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DOI: 10.1089/act.2014.20207 • MARY ANN LIEBERT, INC. • VOL. 20 NO. 2 ALTERNATIVE AND COMPLEMENTARY THERAPIES
APRIL 2014
Abstract
Objective: To assess the effect of aromatherapy (Citrus limon
[lemon] essential oil) on cognitive test anxiety among nursing
students, Cognitive Test Anxiety Survey (CTAS) scores were
measured pre- and postintervention.
Participants: Thirty-nine (39) sophomore nursing students
(35 female and 4 male) from a private, 4-year college partici-
pated in this study.
Materials and Methods: A quantitative, randomized, pre-
test–posttest design was used. One nursing examination was
used for baseline data and all participants were e-mailed the
CTAS. The experimental group completed the second exami-
nation in a room with diffused aromatherapy, and the control
group remained in a classroom without aromatherapy. The
CTAS was e-mailed for comparison data.
Results: There were no significant differences between the
control and study groups in relation to preintervention cogni-
tive anxiety scores (mean [M] = 78.17 and M = 73.62), re-
spectively. In the control group, there was a 3-point decrease
in cognitive test anxiety scores between pretest and post-test.
However, there was a significant decrease in cognitive test
anxiety scores in the students who received aromatherapy,
compared to those who did not (P = 0.10). Age and gender
were not moderating variables in this study.
Conclusions: Diffused lemon essential oil is a safe, cost-
effective intervention that had a positive effect on cognitive
test anxiety among nursing students.
Introduction
Nursing programs are designed to educate and transform adult
learners to the professional nursing role. The process of educat-
ing students has become more complex and stressful because of
advances in technology, patient demographics, national safety
standards, high expectations in the classroom and clinical en-
vironments, and nursing faculty shortages.
1–3
Nursing students
are experiencing stressful learning environments from multiple
sources, which consequently impede their success.
One of the major barriers to nursing-student success across
all nursing programs is test anxiety, which potentially reduces
student graduation rates, and thus the goal of obtaining profes-
sional licensure. Swafford
4
used the State-Trait Anxiety Inven-
tory (STAI) with 107 first-semester nursing students. It was
concluded that as anxiety increased, academic performance
(test scores) decreased. Among a myriad of alternative and
complementary therapies, aromatherapy appears to be a safe,
cost-effective intervention for managing test anxiety among
nursing students.
The use of aromatherapy is well-known in some environ-
ments but this use is limited in educational settings. Aro-
matherapy uses essential oils that are extracted and distilled
from a plant’s flower, bark, stems, roots, peel, or leaf.
5–7
Clini-
cal aromatherapy is the controlled practice of using essential
oils for specific outcomes that are measureable on mind, body,
and spirit.
8–11
Cognitive test anxiety research has been conducted in pri-
mary and secondary educational settings, but there is a lack of
scientific evidence to explain how nursing students can man-
age their test anxiety effectively. A majority of studies among
undergraduate nursing students has been limited to an assess-
ment aspect of test anxiety only, without interventions. There
are limited published studies that evaluate test anxiety and
aromatherapy in a nursing program.
5–7
Therefore, the purpose
of this study was to examine the effect of aromatherapy on
cognitive test anxiety among nursing students.
Materials and Methods
Nursing Students
This quantitative study was approved by the institutional
review board of the nursing school. A total of 46 sophomore
nursing students were screened for contraindications to Citrus
limon (lemon) essential oil, and written informed consents were
Original Article
Eect of Aromatherapy on Cognitive
Test Anxiety Among Nursing Students
Catherine E. Johnson, PhD, RN, MSN, MBA
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ALTERNATIVE AND COMPLEMENTARY THERAPIES • APRIL 2014
MARY ANN LIEBERT, INC. • VOL. 20 NO. 2
Original Article
Eect of Aromatherapy on Cognitive
Test Anxiety Among Nursing Students
obtained at the beginning of the study.
12
The students were ran-
domized into two groups, control and experimental, with 23 stu-
dents in each group. A total of 41 students completed the Cogni-
tive Test Anxiety Survey (CTAS) preintervention, and of the 41
students, 39 also completed the CTAS postintervention.
Thus, the final sample size for this study was N = 39. Nurs-
ing students had a mean age of 25.79 years; 35 were female
and 4 were male. Tables 1 and 2 show there was not a statis-
tically significant difference in the average CTAS scores be-
tween the two groups preintervention, t(37) = 1.06; P = 0.29. It
was concluded that randomization produced equivalent groups
effectively, with respect to cognitive test anxiety at the begin-
ning of the study.
Aromatherapy
There are many essential oils that could have been used in
this study, such as Lavandula spp. (lavender), Mentha x pip-
erita (peppermint), or Salvia sclarea (clary sage). However,
lemon oil is another safe essential oil that has been researched
with adults as well as with children.
13,14
Based on the safety
and the primary chemical component of limonene, C. limon
oil was chosen for its benefits with respect to cognitive func-
tioning, attention levels, and memory
13,14
The 100% lemon
essential oil was produced in Brazil and purchased from
Resources for Living Well. The bottle was not opened until
the day of the intervention for maximum therapeutic effects.
Fifteen minutes before the students arrived, the second-floor
classroom (~ 1100 square feet) was diffused with lemon es-
sential oil. However, the TheraPro™ Premium Diffuser had a
maximum diffusion capacity of 600–800 square feet. The full
bottle of lemon essential oil was placed in the diffuser and
diffused for the entire time of the examination, which was ~
25 minutes. In this study, the nurse–aromatherapist was certi-
fied, with > 800 hours of continuing education from nation-
ally recognized programs.
Procedures
All nursing students in this study completed an initial ex-
amination without any intervention, and were e-mailed the
CTAS via a Survey Monkey link within 1 day following the
first examination. A follow-up CTAS was administered and
completed within 1 day after the second examination. The
CTAS was administered in this study because this survey tool
included the domain of worry during an examination. The do-
main of worry has been identified as the primary factor that
inhibits academic performance.
15–18
Worry is a significant
cognitive element in anxiety and the primary reason for de-
creased academic performance in students with high levels of
test anxiety.
19
Bembenutty
16,17
argued that worry limits cog-
nitive capacity, thus, interfering with concentration, recalling
information, and thinking.
Statistical Analysis
Statistical analyses were performed using SPSS for Win-
dows, version 19.0. All of the analyses were two-sided with
a 5% a level. Cronbach’s a was used to measure the internal
consistency of the cognitive test scores.
Results
The research question was: What effect does aromatherapy
have on the level of cognitive test anxiety among baccalau-
reate nursing students? There was a significant decrease in
cognitive test anxiety scores in the students who received aro-
matherapy, compared to those who did not (P = 0.10). In addi-
tion, as Table 3 shows, there was not a statistically significant
difference in the average CTAS score between preintervention
and postintervention within the control group, t(17) = 2.01, P
= 0.06. Therefore, it was concluded that there was no differ-
ence in the average CTAS scores among students who did not
receive aromatherapy.
Table 1.
Descriptive Statistics for the Cognitive Test Anxiety Scores
(Preintervention) by Study Group
N
Study group Valid Missing
M SD
Minimum Maximum
Control 18 0 78.17 14.15 54.00 103.00
Experimental 21 0 73.62 12.53 45.00 90.00
SD, standard deviation; M, mean.
Table 2. Two-Sample t-Test to Compare the Average Cognitive
Test Anxiety Scores (Preintervention) by Study Group
t-
Test for equality of means
Score
t df
P-value
Cognitive test anxiety
s
core (preintervention) 1.06
37
0.29
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ALTERNATIVE AND COMPLEMENTARY THERAPIES • APRIL 2014
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In the experimental group, the average postintervention
CTAS scores were statistically significantly lower than the
average preintervention scores. The average (and standard
deviation) CTAS score was 73.62 (12.54) versus 67.62
(15.38) for preintervention and postintervention, respectively,
t(20) = 2.83; P = 0.01. It was concluded that students who
received aromatherapy scored lower on the postintervention
CTAS, compared to before receiving the intervention.
In comparison, there was not a statistically significant dif-
ference in the average change in CTAS scores between the
two study groups, t (37) = 1.12; P = 0.27. It was concluded
that there was no difference in the amount of change in cog-
nitive test anxiety from pre- to postintervention between par-
ticipants who did not receive aromatherapy and those who
did receive aromatherapy.
The moderating variables of age and gender were also eval-
uated in this study. Multiple linear regression analysis was
used to determine if age and gender moderated the effect of
aromatherapy on the amount of change in cognitive test anxi-
ety from preintervention and postintervention. The interaction
between study group, and age and gender was not statistically
significant (P = 0.22 and P = 0.26), respectively. It was con-
cluded that age and gender did not moderate the effect of aro-
matherapy on the amount of change in cognitive test anxiety.
Discussion
The objective of this randomized assignment, experimental
study was to examine the effect of aromatherapy on cogni-
tive test anxiety among sophomore nursing students. Several
studies have been conducted in nursing education to examine
various strategies for addressing test anxiety.
20–22
The results
of this study supported the intervention of aromatherapy dur-
ing an examination to decrease anxiety for nursing students
during test taking. Lemon essential oil decreased cogni-
tive test anxiety scores for 21 nursing students from pretest
(M = 73.62) to post-test (M = 67.62). In addition, a paired
t-test confirmed further that the average postintervention CTAS
score was significantly lower than the average preinterven-
tion score among nursing students who received diffused aro-
matherapy, t = 2.83; P = 0.01.
The CTAS was an appropriate tool for college-level stu-
dents and has demonstrated high internal consistency over the
years (a = 0.91–0.93).
23–25
The a coefficient in this study was
0.92 for the preintervention and 0.94 for the postintervention,
which was consistent with previous studies. The CTAS was an
acceptable, reliable instrument, which the current author had
not found published in nursing education literature at the time
of this study.
There were several limitations in this study. Although the
sample size changed over time, the effect sizes remained
consistent throughout the study (0.70–0.92). As a longitudi-
nal study, attrition was anticipated, although a specific rate
was not predicted. Initially, 46 nursing students consented to
the study, but only 39 completed the second CTAS, which re-
sulted in a 15% attrition rate from nursing students not com-
pleting the second CTAS. It is not known why this attrition
rate occurred. The classroom size may have contributed to
the lack of significance in the pre-to-post scores between the
two study groups.
The implementation time of the CTAS may have been an-
other limitation in this study. The study was designed for stu-
dents to complete the CTAS within 24 hours of the examina-
tion. This may have been too much time to assess cognitive
test anxiety accurately, although Cassady
23–26
acknowledges
that cognitive test anxiety is present before, during, and af-
ter an examination. In retrospect, the study should have been
designed for students to complete the CTAS immediately af-
ter class in the computer laboratory. This process change may
have also minimized the attrition rate.
Conclusions
Lemon essential oil was shown to be an effective interven-
tion for reducing test anxiety among nursing students. Nursing
education can be a stressful experience based on high-stakes
testing situations. It would be helpful if nursing educators ex-
plored innovative ideas to reduce stress in their students.
Disclosure Statement
No competing financial interests exist. n
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Catherine E. Johnson, PhD, RN, MSN, MBA, is an assistant professor of
nursing, at Westfield State University, in Southwick, Massachusetts.
To order reprints of this article, e-mail Karen Ballen at: Kballen@liebertpub.com
or call (914) 740-2100.
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