The effect of aromatherapy and music therapy on blood pressure and heart rate of nursing students before taking the exam

Abstract

Anxiety associated with taking exams jeopardizes students’ mental and physical health. Complementary alternative methods, such as aromatherapy and music therapy, have shown promise in reducing negative emotions among students. However, few studies have examined the effects of these interventions. This study aimed to investigate the effects of aromatherapy and music therapy on nursing students’ blood pressure (BP) and heart rate before taking an exam. This quasi-experimental, double-blinded study was conducted in 2023 at the Nursing College of Abadan University of Medical Sciences in Abadan, Iran. The research included a total of 169 nursing students, who were randomly assigned to three groups: an aromatherapy group (n = 60), a music therapy group (n = 56), and a control group (n = 53). Aromatherapy was administered by inhaling lavender and damask rose essences, while music therapy involved listening to Beethoven’s “Moonlight Sonata.” The control group received a placebo intervention consisting of cotton soaked in 10 drops of water. Each intervention lasted twenty minutes and was conducted in separate rooms before an exam. Students’ heart rates and BP (both systolic and diastolic) were recorded before and after the intervention. The study showed remarkable effects of aromatherapy and music therapy on blood pressure and pulse rate. While systolic blood pressure (SBP) was similar in all groups at the beginning of the study (p = 0.205), SBP decreased significantly after the intervention (p = 0.016), especially in the aromatherapy (p = 0.003) and music therapy (p < 0.001) groups. Both interventions also significantly reduced diastolic blood pressure and pulse rate (p < 0.001) compared to baseline. However, except for SBP (p = 0.021), ANCOVA tests did not reveal significant differences between the study groups for diastolic blood pressure and pulse rate (p > 0.05). The reduction in students’ systolic BP before exams, observed with complementary therapies like music therapy and aromatherapy using lavender and damask rose extracts, suggests a decrease in stress-related physiological responses, However, the specific link to exam-related anxiety requires further clarification.

Introduction

Nursing students often experience high levels of anxiety¹. Various factors influence this stress, including gender, family income, academic semester, interest in the field, and health status². Excessive stress can negatively affect both the physical and mental well-being of students, leading to reduce their clinical performance and potentially compromising the quality of patient care³. Exam anxiety is a specific type of anxiety characterized by intense physical, emotional, and mental reactions to the fear of failing an exam. This anxiety is often accompanied by worry, which can hinder concentration⁴. Students with higher levels of exam anxiety tend to show lower academic performance and progress⁵. Research indicates that approximately 25% of students experience severe exam anxiety⁶, with a higher prevalence observed in females compared to males⁷. Anxiety triggers the sympathetic nervous system, leading to physiological symptoms such as increased heart rate, elevated blood pressure (BP), and rapid respiration⁸. The severity of exam anxiety varies among individuals. Mild symptoms may present as slight stomach discomfort, while more severe cases can involve concentration difficulties, impaired test performance, and chronic symptoms. Some individuals may also experience increased heart rate, tremors, and fatigue. In extreme cases, symptoms can escalate to nausea, shortness of breath, or even panic attacks⁹. Assessing vital signs can provide valuable insights into the sympathetic nervous system’s activity and an individual’s anxiety levels¹⁰. To alleviate anxiety, a range of non-pharmacological methods—such as music therapy, relaxation exercises, hypnosis, and aromatherapy- are utilized alongside pharmacological interventions¹¹. Music is not only an art form but can also serve as a powerful therapeutic tool. Given its popularity among students, music therapy can help reduce negative emotions. In this therapeutic approach, therapists utilize music to promote overall wellness. Music stimulates the parasympathetic nervous system, resulting in relaxation and emotional relief. Additionally, by stimulating emotions, music influences the activity of the limbic and paralimbic brain systems, which are crucial for emotional processing¹². Furthermore, inhaling various scents can also stimulate the limbic system by allowing scent molecules to enter the nasal mucosa, leading to relaxation and a sense of calm¹³. The National Cancer Institute (cancer.gov) describes aromatherapy, or scent therapy, as the use of plant essences to enhance mental, emotional, and physical well-being. According to Masuo et al., essences such as lavender, rose, rosemary, chamomile, bergamot, grapefruit, and citrus are particularly effective in reducing stress¹⁴. Lavender, in particular, promotes calmness and is effective in managing various types of anxiety, including exam-related anxiety.

A study by Kutlu et al. investigated the effect of inhaling lavender scent on exam anxiety and scores among nursing students. Participants were exposed to lavender fragrance for 15 min, resulting in a significant reduction in anxiety compared to the control group. While their exam scores were higher than those of the control group, the difference was not statistically significant¹⁵. Son et al. (2019) conducted a study to determine the effects of aromatherapy alone and in combination with music therapy on exam anxiety (p = 0.016), state anxiety (p = 0.011), stress (p = 0.012), and fundamental nursing skills (p = 0.001) among nursing students in Korea. The combined approach significantly reduced exam anxiety, state anxiety, and stress, while also enhancing fundamental nursing skills compared to the single-intervention groups. However, there was no significant difference observed between the music therapy and aromatherapy groups¹⁶. Arsaln et al. (2020) explored the correlation between psychological and physiological outcomes after inhaling lavender oil scent among dental patients. Physiological changes were assessed by monitoring vital signs. The lavender group showed lower anxiety and pain scores following dental extractions. Additionally, this group exhibited lower BP levels and a significant decrease in heart rate after inhalation¹⁷.

Recognizing the negative impact of anxiety on individuals, particularly nursing students, and the importance of managing exam-related anxiety, researchers aimed to investigate the effects of aromatherapy and music therapy on the BP and heart rate of nursing students before exams. Given the availability of various non-pharmacological methods for reducing anxiety and the limited evidence comparing aromatherapy and music therapy, this study seeks to enhance the psychological and academic well-being of students.

Methods

Study and design setting

This quasi-experimental, double-blinded study was conducted in 2023. The sample size was calculated using a significance level of 0.05, a power of 0.80, and an effect size of 0.26, which was derived from a previous study¹⁶ involving aromatherapy with students. As a result, the minimum sample size needed for the study was determined to be 147 participants. To account for a potential 10% drop-out rate, the target sample size was set at 174 individuals. However, five participants were excluded from the study for not meeting the inclusion criteria. Ultimately, the final sample consisted of 169 participants. The inclusion criteria required participants to be nursing students in their second semester or higher, and not have participated in any previous research projects. Students were excluded from the study if they had a history of chronic psychological illness, had used sedative drug, had allergies to essential oils, or suffered from hearing disorders that would prevent them from participating in music therapy.

Enrollment, randomization, and blinding

Data were collected from March 28, 2023, to April 14, 2023. Written informed consent was obtained from the subjects. Participants were randomized into three groups by a research assistant not involved in the study, using the Research Randomizer (https://www.randomizer.org/). Each participant received a card with a randomly assigned number indicating their group, which was placed in an opaque envelope. The research assistant opened the envelope for each participant in the order of their arrival and confirmed their assigned group. A double-blind method was employed, ensuring that neither the evaluators nor the participants were aware of the assigned group.

Data collection tool

Data were collected using a personal information questionnaire and vital sign registration forms. The questionnaire was uploaded to the Porsline website, and its link was provided to the students via WhatsApp groups, allowing each student access to the questionnaire based on their student ID. The questionnaire included fields for age, gender, marital status, name of the exam, semester, drug history, allergy history, and hearing disorders.

Interventions

Group A received aromatherapy, Group B experienced music therapy, and Group C served as the control group (Fig. 1). Upon entering the classroom, students were briefed on the cooperation method. To stabilize vital signs after a 16-minute rest¹⁸, research assistants recorded each student’s pulse and BP using a Glamor digital arm BP monitor, ensuring that the cuff closure area was properly marked. Following this, the intervention lasted for 20 min¹⁶. The functionality of the three BP monitors was assessed and calibrated before each test, and each individual’s BP was measured using all three devices to ensure consistency.

Fig. 1.

Research flow diagram.

Group A received aromatherapy with lavender and damask rose essence. Students were instructed not to use any perfume. For this method, cotton balls of equal weight were prepared just before the exam, soaked with seven drops of lavender and three drops of rose essence¹⁹, and stored in a gallipot until the exam began. During the intervention, after checking vital signs, each student in Group A took a cotton ball and placed it under their nose. The extraction of the essences was conducted at Abadan University of Medical Sciences. Petals from damask rose and lavender plants, which had been air-dried in the shade, were prepared and ground. These ground plants were then soaked in a solution of distilled water and alcohol at a 1:10 ratio and shaken using a shaker device for 48 h at room temperature. The extracts were filtered and left at room temperature for ten days to allow the alcohol solvent to evaporate. In Group B, after the initial vital sign assessments, a speaker played Beethoven’s “Moonlight Sonata” for 20 min. Studies have shown that classical music can activate brain functions associated with relaxation and concentration, further supporting its effectiveness as a tool for reducing stress. In addition, studies have shown that Moonlight Sonata, a well-known classical composition, may play a role in reducing anxiety; however, its effect depends on individual factors and listening conditions¹⁶. Group C received a placebo intervention, consisting of cotton soaked in 10 drops of water, for 20 min after completing the questionnaires and initial vital sign checks. Following the intervention, vital signs were re-evaluated using the same instruments. To prevent bias and errors, the post-intervention vital signs were assessed and recorded by different research assistants from those who conducted the initial assessments, using marked areas and separate forms from the pre-test. To control for confounding variables in each group, exams were held in similar locations concerning temperature, light, and environmental conditions. Additionally, to prevent the influence of one group’s intervention on another, exam venues were chosen to be significantly distant from each other. Students with a history of mental illness or those who had used psychotropic drugs in the past month were excluded from the study to mitigate confounding effects. After the interventions, the students took the exam.

Analyzing data

Data analyses were conducted using IBM SPSS Statistics ver. 16 software (IBM Corp., Armonk, NY, USA). Statistical significance was defined as p < 0.05. Descriptive statistics (frequency, mean and standard deviation) and inferential statistics (paired t-test, One-way ANOVA, and ANCOVA) were also utilized.

Ethical considerations

This research was conducted in full compliance with the ethical standards of both the institutional and national research committees. Ethics approval was obtained from the Abadan University of Medical Sciences, prior to the commencement of the study (IR.ABADANUMS.REC.1401.162). All methods were performed in accordance with the relevant guidelines and regulations by the ethical committee of Abadan University of Medical Sciences. All experimental protocols were approved by the ethical committee of Abadan University of Medical Sciences. Participation was voluntary, written consent was obtained from the subjects. Participants had the right to withdraw from the study at any time without prejudice. Clinical trial number: not applicable.

Results

Table 1 presents the general characteristics of the subjects. There were no significant differences among the three groups (p > 0.05). The results indicate that 90.5% of the students were 25 years old or younger. More than half of the students (52%) were women, and the majority were single (94.1%). Most of the students taking the exam were in their second semester, accounting for 36.1% of participants. The largest sample size was recorded during the nursing care at home exam, comprising 24.9% of the total. Five participants with a history of chronic mental disorders or sedative use in the past month were excluded from the study.

Table 1.

Baseline characteristics of participates.

Variable		Aroma (n = 60)		Music (n = 56)		Control (n = 53)
		n	%	n	%	N	%
Age group	25 years and under	55	35.9%	51	33.3%	47	30.7%
	Above 25 years	5	31.3%	5	31.3%	6	37.5%
Gender	Male	30	37.5%	22	27.5%	28	35.0%
	Female	30	33.7%	34	38.2%	25	28.1%
Marital status	Single	60	37.7%	53	33.3%	46	28.9%
	Married	0	0.0%	3	30.0%	7	70.0%
Name of exam	Community health nursing	12	32.4%	13	35.1%	12	32.4%
	Pediatric nursing	8	34.8%	7	30.4%	8	34.8%
	Psychiatric nursing	12	35.3%	13	38.2%	9	26.5%
	Home nursing care	16	38.1%	13	31.0%	13	31.0%
	Maternal and newborn health nursing	12	36.4%	10	30.3%	11	33.3%
Semester	Second	22	36.1%	17	27.9%	22	36.1%
	Third	9	29.0%	11	35.5%	11	35.5%
	Forth	9	36.0%	11	44.0%	5	20.0%
	Fifth	10	43.5%	6	26.1%	7	30.4%
	Sixth	10	34.5%	11	37.9%	8	27.6%
Drug history/psychological disorder	Yes	0	0.0%	0	0.0%	0	0.0%
	No	60	35.7%	56	32.7%	53	31.5%
Allergy history	Yes	0	0.0%	0	0.0%	0	0.0%
	No	60	35.7%	56	32.7%	53	31.5%
Hearing disorder	Yes	0	0.0%	0	0.0%	0	0.0%
	No	60	35.7%	56	32.7%	53	31.5%

Table 2 presents the effects of the interventions. A paired t-test was used to compare mean scores before and after the intervention, while ANOVA and ANCOVA tests were used to assess differences in mean scores across the three groups: aromatherapy, music therapy, and control. The results indicate that the mean systolic BP before the intervention did not significantly differ among participants (p = 0.205). However, after the intervention, the mean systolic BP significantly decreased (p = 0.016), and the difference was significant just in the aromatherapy group (p-value = 0.003) and the music therapy group (p < 0.001). There was a difference in the mean scores after the intervention in the three study groups (p = 0.021). Considering the decrease in the mean values and the difference in p-values, it can be concluded that the effect of music therapy on systolic BP was greater than aromatherapy. Overall, the mean diastolic BP and pulse rate decreased after the intervention compared to before (p < 0.001), which was only significant in the music therapy and aromatherapy groups. However, the results of the ANCOVA test did not show a significant difference between the study groups for both variables (p = 0.159 and p = 0.262).

Table 2.

Intervention effects on students BP and heart rate.

Factor	Total		Group
			Aroma (n = 60)		Music (n = 56)		Control (n = 53)		P-value¶
	Mean	SD	Mean	SD	Mean	SD	Mean	SD
pre_sBP	121.28	16.27	124.27	12.53	119.29	15.09	120.02	20.49	0.205
post_sBP	117.80	13.58	120.68M	12.95	113.70A	12.72	118.87	14.33	0.016, 021*
P-value†	< 0.001		0.003		< 0.001		0.607
pre_dBP	76.05	8.26	76.25	7.62	73.91C	8.58	78.08M	8.22	0.030
post_dBP	74.17	8.36	74.30	7.80	71.63C	8.01	76.72M	8.69	0.006, 0.159*
P-value†	< 0.001		0.009		0.031		0.126
pre_pulse	91.10	15.23	95.05C	17.30	91.00	14.04	86.74A	12.82	0.014
post_pulse	87.96	14.20	91.93C	16.15	86.45	11.31	85.08A	13.82	0.022, 0.262*
P-value†	< 0.001		0.016		< 0.001		0.167

^†P-value conducted from paired t-test. ^¶P-value conducted from One-way ANOVA test. Following a Tukey post-hoc test. A, M, and C signs of significant between two groups. SD standard deviation. *P-value conducted from ANCOVA test. A: Aromatherapy, M: Music therapy, C: Control, SD standard division. Significant value are in bold.

Discussion

This study aimed to assess the effects of aromatherapy and music therapy on the BP and heart rate of nursing students before exams. Both therapies, utilizing of lavender and damask rose extracts and music therapy, were found to reduce students’ systolic BP prior to exams. While both interventions were effective, music therapy had a more pronounced impact compared to aromatherapy. Exam anxiety poses a significant challenge for students, leading to various physiological and psychological effects, including stress and physical symptoms, in addition to psychological burdens²⁰. Myoungsuk Kim et al.²¹ demonstrated that lavender extract aromatherapy lower systolic BP, supporting the findings of this study. Furthermore, another study showed that music therapy could reduce systolic BP and pulse rate in patients after surgery, without affecting diastolic BP²². Another study in Turkey also indicated that music plays a significant role in reducing systolic BP among elderly individuals²³. In contrast, Khoshkesht et al.²⁴ examining nursing students’ anxiety before exams found no changes in BP before and after the intervention. It is important to note our study sample size approximately twice that of the mentioned study, which may enhance the reliability of our results. Additionally, our study utilized a combination of two extracts for aromatherapy, whereas the mentioned study relied solely on lavender. The concurrent use of multiple aromas can amplify their effects as emphasized in our findings¹⁶. Aromatherapy influences the autonomic nervous system, and our stud employed an inhalation method for this purpose. Inhalation aromatherapy is particularly effective for stress management compared to other complementary medicine methods, significantly impacting BP, heart rate, and cortisol levels. It has garnered increasing attention recently for addressing both acute and chronic stress²⁵.

The comparison between aroma and music therapy revealed a decrease in mean systolic BP, diastolic BP, and pulse rate following the intervention. However, no significant differences were found among the three study groups, suggesting that music therapy and aromatherapy using lavender and damask rose extracts did not lead to changes in diastolic BP and heart rate in students prior to exams. This lack of effect may be attributed to the duration of the intervention, as the observed differences were only noted in the pre- and post-intervention results, not between the various groups. Additionally, confounding factors not considered in this study may have played a role. Conditions such as cardiovascular diseases, hypertension medication, contraceptive use, kidney diseases, hyperthyroidism, and exercise history²⁶ could influence BP and were not investigated, which should be addressed in future studies. Hashemi et al.¹⁹ in their study found that aromatherapy with lavender and rose extract significantly impacted systolic and diastolic BP and heart rate. The discrepancy in results may stem from the method of administering the extract; in the current study, the extract was delivered using an absorbent cotton pad, while in Hashemi et al.‘s study, a non-absorbent pad was utilized, which may have affected the amount of extract available to participants. Furthermore, the quantity of rose extract used in that study was approximately three times greater than in this study. The strength of this research lies use of freshly prepared extracts, as opposed to the ready-made extracts commonly used in other studies. The extraction process was conducted in a university laboratory using a simple, hands-on method. However, this study did not account for the influence of personality traits and pre-existing cardiovascular conditions on the variables evaluated. Additionally, due to the small sample size and the variation in lessons during the exam (despite the exams being standardized), it is recommended that these factors be considered in future studies. It is also recommended that future studies be conducted using different genres of music and different intervention durations than the present study. Although the choosing of Beethoven’s “Moonlight Sonata” was justified based on other research and its known calming effects, the subjective nature of music therapy required further investigation. Future studies should be conducted incorporating a wide range of music genres, personalized playlists, and culturally relevant music to provide a more comprehensive understanding of music therapy’s effectiveness in reducing exam-related anxiety. Additionally, exploring different durations and timing of music therapy interventions could help optimize its benefits for students.

Conclusions

Exam anxiety among students is a common experience that can negatively impact physiological factors like BP and pulse rate, ultimately affecting their mental well-being and academic performance. The results have illustrated music therapy and aromatherapy using lavender and damask rose extracts decrease students’ systolic BP before exams, indicating a decrease in exam-related anxiety. To mitigate this anxiety, complementary methods such as music therapy and aromatherapy present safe, accessible, and effective solutions. It is advisable to implement these methods regularly in university exam centers. For a well-rounded conclusion, future studies should explore these recommendations further.

Abbreviations

BP

Blood pressure

SBP

Systolic blood pressure

DBP

Diastolic blood pressure

P

Pulse

Author contributions

MT, TB, ME: Conceptualization; Data gathering; Formal analysis; Investigation; Project administration; Resources; Supervision; Roles/Writing—original draft. RT, NK, MAM: Conceptualization; Formal analysis; Investigation; Roles/Writing—original draft; Funding acquisition; Methodology; Writing—review and editing. HKA, FH: Conceptualization; Investigation; Methodology; Validation; Writing—review and editing. All authors read and approved the final manuscript.

Data availability

All data generated and analyzed during the current study are not publicly available but are available from the corresponding author on reasonable request and the Abadan University of Medical Sciences’ approval.

Declarations

Competing interests

The authors declare no competing interests.

Ethics approval and consent to participate

This research was conducted in full compliance with the ethical standards of both the institutional and national research committees. Ethics approval was obtained from the Abadan University of Medical Sciences, prior to the commencement of the study (IR.ABADANUMS.REC.1401.162). All methods were performed in accordance with the relevant guidelines and regulations by the ethical committee of Abadan University of Medical Sciences. All experimental protocols were approved by the ethical committee of Abadan University of Medical Sciences. Participation was voluntary, written consent was obtained from the subjects. Participants had the right to withdraw from the study at any time without prejudice. Clinical trial number: not applicable.