EFFECT OF LAVENDER AROMATHERAPY ON VITAL SIGNS AND PERCEIVED QUALITY OF SLEEP IN THE INTERMEDIATE CARE UNIT：A PILOT STUDY

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By Jamie Lytle, RN, BSN, Catherine Mwatha, RN, BS, and Karen K. Davis, RN, PhD Background Sleep deprivation in hospitalized patients is common and can have serious detrimental effects on recovery from illness. Lavender aromatherapy has improved sleep in a variety of clinical settings, but the effect has not been tested in the intermediate care unit. Objectives To determine the effect of inhalation of 100% lavender oil on patients’ vital signs and perceived quality of sleep in an intermediate care unit. Methods A randomized controlled pilot study was conducted in 50 patients. Control patients received usual care. The treatment group had 3 mL of 100% pure lavender oil in a glass jar in place at the bedside from 10 PM until 6 AM. Vital signs were recorded at intervals throughout the night. At 6 AM all patients completed the Richard Campbell Sleep Questionnaire to assess quality of sleep. Results Blood pressure was significantly lower between midnight and 4 AM in the treatment group than in the control group (P = .03) According to the overall mean change score in blood pressure between the baseline and 6 AM measurements, the treatment group had a decrease in blood pressure and the control group had an increase; however, the difference between the 2 groups was not significant (P = .12). Mean overall sleep score was higher in the intervention group (48.25) than in the control group (40.10), but the difference was not significant. Conclusion Lavender aromatherapy may be an effective way to improve sleep in an intermediate care unit. (American Journal of Critical Care. 2014;23:24-29) EFFECT OF LAVENDER AROMATHERAPY ON VITAL SIGNS AND PERCEIVED QUALITY OF SLEEP IN THE INTERMEDIATE CARE UNIT: A PILOT STUDY ©2014 American Association of Critical-Care Nurses doi: http://dx.doi.org/10.4037/ajcc2014958 Innovative Approaches 24 AJCCAMERICAN JOURNAL OF CRITICAL CARE, January 2014, Volume 23, No. 1 www.ajcconline.org Downloaded from ajcc.aacnjournals.org by guest on April 27, 2015

leep is an essential component of health and is related to physical and psychologi- cal well-being.Inadequate quality and quantity of sleep in hospitalized patients are common problems,particularly in intensive care or intermediate care units (IMCUs)and can have serious detrimental effects on health and recovery from ill- ness.The association between the severity of illness and sleep disturbance in patients in the intensive care unit has been evaluated.?Sleep disruption was greater in patients who died and in patients who had a higher disease severity score than in patients who survived and had lower scores.In addition,sleep deprivation has a adverse effect on the immune sys- tem and is associated with increased morbidity in critically ill patients.Among patients who received an influenza vaccine,patients who were sleep deprived produced less than half the level of antibodies produced by patients who had normal sleep times.3 Also,sleep deprivation is one of the most frequent complaints of patients after hospital stays.? A systematic review of nursing interventions done to establish effects of lavender aromatherapy indicated that little research is available on use of on sleep in an acute care hospital setting. aromatherapy to improve sleep in the hospital. Investigating ways to promote and provide a Aromatherapy is the use of pure essential oils from restful night of sleep for hospitalized patients is fragrant plants to help relieve health problems and important.Vital signs can be a measure of the body's improve quality of life in general.s Aromatherapy response to stress,illness,and relaxation.A decrease has been used in a variety of settings to assist in in blood pressure,heart rate,and relaxation and aid in sleep.In a study of 122 patients respiratory rate correlates with a Patients who die in an intensive care unit by Dunn et al,patients greater relaxation state."Our aim exposed to aromatherapy had significantly greater was to evaluate the effectiveness of and those with improvements in mood and perceived levels of inhalation of 100%lavender oil on higher disease anxiety than did patients not exposed.In a random- the vital signs and perceived quality ized controlled study'in a hospice,the use of laven- of sleep of IMCU patients.We severity scores der and massage resulted in improved sleep scores, hypothesized that patients who have greater but the results were not significant because of the received the aromatherapy would small number of patients in the sample.Several experience a decrease in blood pres- sleep disruption. studies have indicated that lavender aromatherapy sure,heart rate,and respiratory rate affects the autonomic nervous system,reducing anx- during the night and would report higher quality of iety in patients in different settings,such as inpa- sleep than would patients who did not receive the tients and outpatients.Sleep deprivation leads to aromatherapy markedly impaired glucose tolerance and reduc- tions in acute insulin responses to glucose.Glucose Methods control is an important marker in healing for criti- Study Design and Sample cally ill patients.'Lavender aromatherapy can also This randomized controlled pilot study was reduce mild insomnia in patients in their home set- conducted in the IMCU of a large academic teach- ting.1 We chose lavender rather than another ing hospital between August 2,2011,and Decem- essential oil because of the studies that support ber 2,2011.Patients were eligible if they were older using lavender to promote rest and relaxation in than 21 years and admitted to the IMCU for at least different settings.Little scientific research has been 2 nights.Patients were excluded if they could not speak English,were confused,had respiratory prob- lems requiring mechanical ventilation or continu- About the Authors ous positive airway pressure,were receiving oxygen Jamie Lytle and Catherine Mwatha are nurse clinicians via mask,had an allergy or sensitivity to oils or fra- and Karen K.Davis is director of nursing,Department of Medicine,Johns Hopkins Hospital,Baltimore,Maryland. grances,or had received a new blood pressure med- Corresponding author:Karen K.Davis,RN,PhD,Johns ication or a sleeping pill on the night of the study. Hopkins Hospital,1830 E Monument St,9th Floor,Room Potential patients were referred to the study team 9061,Baltimore,MD 21287 (e-mail:Kdavis4@jhmi.edu). by the nursing staff.Any time after the first night in www.ajcconline.org AJCC AMERICAN JOURNAL OF CRITICAL CARE,January 2014,Volume 23,No.1 25 Downloaded from ajcc.aacnjournals.org by guest on April 27,2015

A systematic review4 of nursing interventions indicated that little research is available on use of aromatherapy to improve sleep in the hospital. Aromatherapy is the use of pure essential oils from fragrant plants to help relieve health problems and improve quality of life in general.5 Aromatherapy has been used in a variety of settings to assist in relaxation and aid in sleep. In a study of 122 patients in an intensive care unit by Dunn et al,6 patients exposed to aromatherapy had significantly greater improvements in mood and perceived levels of anxiety than did patients not exposed. In a randomized controlled study7 in a hospice, the use of lavender and massage resulted in improved sleep scores, but the results were not significant because of the small number of patients in the sample. Several studies have indicated that lavender aromatherapy affects the autonomic nervous system, reducing anxiety in patients in different settings, such as inpatients and outpatients.8 Sleep deprivation leads to markedly impaired glucose tolerance and reductions in acute insulin responses to glucose. Glucose control is an important marker in healing for critically ill patients.9 Lavender aromatherapy can also reduce mild insomnia in patients in their home setting.10 We chose lavender rather than another essential oil because of the studies that support using lavender to promote rest and relaxation in different settings. Little scientific research has been done to establish effects of lavender aromatherapy on sleep in an acute care hospital setting. Investigating ways to promote and provide a restful night of sleep for hospitalized patients is important. Vital signs can be a measure of the body’s response to stress, illness, and relaxation. A decrease in blood pressure, heart rate, and respiratory rate correlates with a greater relaxation state.11 Our aim was to evaluate the effectiveness of inhalation of 100% lavender oil on the vital signs and perceived quality of sleep of IMCU patients. We hypothesized that patients who received the aromatherapy would experience a decrease in blood pressure, heart rate, and respiratory rate during the night and would report higher quality of sleep than would patients who did not receive the aromatherapy. Methods Study Design and Sample This randomized controlled pilot study was conducted in the IMCU of a large academic teaching hospital between August 2, 2011, and December 2, 2011. Patients were eligible if they were older than 21 years and admitted to the IMCU for at least 2 nights. Patients were excluded if they could not speak English, were confused, had respiratory problems requiring mechanical ventilation or continuous positive airway pressure, were receiving oxygen via mask, had an allergy or sensitivity to oils or fragrances, or had received a new blood pressure medication or a sleeping pill on the night of the study. Potential patients were referred to the study team by the nursing staff. Any time after the first night in S leep is an essential component of health and is related to physical and psychological well-being. Inadequate quality and quantity of sleep in hospitalized patients are common problems, particularly in intensive care or intermediate care units (IMCUs) and can have serious detrimental effects on health and recovery from illness.1 The association between the severity of illness and sleep disturbance in patients in the intensive care unit has been evaluated.2 Sleep disruption was greater in patients who died and in patients who had a higher disease severity score than in patients who survived and had lower scores. In addition, sleep deprivation has a adverse effect on the immune system and is associated with increased morbidity in critically ill patients. Among patients who received an influenza vaccine, patients who were sleep deprived produced less than half the level of antibodies produced by patients who had normal sleep times.3 Also, sleep deprivation is one of the most frequent complaints of patients after hospital stays.2 About the Authors Jamie Lytle and Catherine Mwatha are nurse clinicians and Karen K. Davis is director of nursing, Department of Medicine, Johns Hopkins Hospital, Baltimore, Maryland. Corresponding author: Karen K. Davis, RN, PhD, Johns Hopkins Hospital, 1830 E Monument St, 9th Floor, Room 9061, Baltimore, MD 21287 (e-mail: Kdavis4@jhmi.edu). www.ajcconline.org AJCC AMERICAN JOURNAL OF CRITICAL CARE, January 2014, Volume 23, No. 1 25 Patients who die and those with higher disease severity scores have greater sleep disruption. Downloaded from ajcc.aacnjournals.org by guest on April 27, 2015

the unit,patients were approached by 1 of 2 trained vital sign spread sheet,and administer the sleep research assistants and asked if they would be willing questionnaire at 6 AM.The care providers document- to participate in the study.Oral consent was obtained. ing the vital signs and collecting the perceived sleep The investigation conformed to the principles out- data were aware of each patient's group. lined in the Declaration of Helsinki.Approval for the study was obtained from the appropriate insti- Measurements tutional review board. The Richard Campbell Sleep Questionnaire is a Demographics,clinical characteristics,and vital visual analog scale that provides self-reported scores signs were collected from the electronic record.Unit on depth of sleep,ease of falling asleep,frequency guidelines require that vital signs be collected at the of awakening,ease in return to sleep,and quality patient's bedside,so remote monitoring was not pos- of sleep."The items are marked by the patient on a sible.Fifty patients were randomized to the control 100-mm line with words describing the poorest group or the intervention group by using a computer- possible sleep(0 mm)to the best possible sleep generated assignment list.Each group had 25 patients. (100 mm).Patients place a mark on the 100-mm The control group received usual care.Each patient line,and a score from 0 to 100 can be calculated in the treatment group received for each item by measuring the distance from the The treatment usual care and had 3 mL of 100% right end of the line with a millimeter ruler.Higher pure therapeutic-grade essential oil scores indicate better sleep.The total sleep score is group received of lavender,sold by Eden's Garden, calculated by determining the mean of the 5 scores. 3 mL lavender oil in a small glass jar at the bedside The tool has been tested in intensive care patients placed within 1 m of the patient and has adequate reliability(Cronbach a=0.82)." placed within 3 from 10 PM until 6 AM.Diffusers or Vial signs were obtained from the electronic med- feet from 10 PM heat administration of the lavender ical record and transferred to a data collection tool was not approved by the infectious designed for this study.Mean arterial blood pressure until 6 AM. disease department because of the is the mean pressure within an artery over a com- risk of spreading germs and of heat- plete cycle of 1 heartbeat.The following equation is related injuries.Because Dunn et als noted that the used for calculation:mean arterial pressure=([2 x effects of lavender were not sustained,placement of diastolic]+systolic)/3.This measure for blood pres- the oil of lavender was maintained throughout the sure was used to compare mean changes in blood night.The oil was premeasured by a study team pressure over time. member before use in the aromatherapy. Patients in both groups had vital signs measured Statistical Analysis at the start of the intervention(10 PM),then at 4- Descriptive statistics were computed for all study hour intervals throughout the night(per unit stan- variables.Frequencies and percentages were used to dards),and at the end of the intervention at 6 AM. describe categorical variables,and means and stan- At 6 AM all patients were asked to fill out the sleep dard deviations were used to describe continuous questionnaire.The nurses on the unit received train- variables.Group differences in demographics and ing to administer the aromatherapy,complete the dependent variables at baseline were assessed by using x2analysis and the Fisher exact test for cate- gorical variables and t tests for continuous variables Table 2 Mean(SD)for vital signs and change scores Baseline (10 PM) Change from 10 PM to midnight Change from midnight to 4 AM Vital sign Control Intervention Control Intervention P Control Intervention P Mean arterial pressure, 87.7(14.7) 89.9(17.6) 2.41(9.1) 2.9(12.9) 87 -3.4(10.8) 3.5(10.4) 03 mm Hg Heart rate,beats per 87.8(16.8) 87.1(17.1) 3.5(10.2) 1.4(7.5) .41 1.4(7.8) 2.3(9.4) 0 minute Respiratory rate, 22.7(11.2) 22.3(6.2) 3.1(8.8) 2.2(5.2) 67 0.5(5.9) 1.7(3.8) .40 breaths per minute Oxygen saturation,% 96.6(2.5) 97.4(2.7 -0.3(2.2) -0.2(2.0) .79 0.4(2.0) 0.4(1.2) .93 26 AJCC AMERICAN JOURNAL OF CRITICAL CARE,January 2014,Volume 23,No.1 www.ajcconline.org Downloaded from ajcc.aacnjournals.org by guest on April 27,2015

Table 2 Mean (SD) for vital signs and change scores Vital sign Control Intervention Baseline (10 PM) Change from 10 PM to midnight Change from midnight to 4 AM Control Intervention P Control Intervention P Mean arterial pressure, mm Hg Heart rate, beats per minute Respiratory rate, breaths per minute Oxygen saturation, % 87.7 (14.7) 87.8 (16.8) 22.7 (11.2) 96.6 (2.5) 89.9 (17.6) 87.1 (17.1) 22.3 (6.2) 97.4 (2.7) 2.41 (9.1) 3.5 (10.2) 3.1 (8.8) -0.3 (2.2) 2.9 (12.9) 1.4 (7.5) 2.2 (5.2) -0.2 (2.0) .87 .41 .67 .79 -3.4 (10.8) 1.4 (7.8) 0.5 (5.9) 0.4 (2.0) 3.5 (10.4) 2.3 (9.4) 1.7 (3.8) 0.4 (1.2) .03 .70 .40 .93 vital sign spread sheet, and administer the sleep questionnaire at 6 AM. The care providers documenting the vital signs and collecting the perceived sleep data were aware of each patient’s group. Measurements The Richard Campbell Sleep Questionnaire is a visual analog scale that provides self-reported scores on depth of sleep, ease of falling asleep, frequency of awakening, ease in return to sleep, and quality of sleep.12 The items are marked by the patient on a 100-mm line with words describing the poorest possible sleep (0 mm) to the best possible sleep (100 mm). Patients place a mark on the 100-mm line, and a score from 0 to 100 can be calculated for each item by measuring the distance from the right end of the line with a millimeter ruler. Higher scores indicate better sleep. The total sleep score is calculated by determining the mean of the 5 scores. The tool has been tested in intensive care patients and has adequate reliability (Cronbach α= 0.82).9 Vial signs were obtained from the electronic medical record and transferred to a data collection tool designed for this study. Mean arterial blood pressure is the mean pressure within an artery over a complete cycle of 1 heartbeat. The following equation is used for calculation: mean arterial pressure = ([2 x diastolic] + systolic)/3. This measure for blood pressure was used to compare mean changes in blood pressure over time. Statistical Analysis Descriptive statistics were computed for all study variables. Frequencies and percentages were used to describe categorical variables, and means and standard deviations were used to describe continuous variables. Group differences in demographics and dependent variables at baseline were assessed by using χ2 analysis and the Fisher exact test for categorical variables and t tests for continuous variables. the unit, patients were approached by 1 of 2 trained research assistants and asked if they would be willing to participate in the study. Oral consent was obtained. The investigation conformed to the principles outlined in the Declaration of Helsinki. Approval for the study was obtained from the appropriate institutional review board. Demographics, clinical characteristics, and vital signs were collected from the electronic record. Unit guidelines require that vital signs be collected at the patient’s bedside, so remote monitoring was not possible. Fifty patients were randomized to the control group or the intervention group by using a computergenerated assignment list. Each group had 25 patients. The control group received usual care. Each patient in the treatment group received usual care and had 3 mL of 100% pure therapeutic-grade essential oil of lavender, sold by Eden’s Garden, in a small glass jar at the bedside placed within 1 m of the patient from 10 PM until 6 AM. Diffusers or heat administration of the lavender was not approved by the infectious disease department because of the risk of spreading germs and of heatrelated injuries. Because Dunn et al6 noted that the effects of lavender were not sustained, placement of the oil of lavender was maintained throughout the night. The oil was premeasured by a study team member before use in the aromatherapy. Patients in both groups had vital signs measured at the start of the intervention (10 PM), then at 4- hour intervals throughout the night (per unit standards), and at the end of the intervention at 6 AM. At 6 AM all patients were asked to fill out the sleep questionnaire. The nurses on the unit received training to administer the aromatherapy, complete the 26 AJCCAMERICAN JOURNAL OF CRITICAL CARE, January 2014, Volume 23, No. 1 www.ajcconline.org The treatment group received 3 mL lavender oil placed within 3 feet from 10 PM until 6 AM. Downloaded from ajcc.aacnjournals.org by guest on April 27, 2015

Table 1 Baseline demographic characteristics(N=50)a The scores on the Richard Campbell Sleep Ques- Control group Intervention group tionnaire were calculated by using the established Characteristic (n=25) (n=25) standards.The change scores between the inter- vention group and the control group were analyzed Age,mean (SD),y 54(15) 50(20) 45 by using mean scores and compared by using inde- Sex .77 pendent sample t tests.The value a=0.05 was set as Male 8(32) 9(36) an acceptable level of significance.This investigation Female 17(68) 16(64) was a pilot study,so power analysis and sample-size Diagnosis .24 calculations were not performed. Cardiac 5(20) 3(12) Digestive 8(32) 8(32) Endocrine/metabolic 8(32) 3(12) Results Autoimmune 1(4) 1(4) Of the 50 patients who participated in the study, Infectious 2(8) 3(12) 25 were allocated to the intervention group and 25 Hematologic 0(0) 4(16) to the control group.The sample was predominantly Urologic 1(4) 3(12) female,with a mean age of 52 years.The majority Oxygen therapy 37 of patients were admitted to the IMCU because of Yes 5(20) 7(28) cardiac,digestive,or endocrine conditions.Most No 20(80) 18(72) patients did not receive oxygen therapy or pain med- Pain medication .50 ication during the night of the study.The 2 groups Yes 4(16) 3(12) did not differ in any of the baseline demographic or No 21(84 22(88) clinical characteristics (Table 1). .Unless otherwise indicated,data in the table are expressed as number(percentage). bFrom x2 analysis,Fisher exact test,or t test. Vital Signs Baseline vital signs for both groups were similar. rate,and oxygen saturation,but none of the differ- Mean change scores for the interval 10 PM to mid- ences were significant. night were similar for both groups(Table 2).How- ever,mean change scores for the interval midnight Perceived Quality of Sleep to 4 AM indicated that patients in the intervention Mean sleep scores for depth of sleep,ease of group had a decrease in blood pressure,whereas falling asleep,ease in return to sleep,and quality of those in the control group had an increase in blood sleep were higher in the intervention group than in pressure;this difference between the 2 groups was the control group,but the difference was not signif- significant(P=.03).For the interval 4 AM to 6 AM, icant(Table 3.)Scores for frequency of awakening both groups had a decrease in blood pressure.The were similar across both groups.Mean overall sleep overall mean change score between blood pressure score was higher in the intervention group(48.25) at 10 PM and blood pressure at 6 AM indicated that than in the control group (40.10),but this differ- patients in the intervention group had a decrease in ence was not significant. blood pressure and patients in the control group had an increase;however,this difference between the 2 Discussion_ groups was not significant(P=.12).Similar trends Although aromatherapy has been used in a vari- occurred in the changes in heart rate,respiratory ety of settings,to our knowledge,no interventional Change from 4 AM to 6 AM Final at 6 AM Overall mean change 10 PM to 6 AM Control Intervention Control Intervention Control Intervention -2.3(10.2) -3.6(9.4) .64 91.1(18.9) 87.0(14.5) -3.4(12.8) 2.9(15.2) .12 -1.7(6.3) 0.9(8.6) 23 84.8(15.5) 82.6(14.9) 3.1(10.4) 4.6(11.4) .64 -2.2(7.0) -1.3(4.0) .61 21.3(7.6) 19.7(5.1) 1.4(10.3) 2.6(4.8) .61 -0.8(2.4) -0.5(2.0) 65 97.2(2.3) 97.6(2.4) -0.6(2.6) -0.3(2.1) .59 www.ajcconline.org AJCC AMERICAN JOURNAL OF CRITICAL CARE,January 2014,Volume 23,No.1 27 Downloaded from ajcc.aacnjournals.org by guest on April 27,2015

Table 1 Baseline demographic characteristics (N = 50)a 54 (15) 8 (32) 17 (68) 5 (20) 8 (32) 8 (32) 1 (4) 2 (8) 0 (0) 1 (4) 5 (20) 20 (80) 4 (16) 21 (84) 50 (20) 9 (36) 16 (64) 3 (12) 8 (32) 3 (12) 1 (4) 3 (12) 4 (16) 3 (12) 7 (28) 18 (72) 3 (12) 22 (88) .45 .77 .24 .37 .50 Age, mean (SD), y Sex Male Female Diagnosis Cardiac Digestive Endocrine/metabolic Autoimmune Infectious Hematologic Urologic Oxygen therapy Yes No Pain medication Yes No a Unless otherwise indicated, data in the table are expressed as number (percentage). b From χ2 analysis, Fisher exact test, or t test. Intervention group (n = 25) Control group Characteristic (n = 25) Pb Change from 4 AM to 6 AM Final at 6 AM Overall mean change 10 PM to 6 AM Control Intervention P Control Intervention Control Intervention P -2.3 (10.2) -1.7 (6.3) -2.2 (7.0) -0.8 (2.4) -3.6 (9.4) 0.9 (8.6) -1.3 (4.0) -0.5 (2.0) .64 .23 .61 .65 91.1 (18.9) 84.8 (15.5) 21.3 (7.6) 97.2 (2.3) 87.0 (14.5) 82.6 (14.9) 19.7 (5.1) 97.6 (2.4) -3.4 (12.8) 3.1 (10.4) 1.4 (10.3) -0.6 (2.6) 2.9 (15.2) 4.6 (11.4) 2.6 (4.8) -0.3 (2.1) .12 .64 .61 .59 www.ajcconline.org AJCC AMERICAN JOURNAL OF CRITICAL CARE, January 2014, Volume 23, No. 1 27 The scores on the Richard Campbell Sleep Questionnaire were calculated by using the established standards.12 The change scores between the intervention group and the control group were analyzed by using mean scores and compared by using independent sample t tests. The value α= 0.05 was set as an acceptable level of significance. This investigation was a pilot study, so power analysis and sample-size calculations were not performed. Results Of the 50 patients who participated in the study, 25 were allocated to the intervention group and 25 to the control group. The sample was predominantly female, with a mean age of 52 years. The majority of patients were admitted to the IMCU because of cardiac, digestive, or endocrine conditions. Most patients did not receive oxygen therapy or pain medication during the night of the study. The 2 groups did not differ in any of the baseline demographic or clinical characteristics (Table 1). Vital Signs Baseline vital signs for both groups were similar. Mean change scores for the interval 10 PM to midnight were similar for both groups (Table 2). However, mean change scores for the interval midnight to 4 AM indicated that patients in the intervention group had a decrease in blood pressure, whereas those in the control group had an increase in blood pressure; this difference between the 2 groups was significant (P = .03). For the interval 4 AM to 6 AM, both groups had a decrease in blood pressure. The overall mean change score between blood pressure at 10 PM and blood pressure at 6 AM indicated that patients in the intervention group had a decrease in blood pressure and patients in the control group had an increase; however, this difference between the 2 groups was not significant (P = .12). Similar trends occurred in the changes in heart rate, respiratory rate, and oxygen saturation, but none of the differences were significant. Perceived Quality of Sleep Mean sleep scores for depth of sleep, ease of falling asleep, ease in return to sleep, and quality of sleep were higher in the intervention group than in the control group, but the difference was not significant (Table 3 .) Scores for frequency of awakening were similar across both groups. Mean overall sleep score was higher in the intervention group (48.25) than in the control group (40.10), but this difference was not significant. Discussion Although aromatherapy has been used in a variety of settings, to our knowledge, no interventional Downloaded from ajcc.aacnjournals.org by guest on April 27, 2015

Table 3 Mean(SD)scores for Richard Campbell Sleep Questionnaire Louis and Kowalski measured not only vital Control Intervention signs but also pain,anxiety,depression,and sense Item (n=25) (n=25) of well-being in a group of 17 cancer patients who each received aromatherapy,a humidified-water Deep/light sleep 41.44(32.50) 52.60(34.09) .24 treatment,and then no treatment during a 3-day Ease of falling asleep 36.92(30.83) 47.76(34.41) .25 period.The aromatherapy and the treatment with Awakenings 46.36(34.61) 46.24(35.47) 99 humidified water lowered blood pressure and pulse and had a positive effect on the other variables,but Ease of return to sleep 36.20(33.22) 49.48(37.22) .19 the differences were not significant.Perhaps larger Quality of sleep 39.56(32.52) 45.16(38.99) 58 sample sizes are needed to detect the subtle changes Overall sleep score 40.10(23.42) 48.25(32.09) 31 in vital signs that may occur with aromatherapy. Further testing in larger numbers of patients is needed to determine what strategies will improve studies of the outcomes have been conducted in sleep and restfulness in hospitalized patients. patients in an IMCU.Our investigation is the first pilot study on the effects of aromatherapy on blood Limitations and Recommendations pressure,heart rate,respiratory rate,and perceived Most of the patients in our study were women. quality of sleep in the IMCU.The primary finding is Perhaps sleep is affected by sex-related factors, that aromatherapy with 100%essential oil of laven- which were not explored.We used the Richard der resulted in lower blood pressure after 6 hours of Campbell Sleep Questionnaire,which involves therapy.Other vital signs did not seem to be affected. self-reporting by patients,and so our results are Other researchers have had similar results.Accord- subjective.Other methods provide a more accurate ing to a systematic literature review,aromatherapy measure of sleep.Polysomnography is the gold yielded positive improvement in physiological stress standard for measuring sleep quality and quantity; in 1 study,as indicated by heart rate,systolic blood however,this method is expensive and requires pressure,and respiratory rate;caused no change in continuous electroencephalographic monitoring and physiological stress in 2 studies;and had no effect a specialized trained technician throughout the study. on sleep quality in 1 study.Chien et al'found sim- We did not have financial support for polysomnog- ilar results in vital signs and sleep improvement.In raphy in the pilot phase.Aromatherapy is typically their study in 67 middle-aged women on the effect conducted by using a heat source or a diffuser,which of lavender aromatherapy on the autonomic nervous our infectious disease department prohibited in a system,the 34 women in the aromatherapy group hospital setting.We recognize that oxygen therapy had a significant decrease in mean heart rate.Chien could disrupt aromatherapy,but oxygen delivered et al also found that lavender aromatherapy led to a via nasal cannula was allowed during the study significant improvement in sleep quality when the because we thought patients would still be able to women had a 20-minute exposure twice a week sense the lavender aroma and because most patients during a 12-week period.Using the St Mary's Hos- on the IMCU receive some form of oxygen therapy. pital Sleep Questionnaire to measure sleep in a sam- Our research was a pilot study;thus the number ple of 64 patients in 2 cardiac care units in Iran, of patients in our sample might not have been ade- Moeini et al'5 found significant improvement in quate to detect subtle changes in vital signs and mean sleep quality scores after lavender aromather- perceptions of sleep.Although we did monitor vital apy.In their study,5 sleep was measured before and signs at baseline and throughout the night,we meas- after therapy for 3 nights of lavender aromatherapy. ured sleep only once,at the end of the intervention, In our study,patients who had aromatherapy because the Richard Campbell Sleep Questionnaire reported higher quality of sleep than did patients in has not yet been validated as a tool for use before and the control group;however,the difference between after treatment.Studies in which a pretest-posttest the 2 groups was not significant.This finding may design was used or sleep was measured more than 1 be related to the small number of patients in the night were more likely to have significant results.7 study sample.The size of the study sample is a Research on aromatherapy has several method- common limitation in the studies on lavender aro- ological challenges.In this pilot study,the data col- matherapy;most of the samples consist of a small lectors,care providers,and participants knew the number of patients and have flaws in the methods group assignment of each patient because of the used.Thus,results should be interpreted with some lavender odor at the bedside.This situation could degree of caution. introduce both interviewer and participant bias.In 28 AJCC AMERICAN JOURNAL OF CRITICAL CARE,January 2014,Volume 23,No.1 www.ajcconline.org Downloaded from ajcc.aacnjournals.org by guest on April 27,2015

Louis and Kowalski17 measured not only vital signs but also pain, anxiety, depression, and sense of well-being in a group of 17 cancer patients who each received aromatherapy, a humidified-water treatment, and then no treatment during a 3-day period. The aromatherapy and the treatment with humidified water lowered blood pressure and pulse and had a positive effect on the other variables, but the differences were not significant. Perhaps larger sample sizes are needed to detect the subtle changes in vital signs that may occur with aromatherapy. Further testing in larger numbers of patients is needed to determine what strategies will improve sleep and restfulness in hospitalized patients. Limitations and Recommendations Most of the patients in our study were women. Perhaps sleep is affected by sex-related factors, which were not explored. We used the Richard Campbell Sleep Questionnaire, which involves self-reporting by patients, and so our results are subjective. Other methods provide a more accurate measure of sleep. Polysomnography is the gold standard for measuring sleep quality and quantity; however, this method is expensive and requires continuous electroencephalographic monitoring and a specialized trained technician throughout the study. We did not have financial support for polysomnography in the pilot phase. Aromatherapy is typically conducted by using a heat source or a diffuser, which our infectious disease department prohibited in a hospital setting. We recognize that oxygen therapy could disrupt aromatherapy, but oxygen delivered via nasal cannula was allowed during the study because we thought patients would still be able to sense the lavender aroma and because most patients on the IMCU receive some form of oxygen therapy. Our research was a pilot study; thus the number of patients in our sample might not have been adequate to detect subtle changes in vital signs and perceptions of sleep. Although we did monitor vital signs at baseline and throughout the night, we measured sleep only once, at the end of the intervention, because the Richard Campbell Sleep Questionnaire has not yet been validated as a tool for use before and after treatment. Studies in which a pretest-posttest design was used or sleep was measured more than 1 night were more likely to have significant results.15,17 Research on aromatherapy has several methodological challenges. In this pilot study, the data collectors, care providers, and participants knew the group assignment of each patient because of the lavender odor at the bedside. This situation could introduce both interviewer and participant bias. In studies of the outcomes have been conducted in patients in an IMCU. Our investigation is the first pilot study on the effects of aromatherapy on blood pressure, heart rate, respiratory rate, and perceived quality of sleep in the IMCU. The primary finding is that aromatherapy with 100% essential oil of lavender resulted in lower blood pressure after 6 hours of therapy. Other vital signs did not seem to be affected. Other researchers have had similar results. According to a systematic literature review,13 aromatherapy yielded positive improvement in physiological stress in 1 study, as indicated by heart rate, systolic blood pressure, and respiratory rate; caused no change in physiological stress in 2 studies; and had no effect on sleep quality in 1 study. Chien et al14 found similar results in vital signs and sleep improvement. In their study in 67 middle-aged women on the effect of lavender aromatherapy on the autonomic nervous system, the 34 women in the aromatherapy group had a significant decrease in mean heart rate. Chien et al also found that lavender aromatherapy led to a significant improvement in sleep quality when the women had a 20-minute exposure twice a week during a 12-week period. Using the St Mary’s Hospital Sleep Questionnaire to measure sleep in a sample of 64 patients in 2 cardiac care units in Iran, Moeini et al15 found significant improvement in mean sleep quality scores after lavender aromatherapy. In their study,15 sleep was measured before and after therapy for 3 nights of lavender aromatherapy. In our study, patients who had aromatherapy reported higher quality of sleep than did patients in the control group; however, the difference between the 2 groups was not significant. This finding may be related to the small number of patients in the study sample. The size of the study sample is a common limitation in the studies on lavender aromatherapy; most of the samples consist of a small number of patients and have flaws in the methods used. Thus, results should be interpreted with some degree of caution.16 Table 3 Mean (SD) scores for Richard Campbell Sleep Questionnaire 41.44 (32.50) 36.92 (30.83) 46.36 (34.61) 36.20 (33.22) 39.56 (32.52) 40.10 (23.42) 52.60 (34.09) 47.76 (34.41) 46.24 (35.47) 49.48 (37.22) 45.16 (38.99) 48.25 (32.09) .24 .25 .99 .19 .58 .31 Deep/light sleep Ease of falling asleep Awakenings Ease of return to sleep Quality of sleep Overall sleep score Intervention (n = 25) Control Item (n = 25) P 28 AJCCAMERICAN JOURNAL OF CRITICAL CARE, January 2014, Volume 23, No. 1 www.ajcconline.org Downloaded from ajcc.aacnjournals.org by guest on April 27, 2015

addition,determining the purity of the oil and how REFERENCES 1.Dogan O,Ertekin S,Dogan S.Sleep quality in hospital- much a patient actually sensed or perceived the ized patients.J Clin Nurs.2005;14(1):107-113. aroma is difficult and could introduce intervention 2.Patel M,Chipman J,Carlin BW,Shade D.Sleep in the bias.Despite these challenges,patients in the treat- intensive care unit setting.Crit Care Nurs Q.2008;31 (4:309-318. ment group had higher sleep scores than did the 3.Spiegel K,Sheridan JF,Van Cauter E.Effect of sleep deprivation on response to immunization.JAMA.2002; control group for most questions,suggesting that 288(12:1471-1472. lavender aromatherapy may be a promising inter- 4.Hellstrom A,Fagerstrom C,Wilman A.Promoting sleep by nursing interventions in health care settings:a sys- vention to enhance perceived sleep.On the basis tematic review.Worldviews Evid Based Nurs.2011;8(3): of our results,we suggest that future studies be con 128=142. ducted in larger numbers of patients,with a pretest- 5.Buckle J.Literature review:should nursing take aro matherapy more seriously?Br J Nurs.2007;16(2):116-120. posttest design and use of methods to reduce bias. 6.Dunn C,Sleep J,Collett D.Sensing an improvement: Because of the adverse effect of poor sleep quality an experimental study to evaluate the use of aromather- apy,massage,and periods of rest in an intensive care in critically ill patients,research on ways to improve unit.JAdv Nurs.1995;21:34-40. 7.Soden K,Vincent K,Craske S,Lucas C,Ashley S.A sleep in acute care settings should continue. randomized controlled trial of aromatherapy massage in a hospice setting.Palliat Med.2004;18(2):87-92. Conclusion 8.Van der Watt G,Janca A.Aromatherapy in nursing and mental health care.Contemp Nurse.2008;30(1):69-75. Despite limitations,the results of our pilot 9.Van Cauter E,Spiegel K,Tasali E,Leproult R.Metabolic study on alternative therapy to enhance sleep have consequences of sleep and sleep loss.Sleep Med. 2008:9(suppl1):S23-S28. important implications.Sleep is essential to healing, 10.Lewith GT,Godfrey AD,Prescott P.A single-blinded, and finding ways to offer patients more restful sleep randomized pilot study evaluating the aroma of Lavan- dula augustifolia as a treatment for mild insomnia.J while they are hospitalized is critical,particularly in Altern Complement Med.2005;11(4):631-637. 11. more acute care settings such as the IMCU.We Penzel T,Kantelhardt J,Lo C,Voigt K,Vogelmeier C. Dynamics of heart rate and sleep stages in normals detected a decrease in blood pressure after the 6 hours and patients with sleep apnea.Neuropsychopharma- of treatment and higher satisfaction with sleep after cology.2003:28(suppl 1):S48-S53. 12.Richards KC,O'Sullivan PS,Phillips RL Measu rement the use of lavender aromatherapy.We think that of sleep in critically ill patients.J Nurs Meas.2000:8(2): 131.144 conducting a randomized controlled trial of aro- 13.Halm M.Essential oils for management of symptoms matherapy in an IMCU is feasible.Research using in critically ill patients.Am J Crit Care.2008;17;160-163 larger numbers of patients is required to understand 14.Chien LW,Cheng SL,Liu FC.The effects of lavender aromatherapy on autonomic nervous system in midlife the effects of lavender aromatherapy on sleep in the women with insomnia.Evid Based Complementary Altern Med.2012:2012:740813. hospital and whether a combination of alternative 15. Moeini M,Khadibi M,Bekhradi R,Mahmoudian SA therapies,such as massage or music,would have Nazari F.Effect of aromatherapy on the quality of sleep greater effects than aromatherapy alone. in ischemic heart disease patients hospitalized in inten- sive care units of heart hospitals of the Isfahan University of Medical Sciences.Iran J Nurs Midwifery Res.2010; ACKNOWLEDGMENTS 15(4:234-239. We acknowledge Maddy Biggs,Kathy Wagner-Kosmakos 16.Cooke B,Ernst E.Aromatherapy:a systematic review. and the nurses on the medical progressive care unit. Br J Gen Pract..2000:50(455:493-496. 17.Louis M.Kowalski SD.Use of aromatherapy with hospice FINANCIAL DISCLOSURES patients to decrease pain,anxiety,and depression and This work was supported through the Crickett Julius to promote an increased sense of well-being.Am J Hosp Palliat Care.2002;19(6):381-386. Memorial Scholarship Fund. eLetters To purchase electronic or print reprints,contact the Now that you've read the article,create or contribute to an American Association of Critical-Care Nurses,101 online discussion on this topic.Visit www.ajcconline.org Columbia,Aliso Viejo,CA 92656.Phone,(800)899-1712 and click "Responses"in the second column of either the full-text or PDF view of the article. or(949)362-2050(ext532:fax,(949)362-2049:e-mail, reprints@aacn.org. www.ajcconline.org AJCC AMERICAN JOURNAL OF CRITICAL CARE,January 2014,Volume 23,No.1 29 Downloaded from ajcc.aacnjournals.org by guest on April 27,2015

addition, determining the purity of the oil and how much a patient actually sensed or perceived the aroma is difficult and could introduce intervention bias. Despite these challenges, patients in the treatment group had higher sleep scores than did the control group for most questions, suggesting that lavender aromatherapy may be a promising intervention to enhance perceived sleep. On the basis of our results, we suggest that future studies be conducted in larger numbers of patients, with a pretestposttest design and use of methods to reduce bias. Because of the adverse effect of poor sleep quality in critically ill patients, research on ways to improve sleep in acute care settings should continue. Conclusion Despite limitations, the results of our pilot study on alternative therapy to enhance sleep have important implications. Sleep is essential to healing, and finding ways to offer patients more restful sleep while they are hospitalized is critical, particularly in more acute care settings such as the IMCU. We detected a decrease in blood pressure after the 6 hours of treatment and higher satisfaction with sleep after the use of lavender aromatherapy. We think that conducting a randomized controlled trial of aromatherapy in an IMCU is feasible. Research using larger numbers of patients is required to understand the effects of lavender aromatherapy on sleep in the hospital and whether a combination of alternative therapies, such as massage or music, would have greater effects than aromatherapy alone. ACKNOWLEDGMENTS We acknowledge Maddy Biggs, Kathy Wagner-Kosmakos, and the nurses on the medical progressive care unit. FINANCIAL DISCLOSURES This work was supported through the Crickett Julius Memorial Scholarship Fund. REFERENCES 1. Dogan O, Ertekin S, Dogan S. Sleep quality in hospitalized patients. J Clin Nurs. 2005;14(1):107-113. 2. Patel M, Chipman J, Carlin BW, Shade D. Sleep in the intensive care unit setting. Crit Care Nurs Q. 2008;31 (4):309-318. 3. Spiegel K, Sheridan JF, Van Cauter E. Effect of sleep deprivation on response to immunization. JAMA. 2002; 288(12):1471-1472. 4. Hellstrom A, Fagerström C, Wilman A. Promoting sleep by nursing interventions in health care settings: a systematic review. Worldviews Evid Based Nurs. 2011;8(3): 128-142. 5. Buckle J. Literature review: should nursing take aromatherapy more seriously? Br J Nurs. 2007;16(2):116-120. 6. Dunn C, Sleep J, Collett D. Sensing an improvement: an experimental study to evaluate the use of aromatherapy, massage, and periods of rest in an intensive care unit. J Adv Nurs. 1995;21:34-40. 7. Soden K, Vincent K, Craske S, Lucas C, Ashley S. A randomized controlled trial of aromatherapy massage in a hospice setting. Palliat Med. 2004;18(2):87-92. 8. Van der Watt G, Janca A. Aromatherapy in nursing and mental health care. Contemp Nurse. 2008;30(1):69-75. 9. Van Cauter E, Spiegel K, Tasali E, Leproult R. Metabolic consequences of sleep and sleep loss. Sleep Med. 2008;9(suppl 1):S23-S28. 10. Lewith GT, Godfrey AD, Prescott P. A single-blinded, randomized pilot study evaluating the aroma of Lavandula augustifolia as a treatment for mild insomnia. J Altern Complement Med. 2005;11(4):631-637. 11. Penzel T, Kantelhardt J, Lo C, Voigt K, Vogelmeier C. Dynamics of heart rate and sleep stages in normals and patients with sleep apnea. Neuropsychopharmacology. 2003;28(suppl 1):S48-S53. 12. Richards KC, O’Sullivan PS, Phillips RL. Measurement of sleep in critically ill patients. J Nurs Meas. 2000;8(2): 131-144. 13. Halm M. Essential oils for management of symptoms in critically ill patients. Am J Crit Care. 2008;17;160-163. 14. Chien LW, Cheng SL, Liu FC. The effects of lavender aromatherapy on autonomic nervous system in midlife women with insomnia. Evid Based Complementary Altern Med. 2012;2012:740813. 15. Moeini M, Khadibi M, Bekhradi R, Mahmoudian SA, Nazari F. Effect of aromatherapy on the quality of sleep in ischemic heart disease patients hospitalized in intensive care units of heart hospitals of the Isfahan University of Medical Sciences. Iran J Nurs Midwifery Res. 2010; 15(4):234-239. 16. Cooke B, Ernst E. Aromatherapy: a systematic review. Br J Gen Pract. 2000;50(455):493-496. 17. Louis M, Kowalski SD. Use of aromatherapy with hospice patients to decrease pain, anxiety, and depression and to promote an increased sense of well-being. Am J Hosp Palliat Care. 2002;19(6):381-386. To purchase electronic or print reprints, contact the American Association of Critical-Care Nurses, 101 Columbia, Aliso Viejo, CA 92656. Phone, (800) 899-1712 or (949) 362-2050 (ext 532); fax, (949) 362-2049; e-mail, reprints@aacn.org. eLetters Now that you’ve read the article, create or contribute to an online discussion on this topic. Visit www.ajcconline.org and click “Responses” in the second column of either the full-text or PDF view of the article. www.ajcconline.org AJCC AMERICAN JOURNAL OF CRITICAL CARE, January 2014, Volume 23, No. 1 29 Downloaded from ajcc.aacnjournals.org by guest on April 27, 2015

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