Complementary Therapies in Clinical Practice 20(2014)159-163 Contents lists available at ScienceDirect Complementary Therapies in Clinical Practice CLINICAL PRACTICE ELSEVIER journal homepage:www.elsevier.com/locate/ctcp Effect of Rosa damascene aromatherapy on sleep quality in cardiac CrossMark patients:A randomized controlled trial Ali Hajibagheri Atye Babaii,Mohsen Adib-Hajbaghery" Faculty of Nursing Midwifery.Kashan University of Medical Sciences,Kashan,Iran ABSTRACT Keywords: Objective:Sleep disorders are common among patients hospitalized in coronary care unit(CCU).This Nursing Aromatherapy study aimed to investigate the effect of Rosa damascene aromatherapy on sleep quality of patients Sleep quality hospitalized in CCU. Coronary care unit Methods:In this randomized controlled trial,60 patients who met the inclusion criteria were conve- niently sampled and randomly allocated to the experimental and control groups.Patients in the control group received routine care.In the experimental group,patients received routine care and Rosa dama- scene aromatherapy for three subsequent nights.In the both groups the sleep quality was assessed using the Pittsburgh Sleep Quality Index. Results:After the study,the mean scores of five domains of Pittsburg Sleep Quality Index as well as the mean of total score of the index in the experimental group were significantly lower than the control group. Conclusion:Rosa damascene aromatherapy can significantly improve the sleep quality of patients hos- pitalized in CCUs. 2014 Elsevier Ltd.All rights reserved. 1.Introduction example,sedative-hypnotic agents can increase the quality of sleep significantly.However,pharmacologic agents are usually associated Sleep is a fundamental human need and also a determinant of with different side-effects[5.Complementary therapies-includ- health maintenance and recovery from diseases [1].Most of hos- ing aromatherapy,muscle relaxation,and using eye mask and pitalized patients,particularly patients who are hospitalized in earplug-can also improve the sleep quality without causing coronary care units(CCU),have some degrees of sleep disorders [2]. serious side-effects 3.6,7]. In CCUs,environmental factors such as noises,intervention-related Aromas can increase patients'calmness through affecting the pain and discomfort,psychological stress of having an acute dis- limbic system [8].However.research findings about the effective- ease,and disease complications may put patients at risk for ness of aromatherapy in improving sleep quality are conflicting.For developing sleep disorders [3.4].Wenham and Pittard(2009)re- example,Moeini et al.found that aromatherapy enhanced sleep ported that in intensive care units,patients cannot sleep well and quality among cardiac patients [3].Chen et al.also found that may stay awake for about 30-40%of their sleep time [2]. valerian aromatherapy increased sleep duration and decreased Sleep disorders can be associated with increased sympathetic insomnia among patients hospitalized in intensive care unit [9]. activity and subsequent increased blood pressure and heart rate. However,a systematic review revealed that lavender aromatherapy raising the risk for developing cardiovascular problems among has no significant effect on sleep quality [101.Williams also found patients hospitalized in CCU [1].Consequently,improving sleep that aromatherapy has no effect on sleep quality among children quality in cardiac patients is a matter of great importance.Many with autism 11. strategies have been developed for improving sleep quality.For Rosa damascene aroma is also used as a complementary ther- apy.According to Boskabady et al,Rosa damascene has hypnotic. Corresponding author.Tel.:+98 3615550021:fax:+98 3615556633. sedative,and anticonvulsive effects on the central nervous system E-mail addresses:ali.hajibagheri@yahoo.com (A.Hajibagheri).atyebabaii@ [12.Studies have shown that Rosa damascene alleviates anxiety yahoo.com (A.Babaii).adib1344@yahoo.com,adibhajbagheri_m@kaums.ac.ir and promotes relaxation [13-15].As anxiety negatively contributes (M.Adib-Hajbaghery). 1Tel.:+983615550021 to sleep quality 16,Rosa damascene aroma may also have htp:/dx.doi.org/10.1016j.ctcp.2014.05.001 1744-3881/2014 Elsevier Ltd.All rights reserved
Effect of Rosa damascene aromatherapy on sleep quality in cardiac patients: A randomized controlled trial Ali Hajibagheri 1 , Atye Babaii, Mohsen Adib-Hajbaghery* Faculty of Nursing & Midwifery, Kashan University of Medical Sciences, Kashan, Iran Keywords: Nursing Aromatherapy Sleep quality Coronary care unit abstract Objective: Sleep disorders are common among patients hospitalized in coronary care unit (CCU). This study aimed to investigate the effect of Rosa damascene aromatherapy on sleep quality of patients hospitalized in CCU. Methods: In this randomized controlled trial, 60 patients who met the inclusion criteria were conveniently sampled and randomly allocated to the experimental and control groups. Patients in the control group received routine care. In the experimental group, patients received routine care and Rosa damascene aromatherapy for three subsequent nights. In the both groups the sleep quality was assessed using the Pittsburgh Sleep Quality Index. Results: After the study, the mean scores of five domains of Pittsburg Sleep Quality Index as well as the mean of total score of the index in the experimental group were significantly lower than the control group. Conclusion: Rosa damascene aromatherapy can significantly improve the sleep quality of patients hospitalized in CCUs. 2014 Elsevier Ltd. All rights reserved. 1. Introduction Sleep is a fundamental human need and also a determinant of health maintenance and recovery from diseases [1]. Most of hospitalized patients, particularly patients who are hospitalized in coronary care units (CCU), have some degrees of sleep disorders [2]. In CCUs, environmental factors such as noises, intervention-related pain and discomfort, psychological stress of having an acute disease, and disease complications may put patients at risk for developing sleep disorders [3,4]. Wenham and Pittard (2009) reported that in intensive care units, patients cannot sleep well and may stay awake for about 30e40% of their sleep time [2]. Sleep disorders can be associated with increased sympathetic activity and subsequent increased blood pressure and heart rate, raising the risk for developing cardiovascular problems among patients hospitalized in CCU [1]. Consequently, improving sleep quality in cardiac patients is a matter of great importance. Many strategies have been developed for improving sleep quality. For example, sedative-hypnotic agents can increase the quality of sleep significantly. However, pharmacologic agents are usually associated with different side-effects [5]. Complementary therapiesdincluding aromatherapy, muscle relaxation, and using eye mask and earplugdcan also improve the sleep quality without causing serious side-effects [3,6,7]. Aromas can increase patients’ calmness through affecting the limbic system [8]. However, research findings about the effectiveness of aromatherapy in improving sleep quality are conflicting. For example, Moeini et al. found that aromatherapy enhanced sleep quality among cardiac patients [3]. Chen et al. also found that valerian aromatherapy increased sleep duration and decreased insomnia among patients hospitalized in intensive care unit [9]. However, a systematic review revealed that lavender aromatherapy has no significant effect on sleep quality [10]. Williams also found that aromatherapy has no effect on sleep quality among children with autism [11]. Rosa damascene aroma is also used as a complementary therapy. According to Boskabady et al., Rosa damascene has hypnotic, sedative, and anticonvulsive effects on the central nervous system [12]. Studies have shown that Rosa damascene alleviates anxiety and promotes relaxation [13e15]. As anxiety negatively contributes to sleep quality [16], Rosa damascene aroma may also have * Corresponding author. Tel.: þ98 3615550021; fax: þ98 3615556633. E-mail addresses: ali.hajibagheri@yahoo.com (A. Hajibagheri), atyebabaii@ yahoo.com (A. Babaii), adib1344@yahoo.com, adibhajbagheri_m@kaums.ac.ir (M. Adib-Hajbaghery). 1 Tel.: þ98 3615550021. Contents lists available at ScienceDirect Complementary Therapies in Clinical Practice journal homepage: www.elsevier.com/locate/ctcp http://dx.doi.org/10.1016/j.ctcp.2014.05.001 1744-3881/ 2014 Elsevier Ltd. All rights reserved. Complementary Therapies in Clinical Practice 20 (2014) 159e163
160 A.Hajibagheri et al Complementary Therapies in Clinical Practice 20(2014)159-163 potential effect on the quality of sleep among patients.However,to we used Persian version of PSOL.Validation of the Persian version the best of our knowledge,this effect has not been examined yet. has yielded satisfactory results.Cronbach's alpha coefficient was Accordingly,we conducted this study aiming at investigating the 0.77 and corrected item-total correlations ranged from 0.30 to 0.75 effect of Rosa damascene aromatherapy on sleep quality among for the seven component scores of the PSQI [171. patients hospitalized in CCU. 2.5.Intervention 2.Methods At the start of the study (in the second day of hospitalization) 2.1.Design we asked all the patients in both study groups to complete the PSQl Moreover,we gathered patients'demographic and clinical data by This was a non-blind randomized controlled trial conducted in referring to their medical records.The onset of intervention was in September-December 2013.The study setting included the two the second night of hospitalization.In the control group,patients CCUs of a teaching hospital affiliated to Kashan University of received the sleep care routinely provided in the study setting.The Medical Sciences,Kashan,Iran. routine sleep care included of reducing environmental noises decreasing indoor lighting level,and providing nursing care during 2.2.Participants daytime to avoid interrupting patients'sleep for nighttime care provision.Patients in the experimental group received routine The study population comprised all patients hospitalized in the sleep care as well as aromatherapy.Each night,we applied three study setting.The inclusion criteria were being oriented to time drops of Rosa damascene (Barijessence Co.,Kashan,Iran)to a piece place,and person,having a cardiac ejection fraction of at least 40% of paper towel and attached the towel to the side of each patient's having no known sleep-disturbing diseases(such as rheumatoid pillow.The towel remained in place for eight hours(22:00-06:00). arthritis and migraine),having no known sleep disorders (as In the morning of the fourth day of the study (i.e.after the third mentioned by participants),having no history of asthma,having no aromatherapy session),we asked patients in both groups to fill out allergy to flowers,aromas,and herbal essences,having no history of PSQI again. orthopnea or nocturnal respiratory disorders and receiving no medical treatment during sleeping hours (22:00-06:00).The 2.6.Data analysis exclusion criteria included patient's reluctance to remain in the study,developing allergy to aromatherapy,developing orthopnea Study data were analyzed by using the Statistical Package for or any other nocturnal respiratory problems.decreased con- Social Sciences(SPSS.v.11.5).The matching of the study groups sciousness,cardiac arrest and using over-the-counter tranquilizers regarding demographic and clinical data was assessed by using the or hypnotic-sedative agents. independent-samples t and the Chi-square tests.Moreover,we The study sample size was calculated using the results of a local used the Kolmogorov-Smirnov test for testing the normality of the study conducted by Daneshmandi et al.(2012).Based on the results study main variable (the sleep quality scores).The results of this of Daneshmandi et al.(2012).S1,S2,u1,and u2 were respectively test revealed that the scores of PSQl and its domains did not have a equal to 0.70,0.40,1.60,and 0.60.Accordingly,with a type I error normal distribution.Accordingly.we used the non-parametric probability of 0.05 and a power of 0.80,the sample size was Wilcoxon signed-rank and Mann-Whitney U tests respectively determined to be fifteen patients for each group.However,for for within-and between-groups comparisons.The level of signifi- compensating probable attritions and achieving more reliable re- cance was set at below 0.05. sults,we recruited 30 patients for each group.Patients were recruited to the study by using the convenience sampling method. 2.7.Ethical considerations 2.3.Randomization The Ethics Committee of Kashan University of Medical Sciences approved the study.Also,permissions were obtained from the We randomly assigned the study participants to the study hospital and the wards authorities.We informed the study partic- groups by using the permuted block randomization technique. ipants about the aim and the course of the study,being free to Primarily,the six-block size of four was formed.Then,the sequence participate in the study,being free to withdraw from the study at of blocks was determined using a table of random numbers.All the any stage,confidentiality of personal information and the lack of study interventions were implemented by the same researcher adverse effects of aromatherapy.Then we obtained a written who was not blind to the study. informed consent from them. 2.4.Outcome measures 3.Findings The study instrument comprised two parts including a de- Thirty patients were enrolled in each group (Fig.1).The mean mographic questionnaire and the Pittsburgh Sleep Quality Index. and standard deviation of participants'age in the experimental and The demographic questionnaire consisted of questions about par- the control groups were 61.40+11.64 and 63.9+10.23 years, ticipants'demographic and clinical data (including age,gender, respectively.Most of the participants were married(88.3%).literate marriage,employment,educational status,previous history of (61.70%),and male (58.30%).The medical diagnosis for most par- hospitalization,and medical diagnosis).The Pittsburgh Sleep ticipants was acute coronary syndrome(66.70%).Most of the par- Quality Index (PSQl)is a self-report questionnaire developed for ticipants(68.30%)had been previously hospitalized for at least one evaluating sleep quality [17.18].The PSQI consists of 7 components: time.The statistical analysis showed no significant differences in subjective sleep quality,sleep latency,sleep duration,habitual age,gender,marriage,employment,educational status,previous sleep efficiency,sleep disturbances,use of sleeping medications history of hospitalization,and established medical diagnosis be- and daytime dysfunction.The score for each component ranges tween the two groups (P value 0.05:Table 1). from 0 to 3.resulting in a total PSQI score of 0-21.Higher scores The Wilcoxon signed-rank test showed that in the experimental represent lower sleep quality and vice versa[19-21.In this study group,the mean scores of the sleep latency,the sleep duration,the
potential effect on the quality of sleep among patients. However, to the best of our knowledge, this effect has not been examined yet. Accordingly, we conducted this study aiming at investigating the effect of Rosa damascene aromatherapy on sleep quality among patients hospitalized in CCU. 2. Methods 2.1. Design This was a non-blind randomized controlled trial conducted in SeptembereDecember 2013. The study setting included the two CCUs of a teaching hospital affiliated to Kashan University of Medical Sciences, Kashan, Iran. 2.2. Participants The study population comprised all patients hospitalized in the study setting. The inclusion criteria were being oriented to time, place, and person, having a cardiac ejection fraction of at least 40%, having no known sleep-disturbing diseases (such as rheumatoid arthritis and migraine), having no known sleep disorders (as mentioned by participants), having no history of asthma, having no allergy to flowers, aromas, and herbal essences, having no history of orthopnea or nocturnal respiratory disorders and receiving no medical treatment during sleeping hours (22:00e06:00). The exclusion criteria included patient’s reluctance to remain in the study, developing allergy to aromatherapy, developing orthopnea or any other nocturnal respiratory problems, decreased consciousness, cardiac arrest and using over-the-counter tranquilizers or hypnotic-sedative agents. The study sample size was calculated using the results of a local study conducted by Daneshmandi et al. (2012). Based on the results of Daneshmandi et al. (2012), S1, S2, m1, and m2 were respectively equal to 0.70, 0.40, 1.60, and 0.60. Accordingly, with a type I error probability of 0.05 and a power of 0.80, the sample size was determined to be fifteen patients for each group. However, for compensating probable attritions and achieving more reliable results, we recruited 30 patients for each group. Patients were recruited to the study by using the convenience sampling method. 2.3. Randomization We randomly assigned the study participants to the study groups by using the permuted block randomization technique. Primarily, the six-block size of four was formed. Then, the sequence of blocks was determined using a table of random numbers. All the study interventions were implemented by the same researcher who was not blind to the study. 2.4. Outcome measures The study instrument comprised two parts including a demographic questionnaire and the Pittsburgh Sleep Quality Index. The demographic questionnaire consisted of questions about participants’ demographic and clinical data (including age, gender, marriage, employment, educational status, previous history of hospitalization, and medical diagnosis). The Pittsburgh Sleep Quality Index (PSQI) is a self-report questionnaire developed for evaluating sleep quality [17,18]. The PSQI consists of 7 components: subjective sleep quality, sleep latency, sleep duration, habitual sleep efficiency, sleep disturbances, use of sleeping medications and daytime dysfunction. The score for each component ranges from 0 to 3, resulting in a total PSQI score of 0e21. Higher scores represent lower sleep quality and vice versa [19e21]. In this study we used Persian version of PSQI. Validation of the Persian version has yielded satisfactory results. Cronbach’s alpha coefficient was 0.77 and corrected item-total correlations ranged from 0.30 to 0.75 for the seven component scores of the PSQI [17]. 2.5. Intervention At the start of the study (in the second day of hospitalization), we asked all the patients in both study groups to complete the PSQI. Moreover, we gathered patients’ demographic and clinical data by referring to their medical records. The onset of intervention was in the second night of hospitalization. In the control group, patients received the sleep care routinely provided in the study setting. The routine sleep care included of reducing environmental noises, decreasing indoor lighting level, and providing nursing care during daytime to avoid interrupting patients’ sleep for nighttime care provision. Patients in the experimental group received routine sleep care as well as aromatherapy. Each night, we applied three drops of Rosa damascene (Barijessence Co., Kashan, Iran) to a piece of paper towel and attached the towel to the side of each patient’s pillow. The towel remained in place for eight hours (22:00e06:00). In the morning of the fourth day of the study (i.e. after the third aromatherapy session), we asked patients in both groups to fill out PSQI again. 2.6. Data analysis Study data were analyzed by using the Statistical Package for Social Sciences (SPSS, v. 11.5). The matching of the study groups regarding demographic and clinical data was assessed by using the independent-samples t and the Chi-square tests. Moreover, we used the KolmogoroveSmirnov test for testing the normality of the study main variable (the sleep quality scores). The results of this test revealed that the scores of PSQI and its domains did not have a normal distribution. Accordingly, we used the non-parametric Wilcoxon signed-rank and ManneWhitney U tests respectively for within- and between-groups comparisons. The level of signifi- cance was set at below 0.05. 2.7. Ethical considerations The Ethics Committee of Kashan University of Medical Sciences approved the study. Also, permissions were obtained from the hospital and the wards authorities. We informed the study participants about the aim and the course of the study, being free to participate in the study, being free to withdraw from the study at any stage, confidentiality of personal information and the lack of adverse effects of aromatherapy. Then we obtained a written informed consent from them. 3. Findings Thirty patients were enrolled in each group (Fig. 1). The mean and standard deviation of participants’ age in the experimental and the control groups were 61.40 11.64 and 63.9 10.23 years, respectively. Most of the participants were married (88.3%), literate (61.70%), and male (58.30%). The medical diagnosis for most participants was acute coronary syndrome (66.70%). Most of the participants (68.30%) had been previously hospitalized for at least one time. The statistical analysis showed no significant differences in age, gender, marriage, employment, educational status, previous history of hospitalization, and established medical diagnosis between the two groups (P value > 0.05; Table 1). The Wilcoxon signed-rank test showed that in the experimental group, the mean scores of the sleep latency, the sleep duration, the 160 A. Hajibagheri et al. / Complementary Therapies in Clinical Practice 20 (2014) 159e163
A.Hajibagheri et aL Complementary Therapies in Clinical Practice 20(2014)159-163 161 Assessed for eligibllity (n=236) Excluded (n=176) ng in ria(n=169 .Declined to participate (n=7) Randomized (n=60) cated to int Allocated to contr Analyzed (n=30) Analyzed (n=30) .Excluded from analysis (n=0) .Excluded from analysis (n=0) Fig.1.Consort flow diagram. habitual sleep efficiency.and the sleep disturbances domains as The present study found that Rosa damascene aromatherapy well as the mean score of total PSQI significantly decreased after the significantly reduced sleep latency and sleep disturbances and intervention(P0.05; domain in the experimental group was significantly higher than the Table 2).On the other hand,neither the scores of the domains nor control group.However,after the study,the difference between the the total score of PSQl changed significantly at the end of the study study groups in terms of daytime dysfunction was not significant in the control group (P >0.05;Table 2). This finding implies that aromatherapy was also effective in alle- The results of the Mann-Whitney U test for between-groups viating daytime dysfunction in the experimental group.Chen et al. comparison showed that before the study,there was no signifi- found that by exerting sedative-hypnotic effects,aromatherapy cant difference between the study groups in terms of the mean alleviated insomnia,decreased wake frequency,and increased score of total PSQI as well as the mean scores of six (out of seven) sleep duration among patients hospitalized in intensive care unit domains of PSQI(P value >0.05;Table 2).The only exception was [9].However,Lee found that aromatherapy had no significant effect related to the mean score of the daytime dysfunction domain on postpartum sleep duration,wake frequency,and sleep satis- which was significantly higher in the experimental group (P faction [26].Chang et al.also found that aromatherapy was not value =0.004;Table 2).Results of the same test revealed that after effective in decreasing sleep latency and increasing sleep duration the study,the mean scores of five domains of PSQl (including the among nurses working at night shifts [27.This contradiction is subjective sleep quality,the sleep latency,the sleep duration,the habitual sleep efficiency,and the sleep disturbances domains)as well as the mean score of total PSQl in the experimental group Table 1 were significantly lower than the control group (P value 0.05): Patients'demographic characteristics. Table 2). Variable Group P value (Chi- Experimental Control square test) 4.Discussion group [N () group [N () Gender This study investigated the effect of Rosa damascene aroma Female 14(46.7) 21(70) 0.067 therapy on sleep quality among patients hospitalized in CCU.The Male 16(53.3) 9(30) findings revealed that Rosa damascene aromatherapy significantly Marital status improved the participants'sleep quality.This is in line with the Married 26(86.7) 27(90) 0.688 findings of studies conducted by Chien et al.and Soden et al. Single 4(13.3) 3(10) Education [22.23].Moreover,Lewith et al found that aromatherapy signifi- Literate 17(56.7) 20(66.7) 0.426 cantly alleviated insomnia and improved the quality of life [24]. llliterate 13(43.3) 10(133) However,Williams et al.and Lytle et al.found that aromatherapy Previous history of hospitalization had no significant effect on sleep quality [11.25].Williams and Lytle No 10(33.3) 9(30) 0.593 One time 11(36.7) 12(40) difference in results with the current study may be related to dif- More than one time 9(30) 9(30) ferences in sample size and duration of the intervention.In Wil- Medical diagnosis liams's study the sample size was much smaller than the present Acute coronary syndrome 21(70) 19(633) 0.682 study (12 vs.60),also in duration of intervention in Lytle's study Dysrhythmia 2(6.7) 4(133) was smaller than the present study(1 vs.3 night). Congestive heart failure 7(233) 7(23.3)
habitual sleep efficiency, and the sleep disturbances domains as well as the mean score of total PSQI significantly decreased after the intervention (P 0.05; Table 2). On the other hand, neither the scores of the domains nor the total score of PSQI changed significantly at the end of the study in the control group (P > 0.05; Table 2). The results of the ManneWhitney U test for between-groups comparison showed that before the study, there was no signifi- cant difference between the study groups in terms of the mean score of total PSQI as well as the mean scores of six (out of seven) domains of PSQI (P value > 0.05; Table 2). The only exception was related to the mean score of the daytime dysfunction domain which was significantly higher in the experimental group (P value ¼ 0.004; Table 2). Results of the same test revealed that after the study, the mean scores of five domains of PSQI (including the subjective sleep quality, the sleep latency, the sleep duration, the habitual sleep efficiency, and the sleep disturbances domains) as well as the mean score of total PSQI in the experimental group were significantly lower than the control group (P value < 0.05); Table 2). 4. Discussion This study investigated the effect of Rosa damascene aromatherapy on sleep quality among patients hospitalized in CCU. The findings revealed that Rosa damascene aromatherapy significantly improved the participants’ sleep quality. This is in line with the findings of studies conducted by Chien et al. and Soden et al. [22,23]. Moreover, Lewith et al. found that aromatherapy signifi- cantly alleviated insomnia and improved the quality of life [24]. However, Williams et al. and Lytle et al. found that aromatherapy had no significant effect on sleep quality [11,25]. Williams and Lytle difference in results with the current study may be related to differences in sample size and duration of the intervention. In Williams’s study the sample size was much smaller than the present study (12 vs. 60), also in duration of intervention in Lytle’s study was smaller than the present study (1 vs. 3 night). The present study found that Rosa damascene aromatherapy significantly reduced sleep latency and sleep disturbances and significantly improved the efficiency, the subjective quality, and the duration of sleep. Moreover, the study findings revealed that at start of the study, the mean score of the daytime dysfunction domain in the experimental group was significantly higher than the control group. However, after the study, the difference between the study groups in terms of daytime dysfunction was not significant. This finding implies that aromatherapy was also effective in alleviating daytime dysfunction in the experimental group. Chen et al. found that by exerting sedative-hypnotic effects, aromatherapy alleviated insomnia, decreased wake frequency, and increased sleep duration among patients hospitalized in intensive care unit [9]. However, Lee found that aromatherapy had no significant effect on postpartum sleep duration, wake frequency, and sleep satisfaction [26]. Chang et al. also found that aromatherapy was not effective in decreasing sleep latency and increasing sleep duration among nurses working at night shifts [27]. This contradiction is Fig. 1. Consort flow diagram. Table 1 Patients’ demographic characteristics. Variable Group P value (Chisquare test) Experimental group [N (%)] Control group [N (%)] Gender Female 14 (46.7) 21 (70) 0.067 Male 16 (53.3) 9 (30) Marital status Married 26 (86.7) 27 (90) 0.688 Single 4 (13.3) 3 (10) Education Literate 17 (56.7) 20 (66.7) 0.426 Illiterate 13 (43.3) 10 (13.3) Previous history of hospitalization No 10 (33.3) 9 (30) 0.593 One time 11 (36.7) 12 (40) More than one time 9 (30) 9 (30) Medical diagnosis Acute coronary syndrome 21 (70) 19 (63.3) 0.682 Dysrhythmia 2 (6.7) 4 (13.3) Congestive heart failure 7 (23.3) 7 (23.3) A. Hajibagheri et al. / Complementary Therapies in Clinical Practice 20 (2014) 159e163 161
162 A.Hajibagheri et al Complementary Therapies in Clinical Practice 20(2014)159-163 Table 2 Acknowledgment Sleep quality in experimental and control groups. PSQI domains Groups Before After P value" This article is the report of a Master's thesis funded by Kashan Subjective sleep quality University of Medical Sciences with the number 9276.The recorded Experimental 093±0.69 0.66±0.800.135 Control 120±0.71 1.13±0.620480 code in the registration center of clinical trials is IRCT201 P value 0114 0.012 3052013403N1.We would like to gratefully thank the Research Sleep latency Experimental 2.03±1.15 1.03±1.240.000 Administration of the funding university as well as the adminis- Control 2.50±097 260±0.67 0.546 P valueb 0.068 0.000 trators and the staffs of the study setting who helped and sup- Sleep duration Experimental1.66±1.341.03±1.400.009 ported us during the study.We also are thankful of the patients for Control 1.60±1.00 1.73±1.14 0355 their participation in this study. P valueb 0.679 0.042 Habitual sleep efficiency Experimental 1.40+1.42 080±1290023 Control 1.76±1.30 1.83±134 0.804 References P value 0208 0.002 Sleep disturbances Experimental 1.00±0.37 0.66±0.600.004 [1]Elliott R.McKinley S.Cistulli P.The quality and duration of sleep in the Control 0.96±0.31 0.93±0360.564 intensive care setting:an integrative review. Int J Nurs Stud 2011:48:384- P value 400. 0710 0.031 Use of sleep medications Experimental 1.00±0.26 1.00±0.37 1.000 [2]Wenham T.Pittard A.Intensive care unit environment.Contin Educ Anaesth Control 096士0.18 1.00±0.000317 Crit Care Pain 2009:9:178-83. P valueb [3]Moeini M.Khadibi M.Bekhradi R.Mahmoudian SA.Nazari F.Effect of 0.570 1.000 Daytime dysfunction Experimental0.66±0.800.43±0.850.143 aromatherapy on the quality of sleep in ischemic heart disease patients hospitalized in intensive care units of heart hospitals of the Isfahan University Control 0.16士037 0.10±030 0317 of Medical Sciences.Iran J Nurs Midwifery Ress 2010:15:234-9. P value 0.004 0.081 [4]Chokroverty S.Sahota P.Acute and emergent events in sleep disorders.New Total PSQI score Experimental 8.70+3.96 5.63±5.130001 York Oxford University Press:2010 Control 9.16±3.27 926±3.00 0.408 [5]Glass J.Lanctot KL,Herrmann N.Sproule BA,Busto UE.Sedative hypnotics in P value 0.929 0.031 older people with insomnia:meta-analysis of risks and benefits.BMJ 2005:331:1169-75 a The results of the Mann-Whitney U test for between-groups comparison [6]Saeedi M,Ashk Torab T.Saatchi K.Zayeri F.Amir Ali Akbari S.The effect of b The results of the Wilcoxon signed-rank test for within-groups comparison. progressive muscle relaxation on sleep quality of patients undergoing he- modialysis.IJCCN 2012:5:23-8. [7]Jones C.Dawson D.Eye masks and earplugs improve patient's perception of probably due to the discrepancies in the interventions of these sleep.Nurs Crit Care 2012:17:247-54. studies.For example,Lee administered aromatherapy between [8]Redeker N.McEnany GP.Sleep disorders and sleep promotion in nursing practice.New York:Spri ringer Publishing Company:2011 14:00 and 20:00,while we administered it during night-from [9]Chen JH,Chao YH,Lu SF.Shiung TF.Chao YF.The effectiveness of valerian 22:00 to 06:00.On the other hand,while we investigated the effect acupressure on the sleep of ICU patients:a randomized clinical trial.Int J Nurs of aromatherapy on patients'nighttime sleep,Chang et al.focused Sud2012:49:913-20. [10]Fismer KL,Pilkington K.Lavender and sleep:a systematic review of the evi- on the effects of aromatherapy on nurses'daytime sleep. dence.EuM2012:4:436-47. The study findings showed that Rosa damascene aromatherapy [11]Williams TL Evaluating effects of aromatherapy massage on sleep in children had no significant effect on patients'use of sleep medications. with autism:a pilot study.Evid Based Complement Altern Med 2006:3:373- Saeedi et al.noted that complementary therapies had no significant [12]Boskabady MH,Shafei MN.Saberi Z.Amini S.Pharmacological effects of Rosa effect on patients'use of sleep medications61.Most patients in the damascena.Iran J Basic Med Sci 2011:14:295 intensive care unit of doctor's orders requiring medication are [13]Setayeshvali Pour N.Kheirkhah M.Neisani L Haghani H.Comparison of the effects of aromatherapy with essential oils of damask rose and hot footbath on sleeping at night.In Iran most patients have confidence in their the first stage of labor anxiety in Nulliparous women.Complement Med J Fac physician's instructions such as sleep medications and execute Nurs Midwifery 2012:2:1-9. them 28.Therefore do not start or discontinue drugs with their [14]Hongratanaworakit T.Relaxing effect of rose oil on humans.Nat Prod Com- mun2009:4291-6. authorization. [15]Sahebalzamin M.Khanavi M.Alvi majd H,Mirkarimi SM,Karimi M.Effects of This study has several limitations.Different people have inhalation aromatherapy on female students'anxiety and depression settling different levels of psychological development and hence,have in dormitory of Tehran University of medical saences med sai lislamic Azad Univ Tehran Med Branch 2010:20:175-81 different abilities for coping with strains and pressures that disturb [16]Afkham Ebrahimi A.Ghale Bandi MF.Salehi M.Kafian Tafti AR,Vakili Y. sleep.Moreover,different people have different sleeping habits. Akhlaghi Farsi E.Sleep parameters and the factors affecting the quality of These two factors might have affected our findings. sleep in patients attending selected clinics of Rasoul-e-Akram Hospital.RJMS 2008:15:31-8. [17]Farrahi Moghaddam J.Nakhaee N,Sheibani V.Garrusi B.Amirkafi A.Reliability 5.Conclusion and validity of the Persian version of the Pittsburgh Sleep Quality Index(PSQI- P).Sleep Breath 2012:16:79-82. The findings of this study indicate that Rosa damascene [18]Rener-Sitar K,John MT,Bandyopadhyay D.Howell MJ.Schiffman EL Explo- ration of dimensionality and psychometric properties of the Pittsburgh Sleep aromatherapy can significantly improve the sleep quality of cardiac Quality Index in cases with temporomandibular disorders.Health Qual Life patients hospitalized in CCU.Accordingly,healthcare providers can 0 utcomes2014:12:10. use Rosa damascene aroma-either in combination with current [19]Spira AP.Beaudreau SA,Stone KL Kezirian EJ.Lui LY.Redline S,et al.Reli- ability and validity of the Pittsburgh Sleep Quality Index and the Epworth treatments or alternatively-for promoting patients'sleep without Sleepiness Scale in older men.J Gerontol A Biol Sci Med Sci 2012:67:433-9. causing them the adverse side-effects of routine sleep medications. [20]Izadi Avanji FS.Adib Hajbaghery M,Afazel MR.Quality of sleep and it's related However,conducting further long-term,large-scale studies on factors in the hospitalized elderly patients of Kashan hospitals in 2007.Feyz 2009:12:52-60. cardiac patients as well as other patient populations is necessary [21]Buysse DI.Reynolds 3rd CF.Monk TH.Berman SR,Kupfer DJ.The Pittsburgh for providing ample evidence regarding the effectiveness of Rosa Sleep Quality Index:a new instrument for psychiatric practice and research damascene aromatherapy in promoting sleep.Moreover, Psychiatry Res 1989:28:193-213. [22]Chien LW.Cheng SL Liu CF.The effect of lavender aromatherapy on autonomic comparing the effects of Rosa damascene aromatherapy with sleep nervous system in midlife women with insomnia.eCAM 2012:2012:1-8 medications on patients'sleep quality is also recommended. [23]Soden K.Vincent K.Craske S.Lucas C,Ashley S.A randomized controlled trial of aromatherapy massage in a hospice setting.Palliat Med 2004:18:87-92. Conflict of interest statement [24]Lewith GT.Godfrey AD.Prescott P.A single-blinded,randomized pilot study evaluating the aroma of Lavandula augustifolia as a treatment for mild The authors have no conflict of interest to declare. insomnia.J Altern Complement Med 2005:11:631-7
probably due to the discrepancies in the interventions of these studies. For example, Lee administered aromatherapy between 14:00 and 20:00, while we administered it during nightdfrom 22:00 to 06:00. On the other hand, while we investigated the effect of aromatherapy on patients’ nighttime sleep, Chang et al. focused on the effects of aromatherapy on nurses’ daytime sleep. The study findings showed that Rosa damascene aromatherapy had no significant effect on patients’ use of sleep medications. Saeedi et al. noted that complementary therapies had no significant effect on patients’ use of sleep medications [6]. Most patients in the intensive care unit of doctor’s orders requiring medication are sleeping at night. In Iran most patients have confidence in their physician’s instructions such as sleep medications and execute them [28]. Therefore do not start or discontinue drugs with their authorization. This study has several limitations. Different people have different levels of psychological development and hence, have different abilities for coping with strains and pressures that disturb sleep. Moreover, different people have different sleeping habits. These two factors might have affected our findings. 5. Conclusion The findings of this study indicate that Rosa damascene aromatherapy can significantly improve the sleep quality of cardiac patients hospitalized in CCU. Accordingly, healthcare providers can use Rosa damascene aromadeither in combination with current treatments or alternativelydfor promoting patients’ sleep without causing them the adverse side-effects of routine sleep medications. However, conducting further long-term, large-scale studies on cardiac patients as well as other patient populations is necessary for providing ample evidence regarding the effectiveness of Rosa damascene aromatherapy in promoting sleep. Moreover, comparing the effects of Rosa damascene aromatherapy with sleep medications on patients’ sleep quality is also recommended. Conflict of interest statement The authors have no conflict of interest to declare. Acknowledgment This article is the report of a Master’s thesis funded by Kashan University of Medical Sciences with the number 9276. The recorded code in the registration center of clinical trials is IRCT201 3052013403N1. We would like to gratefully thank the Research Administration of the funding university as well as the administrators and the staffs of the study setting who helped and supported us during the study. We also are thankful of the patients for their participation in this study. References [1] Elliott R, McKinley S, Cistulli P. The quality and duration of sleep in the intensive care setting: an integrative review. Int J Nurs Stud 2011;48:384e 400. [2] Wenham T, Pittard A. Intensive care unit environment. Contin Educ Anaesth Crit Care Pain 2009;9:178e83. [3] 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 Ress 2010;15:234e9. [4] Chokroverty S, Sahota P. Acute and emergent events in sleep disorders. New York: Oxford University Press; 2010. [5] Glass J, Lanctot KL, Herrmann N, Sproule BA, Busto UE. Sedative hypnotics in older people with insomnia: meta-analysis of risks and benefits. BMJ 2005;331:1169e75. [6] Saeedi M, Ashk Torab T, Saatchi K, Zayeri F, Amir Ali Akbari S. The effect of progressive muscle relaxation on sleep quality of patients undergoing hemodialysis. IJCCN 2012;5:23e8. [7] Jones C, Dawson D. Eye masks and earplugs improve patient’s perception of sleep. Nurs Crit Care 2012;17:247e54. [8] Redeker N, McEnany GP. Sleep disorders and sleep promotion in nursing practice. New York: Springer Publishing Company; 2011. [9] Chen JH, Chao YH, Lu SF, Shiung TF, Chao YF. The effectiveness of valerian acupressure on the sleep of ICU patients: a randomized clinical trial. Int J Nurs Stud 2012;49:913e20. [10] Fismer KL, Pilkington K. Lavender and sleep: a systematic review of the evidence. EuJIM 2012;4:436e47. [11] Williams TI. Evaluating effects of aromatherapy massage on sleep in children with autism: a pilot study. Evid Based Complement Altern Med 2006;3:373e 7. [12] Boskabady MH, Shafei MN, Saberi Z, Amini S. Pharmacological effects of Rosa damascena. Iran J Basic Med Sci 2011;14:295. [13] Setayeshvali Pour N, Kheirkhah M, Neisani L, Haghani H. Comparison of the effects of aromatherapy with essential oils of damask rose and hot footbath on the first stage of labor anxiety in Nulliparous women. Complement Med J Fac Nurs Midwifery 2012;2:1e9. [14] Hongratanaworakit T. Relaxing effect of rose oil on humans. Nat Prod Commun 2009;4:291e6. [15] Sahebalzamin M, Khanavi M, Alvi majd H, Mirkarimi SM, Karimi M. Effects of inhalation aromatherapy on female students’ anxiety and depression settling in dormitory of Tehran University of Medical Sciences. Med Sci J Islamic Azad Univ Tehran Med Branch 2010;20:175e81. [16] Afkham Ebrahimi A, Ghale Bandi MF, Salehi M, Kafian Tafti AR, Vakili Y, Akhlaghi Farsi E. Sleep parameters and the factors affecting the quality of sleep in patients attending selected clinics of Rasoul-e-Akram Hospital. RJMS 2008;15:31e8. [17] Farrahi Moghaddam J, Nakhaee N, Sheibani V, Garrusi B, Amirkafi A. Reliability and validity of the Persian version of the Pittsburgh Sleep Quality Index (PSQIP). Sleep Breath 2012;16:79e82. [18] Rener-Sitar K, John MT, Bandyopadhyay D, Howell MJ, Schiffman EL. Exploration of dimensionality and psychometric properties of the Pittsburgh Sleep Quality Index in cases with temporomandibular disorders. Health Qual Life Outcomes 2014;12:10. [19] Spira AP, Beaudreau SA, Stone KL, Kezirian EJ, Lui LY, Redline S, et al. Reliability and validity of the Pittsburgh Sleep Quality Index and the Epworth Sleepiness Scale in older men. J Gerontol A Biol Sci Med Sci 2012;67:433e9. [20] Izadi Avanji FS, Adib Hajbaghery M, Afazel MR. Quality of sleep and it’s related factors in the hospitalized elderly patients of Kashan hospitals in 2007. Feyz 2009;12:52e60. [21] Buysse DJ, Reynolds 3rd CF, Monk TH, Berman SR, Kupfer DJ. The Pittsburgh Sleep Quality Index: a new instrument for psychiatric practice and research. Psychiatry Res 1989;28:193e213. [22] Chien LW, Cheng SL, Liu CF. The effect of lavender aromatherapy on autonomic nervous system in midlife women with insomnia. eCAM 2012;2012:1e8. [23] Soden K, Vincent K, Craske S, Lucas C, Ashley S. A randomized controlled trial of aromatherapy massage in a hospice setting. Palliat Med 2004;18:87e92. [24] 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;11:631e7. Table 2 Sleep quality in experimental and control groups. PSQI domains Groups Before After P valuea Subjective sleep quality Experimental 0.93 0.69 0.66 0.80 0.135 Control 1.20 0.71 1.13 0.62 0.480 P valueb 0.114 0.012 Sleep latency Experimental 2.03 1.15 1.03 1.24 0.000 Control 2.50 0.97 2.60 0.67 0.546 P valueb 0.068 0.000 Sleep duration Experimental 1.66 1.34 1.03 1.40 0.009 Control 1.60 1.00 1.73 1.14 0.355 P valueb 0.679 0.042 Habitual sleep efficiency Experimental 1.40 1.42 0.80 1.29 0.023 Control 1.76 1.30 1.83 1.34 0.804 P valueb 0.208 0.002 Sleep disturbances Experimental 1.00 0.37 0.66 0.60 0.004 Control 0.96 0.31 0.93 0.36 0.564 P valueb 0.710 0.031 Use of sleep medications Experimental 1.00 0.26 1.00 0.37 1.000 Control 0.96 0.18 1.00 0.00 0.317 P valueb 0.570 1.000 Daytime dysfunction Experimental 0.66 0.80 0.43 0.85 0.143 Control 0.16 0.37 0.10 0.30 0.317 P valueb 0.004 0.081 Total PSQI score Experimental 8.70 3.96 5.63 5.13 0.001 Control 9.16 3.27 9.26 3.00 0.408 P valueb 0.929 0.031 a The results of the ManneWhitney U test for between-groups comparison. b The results of the Wilcoxon signed-rank test for within-groups comparison. 162 A. Hajibagheri et al. / Complementary Therapies in Clinical Practice 20 (2014) 159e163
A.Hajibagheri et aL Complementary Therapies in Clinical Practice 20(2014)159-163 163 [25]Lytle J.Mwatha C.Davis KK.Effect of lavender aromatherapy on vital signs [27]Chang SB.Chu SH,Kim YI,Yun SH.The effects of aroma inhalation on sleep and perceived quality of sleep in the intermediate care unit:a pilot study.Am and fatigue in night shift nurses.Kor J Adult Nurs 2008:20:941-9. JCrit Care 2014:23:24-9. [28]Abbasi M,Salemi S.Seyed Fatemi N.Hosseini F.Hypertensive patients.their [26]Lee SH.Effects of aroma inhalation on fatigue and sleep quality of postpartum compliance level and its'relation to their health beliefs.Iran J Nurs 2005:18: mothers.Kor J Women Health Nurs 2004:10:235-43. 61-8
[25] Lytle J, Mwatha C, Davis KK. Effect of lavender aromatherapy on vital signs and perceived quality of sleep in the intermediate care unit: a pilot study. Am J Crit Care 2014;23:24e9. [26] Lee SH. Effects of aroma inhalation on fatigue and sleep quality of postpartum mothers. Kor J Women Health Nurs 2004;10:235e43. [27] Chang SB, Chu SH, Kim YI, Yun SH. The effects of aroma inhalation on sleep and fatigue in night shift nurses. Kor J Adult Nurs 2008;20:941e9. [28] Abbasi M, Salemi S, Seyed Fatemi N, Hosseini F. Hypertensive patients, their compliance level and its’ relation to their health beliefs. Iran J Nurs 2005;18: 61e8. A. Hajibagheri et al. / Complementary Therapies in Clinical Practice 20 (2014) 159e163 163