International Journal of

Environmental Research
and Public Health

Article
Effects of Aromatherapy Combined with Music
Therapy on Anxiety, Stress, and Fundamental
Nursing Skills in Nursing Students: A Randomized
Controlled Trial
Hae Kyoung Son 1 , Wi-Young So 2, *,† and Myoungsuk Kim 3, *,†
1 College of Nursing, Eulji University, Gyeonggi-Do 13135, Korea; [email protected]
2 Sports and Health Care Major, College of Humanities and Arts, Korea National University of Transportation,
Chungju-si 27469, Korea
3 College of Nursing, Kangwon National University, Gangwon-Do 24341, Korea
* Correspondence: [email protected] (W.-Y.S.); [email protected] (M.K.); Tel.: +82-43-841-5993 (W.-Y.S.);
+82-33-250-8877 (M.K.); Fax: +82-43-841-5990 (W.-Y.S.); +82-33-259-5636 (M.K.)
† The corresponding two authors (Wi-Young So and Myoungsuk Kim) contributed equally to this work.




Received: 6 October 2019; Accepted: 25 October 2019; Published: 29 October 2019


Abstract: Purpose: Nursing students often experience anxiety and stress when taking exams that
test their fundamental nursing skills. Complementary alternative methods, such as aromatherapy
and music therapy, have effectively alleviated such negative emotions among nursing students.
However, few studies have examined the effects of combined therapy interventions or compared
the effects of different interventions. This study identified the individual and combined effects of
aromatherapy and music therapy on test anxiety, state anxiety, stress, and fundamental nursing
skills among nursing students in Korea. Methods: A double-blinded, randomized, controlled trial
design was used. The study was conducted at the nursing college at Sungshin Women’s University,
Seoul, Republic of Korea. Ninety-eight sophomore female nursing students participated in the study.
Subjects were randomly categorized under three groups: aromatherapy (n = 32), music therapy (n = 32),
and aromatherapy combined with music therapy (n = 34). Aromatherapy was carried out through
the inhalation method using an aroma lamp and three drops of Origanum majorana and Citrus sinensis.
Music therapy was carried out using Beethoven’s Moonlight Sonata. Twenty-minute interventions
were performed in separate rooms before an exam was administered. Data were collected through
self-report questionnaires, including demographics, test anxiety, state anxiety, and stress. Participants’
Foley catheterization skill was likewise evaluated. Results: Aromatherapy combined with music
therapy had a significant effect on test anxiety (F = 4.29, p = 0.016), state anxiety (F = 4.77, p = 0.011),
stress (F = 4.62, p = 0.012), and performance of fundamental nursing skills (F = 8.04, p = 0.001)
compared with aromatherapy and music therapy as separate interventions. Conclusions: The results
suggest that nursing education that includes aromatherapy combined with music therapy may be
effective for improving the performance of fundamental nursing skills and reducing anxiety and stress
among nursing students.

Keywords: anxiety; aromatherapy; music therapy; nursing skills; nursing students

1. Introduction
Nursing is generally based on clinical practice [1] and clinical practice is based on fundamental
nursing skills [2], making it important for nurses-in-training to acquire robust fundamental nursing
skills. Thus, nursing science curricula have emphasized the importance of fundamental nursing skills

Int. J. Environ. Res. Public Health 2019, 16, 4185; doi:10.3390/ijerph16214185 www.mdpi.com/journal/ijerph
Int. J. Environ. Res. Public Health 2019, 16, 4185 2 of 10

and universities have reinforced the importance of these skills by testing nursing students’ skills
regularly. Nursing students often experience anxiety over undergoing tests of fundamental nursing
skills; their test anxiety is generally higher than that of students in other health-related majors [3].
Additionally, nursing students are required to take various courses in their major besides fundamental
nursing skills. Consequently, they experience higher levels of stress than students in other majors [3,4].
Moreover, nursing students’ anxiety and stress increase the likelihood that they will experience
negative physiological and behavioral responses regarding the timing of these tests [4,5], which in
turn negatively affects their academic performance [6,7]. Experiencing an appropriate level of anxiety
or stress can help someone solve a problem or control a situation [6,8]. However, an excessively
high level of anxiety and stress can negatively impact someone’s ability to remember important
information–especially information stored in the hippocampus [8,9]. That is, the excessive anxiety
and stress experienced by nursing students negatively affect their concentration and, by extension,
their test performance. Anxiety and stress are also directly related to academic performance, which is
negatively affected by decreased interest or motivation difficulty in identifying or describing negative
feelings which impacts anxiety and stress [10]. As a result, nursing students often experience
maladjustment to campus life and burnout, which results in them taking time off or experiencing
withdrawal [11].
The development and validation of interventions that employ complementary alternative methods
to alleviate negative emotions among nursing students have been attracting more and more attention.
Among these, aromatherapy is of specific interest. Aromatherapy has been reported to have a significant
clinical effect on anxiety, depression, and stress. It enhances relaxation and concentration using essential
oils extracted from the flowers, stems, roots, and leaves of plants [12–14]. In aromatherapy, odorants
with relatively small and volatile molecules are easily and swiftly inhaled into the body through the nose
and passed through the blood-brain barrier, directly affecting the central nervous system [13–15].
Another of these interventions is music therapy, which influences the neuroendocrine system
and the autonomic nervous system. Music therapy, such as listening to calm and slow-tempo music,
has been reported to reduce anxiety and facilitate relaxation by affecting the limbic system of the brain,
which is primarily responsible for controlling emotions [16,17]. Although several studies have assessed
these interventions separately, few studies have considered interventions with combined therapies
or have compared the effects of different interventions. One exception is a comparative study [18]
that compared music therapy and aromatherapy. It concluded that aromatherapy was more effective in
soothing anxiety among dental patients and lowering their diastolic blood pressure and respiratory rate.
In addition, another study [19] found that combining different types of interventions, such as music
therapy, aromatherapy, and meditation, effectively relieved stress and fostered relaxation through
a synergistic effect.
Therefore, this study compared the effects of interventions which have been proven effective in
addressing anxiety and stress among nursing students who experience extreme anxiety and stress
and likewise assessed the effectiveness of a combined intervention. This study is expected to help
identify effective interventions to relieve negative emotions related to tests, thereby improving nursing
students’ overall academic performance and mental health.

2. Materials and Methods

2.1. Subjects and Setting

A double-blinded, randomized, controlled trial design was used. Subjects were sophomore
students of the nursing college at Sungshin Women’s University, Seoul, Republic of Korea. Subjects were
scheduled to undergo a fundamental nursing skill performance test. Individuals who were: allergic to
essential oils or had hearing impairments that prevented them from receiving music therapy;
participating in other relaxation interventions that affected their anxiety and stress; taking medications
Int. J. Environ. Res. Public Health 2019, 16, 4185 3 of 10

for depression or anxiety that could affect stress and anxiety levels; or diagnosed with a psychiatric
disorder or known to struggle with substance abuse were excluded from the study.
The sample size was set at a significance level of 0.05, power of 0.80, and an effect size
of 0.40, which was extracted from a previous study [13] that researched aromatherapy with
students. We calculated the minimum number of subjects required for each of the three groups
(aromatherapy, music therapy, and aromatherapy combined with music therapy) for one-way analysis
of variance as 27 per group, using G * Power software (G * Power 3.1.7, Heinrich-Heine-University,
Düsseldorf, Germany).

2.2. Enrollment, Randomization, and Blinding

Data were collected from October 1 to November 10, 2017. Subjects were given verbal and written
explanations of the study approximately one week before the test. The researchers conducted
the preliminary survey after obtaining written consent from the subjects, with a total of 107 subjects
taking part in
Int. J. Environ. the
Res. survey.
Public Health 2019, 16, x 4 of 11

Assessed for eligibility (N = 107)

Excluded (n = 0)
Not meeting inclusion criteria (n = 0)
Declined to participate (n = 0)
Other reasons (n = 0)

Informed consent
Baseline measurements
Random allocation (N = 107)

Group 1 (n = 36) Group 2 (n = 35) Group 3 (n = 36)

Intervention: Aromatherapy
Intervention: Aromatherapy Intervention: Music therapy
combined with music therapy

Lost to follow-up (incomplete Lost to follow-up (incomplete Lost to follow-up (incomplete

participation in program; n = 2) participation in program; n = 2) participation in program; n = 1)

Incomplete questionnaire Incomplete questionnaire Incomplete questionnaire

responses (n = 2) responses (n = 1) responses (n = 1)
Analyzed (n = 32) Analyzed (n = 32) Analyzed (n = 34)

Figure 1. Research flow diagram.

Figure 1. Research flow diagram.
Randomization was conducted by a research assistant who was not associated with the study using
the
2.3.Research Randomizer (https://www.randomizer.org/). A card with a randomly assigned number
Interventions
The essential oils utilized in the intervention were selected after consultation with a licensed
aromatherapy expert who has been teaching an aromatherapy training course for more than 16 years,
together with a review of previous literature. Based on this consultation and review, we selected
Origanum majorana (sweet marjoram), which is effective in relieving stress, soothing, and emotional
Int. J. Environ. Res. Public Health 2019, 16, 4185 4 of 10

indicating an assigned group was put into an opaque envelope. The research assistant opened the envelope
for each subject in the order of their arrival and confirmed their assigned group. The double-blinded
method was used so that neither the evaluators nor the subjects knew the assigned group.
The subjects who wanted to participate in the study because they had been notified that
the department was recruiting research assistants were screened for suitability based on the inclusion
criteria. All 107 eligible participants were enrolled (Figure 1). After completing the enrollment
and baseline measurements, the participants were randomly assigned to the aromatherapy group
(n = 36), music therapy group (n = 35), or aromatherapy combined with music therapy group
(n = 36). Two subjects did not fully participate in the intervention in the aromatherapy group,
two in the music therapy group, and one in the aromatherapy combined with music therapy group.
Additionally, all items in the questionnaire were left unchecked by two subjects in the aromatherapy
group, one in the music therapy group, and one in the aromatherapy combined with music therapy
group. Excluding those nine subjects, 32 students participated in aromatherapy, 32 participated in
music therapy, and 34 participated in aromatherapy combined with music therapy. Therefore, this
study analyzed the data of 98 subjects in total.

2.3. Interventions
The essential oils utilized in the intervention were selected after consultation with a licensed
aromatherapy expert who has been teaching an aromatherapy training course for more than 16 years,
together with a review of previous literature. Based on this consultation and review, we selected Origanum
majorana (sweet marjoram), which is effective in relieving stress, soothing, and emotional relaxation,
and Citrus sinensis (orange), which is effective in reducing nervousness and stress [20]. Based on results
of previous studies which found that combining two to three types of essential oils is more effective for
relieving stress and relaxation than a single type of essential oil [15], three drops of Origanum majorana
and Citrus sinensis were mixed together at a ratio of 1:1 and diffused into the air using a lamp so that
subjects could inhale the odorants. The diffused essential oil was inhaled and spread through the body
and reached peak levels within 20 min [14,15]. Thus, aromatherapy was conducted for 20 min in this study.
For music therapy, Beethoven’s Moonlight Sonata [16] was used, as it has been proven effective in
relieving test anxiety and state anxiety by improving listeners’ stress levels, blood pressure, pulse rate,
and body temperature. Music was played continuously in a space equipped with a sound system so
that subjects could listen to it casually, without earphones. Each intervention session was conducted for
20 min [16]. The results of a previous study found that listening to soft music for five min before taking
a test reduced anxiety levels, improved blood pressure and pulse rate, and improved the academic
performance of college students [21]. Based on previous results, the subjects in this study were naturally
exposed to music for the same 20-min intervention time as the subjects in the aromatherapy group.
The interventions developed for each group in this study are presented in Table 1. Each subject was
told to arrive at the intervention site 40 min prior to the scheduled test. Once each subject arrived, they
were randomly assigned to a group by a research assistant. The subject was then immediately guided
by the research assistant to the intervention room to prevent them from discussing the intervention
with other subjects.
Each subject received the assigned intervention for 20 min in a separate room before the test
of fundamental nursing skills. Each intervention space had the same temperature of 26–27 ◦ C
and medium-level lighting to eliminate factors other than the intervention. Additionally, roller shades
were used to control the lighting and prevent subjects from looking out of the window. Three research
assistants were given prior training via the manual and allocated to each intervention space.
The research assistants were responsible for preparing the questionnaire, checking the intervention time
and environment, and giving subjects notice about starting the test. For aromatherapy, different types
of aroma oils were mixed by a researcher with an aromatherapy license according to the opinions of
an aromatherapy expert. The research assistants who were assigned to groups receiving aromatherapy
checked whether the aroma oil had been diffused into the air. They replenished the water in the lamp
Int. J. Environ. Res. Public Health 2019, 16, 4185 5 of 10

when it was depleted and refreshed the prepared mixture of aroma oil. The research assistants in
the groups receiving music therapy ensured that music played continuously and insured that sound
fidelity was adequate.

Table 1. Intervention process.

Group
Process Duration(min)
AG MG AMTG
Baseline measurements Music preferences, preference for aromatherapy, exclusion criteria 5
Program introduction
Introduction 5
(procedure, pretest, posttest, fundamental nursing skill test)
Pretest Test anxiety, state anxiety, stress 10
Method: lamp inhalation
Aromaoil: marjoram
Method: lamp inhalation Music type:
and orange
Intervention Aroma oil: marjoram Beethoven’s Moonlight 20
Music type:
and orange Sonata
Beethoven’s Moonlight
Sonata
Posttest Test anxiety, state anxiety, stress 5
Fundamental nursing
Fundamental nursing skill performance test 10
skill test
AG: aromatherapy group; MTG: music therapy group; AMTG: aromatherapy combined with music therapy group.

After the intervention, each subject’s proficiency in fundamental nursing skills was evaluated by
three professors (namely Foley catheterization) in an environment separate from the intervention area.
The test required 10 min for each subject. The test was conducted under consistent physical conditions,
including temperature, lighting, and prepared items (model for Foley catheterization, catheter, and so
forth). To reduce inconsistencies between evaluators, the evaluators used a structured score-card
provided by the Korea Accreditation Board of Nursing Education, which clearly presents detailed
assessment items and guidelines for evaluators. To reduce evaluator-specific bias, the assessors rated
subjects without knowing their intervention group. Subjects were immediately guided by research
assistants from the intervention area to the testing area, and subjects returned home immediately after
the test. Therefore, contact between subjects during the experiment was prevented.

2.4. Assessments

2.4.1. General Characteristics

Subjects’ characteristics, including religion, subjective health status, satisfaction with nursing,
overall grade point average in the prior semester, music preferene, and demand for aromatherapy
were considered.

2.4.2. Test Anxiety

Test anxiety was measured using the Korean version of the Revised Test Anxiety Scale developed
by Benson and El-Zahhar [22] and translated and validated by Cho [23]. The scale consists of four
sub-factors and a total of 20 questions, with five questions on nervousness, six on concern, five on
physical symptoms, and four on error-free tests. Each question is answered on a four-point Likert scale,
with a score of one denoting “I rarely feel it,” and a score of four denoting “I almost always feel it.”
The higher the score, the higher the level of test anxiety. In Cho’s study [23], Cronbach’s α was 0.90;
in the current study, it was 0.93.

2.4.3. State Anxiety

State anxiety was measured using the Korean version of the Spielberger State Anxiety Inventory-Y
developed by Hahn, Lee, and Chon [24]. Questions are answered on a four-point Likert scale,
with a score of one denoting “It is completely untrue,” and a score of four denoting “It is absolutely
true.” Scores are totaled to give a possible range of 20 to 80 points. Higher scores denote higher
Int. J. Environ. Res. Public Health 2019, 16, 4185 6 of 10

levels of anxiety. The scale was purchased from the website of Hakjisa Publisher, Inc., which owns
the copyright for the Korean version of the instrument. At the time of translation, the instrument’s
reliability, as represented by Cronbach’s α, was 0.92 [24]. It was 0.89 in this study.

2.4.4. Stress
Stress was measured using a numeric rating score (NRS) developed by Cohen, Kamarck,
and Mermelstein [25], which provides a subjective score for stress. This instrument allowed participating
nursing students to indicate their perceived level of stress ranging from 0 (“I have no stress at all”)
to 10 (“I have a very high level of stress”). At the time of translation, the reliability of the instrument,
as represented by Cronbach’s α, was 0.76 [26]. It was 0.84 in this study.

2.4.5. Performance of Nursing Skills

To measure nursing skills, we converted items from the indwelling catheter insertion skill test into
a checklist format. The specific skill test was the Essential Fundamental Nursing Skill Assessment Items
Protocol (version 4.1), developed by the Korea Accreditation Board of Nursing [27]. Each item was
checked as “performed” or “not performed,” and a composite score was generated based on a 100-point
scale; the higher the composite score, the higher the level of the subjects’ nursing skill performance.

2.5. Ethical Considerations

This study was approved by the institutional review board (No. SSWUIRB 2017-055) of Sungshin
Women’s University and was conducted with participants who met the inclusion criteria. Participants
were given a prior explanation of the purpose and methods of the study using a structured research
guide. Written informed consent was obtained from each participant. The researchers informed
the participants that the collected data would not be used for any other purpose and that anonymity,
confidentiality, and destruction of the data after the study were guaranteed. Furthermore, the researchers
respected the voluntary participation and intentions of participants and informed the participants that
they could withdraw from the study at any time.

2.6. Statistical Analysis

IBM SPSS Statistics ver. 21.0 software (IBM Corp., Armonk, NY, USA) was used for data analysis.
Homogeneity tests for the general characteristics of each group consisted of the χ2 -test and Fisher’s
exact test, and the normality of the dependent variables was confirmed using the Shapiro–Wilk test.
One-way analysis of variance was conducted on the dependent variables to determine the effects of
the experimental intervention. Statistical significance was defined as p < 0.05.

3. Results
Subjects’ general characteristics are presented in Table 2. There were no significant differences
in these characteristics among the three groups (p > 0.05). Additionally, baseline scores of the main
variables (test anxiety, state anxiety, and stress) did not differ among groups before the intervention.
The effects of the interventions are presented in Table 3. There was a significant difference
among all three groups for test anxiety (F = 4.29, p = 0.016), state anxiety (F = 4.77, p = 0.011), stress
(F = 4.62, p = 0.012), and fundamental nursing skill performance (F = 8.04, p = 0.001). Aromatherapy
combined with music therapy was associated with a significant decrease in test anxiety, state anxiety,
stress, and increased subjects’ fundamental nursing skill performance, as compared with the separate
intervention groups. There was no significant difference between the separate intervention groups.
Int. J. Environ. Res. Public Health 2019, 16, 4185 7 of 10

Table 2. Homogeneity of subjects’ general characteristics and variables among groups.

Characteristics AG (n = 32) MTG (n = 32) AMTG (n = 34) χ2 or F p

Christianity 8 (25.0) 7 (21.9) 3 (8.8)
Buddhism 2 (6.3) 2 (6.3) 0 (0.0)
Religion 6.53 0.340
Catholicism 2(6.3) 3 (9.4) 4 (11.8)
None 20 (62.5) 20 (62.5) 27 (79.4)
Good 23 (71.9) 25 (78.1) 29 (85.3)
Subjective health
Moderate 8 (25.0) 7 (21.9) 5 (14.7) 3.18 0.507
status
Poor 1 (3.1) 0 (0.0) 0 (0.0)
Satisfied 19 (59.4) 14 (43.8) 17 (50.0)
Satisfaction with
Moderate 11 (34.4) 16 (50.0) 17 (50.0) 4.18 0.354
nursing
Not satisfied 2 (6.3) 2 (6.3) 0 (0.0)
≥ 4.0 1 (3.1) 5 (15.6) 6 (11.9)
Overall GPA in 3.5–3.99 16 (50.0) 16 (50.0) 20 (58.8)
9.62 0.128
the prior semester 3.0–3.49 10 (31.3) 8 (25.0) 8 (23.5)
< 3.0 5 (15.6) 3 (9.4) 0 (0.0)
Classical 18 (56.3) 21 (65.6) 19 (55.9)
Music preference Ballad 5 (15.6) 6 (18.8) 4 (11.8)
4.27 0.658
before evaluation Jazz 7 (21.9) 4 (12.5) 6 (17.6)
Others 2 (6.3) 1 (3.1) 5 (14.7)
Very needed 16 (50.0) 15 (46.9) 14 (41.2)
Demand for Needed 12 (37.5) 16 (50.0) 12 (35.3)
6.71 0.293
aromatherapy Moderately needed 3 (9.4) 1 (3.1) 7 (20.6)
Unnecessary 1 (2.9) 0 (0.0) 1 (2.9)
Test anxiety 42.71 ± 7.85 43.09 ± 12.47 42.32 ± 7.00 0.05 0.946
State anxiety 54.31 ± 10.23 54.43 ± 10.87 55.05 ± 7.18 0.06 0.943
Stress 6.34 ± 2.05 6.81 ± 1.22 6.41 ± 1.04 0.91 0.404
AG: aromatherapy group; MTG: music therapy group; AMTG: aromatherapy combined with music therapy group;
Values are mean ± standard deviation or n (%); Tested by Fisher’s exact test or analysis of variance.

Table 3. Comparisons of the change in scores among groups (n = 98).

Difference
Variables Group Pre-test Post-test F p Scheffé post-hoc
(pre-post)
AG (n = 32) 42.71 ± 7.85 42.21 ± 9.01 0.50 ± 6.68
Test anxiety MTG (n = 32) 43.09 ± 12.47 42.68 ± 10.09 0.41 ± 5.47 4.29 0.016* AMTG > AG, MTG
AMTG (n = 34) 42.32 ± 7.00 38.06 ± 6.55 4.26 ± 6.16
AG (n = 32) 54.31 ± 10.23 53.09 ± 8.20 1.22 ± 8.82
State anxiety MTG (n = 32) 54.43 ± 10.87 52.78 ± 9.34 1.65 ± 7.53 4.77 0.011* AMTG > AG, MTG
AMTG (n = 34) 55.05 ± 7.18 48.47 ± 7.69 6.58 ± 7.20
AG (n = 32) 6.34 ± 2.05 6.31 ± 0.96 0.03 ± 1.84
Stress MTG (n = 32) 6.81 ± 1.22 6.68 ± 1.46 0.12 ± 1.73 4.62 0.012* AMTG > AG, MTG
AMTG (n = 34) 6.41 ± 1.04 5.17 ± 1.88 1.24 ± 1.81
Fundamental AG (n = 32) 73.37 ± 17.41
nursing skills MTG (n = 32) 68.90 ± 20.34 8.04 0.001** AMTG > AG, MTG
performance AMTG (n = 34) 84.29 ± 6.96
AG: aromatherapy group; MTG: music therapy group; AMTG: aromatherapy combined with music therapy group;
Values are mean ± standard deviation; * p < 0.05 by analysis of variance in difference (pre-post); ** p < 0.01 by
analysis of variance in post-test.

4. Discussion
This study confirmed the effects of aromatherapy and music therapy when applied separately
and when combined. Additionally, this randomized experimental study used interventions with high
reproducibility, which could be utilized by nursing students before a test. Aromatherapy combined
with music therapy was associated with a significant decrease in test anxiety, state anxiety, and stress,
and significantly increased students’ fundamental nursing skill performance compared with the other
separate intervention groups.
Int. J. Environ. Res. Public Health 2019, 16, 4185 8 of 10

Excessive test anxiety and stress negatively affect academic performance [6,7] and have a negative
impact on students’ ability to perform academic tasks [8,9]. Aromatherapy has been proven to be
an effective strategy to lower students’ level of distraction caused by test anxiety and stress [3].
Additionally, music therapy has been confirmed to be an effective diversion therapy to relieve anxiety
and foster relaxation under circumstances that cause extreme nervousness and stress [16,21,28]. A study
of the effects of interventions that combined aromatherapy, music therapy, meditation, and other
methods of relieving anxiety and stress confirmed that combination therapy was more effective
than individual therapies in relieving anxiety and stress [19]. The combined use of two types of
interventions in this study was associated with significantly improved performance of fundamental
nursing skills and reduced stress and test anxiety through a synergistic effect. This indicates that
aromatherapy, combined with music therapy, is an effective intervention for improving performance
among nursing students.
Additionally, although there was a significant difference between aromatherapy combined with
music therapy and single intervention modalities, there was no significant difference between separate
interventions of aromatherapy and music therapy. This is consistent with previous studies [3,21,28],
wherein no significant difference was observed between the separate interventions because both
aromatherapy and music therapy reduce negative emotions, such as anxiety or stress, among subjects
who perform demanding cognitive tasks.
The aromatherapy techniques in this study were based on previous studies [14,15]. The essential
oil was diffused through the lamp in the intervention room, inhaled, and spread throughout the body.
This method minimized the bias that could have been caused by applying individual interventions
to the subjects in different rooms. Moreover, essential oils reach their maximum level in the body
within 20 min of inhalation and directly affect the brain [14,15]. Therefore, it was considered
appropriate to provide aromatherapy for 20 min. This intervention method and duration can be
applied to nursing students preparing for tests because the method does not impose a heavy burden
on the intervention recipient.
Music therapy was provided by selecting music that has been found to be effective for relieving
test anxiety in previous studies [16,19,21]. The music was played in the intervention area prior to
the test so that subjects could listen to music under normal circumstances. Beethoven’s Moonlight
Sonata was chosen based on previous studies [16,29] that found music effective for relieving anxiety,
and considering the results of a preliminary survey which revealed that the subjects preferred classical
music. Additionally, in a previous study, subjects showed increased positive emotions, decreased
anxiety [28,30], and improved performance when they performed tasks [28] while listening to their
preferred music. Therefore, it is important to consider music preferences when providing music therapy.
For the combined therapy environment, this study tried to mitigate the influence of external
variables by regulating the intervention room’s temperature and lighting. It is assumed that effective
use of these therapies requires a suitable physical space to comfortably undergo aroma and music
therapy. This suggests that the findings of this study can be applied to real-life situations, provided
that students can reserve the necessary space to pursue these therapies. If it is not possible to prepare
such an intervention room, it may be better to control the environment through other means because
various external variables will be affected by the surrounding environment.
This study is of particular utility because it explored various aspects of the effects of aromatherapy
combined with music therapy and also compared the effects of separate interventions. Further, this study
used a double-blinded, randomized method. The results of this study are highly applicable to nursing
students preparing for tests, such as tests of fundamental nursing skills, and provides basis for more
effective educational interventions for nursing students.
Based on the results of this study, we note the following limitations and provide suggestions
accordingly. First, as this study was conducted with sophomores at a nursing college for convenience,
it did not consider participants who varied in gender, age, and race. Therefore, researchers should
not generalize the results of this study too widely; personal and social factors that can affect test
Int. J. Environ. Res. Public Health 2019, 16, 4185 9 of 10

anxiety, stress, and task performance should be considered in future research. Second, while this study
used self-report questionnaires to measure anxiety and stress, future research might also measure
physiological variables to enhance the objectivity and validity of study results. Finally, the results of
this study should be interpreted while considering the possibility of placebo effects caused by positive
perceptions of the interventions as reported in the preliminary survey, participants’ intervention
preferences, and the guidance given to the participants prior to the intervention.

5. Conclusions
This study showed that aromatherapy combined with music therapy had a significant effect on test
anxiety, state anxiety, stress, and performance of fundamental nursing skills compared with separate
interventions. Based on the results, aromatherapy combined with music therapy is recommended
as an intervention for nursing students preparing for tests so that they can achieve the learning
objectives of the nursing curriculum. Additionally, this study provided distinctive insights as it
examined the effect by combining aroma and music therapy in nursing students who were facing tests
of their fundamental nursing skills.

Author Contributions: Study design, H.K.S., W.-Y.S., and M.K.; study conduct, H.K.S., W.-Y.S., and M.K.;
data collection, H.K.S., W.-Y.S., and M.K.; data analysis, H.K.S., W.-Y.S., and M.K.; data interpretation, H.K.S.,
W.-Y.S., and M.K.; drafting the manuscript, H.K.S., W.-Y.S., and M.K.; revising the manuscript content, H.K.S.,
W.-Y.S., and M.K.
Funding: This research received no external funding.
Conflicts of Interest: The authors declare no conflict of interest.

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