Innovative Approaches

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

By Jamie Lytle, RN, BSN, Catherine Mwatha, RN, BS, and Karen K. Davis, RN, PhD

2014 American Association of Critical-Care Nurses

doi: http://dx.doi.org/10.4037/ajcc2014958

24

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)

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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

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

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

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 bodys
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.

Patients who die

and those with
higher disease
severity scores
have greater
sleep disruption.

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

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25

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
patients 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 Edens 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
PM
was not approved by the infectious
disease department because of the
AM
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 4hour 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

The treatment
group received
3 mL lavender oil
placed within 3
feet from 10
until 6 .

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 patients 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 = 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 2 analysis and the Fisher exact test for categorical variables and t tests for continuous variables.

Table 2
Mean (SD) for vital signs and change scores
Baseline (10

PM)

PM

to midnight

Change from midnight to 4

AM

Control

Intervention

2.41 (9.1)

2.9 (12.9)

.87

-3.4 (10.8)

3.5 (10.4)

.03

87.1 (17.1)

3.5 (10.2)

1.4 (7.5)

.41

1.4 (7.8)

2.3 (9.4)

.70

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

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

Control

Mean arterial pressure,

mm Hg

87.7 (14.7)

89.9 (17.6)

Heart rate, beats per

minute

87.8 (16.8)

Respiratory rate,
breaths per minute
Oxygen saturation, %

26

Change from 10

Intervention

Vital sign

Intervention

Control

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Table 1
Baseline demographic characteristics (N = 50)a

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 = 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).

Change from 4

AM

to 6

Intervention group
(n = 25)

Pb

Age, mean (SD), y

54 (15)

50 (20)

.45

Sex
Male
Female

8 (32)
17 (68)

9 (36)
16 (64)

Diagnosis
Cardiac
Digestive
Endocrine/metabolic
Autoimmune
Infectious
Hematologic
Urologic

5 (20)
8 (32)
8 (32)
1 (4)
2 (8)
0 (0)
1 (4)

3 (12)
8 (32)
3 (12)
1 (4)
3 (12)
4 (16)
3 (12)

Oxygen therapy
Yes
No

5 (20)
20 (80)

7 (28)
18 (72)

Pain medication
Yes
No

4 (16)
21 (84)

3 (12)
22 (88)

-2.3 (10.2)

-3.6 (9.4)

.64

-1.7 (6.3)

0.9 (8.6)

-2.2 (7.0)
-0.8 (2.4)

.24

.37

.50

otherwise indicated, data in the table are expressed as number (percentage).

From 2 analysis, Fisher exact test, or t test.

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

Final at 6

AM

Intervention

.77

a Unless

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

Control

Control group
(n = 25)

Characteristic

AM

Overall mean change 10

PM

to 6

AM

Intervention

Control

91.1 (18.9)

87.0 (14.5)

-3.4 (12.8)

2.9 (15.2)

.12

.23

84.8 (15.5)

82.6 (14.9)

3.1 (10.4)

4.6 (11.4)

.64

-1.3 (4.0)

.61

21.3 (7.6)

19.7 (5.1)

1.4 (10.3)

2.6 (4.8)

.61

-0.5 (2.0)

.65

97.2 (2.3)

97.6 (2.4)

-0.6 (2.6)

-0.3 (2.1)

.59

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Control

Intervention

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Table 3
Mean (SD) scores for Richard Campbell Sleep
Questionnaire
Control
(n = 25)

Intervention
(n = 25)

Deep/light sleep

41.44 (32.50)

52.60 (34.09)

.24

Ease of falling asleep

36.92 (30.83)

47.76 (34.41)

.25

Awakenings

46.36 (34.61)

46.24 (35.47)

.99

Ease of return to sleep

36.20 (33.22)

49.48 (37.22)

.19

Quality of sleep

39.56 (32.52)

45.16 (38.99)

.58

Overall sleep score

40.10 (23.42)

48.25 (32.09)

.31

Item

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 Marys 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

28

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

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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.
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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, Fagerstrm 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, OSullivan 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.

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Effect of Lavender Aromatherapy on Vital Signs and Perceived Quality of

Sleep in the Intermediate Care Unit: A Pilot Study
Jamie Lytle, Catherine Mwatha and Karen K. Davis
Am J Crit Care 2014;23:24-29 doi: 10.4037/ajcc2014958
2014 American Association of Critical-Care Nurses
Published online http://www.ajcconline.org
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