A Systemic Review of the Impact of Essential Oil Aromatherapy on Nurse Work Related Stress Taylor Brogan, BSN, RN, CCRN; Sandra Hubbard, BSN, RN; Kalyn O’Conner, BSN, RN

A Systemic Review of the Impact of Essential Oil Aromatherapy on Nurse Work-Related Stress Taylor Brogan, BSN, RN, CCRN; Sandra Hubbard, BSN, RN; Kalyn O’Conner, BSN, RN - 9M NTICU *Editors note: This EBP Analysis was completed through an EBP Concentration with the Office of Nursing EBP & Research. Mentor - Kim Carter, PhD, RN, NEA-BC

Stress occurs when the physical and psychological borders of an organism are threatened 1 . Intermittent stress poses little threat to the body; however, when stress is experienced for long periods of time with moderate to severe intensity, anxiety can follow. Nurses who experience high levels of stress for long periods of time are at increased risk of psychological issues such as depression and low self-esteem, as well as physical symptoms such as increased blood pressure and cardiovascular disease 2 . They are also more likely to leave their current position or leave the nursing profession all together 2

. Nurses report that factors that increase job-related stress are moral distress, increased workloads, increasingly higher patient acuity, physician communication struggles, and poor leadership 3

. The result of this cumulative stress can be increased job dissatisfaction, symptoms of moral burnout, and high turnover rates 4 .

Research indicates that nurses who have higher resilience and a larger arsenal of coping mechanisms are better able to cope with work-related stress and are less likely to experience symptoms of moral distress and burnout. One alternative coping mechanism that may be helpful is aromatherapy. Aromatherapy is defined as the "safe and professional use of essential oils, which are extracted and processed from a plant's bark, flower, root, peel or leaf" 5, p. 95

. In addition, clinical aromatherapy is the practice of using essential oils for specific quantifiable effects on the human mind, body and spirit. Holistic approaches to managing stress in the healthcare setting, such as the use ofaromatherapy, are supported by the American Holistic Nurses Association 6 because of the impact on positive health behaviors, resilience, and improved nurse-patient communication, care and satisfaction 5 .

The purpose of this work was to identify current knowledge related to the use of aromatherapy to decrease stress for nurses. The Neuro-Trauma Intensive Care Unit (NTICU) experienced a 26% staff turnover percentage in the 2018 fiscal year. The unit based shared governance initiative for 2019 focused on improving staff wellbeing by identifying and reducing the symptoms and causes of stress and burnout. The emphasis on wellness practices to promote resilience and coping led to the development of this study.

PICOT question: In ICU nurses, what is the effect of essential oil aromatherapy with peppermint, lavender, lemon and bergamot on work-related stress?

Search Strategy and Screening Summary

The study focused on four commonly used essential oils: peppermint, lavender, lemon and bergamot. CINAHL, HERO and TRIP were searched to find peer reviewed, evidence-based articles written in English using the terms, “nurs*, essential oil, peppermint, lavender, lemon, bergamot.” Clinically based, nursing specific studies were chosen for review. Organizational websites such as the American Association of Critical Care Nurses (AACN) and the American Holistic Nurses Association (AHNA) were also consulted. In addition, current Carilion policies were reviewed. The findings were analyzed using a matrix.

The literature was separated into general aromatherapy, peppermint, lavender, lemon, and bergamot (Table 1).

General Aromatherapy

Li and colleagues (2019) conducted a systematic review which analyzed ten articles, and six were relevant to the review criteria 7

. Four of the articles within Li, et al.’s review demonstrated a beneficial effect on nurse stress. Of the two studies of aromatherapy massage, one showed aromatherapy massage has statistically significant positive effects on stress level reduction in nurses. The other study showed no difference in stress levels of nurses; however, anxiety was reduced. Li, et al. concluded thatthere is not enough evidence related to the use of aromatherapy, massage, or aromatherapy massage to reduce nursing stress.They recommend more high-quality studies to understand the effects of aromatherapy on nursing stress.

Peppermint

Four articles related to peppermint were identified. These studies included 3 randomized controlled trials and 1 non-randomized controlled trial.

Toda 8

found salivary cortisol levels, a marker of stress, showed a statistically significant decrease after inhaling peppermint. The participants also had a decrease in subjective perception of stress following peppermint inhalation. Varney 9

demonstrated decreased feelings of burnout among the participants.

Seo 10

used a powered sample and found that aromatherapy mouthwash significantly lowered perceived stress and Xerostomia, and although not statistically significant, objective halitosis was reduced. Lee 11

demonstrated that perceived stress and depression were significantly lower, but there was no difference in symptoms of physiological stress (stress index, ANS activation, or glycated hemoglobin). This study also showed significantly longer sleep and improved sleep quality, but no significant difference in immunity 11 .

The findings related to peppermint consistently support peppermint’s potential effect on subjective perception of stress reduction.

Lavender

Four articles related to lavender were identified. These studies included three quasi-experimental designs and one non-randomized controlled trial.

Eren 12

performed a quasi-experimental study with a powered sample and found there was no difference between the control and experimental groups regarding reduced stress and anxiety. Chen 13

used a non-randomized, controlled study and demonstrated a decrease in stress; however, that decrease was not noted until two days after therapy began. Johnson 4

and Pemberton 14

also conducted quasi-experimental studies that both demonstrated a decrease in stress as a result of aromatherapy. Eren 12

noted that in addition to the aromatherapy, the time away from patient care to conduct the study, may also have contributed to the reduced stress. Johnson 4

noted that staff preferred peppermint and lavender over other oils.

Two articles related to lemon were identified. These studies included one single blinded randomized controlled trial and one quantitative randomized controlled trial.

Glaser 15

examined the effects of lavender and lemon essential oils through a single blinded randomized controlled trial 15

. The participants in this study were not nurses but college students visiting hospital units who were asked to inhale these oils during their visit. While there were no significant results for lavender, there was clear and consistent evidence that lemon oil inhalation enhances positive mood and boosts norepinephrine release. One limitation of the study was a complex set of outcomes and designs. More study is needed with simpler design and outcomes.

Johnson 5

examined the effects of lemon essential oil aromatherapy on test anxiety in nursing students. This quantitative randomized controlled trial concluded that due to a small sample size that led to no statistically significant data, more studies are warranted. One thing to gain from this study, however, is the recommendation that the practice is safe, and there were no adverse effects reported. The safety of aromatherapy is supported by the American Holistic Nurses Association as mentioned in this article.

More study is needed to understand the safety and potential effect of lemon on enhancing mood.

Bergamot

One article was found evaluating the use of bergamot 16

. This quantitative quasi experimental pilot study set out to determine if there was a link between bergamot essential oil aromatherapy and well-being in a clinical waiting room. The experimental group reported higher scores of feeling proud and "active," but also an increase of feeling nervous. The nervousness could potentially be due to the situation of awaiting an appointment. The results showed no adverse effects which may support the safety of aromatherapy in a clinical setting.

More study is needed to understand the safety and potential effect of bergamot on enhancing mood.

Implications for practice and policy

Carilion policies related to essential oil diffusers are ambiguous and open to interpretation. The decoration policy indicates that all products must be flame retardant and have appropriate documentation from the original packaging. Any cool-mist diffusers used would need to meet this standard. The decoration policy also states: "Plug in air fresheners, heated wax air fresheners and other heat producing devices used to produce aromas are not permitted." The cool mist diffuser is not considered an air fresher nor a heated source; therefore, clarification on this policy may be necessary moving forward.

The Carilion Professional Appearance Policy states that, "Colognes, perfumes, scented lotions, body sprays and after shave lotion should not be used because many patients and staff have sensitivities, allergies or respiratory conditions that may be compromised by scents." Based on the current Carilion policy, personal aromatherapy, such as that found in studies where participants attached cotton balls to their clothing, would not be appropriate. This policy does not address the diffusion of oils.

A cool-mist diffuser is not on the list of contraindicated devices in the personal electrical appliance policy; however, the list states it is not all inclusive. This policy also states that appliances should be battery powered only and should not be used if it is disturbing to other persons in the area. Considering this, a battery powered diffuser may be an appropriate option. Clarification would be needed on whether a diffuser would be classified as a personal electrical appliance if used at the nurses’ station or other area.

Carilion New River Valley Medical Center (CNRV) has an aromatherapy policy for the use of essential oil aromatherapy for patients. Key points in this policy include:

Administration is overseen by a certified aromatherapist, Only therapeutic grade essential oils are used, Both topical and aerosol diffusion is used, Therapy is provided after being ordered or approved by the physician.

Conclusions

This EBP analysis identified evidence to support a positive correlation between peppermint, lemon, and lavender aromatherapy and stress reduction. There was limited evidence for bergamot use. While some essential oils can have side effects, the oils in this study were considered safe to use by diffusion. The quality of the evidence was AACN level B and C.

This evidence analysis had some limitations. There is a lack of strong literature regarding aromatherapy practices with nurses, and some studies did not have powered sample sizes. In addition, perceived stress was not consistently measured across studies. The studies evaluated had limited control. For example, study participants may have engaged in other stress relief practices outside of the study that were not controlled for in the study design. Another example of limited control is that the condition of the participant’s patients may have changed during a given shift impacting the nurse’s perceived stress at a given time but was not evaluated as an extraneous variable. Bias in the literature favoring aromatherapy practices and personally using essential oils may exist. More work is needed to evaluate and clarify Carilion policies for relevance to diffused aromatherapy.

Based on this EBP review, we recommend that the Nursing Practice Council review Carilion Clinic policy to address essential oil use in the clinical setting. The current evidence is limited, and further research is needed to determine the relationship between essential oil use and a reduction in work related stress in the clinical setting.

References

1. Eren, N., Oztune, G., (2017). The effects of aromatherapy on the stress and anxiety levels of nurses working in Intensive Care Units. International Journal of Caring Sciences, 10(3), 1615-1623. 2. Roberts, R. & Grubb, P. (2013). The consequences of nursing stress and need for integrated solutions. Rehabilitation Nurse, 39(2), 62-69. doi: 10.1002/mj.97 3. Rushton, C., Batcheller, J., Schroeder, K., & Donohue, P. (2015). Burnout and resilience among nurses practicing in highintensity settings. American Journal of Critical Care, 24(5), 412-420. doi: 10.4037/ajcc2015291 4. Johnson, K., West, T., Diana, S., Todd, J., Haynes, B., Bernhardt, J., & Johnson, R. (2017). Use of aromatherapy to promote a therapeutic nurse environment. Intensive & Critical Care Nursing, 40(1), 18-25. doi: 10.1016/j.iccn.2017.01.006 5. Johnson, C. (2019). Effect of inhaled lemon essential oil on cognitive test anxiety among nursing students. Holistic Nursing Practice, 33(2), 95-100. doi: 10.1097/hnp.0000000000000315 6. American Holistic Nurses Association. www.ahna.org. (2019). Accessed 2019. 7. Li, H., Zhao, M., Shi, Y., Xing, Z., Li, Y., Wang, S., Ying, J. … Sun, J. (2019). The effectiveness of aromatherapy and massage on stress management in nurses: A systematic review. Journal of Clinical Nursing, 28(3/4), 372-385. doi: 10.111/jocn.14596

8. Toda, M. & Morimoto, K. (2011). Evaluation of effects of lavender and peppermint aromatherapy using sensitive salivary endocrinological stress markers. Journal of the International Society for the Investigation of Stress, 27(1), 430-435. 9. Varney, E., Buckle, J., (2013). Effect of inhaled essential oils on mental exhaustion and moderate burnout: a small pilot study. Journal of Alternative and Complimentary Medicine, 19(1), 69-71. doi: 10.1089/acm.2012.0089 10. Seo, E., Song, J., Hur, M., Lee, M., Lee, M. (2017). Effects of aroma mouthwash on stress level, xerostomia, and halitosis in healthy nurses: A non-randomized controlled clinical trial. European Journal of Integrative Medicine, 10(1), 82-89. doi: 10.1016/j.eujim.2017.03.001 11. Lee, M., Lim, S., Song, J., Kim, M., & Hur, M. (2017). The effects of aromatherapy essential oil inhalation on stress, sleep quality, and immunity in healthy adults: Randomized controlled trial. European Journal of Integrative Medicine, 12(1), 79-86. doi: 10.1016/j.eujim.2017.04.009 12. Eren, Nadiye Baris; Oztunc, Gursel. (2017). The Effects of Aromatherapyon the Stress and Anxiety Levels of Nurses Working in Intensive Care Units. International Journal of Caring Sciences, 10(3), 1615-1623. 13. Chen, M., Fang, S., Fang, L., (2015). The effects of aromatherapy in relieving symptoms related to job stress among nurses. International Journal of Nursing Practice, 21(1), 87-93. doi:10.1111/ijn.12229 14. Pemberton, E. & Turpin P. (2008). The effect of essential oils on work-related stress in intensive care unit nurses. Holistic Nursing Practice, 22(2), 97-102. 15. Glaser, K., Graham, J., Malarkey, J., Porter, W., Lemeshow, K., & Glaser, S. (2008). Citrus limonum (lemon), not lavandula angustifolia (lavender), refreshes the senses? Retrieved from Wiley Online Library. 16. Han, X., Gibson, J., Eggett, D., & Parker, T. (2017). Bergamot (citrus bergamia) essential oil inhalation improves positive feelings in the waiting room of a mental health treatment center: A pilot study. Phytotherapy Research, 31(1), 812-816. doi: 10.1002/ptr.5806

Figure 1.

Table 1. Evidence related to select aromatherapies and stress, anxiety, burnout, mood, and sleep

Key: AACN Levels of Evidence, Armola R., Bourgault A., Halm M, et al. 2009. Crtical Care Nurse, 29(4), 70-73

Level A-Meta-analysis of multiple controlled studies or meta-synthesis of qualitative studies with results that consistently support a specific action, intervention or treatment.

Level B -Well-designed controlled studies, both randomized and nonrandomized, with results that consistently support a specific action, intervention, or treatment.

Level C - Qualitative studies, descriptive or correlational studies, integrative reviews, systematic reviews, or randomized controlled trials with inconsistent results. Level D - Peer-reviewed professional organizational standards, with clinical studies to support recommendations.

Level E - Theory-based evidence from expert opinion or multple case reports.

Level M - Manufacturers’ recommendations only.