Asian Nursing Research 8 (2014) 286e292

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Asian Nursing Research

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Research Article

Effects of Autogenic Training on Stress Response and Heart Rate

Variability in Nursing Students
Seung-Joo Lim, PhD, RN, 1 Chunmi Kim, PhD, RN 2, *
1
Department of Nursing, Hoseo University, Asan, South Korea
2
Department of Nursing, Sunmoon University, Asan, South Korea

a r t i c l e i n f o s u m m a r y

Article history: Purpose: This study was undertaken to conrm the effects of autogenic training (AT) on stress response
Received 7 August 2013 and heart rate variability in nursing school students experiencing stress related to clinical training.
Received in revised form Methods: The study was carried out from September 2012 to April 2013 in a quasi-experimental
7 May 2014
nonequivalent control group using a pretest-posttest design. The participants were 40 nursing stu-
Accepted 23 June 2014
dents in their third year at either of two nursing colleges. All consented to participate. Nineteen nursing
students at one college were assigned to the experimental group and underwent the 8-week AT program,
Key words:
and the other 21 were assigned to the control group and did not undergo any training. Stress response
autogenic training
heart rate
was assessed by questionnaire and HRV was measured three times, that is, before the program, at the
stress end of the program, and 6 months after the end of the AT program.
nursing students Results: A signicant time/group interaction was found for stress response (F 4.68, p .012), a sub-
jective indicator. However, no signicant interaction was found for the objective indicators of heart rate
variability, normalized low frequency (F 2.59, p .090), normalized high frequency (F 2.59, p .090),
or low frequency to high frequency ratio (F 1.38, p .257).
Conclusion: The results suggest that AT provides an acceptable approach to stress reduction in nursing
students.
Copyright 2014, Korean Society of Nursing Science. Published by Elsevier. All rights reserved.

Introduction (Elliot, 2002). This stress has a negative effect on adaptation to

Nursing school students are under more stress than students
studying other majors because of the burden imposed by taking
courses while completing clinical training, which accounts for a
large proportion of academic credits (Yoo, Chang, Choi, & Park,
2008). In particular, nursing students experience much more
stress during initial clinical training. The sources of stress for these
students are mainly the result of a lack of professional knowledge
and skills in taking care of patients, the clinical environment, and
teachers and nursing staff (Chan, So, & Fong, 2009; Shaban, Khater,
& Akhu-Zaheya, 2012; Sheu, Lin, & Hwang, 2002). Furthermore,
they have only knowledge of basic medicine and nursing prior to
clinical training (Sheu et al., 2002). Accordingly, they do not know
how to cope with the dynamic and complex clinical environments,
how to establish good relationships with clinical staff and in-
structors or deal with sudden changes in patients' conditions
* Correspondence to: Chunmi Kim, PhD, RN, Department of Nursing, Sunmoon
University, 100 Galsan-ri, Tangjeon-myeon, Asan 336-708, South Korea.
E-mail address: spring4cmk@gmail.com
clinical training, and thus, on student health. Furthermore, if stress
is excessive or prolonged, nursing students fail to adapt to clinical
training (Park, Ha, & Choi, 2004) and experience psychological
difculties, such as anxiety, a sense of anger, indifference, frustra-
tion, and depression (Chang et al., 2007), and physical health
problems, such as indigestion, anorexia, backache, headache, and
insomnia (Choo et al., 2002; Park & Ha, 2003).
As social concerns regarding health have increased, the need for
diverse teaching methods to provide qualied nursing care skills
has been suggested (Whang, 2006). Thus, as the importance of
clinical training increases, nursing students need appropriate stress
coping strategies to reduce the risks of physical and mental health
problems.
Relaxation training provides an excellent strategy for managing
stress, and autogenic training (AT) is one type of this training (Kanji,
White, & Ernst, 2006; Son, 2011). AT is a psychophysiological type
of psychotherapy based on autosuggestion, rst developed by the
German physician and psychiatrist J.H. Schultz in the early 20th
century. AT consists of the phased practice of six simple relaxation
responses. The rst exercise that addresses muscular relaxation is
performed by reiterating a formula to promote a sensation of

http://dx.doi.org/10.1016/j.anr.2014.06.003
1976-1317/Copyright 2014, Korean Society of Nursing Science. Published by Elsevier. All rights reserved.
 S.-J. Lim, C. Kim / Asian Nursing Research 8 (2014) 286e292
heaviness in limbs, and subsequently, attention is focused inac-
tively on sensing warmth, then on slow breathing, abdominal
warmth, a calm heart beat, and a cool forehead. It has been rec-
ommended that the AT program be conducted over 8 weeks and
that it be composed of one group session per week and self-training
three times daily (Kanji et al., 2006; Rhee, 2008). While progressing
through these exercises, most people experience passive concen-
tration, which allows the individual to break out the vicious stress
cycle (Carruthers, 1979). AT leads a high-arousal sympathetic ner-
vous response to low-arousal parasympathetic nervous response
via relaxation (Kanji et al., 2006; Rhee, 2008).
Some reports have claimed that AT has valuable effects on the
mind and body, and is currently used to treat diseases related to or
aggravated by stress, such as irritable bowel syndrome (Shinozaki
et al., 2010), cancer (Wright, Courtney, & Crowther, 2002), and
multiple sclerosis (Sutherland, Andersen, & Morris, 2005). AT is
also used to treat stress. Three trials have been performed to study
the effect of AT on stress in nursing students, which found that AT
reduced anxiety (Charlesworth, Murphy, & Beutler, 1981; Kanji
et al., 2006) and the absence rate due to illness (Bailey, 1984).
Stress is known to affect cardiovascular changes, which are
usually related to autonomic nervous system activity changes
(Rozanski et al., 1988). Heart rate variability (HRV) is one of the
indicators of changes in the autonomic nervous system (Chandola,
Heraclides, & Kumari, 2010), and has been used to measure general
autonomic system function and physiological stress response de-
gree because of its simplicity and noninvasive nature (Sztajzel,
2004; Task Force of the European Society of Cardiology and the
North American Society of Pacing and Electrophysiology, 1996).
Mitani, Fujita, Sakamoto, & Shirakawa (2006) measured changes in
stress and autonomic nervous activity using HRV, and reported that
sympathetic nervous activity increases but parasympathetic ner-
vous activity decreases in stressful situations. Pomeranz et al.
(1985) concluded that HRV is a credible and sensitive indicator of
cardiac autonomic nervous activity through HRV power spectral
analysis.
Studies on AT have been performed over many years overseas,
but little work has been undertaken in Korea. In particular, few
studies have been conducted on the AT Korean Standard developed
by Ju-hee Rhee based on the original AT by Schultz (Rhee, 2006,
2008). Few HRV studies have evaluated the effects of AT.
Purpose of study and hypotheses
This study was undertaken to conrm the effects of AT on stress
response and HRV in nursing school students experiencing stress
related to clinical training. We hypothesized stress response in the
experimental group, members of which were administered with
AT, would be lower than that in the control group, and that
normalized low frequency (LF) would be lower, normalized high
frequency (HF) would be higher, and LF/HF ratio would be lower in
the experimental group.
Methods
Study design
This study used a quasi-experimental, nonequivalent control
group, pretest-posttest design (19 participants in the experimental
group, 21 participants in the control group). Participants in the
experimental group were administered the AT Korean Standard.
Outcomes were measured three times: before the AT program, at
the end of the standard 8-week program, and at 6 months after the
end of the program.
287
Setting and samples
The participants were 40 nursing students in their third year at
two nursing colleges. All consented to participate. Nineteen nursing
students at one college were assigned to the experimental group
and underwent the 8-week AT program, and the other 21 were
assigned to the control group, members of which did not undergo
any training. No participant dropped out of the study. The sample
size for this study was calculated before the investigation. G*power
program, version 3 (Faul, Erdfelder, Lang, & Buchner, 2007) showed
that 16 students per group were required for an effect size of 0.3, at
a power of 95%, and an alpha level of .05. The reasons why we
decided on this small effect size were that no previous AT study has
calculated sample size using the G*power program and the
experimental and control groups were well matched. The selection
criteria were as follows: (a) agreement to participate in the study;
(b) no relaxation therapy during the previous 6 months; and (c) no
cardiovascular or neurological problem.
Ethical considerations
This study was approved by the institutional review board of
Hoseo University (approval no.: 20120009). Participants interested
in this study voluntarily participated in the program. The study
purposes and procedures were explained to participants. Partici-
pants were told that personal information would be protected and
they could drop out of the study without prejudice at any time.
Participants provided written informed consent and were briefed
beforehand on study purposes and procedures, anticipated risks
and benets, privacy protection, compensation methods, and
withdrawal from the study.
Due to their student statuses, honest answers of the participants
were emphasized to avoid ethical problems during the study. In
particular, the risk of making false or attering responses by stu-
dents were prevented by informing them that honest answers
could enhance the quality of the study. Furthermore, participants
were told that all collected data would be used for study purposes
only.
Intervention
Autogenic training
AT was administered according to the AT Korean Standard
(Table 1) in a lecture room by an AT facilitator certied by the
Korean AT Association. AT involved the phased practice of 6 simple
relaxation responses once weekly for 8 weeks. In a relaxed sitting
position with eyes closed, the training involved the use of six short
verbal standard formulae. The rst exercise targeted muscular
relaxation. The principle subject of the verbal formula used was
heaviness. Right-handed students started passive concentration of
My right arm is heavy, whereas left-handed participants started
with the left arm. The second mandatory passive concentration
addressed peripheral warmth using formula My right/left arm is
warm. After learning to generate feelings of heaviness and
warmth, participants were taught to concentrate on breathing,
which was keyed by the instruction My breathing is calm and
regular, and then to warm the abdominal region by using the
formula My solar plexus is warm. The following exercise con-
cerned the cranial region, which should be cooler than the rest of
the body. Here, the formula used was My forehead is cool. Finally,
the focus was placed on cardiac activity with the formula My heart
beat is calm and regular. Each formula was practiced in group
sessions and participants were asked to practice the learned
autogenic exercises alone at least twice daily. In addition, they were
asked to submit a report of their experiences and any questions
288
Table 1 Summary of Korean Standard Autogenic Training Program.
8-week Exercise formulae
sessions
1 My right/left arm
is heavy.
2 My right/left arm
is warm.
3 My breathing is
calm and regular.
4 Review the three
procedures.
5 My solar plexus
is warm.
6 My forehead
is cool.
7 My heart beat is
calm and regular.
8 Final check
regarding their experiences while they practiced the exercises. At
each of the 8 sessions, the facilitator provided feedback to the
participants based on considerations of these reports. If a student
found it difcult to practice the exercises alone, the facilitator
S.-J. Lim, C. Kim / Asian Nursing Research 8 (2014) 286e292
Contents
Explain the principles of AT and the necessity
of self practice
Practice the rst standard procedure using
the rst formula, My right/left arm is heavy.
Solve problems, support, and encourage
by feedback
Give materials for self practice and explain
self practice
Discuss self practice
Review the rst standard procedure
Practice the second standard procedure
using the second formula, My right/left
arm is warm.
Solve problems, support, and encourage
by feedback
Give materials for self practice and explain
self practice
Discuss self practice
Review the rst two standard procedures
Practice the third standard procedure using
the third formula, My breathing is calm
and regular.
Solve problems, support, and encourage
by feedback
Give materials for self practice and explain
self practice
Discuss self practice
Review and practice the rst three standard
procedures
Solve problems, support, and encourage
by feedback
Give materials for self practice and explain
self practice
Discuss self practice
Review the rst three standard procedures
Practice the fourth standard procedure using
the fourth formula, My solar plexus is warm.
Solve problems, support, and encourage
by feedback
Give materials for self practice and explain
self practice
Discuss self practice
Review the rst through fourth standard
procedures
Practice the fth standard procedure using
the fth formula, My forehead is cool.
Solve problems, support, and encourage
by feedback
Give materials for self practice and explain
self practice
Discuss self practice
Review the rst through fth standard
procedures
Practice the sixth standard procedure and
formula, My heart beat is calm and regular.
Solve problems, support, and encourage by
feedback
Give materials for self practice and explain
self practice
Discuss self practice
Review and practice the six standard
procedures
Solve problems, support, and encourage
by feedback
Advise regarding further training: once a
day for a year
encouraged them to nd solutions and made suggestions. Detailed
contents of AT for nursing students are provided in Table 1.
Instruments
Stress response
Stress response is a measure of the physical and mental re-
actions caused by stress. In this study, it refers to the score on the
scale developed by Koh, Park, and Kim (2000). Permission to use
this scale was acquired from Koh et al. (2000), after providing an
explanation of the study purpose. This 39-item scale has seven
subscales: tension, aggression, somatization, anger, depression,
fatigue, and frustration, which are each scored on a 5-point scale. A
higher score means a greater stress response. Cronbach's alpha as
determined by Koh et al. was .97. In the present study it was .92.
HRV
HRV was measured by emWavePSR (HeartMath, Inc., CA, USA)
for 5 minutes, and MATLAB program (The MathWorks, Inc., Kuopio,
FINLAND) with Kubios HRV version 2.0 was used to obtain the in-
dicators for frequency-domain analysis. This analysis entails the
distribution of oscillations in three frequency bands and the
determination of power in each of these bands (Task Force of the
European Society of Cardiology and the North American Society of
Pacing and Electrophysiology, 1996). Power in the HF band
(0.15e0.4 Hz) is an indicator of parasympathetic nervous activity,
whereas power in the LF band (0.05e0.15 Hz) mostly reects
sympathetic nervous activity (Song et al., 2011). Power in the very-
low-frequency (VLF) band (0.005e0.05 Hz) is an additional indi-
cator of parasympathetic nervous activity (Pagani et al., 1986). LF/
HF ratio is a general balance indicator used to evaluate sympa-
thetic/parasympathetic nervous system balance. A high ratio im-
plies intensied activity of the sympathetic nervous system or
suppression of the parasympathetic nervous system (Mellman,
Knorr, Pigeon, Leiter, & Akay, 2004).
In this study, normalized LF, normalized HF, and LF/HF ratio
were used to analyze autonomic nervous system activity. The for-
mula used to calculate normalized LF or HF was as follows:
normalized LF or HF (LF or HF/total power  VLF)  100 (Dishman
et al., 2000).
Data collection
Data was collected from September 2012 to April 2013. AT was
conducted for 8 weeks, from September to October 2012. Data
collection was performed three times: before AT, at the end of AT,
and 6 months after AT completion. To control for factors affecting
the autonomic nervous system when HRV was measured, partici-
pants were asked not to drink alcohol the night before the exam-
ination and not to drink caffeine or smoke for at least 4 hours before
the examination. HRV was measured in a quiet, calm conference
room. Participants were asked to remove jewelry and cell phones,
and to adopt a comfortable posture. After applying the measure-
ment sensor to an ear lobe, the procedure was explained and HRV
was measured for 5 minutes while maintaining a respiration rate of
14e20 breaths per minute (Kim, Hwang, Kim, Sim & Lee, 2005).
Data analysis
Data analysis was performed using SPSS version 18.0 for Win-
dows (IBM SPSS Statistics, Chicago, IL, USA). Chi-square test,
Fisher's exact test, and t test were used for testing homogeneity
between the experimental and control groups. Hypothesis testing
was performed using repeated measures analysis of variance.
 S.-J. Lim, C. Kim / Asian Nursing Research 8 (2014) 286e292 289

Table 2 Homogeneity Testing of General Characteristics in the Experimental and the control group was rejected. There was a signicant time dif-
Control Groups (N 40). ference (F 9.18, p .001), but no signicant time/group interac-
Characteristics Categories Exp (n 19) Cont (n 21) c2 p tion effect was found (F 2.59, p .090) (Table 4). The hypothesis
that parasympathetic nervous activity level (normalized HF) in the
n (%) n (%)
experimental group would be higher than in the control group was
Religion Yes 6 (31.6) 7 (33.3) 0.01 .906a also rejected (Table 4). The hypothesis that LF/HF ratio in the
Burden of tuition Yes 7 (36.8) 13 (61.9) 2.21 .113a
experimental group would be lower than in the control group was
Residence type With parents 4 (21.1) 5 (23.8) 1.45 .505b
Dorm 13 (68.4) 11 (52.4) rejected. There was a signicant time difference (F 7.92, p .001),
Rented room 2 (10.5) 5 (23.8) but no signicant time/group interaction effect was found (F 1.38,
Admission Interest 9 (47.4) 15 (71.4) 2.41 .121a p .257) (Table 4).
motives Suggestion 10 (52.6) 6 (28.6)
Education Positive 14 (73.7) 18 (85.7) 0.90 .442b
satisfaction So-so 5 (26.3) 3 (14.3)
Discussion
Note. Exp experimental group; Cont control group.
a
Calculated by c2-test.
b
Several research ndings related to the effects of AT training of
Calculated by Fisher's exact test.
nursing students to cope with stresses were produced by this study.
These outcomes have following implications.
Results First, the results of this study are consistent with those of pre-
vious studies that focused on the effects of AT. In general, there are
Homogeneity testing of participants two methods of coping with stress, that is, problem-focused
methods aimed at solving or changing the problem, and emotion-
Religion, burden of tuition fees, residence type, motivation for focused coping methods based on psychological and behavioral
major study, and study satisfaction were similar in the experi- efforts (Lazarus & Falkman, 1984). The AT used in this study is a type
mental and control groups (Table 2). No signicant difference in the of emotion-focused coping method. Yurdakul, Holttum, and
total stress response scores or the seven subscales were observed Bowden (2009) analyzed the effect of AT by using grounded the-
between the two groups (Table 3). Furthermore, the three in- ory, and presented clear evidence that AT decreased anxiety levels
dicators of HRV, normalized LF, normalized HF, and LF/HF ratio, in women by enhancing a sense of well-being in the context of
were not signicantly different in the two groups (Table 3). stress management. Kwon (2009) also reported that AT effectively
reduced stress levels in pregnant women. According to a study by
Masato et al. (2006), AT supported the development of mental
Stress response energy to create a positive self image and a sense of self efciency,
and reduced patient anxiety levels. Tsutsumi, Kabeya, and Ogawa
Testing of the hypothesis that total stress response score in the (2012) also reported that AT reduced trait anxiety in patients
experimental group undergoing AT would be lower than in the with chronic subjective dizziness. A meta-analysis of experimental
control group supported the study hypothesis (Table 4). Stress studies by Ernst and Kanji (2000) showed AT had positive effects on
response levels were different in the two groups (F 7.11, p .011) relieving stress in seven cases out of eight. In the present study, it
and times differed within groups (F 5.30, p .007). Furthermore, was found that stress response levels in the experimental group
a signicant time/group interaction effect was found on stress were lower than those in the control group. This nding demon-
response (F 4.68, p .012). In the control group, mean stress strates that the AT program had positive effects on the abilities of
response score increased by 14.70 points from 73.05 at the end of nursing students to cope with stress, which is in line with the
the AT, and by 20.99 points at 6 months after AT. On the other hand, studies mentioned above.
in the experimental group no signicant differences were observed Second, this study differs from other studies with respect to the
between scores (Figure 1). These results signify that AT reduced applicability of the relaxation method to university students. Song
stress response. and Kim (2010) reported that AT, as applied to university students
in Korea, was effective at reducing stress, which indicated AT could
HRV be applicable and effective in patients, adults, and healthy univer-
sity students. However, the research method used by Song and Kim
The hypothesis that the sympathetic nervous activity level was a modied version of the traditional AT intervention, except
(normalized LF) in the experimental group would be lower than in that a tape recorder, rather than autosuggestion, was used to induce

Table 3 Homogeneity Testing of Stress Response and Heart Rate Variability in Experimental and Control Groups (N 40).

Values Exp (n 19) Cont (n 21) Total (n 40) t p

M SD M SD M SD

Stress response Total 68.37 19.39 73.05 19.54 70.83 19.37 0.76 .453
Tension 9.47 2.52 10.29 3.61 9.90 3.13 0.82 .419
Aggression 4.79 1.13 5.71 2.35 4.55 1.01 0.76 .450
Somatization 5.63 2.31 5.67 2.78 5.38 1.92 0.97 .338
Anger 9.58 3.47 10.81 3.37 10.23 3.43 1.14 .263
Depression 11.94 3.72 12.57 3.50 12.23 3.58 0.64 .527
Fatigue 10.47 3.75 11.29 4.39 10.90 4.07 0.63 .535
Frustration 13.58 5.25 14.33 4.95 13.98 5.05 0.47 .643
HRV LF norm 43.01 16.15 39.40 11.19 41.12 13.71 0.83 .414
HF norm 57.00 16.15 60.60 11.19 58.89 13.71 0.83 .414
LF/HF ratio 0.89 0.55 0.72 0.39 0.80 0.47 1.19 .241

Note. Exp experimental group; Cont control group; HRV heart rate variability; LF norm normalized low frequency; HF norm normalized high frequency.
290 S.-J. Lim, C. Kim / Asian Nursing Research 8 (2014) 286e292

Table 4 Differences in Stress Response between Experimental and Control Groups (N 40).

Variables Exp (n 19) Cont (n 21) Between group Within group

Group Time Time  group

M SD M SD F (p) F (p) F (p)

Stress response 1st 68.37 19.39 73.05 19.54 7.11 (.011) 5.30 (.007) 4.68 (.012)
2nd 68.37 18.90 87.71 24.90
3rd 68.00 16.88 94.14 30.10
HRV LF norm (%) 1st 43.01 16.16 39.40 11.19 0.22 (.643) 9.18 (.001) 2.59 (.090)
2nd 46.64 17.07 40.32 14.82
3rd 49.31 14.21 54.39 11.75
HF norm (%) 1st 57.00 16.16 60.00 11.19 0.22 (.643) 9.18 (.001) 2.59 (.090)
2nd 53.36 18.07 59.68 14.82
3rd 50.69 14.21 45.61 11.75
LF/HF ratio 1st 0.89 0.54 0.72 0.39 0.47 (.498) 7.92 (.001) 1.38 (.257)
2nd 0.87 0.46 0.75 0.40
3rd 1.05 0.48 1.04 0.38

Note. Exp experimental group; Cont control group; HRV heart rate variability; LF norm normalized low frequency; HF norm normalized high frequency; 1st before
the AT program; 2nd at the end of the standard 8-week AT program; 3rd 6 months after the end of the AT program.

subject self relaxation. Thus, the present study differs, as it involved
an expansion of AT by using traditional autosuggestion to enhance
passive concentration ability.
Third, the present study differs substantially from previous
studies with respect to subject selection. Kanji et al. (2006) re-
ported that AT induced signicant relief on anxiety in second
through fourth year nursing students. However, Kanji et al. applied
their testing methods to students regardless of their grade, whereas
we used stress response measures and applied them to third year
nursing students, who were experiencing clinical practice for the
rst time, and thus, exposed to higher levels of real stress than
students in other grades.
Fourth, the results of this study showed no effect on physio-
logical variables measured by HRV. We found normalized LF was
increased and normalized HF decreased with time. In other
words, the activity level of the sympathetic nervous system was
elevated and the activity level of the parasympathetic nervous
system was reduced in the experimental and control groups
during the study period. Mitani et al. (2006) investigated the
effect of AT on the autonomic nervous system and found the ac-
tivity level of the sympathetic nervous system was signicantly
reduced and the activity level of the parasympathetic nervous
system was increased in high-risk reghters. Miu, Heilman, and
Miclea (2009) also reported that AT increased HRV and facilitated
vagal control of the heart in healthy volunteers under mental
stress. Lee (2007) also reported that AT increased resistance to
stress by alleviating the sympathetic nervous system and acti-
vating the parasympathetic nervous system in normal adults, and
showed a signicant difference between indicators, that is, mean
HRV, standard deviation of the NN interval, and standard
Figure 1. Changes in stress response overtime. Note. Exp experimental group;
Cont control group; 1st before the AT program; 2nd at the end of the standard 8-
week AT program; 3rd 6 months after the end of the AT program.
deviation of difference between adjacent NN intervals, which
were measured by time-domain analysis. However, in this study,
LF and HF were measured by frequency-domain analysis and
were not found to show any signicant difference. Therefore, a
more elaborate study is required to check HRV by time-domain
and frequency-domain analysis at the same time and to
examine their relationship.
Fifth, this study provides more elaborate information for future
research by presenting inconsistencies between physiological and
psychological variables. Dishman et al. (2000) reported an inverse
relationship between the normalized HF component of HRV and
perceived stress. They found that AT when viewed as a psycho-
logical factor, was effective at relieving stress response, whereas
when viewed as a physiological factor, it did not affect HRV. This
lack of consistency between stress recognition and physical re-
actions concurs with that found by Chung and Kim (2008), who
analyzed relationships between psychological stress and HRV and
showed mental and physical responses were not always consistent.
Chung and Kim suggested this inconsistency was due to differences
in measurement times. During the questionnaire survey subjects
were asked to assess their stress responses for a certain period of
time, such as 1 month or 1 year, whereas they presented physical
state, HRV, at the specic point of measurement time. This result
demonstrated that sociopsychological indicators are not always
consistent with physiological indicators. Therefore, we suggest
more research be conducted to determine the reasons for this
inconsistency and to develop objective and valid measurement
indicators.
Sixth, this study suggests the need to manage stresses experi-
enced by nursing students, and provides methods for coping with
stress. Previous studies have shown nursing students experience
various stresses in clinical practice (Kim & Lee, 2011) that affect
self-efcacy, self-respect, autonomous neuro-systems, and clinical
competence (Kim, 2002; Kim & Lee, 2011; Whang, 2006). However,
it is regarded as the students' responsibility to take care of their
own stress in nursing school. Therefore, we recommend that more
specic, concrete approaches by instructor in the nursing school be
taken to address the issue of nursing students' stress. Furthermore,
nursing students should be given training guidelines, which cite
active stress coping strategies that allow students to adapt to col-
lege life, accept stressful situations positively, and manage them in
advance. In particular, we recommend that a relaxation program,
such as, AT, designed to enable nursing students to manage stresses
arising during clinical training, be incorporated into all university
nursing training programs.
 S.-J. Lim, C. Kim / Asian Nursing Research 8 (2014) 286e292
Limitations
The subjects of this study were third-year nursing students
attending a four-year program at two universities. One of the lim-
itations in this study is that convenience sampling rather than
random sampling was used. The general characteristics of the two
study groups, such as, religion, burden of tuition, residence type,
admission motives, and satisfaction with educational, were similar,
and the groups were well-matched in terms of gender and grade.
However, clinical settings, college-related variables, such as ex-
amination and academic schedules, and personal situations could
not be controlled. Accordingly, it is difcult to generalize our results
to all nursing students. Furthermore, careful consideration of study
design, such as, the provision of a psychologically and physically
comfortable environment is needed for precise HRV measure-
ments, because comfort is likely to affect the autonomic nervous
system. We suggest future studies on AT address these limitations
to enable the generalization of results.
Conclusion
The results of this study are useful and legitimate because they
show AT has a positive effect on relief from stress response in
nursing students, but no effect on HRV. Thus, because nursing
students are expected to cope with stress resulting from their
studies and clinical training, stress coping methods should be
developed via further research so that student experiences of
courses and clinical training are more rewarding. AT is a method
that aids the achievement of these goals because it is offers a cost-
effective approach that can be easily practiced.
Conict of interest
The authors have no potential conict of interest to declare.
Acknowledgments
We gratefully acknowledge nancial support from the Academic
Research Fund of Hoseo University in 2012 (2012-0281).
References
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