Accepted Manuscript

Effect of aromatherapy via inhalation on the sleep quality and

fatigue level in people undergoing hemodialysis

Gamze Muz, Sultan Taşcı

PII: S0897-1897(17)30042-3
DOI: doi: 10.1016/j.apnr.2017.07.004
Reference: YAPNR 50935
To appear in: Applied Nursing Research
Received date: 30 January 2017
Revised date: 20 May 2017
Accepted date: 30 July 2017

Please cite this article as: Gamze Muz, Sultan Taşcı , Effect of aromatherapy via inhalation
on the sleep quality and fatigue level in people undergoing hemodialysis, Applied Nursing
Research (2017), doi: 10.1016/j.apnr.2017.07.004

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Effect of Aromatherapy via Inhalation on the Sleep Quality and Fatigue Level in People

Undergoing Hemodialysis

Gamze Muz, Sultan Taşcı

Gamze Muz, RN, PhD, Assistant Professor in Department of Nursing, Nevsehir Haci Bektas

Veli University Health College, Nevşehir-Turkiye.

Sultan Taşcı, RN, PhD, Professor in Department of Internal Medicine Nursing, Erciyes

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University, Health Science Faculty, Kayseri-Turkiye.

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***This study was announced as verbal announcement at 2. Integrative Medicine Congress
(Abstract:0110) and oral presentation the first prize award.

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*This study was supported with TDK-2014-5222 coded project by Erciyes University
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Scientifical Research Projects Unit.
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Address: Gamze MUZ

Nevsehir Haci Bektas Veli University,

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Semra and Vefa Küçük Health College, Department of Nursing

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50300 Nevşehir-Turkiye
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Tel: +90 384 215 23 80

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Fax: +90 384 215 23 00

E-mail: gucakan@nevsehir.edu.tr
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Address: Sultan TAŞCI

Erciyes University, Faculty of Health Sciences, Melikgazi, Kayseri-Turkiye

Tel: +90 352 437 92 82

Fax: +90 352 437 92 81

E-mail: sultant@erciyes.edu.tr

Correspondence: Assistant Professor Gamze MUZ

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Effect of Aromatherapy via Inhalation on the Sleep Quality and Fatigue Level in People
Undergoing Hemodialysis

Abstract
The most common problems in hemodialysis patients are sleep disorders and fatigue. This
randomized-controlled experimental study was conducted to determine the effect of
aromatherapy applied by inhalation on sleep quality and fatigue level in hemodialysis
patients. The study was completed in five hemodialysis centers settled in two provinces with

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27 intervention group patients and 35 controls, being totally 62 patients, recruited with simple
randomization. Ethical approval, informed consent from the individuals and institutional

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permission were obtained. Data were collected with a questionnaire form and Visual

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Analogue Scale (VAS) for fatigue, Piper Fatigue Scale, Pittsburg Sleep Quality Index (PSQI),
and follow-up forms for the patient and the researcher. Aromatherapy inhalation (sweet
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orange and lavender oil) was performed before going to bed every day for one month to the
intervention group patients. No other application has been made to the control group patients
except for standard hemodialysis treatment. All of the forms were performed at baseline and
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at follow-up at the end of the four weeks (baseline and last follow-up), VAS and Piper Fatigue
Scale were performed during follow-ups at the end of every week (the first, second and third
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follow-ups). Data were statistically analyzed with Independent Samples t test, one way
analysis of variance, Pearson correlation analysis, chi-square test, Friedman and Mann
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Whitney U tests and Bonferroni test. p<0.05 was set as statistically significant in
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comparisons. Mean total and sub-dimension scores of VAS, Piper Fatigue Scale and PSQI
(except for daytime sleepiness dysfunction sub-dimension) of the intervention and control
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groups at baseline were not significantly different (p>0.05). It was found that mean total and
sub-dimension scores of VAS, Piper Fatigue Scale and PSQI of the intervention group
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significantly decreased in other follow-ups compared to the control group (p<0.05).

Consequently, it was determined that aromatherapy applied by inhalation improved sleep
quality, decreased fatigue level and severity in hemodialysis patients. Accordingly,
aromatherapy prepared with sweet orange and lavender oil may be recommended to increase
sleep quality and to decrease fatigue level of the hemodialysis patients.

Key Words: Hemodialysis, aromatherapy, nursing, fatigue, sleep quality.

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1. INTRODUCTION
Recent progress in technology may improve hemodialysis (HD) by extending the lifespan of
patients undergoing dialysis, which can cause some physical and mental problems (e.g.,
fatigue, pain, itching, sleepiness, and depression) (Eti Arslan & Karadakovan, 2010). Iliescu
et al. determined that 71% of dialysis patients suffer from poor sleep (Iliescu et al., 2003).
Given that sleep disorders occur depending on psychological factors and stress, anxiety and
depression can affect the subjective sleep quality of people undergoing dialysis. By contrast,

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sleep problems may improve because of certain problems as limited lifespan, metabolic
changes, pain, diet limitations, excess liquid, dyspnea, fatigue, cramp, advanced age,

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hypocapnia with chronic metabolic acidosis, and peripheric neuropathy that affects upper

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respiratory ways (Kuzeyli Yildirim, Fadiloglu, & Durmaz Akyol, 2004; Parker, 2003; Uzun,
Kara, & Iscan, 2003). Fatigue can occur because of sleep disorders among patients
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undergoing HD. Dialysis and disease progress can affect the quality of life (Liu, 2006;
McCann & Boore, 2000; Mollaoglu & Arslan, 2003; O’Sullivan & McCarthy, 2009).
Fatigue is the most common problem that affects daily life function and quality of life in
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patients with end-stage renal failure (Karakoç, 2008; Liu, 2006; McCann & Boore, 2000;
Mollaoglu & Arslan, 2003; Murtagh, Addington-Hall, & Higginson, 2007; O’Sullivan &
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McCarthy, 2009; Williams, Crane, & Kring, 2007; Yurtsever & Beduk, 2003). People define
fatigue as becoming tired quickly, apathy, weakness, and exhaustion. Fatigue decreases
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physical abilities, increases dependency levels, and affects the quality of life of people by
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influencing daily life activities, work lives, social life, sexual life, and treatment progress
(Karakoç, 2008; Swain, 2000; Yurtsever, 2004). To cope with fatigue and insomnia,
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complementary and integrative methods should be used besides pharmacologic interventions

(Chang, Chu, Kim, & Yun, 2008; Imura, Misao, & Ushijima, 2006; Karadag & Karadakovan,
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2015; Mitchell & Berger, 2006; Mustian et al., 2007; Tsay, 2004). Integrative treatment
methods include yoga, aromatherapy, massage, energy therapy, music therapy, reflexology,
acupuncture, and acupressure (Chang, Chu, Kim, & Yun, 2008; Imura, Misao, & Ushijima,
2006; Karadag & Karadakovan, 2015; Mitchell & Berger, 2006; Mustian et al., 2007; Tsay,
2004). Previous studies have shown that aromatherapy can effectively control some
symptoms such as fatigue, insomnia, uremic pruritus, anxiety, and stress (Hsu et al., 2009;
Imura, Misao, & Ushijima, 2006; Itai et al., 2000; Shahgholian et al., 2010). In our country,
the effect of aromatherapy through sweet orange and lavender oil on sleep problems and
fatigue in patients undergoing dialysis has not yet been determined. Thus, this study was
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conducted to determine the effect of aromatherapy practiced by inhalation (sweet orange and
lavender oil) on the sleep quality and fatigue level in people undergoing HD.
1.1. Hypothesis of the Study
H_01: Aromatherapy (sweet orange and lavender oil) that practiced by inhalation during one
month, for two minutes before sleeping is not effective on increase the sleep quality in
patients treated with hemodialysis.
H_11: Aromatherapy (sweet orange and lavender oil) that practiced by inhalation during one
month, for two minutes before sleeping is effective on increase the sleep quality in patients

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treated with hemodialysis.
H_02: Aromatherapy (sweet orange and lavender oil) that practiced by inhalation during one

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month, for two minutes before sleeping is not effective on decrease fatigue level in patients

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treated with hemodialysis.
H_12: Aromatherapy (sweet orange and lavender oil) that practiced by inhalation during one
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month, for two minutes before sleeping is effective on decrease fatigue level in patients
treated with hemodialysis.
H_03: Aromatherapy (sweet orange and lavender oil) that practiced by inhalation during one
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month, for two minutes before sleeping is not effective on decrease fatigue severity in patients
treated with hemodialysis.
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H_13: Aromatherapy (sweet orange and lavender oil) that practiced by inhalation during one
month, for two minutes before sleeping is effective on decrease fatigue severity in patients
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treated with hemodialysis.

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2. METHODS
2.1. Study design and Sample
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This randomized controlled study was conducted with five HD units in two cities in Turkey.
This study involved 62 patients: 27 patients comprised the experimental group, whereas 35
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patients comprised the control group. These patients were studied between 17.08.2014 and
29.02.2015 (Figure 1). According to power analysis, α = 0.05 and β = 0.20, and the power of
the study was 99.9%.
Inclusion criteria of the study:
 Patients aged 18 and above,
 No eye or hearing disabilities,
 Voluntary participation in the study,
 To undergo HD for 3 months,
 To continue dialysis in the same unit/center,
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 To undergo HD treatment for three sessions in one week,

 Not to take any sleeping pill before aromatherapy and during the course of the study,
 To have average or severe fatigue symptoms (Visual Analogue Scale (VAS) fatigue
score should be 3 or more)
 To have a score of 5 or more from the Pittsburg Sleep Quality Index (PSQI),
 To speak Turkish.
Exclusion criteria of the study:
 To have any respiratory system disease,

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 To have any allergy to essential oils used,
 To have any obstacle to smell,

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 Use of other integrative medicine applications during treatment.

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Figure 1: Sample diagram

Random selection of samples was performed. We believed that patients undergoing dialysis in
the same session could affect each other, so we chose the control and study groups according
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to their session times. Patients who met the criteria were grouped according to the time of
their HD sessions. The ballot method was used to determine which group would start the
study. After balloting, HD patients in the morning session were considered the control group,
whereas those in the afternoon session were regarded as the study group.
Complementary or supportive treatment was not administered for insomnia, fatigue, and other
problems reported by the patients under treatment in the units/centers that participated in the
study. However, for the patients who only had fatigue and sleep problems, medical treatment
directed to the etiology (e.g., hypoglycemia, headache, hypotension, and anemia) was

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performed under a doctor’s orders. The most common medicines used by the patients were
phosphorus bonding agents, erythropoietin, and ferrum drugs. Such drugs were not used to

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evaluate the sleep and fatigue status of patients in HD units.

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Group 1: Aromatherapy group (sweet orange oil and lavender oil) via inhalation for one
month for 2 min before sleeping in patients undergoing standard HD treatment (study group)
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Group 2: Group that did not practice aromatherapy, except standard HD treatment (Control
group)
2.2. Data Collection
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Patient Information Form

The patient information form was developed by the researchers by screening the literature
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(Eglence, Karatas, & Tasci, 2013; Karadag & Karadakovan, 2015; Korkut, 2008; Lee et al.,
2011; Yurtsever & Beduk, 2003). This form consisted of 18 questions that included
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sociodemographic characteristics; levels of hemoglobin (Hb), hematocrit (Htc), albumin, urea,

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creatinine clearance; and characteristics of the disease of the patients. Information was
obtained from face-to-face interviews and from patients’ documents.
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Visual Analog Scale (VAS)

The scale developed by Price et al. (Price, McGrath, Rafii, & Buckingham, 1983) was used to
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evaluate the intensity of pain, which is perceived as subjective. This scale was deemed valid
and reliable. The patients were told that “0” meant “I don’t feel fatigue,” and increased
numbers indicated rising fatigue levels; “10” meant “I feel very fatigued.” After the patients
rated their fatigue severity using the VAS, the distance between the marked point and the
lowest point of the line (0=I don’t feel fatigue) was measured with a ruler (in centimeters).
This value was determined as the fatigue score of the patients.
Piper Fatigue Scale-PFS
This scale that was developed by Barbara F. Piper et al. (Piper et al., 1998) consisted of 27
items, and it evaluated fatigue of the patient with four subdimensions. Answers for every item
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were evaluated from 0 10. The total fatigue score was calculated by adding points of 27 items
and dividing the total score to the item number. A high score indicated a high perceived
fatigue level. Reliability and validity studies for Turkish society was conducted by Can, and
Cronbach’s alpha was determined as 0.94 (Can, 2001). Cronbach’s alpha for the study group
in this study was 0.98, whereas that for the control group was 0.97 before practice of
aromatherapy. By contrast, Cronbach’s alpha was 0.99 in the study group and 0.98 in the
control group after practice.
Pittsburg Sleep Quality Index-PSQI

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The PSQI was developed in 1989 by Buysse et al. (Buysse, Reynolds, Monk, Berman, &
Kupfer, 1989). Reliability and validity studies were conducted by Agargun and colleagues,

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and Cronbach’s alpha was 0.80 (Agargun, Kara, & Anlar, 1996). The scale comprised 18

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items and 7 component scores. Every component was evaluated from 0 to 3. The total of these
component points yielded the total score of the scale, which ranged from 0 to 21. A high score
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(5 or above) indicated poor sleep quality. Sleep quality was classified as good (0–4) and poor
(5–21). In the study, before the practice; Cronbach’s alpha was 0.76 and 0.74 for the study
group and control group, respectively, before aromatherapy practice, but became 0.78 and
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0.71 in the study group and control group, respectively, after practice. Given that a study
criterion was the consumption of any sleeping pill before and during the study, the
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subdimension of the use of a sleeping pill (component 6) was not used for calculation.
Patient Follow Schedule–I (Patient Form)
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This period was used to record the progress of the patients or caregivers about when (day and
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time) and what they did during four weeks.

Patient Follow Schedule–II (Researcher Form)
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For this schedule, the researchers called the patients before sleeping and asked if they
experienced any problems regarding aromatherapy practice. Answers were recorded on the
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form, and necessary support was provided.

Health team members were informed about the aim and content of this study. Forms were
filled in via face-to-face interviews and using patient documents. Similarities were noted
between groups in terms of age, gender, education status, duration of renal failure and HD,
hemoglobin and hematocrit values, scores of VAS, fatigue, Piper fatigue scale, and PSQI (p >
0.05). During sample selection, randomization was not performed for some factors such as Hb
and Htc values, weight, and residual renal function. During the study, intervention was not
performed for the routine treatments of patients in the two groups.
2.3. Process
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Control Group
Only routine care was practiced in this group. During the initial follow up of patients, the
information form, VAS score, Piper fatigue scale, and PSQI were determined via face-to-face
interview and patient documents. In the first week (the first follow up), second week (second
follow up), and third week (third follow up), VAS score and Piper fatigue scale were obtained
by the researcher. After aromatherapy practice for four weeks (the last follow up after one
month), patient information form, laboratory results, VAS score, Piper fatigue scale, and
PSQI were collected.

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Study Group Process
In the study group, the first (the first interview before starting aromatherapy) patient

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information form was completed and VAS, Piper fatigue scale, and PSQI were obtained by

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the researchers through face-to-face interview during dialysis sessions. As seen in Fig. 2,
aromatherapy practice guide was prepared by the research group with the aid of an expert who
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specialized in aromatherapy (Aycemen, 2008; Buckle, 2003; Dabirian et al., 2013; Lee et al.,
2011; Lee, 2004; Ozdemir, 2012).
In practice, lavender and sweet orange oils (1:1) were dropped to a gauze bandage, which was
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placed 5 cm away from under the nose. Patients had to smell the aromatic mixture at this
distance for 2 min. They were asked to take deep breaths three times after smelling the
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mixture was completed. The patients followed this procedure before sleeping every day for a
month.
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Education about aromatherapy via inhalation was provided to the patients. When the patients
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were ready for independent practice, “Inhalation Practice Guidance” prepared by the
researchers was given to the patients. The participants were informed about how to fill in the
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“patient follow-up schedule” form. They were asked to record their daily practice during the
study. A message was sent to their cellphones daily to remind them to apply aromatherapy
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every evening. At the first, second, and third follow-up sessions, interviews were conducted to
determine any problems within the dialysis session at the included dialysis centers every
week. After telephone interviews and visits during dialysis sessions, any problem that was
noted was recorded, and the researchers scheduled another follow-up session. VAS fatigue
scores and Piper fatigue scale were determined at the first week (first follow up), second week
(second follow up), and third week (third follow up). After practice for four weeks (the last
follow up of the participants after one month), patient information forms were completed and
laboratory results, VAS fatigue, Piper fatigue scale, and PSQI were collected.
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2.4. Aromatherapy Practice

Aromatic oils (sweet orange and lavender oil) that were given to the patients in the
aromatherapy group were supplied from essential oils produced by the same company. Oils
(10 mL) were stored in dark colored glass bottles with a dropper. They were closed with
safety covers that could open only when pressed strongly. Oils were kept in appropriate
conditions according to expert views, and patients were instructed to ensure proper storage
and handling of the oils. During the study, routine treatments of the patients in the control and
study groups were not interfered with. For management of sleep and fatigue, aromatherapy

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practice was performed following the evidence-based aromatherapy inhalation practice guide
(Aycemen, 2008; Buckle, 2003; Dabirian et al., 2013; Lee et al., 2011; Lee, 2004; Ozdemir,

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2012).

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Explanation is made and permission is taken

One drop lavender oil and one drop sweet orange oil is dropped to gauze bandage and put almost
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5 cm under nose, aromatic mix is smelt.

If person doesn’t like the smell or he/she feels bad, practice is finished.
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If smell doesn’t disturb 5 cm under nose inhalation occur for 2 minutes

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Patients should be deep breath three times after smelling is completed.

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Every day a new mixture is prepared and same mixture should not be used.

During practice (one month), before sleeping, another smell (perfume, room spray,
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essence,incense) except mixture should not be used.

Some stimulants as caffeine, sleeping medicine, alcohol etc. should not be used before sleeping.
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Used oils during practice should be kept far away from children.

This practice is carried out before bed every day for a month and is recorded in the form of
follow-up after each application.
Figure 2: Aromatherapy practice guide
2.5. Data Analysis
Data were evaluated using IBM SPSS Statistics package program. Normal distribution of the
data was tested by Shapiro–Wilk test. Homogeneity of variances was tested by the Levene
test. The two groups were compared via independent samples t-test, and the paired sample t-
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test was used in nonparametric (Mann–Whitney U test) evaluations. To evaluate more than
two variances, the Bonferroni post-hoc test and Friedman test (Dunn–Bonferroni) were used.
Categorical variables were compared via chi-square analysis, whereas scales were compared
using Pearson correlation analyses. In the study, statistical significance was set at p<0.05.
Mean values of laboratory results were evaluated.
2.6. Ethical Considerations
The study was conducted with permission from the University Ethical Institute (Decision No:
2013.02.02). Written consent was obtained from all centers. The aim of the study was

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explained to the participants, and informed consent forms from the participants were
collected.

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2.7. Limitation

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The sleep and fatigue levels of individuals were determined for only one month. However, the
effects of aromatherapy practice on sleep and fatigue levels for more than a month remain
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unknown.
3. RESULTS
Table 1. Descriptive and disease characteristics of participants in the study and control groups.
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Groups
Characteristics Study Group Control Group
p
(n=27) (n=35)
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n % n %
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Gender
Female 9 33.3 19 54.3
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0.166
Male 18 66.7 16 45.7
Education Status
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Illiterate 3 11.1 8 22.8

Literate 0 0.0 3 8.6
0.174
Primary school 20 74.1 22 62.9
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High school and over 4 14.8 2 5.7

Accommodation to medicine treatment
Adaptable 26 96.3 32 91.4 0.626
Not adaptable 1 3.7 3 8.6
Accommodation to diet
Adaptable 16 59.3 17 48.6
0.562
Not adaptable 11 40.7 18 51.4
Mean age (X ± SD, years) 52.26±14.50 59.26±12.43 0.248
Mean of dialysis duration (month) (X ± SD, month) 6.29±3.91 6.24±5.27 0.965
Mean Hb (X ± SD) 11.30±1.56 11.80±1.95 0.285
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Mean Htc (X ± SD, %) 34.90±5.19 35.94±6.19 0.484

Mean Cr/clirens (X ± SD) 1.75±0.33 1.66±0.41 0.360
Mean albumin (X ± SD) 4.00±0.43 3.81±0.46 0.109

Of the patients in the study group, 66.7% were men with an average age of 52.26 ± 14.50
years. Approximately 74.1% of the patients graduated from primary school. Moreover, their
mean duration of dialysis was 6.29 ± 3.91; 96.3% were adaptable for medicine treatment and
59.3% were adaptable for diet treatment. However, of the participants in the control group,

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54.3% were women with an average age of 59.26 ± 12.43 years. Approximately 62.9% of the
control participants graduated from primary school. In addition, the mean dialysis duration

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was 6.24 ± 5.27; 91.4 were adaptable for medicine treatment and 51.4% were adaptable for
diet treatment. In terms of disease characteristics, the participants in the study and control

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groups were similar (p > 0.05; Table 1).
The first (6.50; 5.30–8.00), second (5.00; 4.00–6.30), third (3.60; 2.00–4.80), and final
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follow-up (2.00; 1.00–4.20) scores of the VAS fatigue scale decreased significantly according
to the initial recorded score of 9.00 (7.00–10.00; p < 0.001). Multiple comparison analysis
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revealed a significant difference between some VAS fatigue scores between the beginning
and second, third, and last follow-up visit (p < 0.001) in the study group. However, of the
participants in the control group, the first (8.00; 7.00–9.60), second (8.00; 7.00–9.60), third
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(8.00; 7.00–9.60), and last follow-up (8.00; 7.00–9.60) VAS fatigue scores increased
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significantly compared with the initial score of 7.80 (7.00–9.50; p < 0.05). Multiple
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comparison analysis indicated a significant difference between the beginning and last follow-
up session in the control group (p < 0.05). The VAS fatigue scores at follow up (first, second,
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third, and last follow) in the study group were significantly lower than those in the control
group (p < 0.001; Table 2).
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Table 2. Distribution of mean, median scores of VAS fatigue scores of the participants in study and control
groups according to measurement time.

Measurement time Study Group (n=27) Control group (n=35)

Median (%25p-%75p) Median (%25p-%75p) p**
a a
Beginning 9.00 (7.00-10.00) 7.80 (7.00-9.50) 0.315
a a
First follow 6.50 (5.30-8.00) 8.00 (7.00-9.60) <0.001
b a
Second follow 5.00 (4.00-6.30) 8.00 (7.00-9.60) <0.001
c a
Third follow 3.60 (2.00-4.80) 8.00 (7.00-9.60) <0.001
c b
Last follow 2.00 (1.00-4.20) 8.00 (7.00-9.60) <0.001
p* <0.001 0.002
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*Friedman test.
** MU test for independent variables
a,b.c
According to multiple compare test (Post-hoc: Dun-Bonferroni) results, this different letters define that there
was a significant difference between scale scores.
The total Piper Fatigue scale and all subscale mean scores significantly decreased in the study
group at follow up compared with those at the beginning of the treatment period (p < 0.001).
The difference between follow-up sessions (first, second, third, and last follow up) was
significant (p < 0.001). In the control group, the total Piper Fatigue scale and all subscale

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mean scores increased in the first, second, third, and last follow up, but the difference was not
statistically significant (p > 0.05). The results showed that all total and subscale mean scores

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of the study group were lower than those of the control group at follow up, and this decrease
was statistically significant (p < 0.001; Table 3).

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Table 3. Piper Fatigue Scale sub-dimensions scores of the participants in the study and control group.
Study Group (n=27) Control Group (n=35)
PFS p**
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( ±SD) ( ±SD)
Behavioral/Severity
Beginning 8.271.34a 7.311.40 0.009
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First follow 6.461.34b 7.381.42 0.012

c
Second follow 5.171.30 7.411.46 <0.001
Third follow 3.891.65d 7.401.51 <0.001
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e
Last follow 3.192.10 7.401.50 <0.001
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p* <0.001 0.415
Affective Meaning
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Beginning 8.401.32a 7.331.27 0.002

b
First follow 6.491.30 7.381.24 0.008
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Second follow 5.151.27c 7.441.29 <0.001

d
Third follow 3.851.47 7.441.35 <0.001
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Last follow 3.101.95e 7.441.40 <0.001

p* <0.001 0.415
Sensory
Beginning 8.541.31a 7.491.16 0.001
First follow 6.591.43b 7.571.16 0.008
c
Second follow 5.281.43 7.641.21 <0.001
Third follow 3.951.67d 7.641.29 <0.001
e
Last follow 3.172.12 7.651.32 <0.001
p* <0.001 0.244
Cognitive/mood
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Beginning 7.761.36a 6.931.08 0.010

b
First follow 6.101.29 7.001.02 0.003
Second follow 4.981.39c 7.091.14 <0.001
d
Third follow 3.651.56 7.091.22 <0.001
Last follow 2.931.93e 7.091.28 <0.001
p* <0.001 0.269

Table 3. PFS sub-dimensions scores of the participants in the study and control (continuing)

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Study Group (n=27) Control Group (n=35)
PFS p**
( ±SD) ( ±SD)
Total Fatigue Scale

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Beginning 8.221.27a 7.251.16 0.003
b
First follow 6.401.28 7.321.14 0.004

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Second follow 5.141.30c 7.381.21 <0.001
d
Third follow 3.831.56 7.371.28 <0.001
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e
Last follow 3.092.01 7.381.33 <0.001
p* <0.001 0.320
*Variance analysis was conducted for repeated measurement.
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**Two sample t test in independent groups was conducted.

a,b,c,d,e
According to multiple compare test (Post-hoc: Bonferroni) results, this different letters define that there
was a significant difference between scale scores.
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All subscales (subjective sleep quality 0.85  0.90, sleep latency 0.81  1.00, sleep duration
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0.22  0.42, habitual sleep efficiency 0.62  0.63, sleep disturbance 1.110.50, daytime
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dysfunction 1.03  0.97, and global sleep quality scale 4.66  3.66) of PSQI in the study
group were lower than the scores of the control group (subjective sleep quality 2.60  0.65,
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sleep latency 2.94  0.23, sleep duration 2.74  0.50, habitual sleep efficiency 2.68  0.79,
sleep disturbance 2.02  0.38, daytime dysfunction 2.62  0.49, and global sleep quality scale
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15.62  1.81), and this decrease was statistically significant (p > 0.001). A significant relation
was found between the PSQI mean score differences at the beginning and the last follow up in
both groups (p < 0.001; Table 4).
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Table 4. PSQI Sub scales scores of the Participants in the study and control groups.
Study Control Study Control
Group Group Group Group
pb pb
(n=27) (n=35) (n=27) (n=35)
PSQI
Beginning
( ±SD)
Last p a
Beginning
( ±SD)
Last p a
Beginning Last
P T( ±SD) ( ±SD)
Difference between
( ±SD) Follow
( ±SD)
( ±SD) Follow
( ±SD)
I
Follow

R
PSQI measurements c
( ±SD)
Subjective
quality
sleep 2.810.39 0.850.90 <0.001 2.680.47 2.600.65 0.324

U SC
0.246 <0.001 1.960.97 0.080.50 <0.001

Sleep latency
Sleep duration
2.880.32
2.850.36
0.811.00
0.220.42
<0.001
<0.001
2.850.35
2.740.44
2.940.23

A
2.740.50
0.083
1.000 N 0.717
0.291
<0.001
<0.001
2.070.99
2.620.49
-0.080.28
0.000.42
<0.001
<0.001
Habitual sleep 2.850.36 0.620.63 <0.001 2.770.42
M
2.680.79 0.585 0.435 <0.001 2.220.64 0.080.91 <0.001

D
efficiency
Sleep disturbance
Daytime
2.030.43
2.920.26
1.110.50
1.030.97
<0.001
<0.001
T E
2.050.41
2.650.48
2.020.38
2.620.49
0.324
0.324
0.834
0.007
<0.001
<0.001
0.920.38
1.880.97
0.020.16
0.020.16
<0.001
<0.001
dysfunction
Global sleep 16.371.52 4.663.66
E P
<0.001 15.741.72 15.621.81 0.669 0.140 <0.001 11.703.39 0.111.56 <0.001
quality
a
Paired t test was done.
C C
b

c
A
Two sample t test in independent groups was conducted.
PSQI score differences; Score taken from last follow subtracted from score taken from the beginning follow.
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4. DISCUSSION
Some symptoms, such as pain, spasm, pruritus, fatigue, and insomnia, caused by HD
treatment negatively affect the quality of life and daily life activities of people with chronic
renal failure. (Akca, Tasci, & Karatas, 2013; Eglence et al., 2013; Eti Arslan & Karadakovan,
2010; Farese et al., 2008; Su, Wu, Lee, Wang, & Liu, 2009; Tsay, Cho, & Chen, 2004; Usta
Yıldırım & Demir, 2014). For the management of fatigue, some integrative medicine practices
including massage, yoga, reflexology, and acupressure are suggested as effective (Chang et
al., 2008; Eglence et al., 2013; Imura et al., 2006; Mitchell & Berger, 2006; Mustian et al.,

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2007; Sood, Barton, Bauer, & Loprinzi, 2007; Tsay, 2004). Aromatherapy, one of the
integrative methods, has been found to reduce the level and severity of fatigue (Aycemen,

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2008; Buckle, 2003; Eglence et al., 2013; Kohara et al., 2004; Lee et al., 2011; Lee, 2004;

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Ozdemir & Oztunc, 2013). In particular, aromatherapy via inhalation is an easy, quick, and
effective treatment for certain physical and physiological problems, such as lower and upper
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respiratory infections, fever, headache, sinusitis, fatigue, depression, and insomnia (Buckle,
2003). In our study, no difference was found in the VAS fatigue scores between the study and
control groups at the beginning of the study (p > 0.05). The VAS fatigue score of the study
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group significantly decreased in all follow-up sessions after aromatherapy practice with
inhalation (p < 0.001), but it increased in the control group from the beginning to the last
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follow up (p < 0.001). Moreover, the total and all subscale mean scores of PFS decreased
according to the initial values in the study group (p < 0.001). However, these scores increased
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in all follow-up sessions in the control group (p > 0.05).

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The fatigue levels of the two groups before the intervention were similar based on VAS
scores, but they differed according to Piper. This difference may be because the PFS measures
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multi-dimensional fatigue levels, whereas the VAS fatigue scale only measures one
dimension of fatigue level.
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These results were similar to the literature (Imura et al., 2006; Kang & Kim, 2002; Kang &
Kim, 2008; Kohara et al., 2004; Lee et al., 2011). In a previous study on on mothers with
postpartum depression who wore a necklace with lavender and eucalyptus oil to supply
inhalation, fatigue levels of mother decreased significantly; however, the difference in sleep
quality between groups was not significant. In another study, aromatherapy practices were
found to be effective on fatigue (Imura et al., 2006; Kang & Kim, 2002). According to
Eglence et al. (Eglence et al., 2013), the application of acupressure for 1 month decreases the
fatigue severity of patients. Lavender oil exerts positive effects on insomnia in various
diseases (Buckle, 2003; Chien, Cheng, & Liu, 2012; Dabirian et al., 2013; Keshavarz Afshar
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et al., 2015; Lee et al., 2011; Moeini et al.,2010). In this study, all subscale and total mean
scores of PSQI for the last follow up in the study group were lower than the score means of
the control group (p > 0.001). A significant relation in PSQI score mean differences was
found between the beginning and last follow up in the study and control groups (p < 0.001).
Steflitsch and Steflitsch reported that Weihbrecht practiced lavender oil with inhalation in 10
people with chronic insomnia (Steflitsch & Steflitsch, 2008). Two drops of lavender oil were
dropped onto paper tissue or pillows, and inhalation was practiced. Eight of the participants
stated that they woke up feeling relaxed. In the study of Moeini et al., the practice of lavender

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inhalation among patients with ischemic heart disease was found to improve the quality of
sleep (Moeini et al., 2010). In the study of Choi and Lee (Choi & Lee, 2012), a significant

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decrease was determined in sleep disorders among participants with essential hypertension

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after inhalation of a mixture of lavender, marjoram, and ylang ylang (4:3:3) for two weeks
(three times in a day for 3 min). The results of our study were similar to results of
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aromatherapy practices in different diseases (Chien et al., 2012; Cho, Min, Hur, & Lee, 2013;
Choi & Lee, 2012; Ju et al., 2013; Keshavarz Afshar et al., 2015; Moeini et al., 2010; Soden
et al.,2004; Steflitsch & Steflitsch, 2008).
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Unwanted side effects related to inhalation of essential oils are rare (Alkanat Ozdemir, 2015).
After aromatherapy, one person reported of nausea and vomiting, and two people presented
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increased blood pressure levels.

5. CONCLUSION
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Inhalation of lavender and sweet orange mix (1:1) through the month once a day for 2 min
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yielded the following results:

 Increased sleep quality in dialysis patients (H_11 hypothesis was accepted)
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 Decreased fatigue level and severity (H_12 and H_13 hypotheses were accepted).
As a result,
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 The patients who reported high fatigue levels and sleep quality scores should be
studied to determine the effects.
 Double-blind randomized controlled studies should be conducted and repeated to
increase the evidence level of the study. Long-term research should be conducted
and repeated.
 Objective evaluation tools (e.g., polysomnographic recording) for evaluating sleep
after aromatherapy practices should be used.
Conflicts of Interest
No conflict of interest has been declared by the authors.
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Acknowledgement
This study was announced as verbal announcement at 2. Integrative Medicine Congress
(Abstract:0110) and oral presentation the first prize award. Moreover, this study was
supported, in part, by a grant from the Erciyes University Scientific Research Projects
Coordination Unit (No. TDK-2014-5222). The authors are grateful to Associate Professor
Ahmet Ozturk (Department of Biostatistics at Erciyes University) for supporting Statistical
analysis.
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Highlights

 This study was conducted to determine the effect of aromatherapy applied by

inhalation on sleep quality and fatigue level in hemodialysis patients.

 Aromatherapy applied by inhalation increased sleep quality.

 Moreover, aromatherapy applied by inhalation decreased fatigue level and severity.

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 Consequently, aromatherapy prepared with sweet orange and lavender oil may be
recommended to increase sleep quality and to decrease fatigue level of the
hemodialysis patients.

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