percentages	1	0.9
Age-based dosing	1	0.9
Online calculations program	1	0.9

Students' challenges laid not only in comprehending these concepts but also in effectively utilising them in practical scenarios. They expressed concerns about difficulties of dilution calculations in clinical settings and shed light on how easily these could lead to confusion.

I find dilution mathematics challenging, not because of the numbers alone but the confusion between diluting in a × mL solvent vs diluting with a solvent to reach × mL.

Apprehension associated with potential calculation errors in clinical settings was a key source of anxiety for nursing students. Fear of making mistakes was a key concern highlighted in the survey (Table 5). One participant emphasised the serious consequences of even minor mistakes, such as incorrect decimal placement.

When I've come into clinical situations, it's more I know that if I was to get any decimals wrong, it can actually be quite serious.

Additionally, a focus group participant described a moment of intense pressure that led to a complete mental block, underscoring how anxiety could impair critical thinking at crucial times.

…I just completely just blanked. Like, I know how to do that calculation…but I just couldn't think. (P3, FG1)

Conversely, for some students, practical application of theoretical knowledge alleviated anxiety. One focus group participant noted a stark contrast between the stress of theoretical mathematic problems and clarity that came with practical application in real-world settings.

…It's a sense of a place…a sense of application to it. There is also a lot of anxiety in first year and second, when there's just a pure math question and it's thrown at you on the spot. (P2, FG3)

The same participant expressed how hands-on practice, such as working alongside an IV pump, helped in understanding and reducing stress by making abstract concepts more tangible and relatable.

…If I'm next to an IV pump and I understand. Oh, okay. Well, that makes sense. It's this many mLs [milliLitres] over these hours, and we're giving this antibiotic because it does this. (P2, FG3)

Internal Doubts and External Pressures

Some survey respondents reported stress-induced cognitive overload. One student's admission of feeling ‘overwhelmed and blanking out’ when stressed highlighted the crippling effect that anxiety could have on cognitive function, particularly in stressful situations. It demonstrated how stress could influence analytical processes that are so important in clinical practice. Confidence issues ranked highest in fear around mathematics (Table 5), manifesting as self-doubt in abilities. One focus group participant described the pervasive nature of this self-doubt, casting a shadow over their confidence and causing them to question their answers and mathematical acumen. Such self-doubt stemmed from deep questioning of own ability to perform mathematical tasks correctly, rather than simply getting an answer wrong.

Probably the biggest thing with my anxiety around maths is self-doubt, wondering whether I've actually got the questions right. (P4, FG 1)

Societal pressures compounded mathematical anxiety for many survey respondents. One participant's remark captured the essence of performance anxiety, intensified by the expectation to deliver correct answers when under scrutiny. The mental block that came with being watched and judged could be paralysing.

…It's like someone's kind of looking to me for an answer or I'm with other people and I can't do my own little weird way of figuring stuff out. Like my mind goes completely blank. (P3, FG 2)

Another student's account of fear that gripped them when required to perform mathematical calculations ‘on the spot’ painted a vivid picture of the acute stress that could be provoked by immediate demands for accuracy, leading to anxiety-driven reactions.

I tend to get a lot of anxiety when it comes to doing maths on the spot…And if I'm just to do it in my head, there's no way. I just freak out. (P2, FG 3)

Navigating Mathematics Education

This theme delves into the critical process of acquiring and applying theoretical knowledge in the fast-paced environment of clinical practice. It focusses on critical processes of identifying gaps in understanding and proactive steps students must take to fill these voids. It also incorporates the transition from theory to practice, an important stage in which students learn to apply classroom knowledge to real-world patient care, transforming abstract concepts into tangible skills and informed decision-making at the bedside.

Foundational Knowledge Gaps

Participants reflected on challenges they faced, attributing them to inadequate or misaligned preparation in mathematics during their formative years. These gaps were not just about missing information; they represented a foundational weakness hindering their abilities to grasp more complex, applied mathematical concepts required in nursing and were highlighted both in focus groups and open-ended survey responses (Table 5). One focus group participant shared a personal insight:

…Gaps in my knowledge go way back from when I was a kid and then into year 11, I only did maths in year 11. (P3, FG 1)

This statement highlights lack of continuous and comprehensive exposure to mathematics throughout participants' schooling, which could have provided stronger foundations for their nursing education. Another participant echoed a similar sentiment but focussed on the relevance of the mathematical skills taught during their school years.

Back at high school I feel like they taught us unnecessary maths that wasn't going to help us as adults. (P4, FG 3)

Theory–Practice Disconnect

Students highlighted challenges they faced when theoretical knowledge did not seamlessly translate into practical application in clinical settings. This mismatch created barriers, leading to a call for more integrated and applied educational methods. One student expressed dissatisfaction with the initial approach to nursing education:

I didn't appreciate in my very first nursing subject this kind of fear that was drilled into us…it should be more integrated with the practice of nursing as opposed to kept separate. (P2, FG 3)

Another pointed out the disjointed nature of their learning experience:

We were never taught in the classroom. We were told to go to (software program)…it's a computer software thing that teaches you the formulas and how to work the problem. (P2, FG 4)

Reliance on self-directed, technology-based learning may not adequately prepare students for real-world nursing challenges. Furthermore, a need for flexibility and adaptability in learning was a recurring theme. Practices taught in university settings were noted to often differ from those encountered in clinical environments, a discrepancy highlighted by one participant:

Even practice-wise like it is very different…then I feel like sometimes our nurses get very angry with us because we're taught one way and then they do it another way. (P1, FG 8)

Diverse Learning Modalities

As a result of the COVID-19 pandemic's forced shift to online learning environments, students reported facing challenges in engaging with complex mathematical concepts. The difficulty of remote learning emerged, particularly for subjects that required high levels of interactive and individualised learning. One student recounted their experience, highlighting the suboptimal learning conditions:

I learnt medication calculations through COVID, so it was on Zoom… The class started at like 6 PM. There was like 50 people in the class…I might just like leave the class because like, I have not picked up…I was on mute all the time. (P3, FG 2)

This statement captures the student's sense of isolation as well as inefficiency of remote learning platforms in effectively delivering mathematical education. The crowded class and late hours exacerbated disconnect, highlighting shortcomings of remote learning structures in facilitating the learning process for mathematical education. Traditional classroom dynamics, on the other hand, presented their own challenges for students attempting to grasp mathematical concepts. For some, the in-person learning environment, which frequently encouraged spontaneous participation, was a source of anxiety. One student expressed their discomfort with the conventional classroom atmosphere, stating:

If it's a class in person, I always tend to get really intimidated and I'm really quiet and I don't speak up. (P2, FG 2)

This reflection demonstrates how a student's fear of speaking up in front of peers can limit ability to engage with material, particularly in mathematics, where active participation may be required to fully understand complex problems.

Unravelling the Medication Mathematics Maze

This theme sheds light on students' multifaceted journeys as they strived to master complexities of medication-related mathematical calculations and profound responsibility that came with them. Their paths to proficiency were marked by challenges and dedication, from seeking the balance between modern digital tools and traditional techniques to foster collaborative verification and mindfulness.

Blending Modern Tools With Conventional Techniques

Students emphasised the importance of using calculators in clinical settings to ensure accuracy in mathematical calculations. They also emphasised importance of having access to formulas and practical examples as reference points for confirming accuracy of their calculations.

I do like doubt myself a lot. And then I look at my phone and make sure I'll do the calculation twice. (P2, FG 7)

They recognised utility of these tools, but, as one student candidly admitted, they were concerned about the potential crutch they represented.

Having to use a calculator for lots of things and feeling dumb because of it. (P1, FG 1)

Some students continued to prefer traditional methods of managing mathematical tasks in their clinical education, such as pen and paper. Such preference was rooted in belief that these traditional tools provided greater clarity and reduced apprehension during complex calculations, and was articulated by a student who explained that writing down calculations helped maintain focus and prevent distractions caused by nervousness.

I like to write it down to calculate, so I'm not distracted from being nervous. (P2, FG 1)

Similarly, one focus group participant echoed this sentiment, emphasising their reliance on pen and paper for calculations, even in minor tasks.

I'm a big pen and paper person. Even if it's the smallest of things, I would much rather look silly with a piece of pen and paper than to get it wrong in my head. (P4, FG 1)

Another highlighted the visibility aspect of using paper. They pointed out that when a mistake was made, it was easier to trace and rectify on paper.

You can sort of see what you're actually…if you've made a mistake, then you can sort of see where you've made that mistake on the paper and recalculate that too. (P1, FG 5)

In various focus group discussions, students frequently highlighted use of pocket-sized handbook guides and personally crafted ‘cheat sheets’, emphasising their utility in clinical settings.

I actually made a cheat sheet and I put formulas on that sheet. (P2, FG 4)

One noted the convenience of carrying a small handbook guide, showcasing its practicality for quick reference during medication tasks. These portable guides were identified as providing essential information at a glance, proving invaluable in the fast-paced environment of clinical practice. Some students identified their approaches to achieving clinical accuracy involved meticulous, multistep processes.

I have multiple steps within my process, and it's just so that I can be 100% correct. So first I'll go through and I'll make the calculation down and also the on paper. I'll double-check it using a calculator… (P2, FG3).

Such combination of traditional methods, digital verification and teamwork highlighted the students' dedication to precision and underscored their commitment to ensuring patient safety.

Collaborative Verification

Students frequently emphasised the importance of collaborative verification when dealing with complex mathematical calculations. The incorporation of a buddy system, where peers worked together to verify calculations, served as an essential safeguard against potential errors. They highlighted benefits of having buddy nurses available for consultation and double-checking. This practice of bouncing ideas off nursing staff and seeking their input was a key aspect of collaborative learning and error prevention.

…You still have people around to bounce off, ask and you know, get them to double-check and stuff as well… (P1, FG 6)

They underscored the ongoing nature of collaborative approaches, extending beyond graduation into professional practice.

…Even after graduation, if you're ever unsure, you're going to ask someone. (P3, FG 1)

Mindfulness and Self-Pacing

Participants also highlighted the beneficial impact of mindfulness practices, such as taking deliberate breaks and deep breathing, to maintain focussed and calm states amidst high-pressure situations. One shared a personal strategy for managing overwhelming situations,

…You've just got to slow down and just take a few breaths, walk away for a minute, come back. (P1, FG 5)

This approach underscored the value of stepping away from stressful tasks to regain composure and perspective, thereby enhancing ability to tackle problems more effectively upon return. Participants also discussed the significance of acknowledging and normalising mistakes, particularly those who were still learning. They emphasised the importance of devoting time to comprehend and apply knowledge.

Just thinking about…people know that you're a student and people know that you're going to make mistakes or, like, take time with you…reminding people that mistakes are normal and it's about taking the time…trusting that you find a formula that works for you. (P4, FG 3)

Enhancing Mathematics Education

This theme encapsulates the overarching goal of improving mathematics education by incorporating a variety of problem-solving approaches, ensuring clarity in instruction and increasing access to educational resources and support. It acknowledges students' diverse learning styles and emphasises importance of educational approaches tailored to diverse needs, particularly in the context of mathematical calculations where precision is critical. It also delves into use of technology in mathematics education.

Hands-On and Diverse Support

Diverse approaches to problem-solving are crucial in mathematics education, accommodating varied learning styles that students bring to the classroom. Clarity in instruction and provision of multiple problem-solving techniques are essential, especially in the context of mathematical calculations where precision is paramount. One student's request for varied methods of calculation is telling:

Provide the calculations that you want us to use…there's different ways of calculating these medications…and I think providing us with the formulas that we need to know, not just for lab, but for the math test that the hospital gave you. We need to be given that and it needs to be person to person. (P1, FG 4)

This comment reflects desire for concrete, accessible instruction tailored to learning needs within the discipline of mathematics. Students expressed a need for direct, tangible assistance with practical aspects of mathematics. A major source of concern was lack of hands-on support, particularly in laboratory settings, as one student's experience illustrated:

I feel like obviously we do the online stuff, but I don't think like in our labs, I guess we're just kind of given the stuff to calculate ourselves, but no one's necessarily there. (P1, FG 6)

This highlights the necessity for effective instructor involvement and support in the learning process, especially in settings where practical application is critical.

Accessible Instruction and Inclusivity

Instructor accessibility and approachability were critical factors in improving educational experience. This subtheme emphasises the importance of creating environments where students feel comfortable seeking assistance and asking questions. One student remarked:

…It's just approachable, which I think is really important, being able to ask questions when you're not sure. (P3, FG 1)

The presence of approachable and supportive educators could also impact on students' abilities to understand and engage with mathematical content, resulting in more effective learning.

It was seen as critical to create inclusive and interactive educational environments for collaborative learning and problem solving, one in which every student feels valued and included. One participant emphasised the importance of inclusivity:

If someone doesn't get it, just don't push them aside. Just so you know. (P1, FG 8)

Technology-Enhanced Independent Learning

Students recognised technology's role in mathematics learning as an empowering tool for self-directed study and practice. Online quizzes and other digital resources demonstrated how technology could supplement traditional mathematics education. Participants shared their proactive engagement with such tools.

There's a lot of quizzes online that you can do to help you. So, I do that a lot as well. (P2, FG 1)

Such approaches to learning mathematics outside of the classroom setting allowed for additional practice, which was often necessary for mastering mathematical principles. One student confirmed the utility of online tools for their independent study habits.

I do a couple of those [online tools] in my spare time…to sort of just revise the formulas and things like that. (P3, FG 2)

Discussion

This study investigated mathematics anxiety among nursing students and its underlying characteristics. The findings unveiled complex interrelationships of factors contributing to mathematics performance and anxiety in nursing and illuminated critical insights. Some of these have been previously identified and this study has extended prior understandings, while others were new. In our sample, around three-quarters reported some level of fear around mathematics, with lack of confidence, fear of making mistakes or harming patients and negative childhood experiences or preparation ranking highest and indicating a significant issue. Lack of confidence has been widely reported as a contributor to mathematics anxiety in nursing (Johnson et al. 2020) and other students (Khasawneh, Gosling, and Williams 2021). The high-stakes impact of medication calculation errors clearly plays a role in anxiety for some students. Extensive application across programs in pressured simulated contexts should be considered to enable students to overcome these fears.

Negative childhood experiences around mathematics preparation were a finding in this study that have received little attention elsewhere. Only one student in Røykenes' (2016) study of nursing students' previous mathematics learning experiences identified having previous negative experience primary school experiences, but there were more negative experiences in lower secondary school. Enabling students to overcome such prior experiences may be beyond the preparation of nurse academics and require more specialised support. Hence, there is a need for more specific research into how school mathematics preparation impacts learning at tertiary level in nursing and other health professions and what specific interventions are needed. In our study cohort, only around 40% were school leavers, suggesting a potential for foundational knowledge gaps and reinforcing the observations of Minty-Walker et al. (2021) about different entry levels. Subsequently, survey items revealed great variability and varied preparation. This adds further complexity for nurse academics attempting to achieve medication calculations mastery for students.

Nurse academics are charged with responsibilities for teaching both basic and applied mathematics, an area they likely have insufficient preparation for. Many in the literature describe utilising various online and/or simulated resources (Bagnasco et al. 2016; Schneidereith 2021), and some were similarly used by some students and educators in our study. Traditionally, medication calculations content has been the remit of nurse academics who possess experience in applying mathematics to practice. However, given the identified deficits in basic mathematics for many students, this raises the question of whether specialist mathematics teachers should also be involved, particularly with teaching fundamental foundation mathematics. No previous studies appear to have reached similar conclusions and this may be one approach to resolving the issue of poor mathematical skills in nursing students that has been described through the nursing literature for decades. Furthermore, skilled mathematics teachers could be better prepared to manage learners with underlying mathematics anxiety.

In this study, psychological dimensions of mathematics anxiety were underscored by participants' deficiencies in confidence and recurrent displays of self-doubt. Numerous studies have provided evidence of adverse impacts that stress has on working memory, an essential element in performing mathematical computations (Beilock and DeCaro 2007; Skagerlund et al. 2019). Such sentiments of inadequacy, not only hinder the learning process but also affect execution of clinical skills, potentially leading to errors with significant consequences (Bridgeman, Bridgeman, and Barone 2018). Educational curricula should integrate evidence-based approaches designed to bolster students' self-efficacy in order to address this issue, and the inclusion of learning psychologists in developing these may be an important addition to teaching teams.

Teaching of medication mathematics requires a combination of strategies. Increasing availability of digital aids serves as an indication of broader technological advancements taking place in health care, aiming to improve precision in clinical work through use of technology (Gause, Mokgaola, and Rakhudu 2022). The proactive nature of students in addressing the challenges of medication management, which necessitates mathematical accuracy, was evident through utilisation of digital resources by some. By diminishing medication errors, these digital tools have the potential to enhance patient safety and elevate standards of care delivered (Gause, Mokgaola, and Rakhudu 2022). Continued use of traditional methods for medication calculations, such as pen-and-paper calculations, on the other hand, demonstrates respect for fundamental principles of nursing education and age-old error correction practices. Nursing students' preferences for manual approaches reflected commitments to developing solid foundational understandings of mathematical concepts. According to cognitive psychology research, writing down calculations can serve as a cognitive strategy to reduce working memory load, thereby reducing anxiety among students (Park, Ramirez, and Beilock 2014). By performing manual calculations to externalise problem-solving processes, students can enhance their abilities to visualise and process information.

While adding new understandings and use of a mixed methods approach, this study does have some acknowledged limitations. The study was conducted at one university in Australia so reflect the experiences of students from one program. Nevertheless, experiences of students and academics elsewhere may be similar. Participation was voluntary, and hence, there is a potential for response bias and limitation due to the self-report nature of the survey. The use of focus groups enabled deeper understandings of survey findings and presents a key strength of the study. Furthermore, the study was conducted during the COVID-19 pandemic, impacting recruitment.

Conclusion

Accurate mathematics is essential for medication safety and other nursing activities. This study examined mathematics anxiety among nursing students using a mixed methods approach and extends previous understandings of this phenomenon. It identified complex and diverse anxieties, presenting challenges for nurse educators who may be insufficiently prepared to support them. Findings suggest varied strategies are needed, including consideration of specialist mathematics teachers and learning psychologists on teaching teams.

Acknowledgements

We are grateful to the students who participated in the study, and to Gayle McKenzie and Rachel Cross for their input into the study design. Open access publishing facilitated by La Trobe University, as part of the Wiley - La Trobe University agreement via the Council of Australian University Librarians.

Conflicts of Interest

The authors declare no conflicts of interest.

Data Availability Statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.

References

Bagnasco, A., L. Galaverna, G. Aleo, A. M. Grugnetti, F. Rosa, and L. Sasso. 2016. “Mathematical Calculation Skills Required for Drug Administration in Undergraduate Nursing Students to Ensure Patient Safety: A Descriptive Study.” Nurse Education in Practice 16: 33–39. [DOI: https://dx.doi.org/10.1016/j.nepr.2015.06.006].