Nurses experience of aromatherapy use with dementia patients experiencing disturbed sleep

patterns. An action research project

abstract
The purpose of this study was to gain an insight into nurses experiences of incorporating
aromatherapy into the care of residents suffering from dementia, anxiety and disturbed sleep
patterns. Twenty-four residents and twelve nurses from four nursing homes participated in an
action research study. The use of lavender augustofolia essential oil diffused nightly was
perceived as an effective care modality reducing insomnia and anxiety in this patient cohort.
Nurses experienced some negative attitudes among colleagues because they considered
aromatherapy as not evidence based. Nurses require greater access to evidence based use of
Aromatherapy. Further research is needed to study how smell can enhance dementia care.
1. Introduction
Nursing home residents with dementia commonly suffer from disturbed sleep patterns,
anxiety and restlessness. These symptoms can increase with age and dementia severity. In
Norway, as in most Western countries, pharmacological medications are commonly used to
ameliorate these symptoms, however these may not have the desired effect or may have side
effects [1e3]. Alternatives to drugs are rarely used in the Norwegian health care system, and
there is no formal specialization in complementary and alternative medicine (CAM).
Although there is increasing evidence of the use of CAM1 internationally, little is known
about the use of CAM and aromatherapy in particular, in residential aged-care facilities [4].

Aromatherapy is the therapeutic use of essential oils [5]. Its main effect is through the skin
and via the olfactory system and this mechanism has been previously documented [6,7]. One
review of evidence supporting the use of aromatherapy to treat behavioral challenges in
dementia patients (BPSD) concluded that aromatherapy could potentially useful however,
data supporting efficacy continues to be scarce [5]. The oil Lavendula augustifolia, is one of
the most commonly used and cited essential oils [8], with a number of studies indicating that
lavender can decrease stress and pain intensity [9]; it can also assist by reducing insomnia
[10]. It appears that Lavender can increases the percentage of deep or slow-wave sleep in
subjects resulting in greater alertness during the day [11]. Studies relating to people with
dementia experiencing, sleep problems and anxiety show generally positive, but varying
results [5,12e16]. However there continues to be a need for further research. Two studies
have indicated a statistical relationship between lavender and calmer behavior [19,20] and in
one study, a combination of oils was found to be effective in reducing anxiety [21]. However
there continues to be a need for greater detail in terms of specific aromatherapy oil usage.
To date, no studies were found when undertaking a literature search of nurses using
aromatherapy in the care of residents with dementia.

1.1. Purpose
The purpose of this study was to gain an insight into the experiences of nurses who chose to
incorporate aromatherapy in their care of residents with dementia who suffer from anxiety
and disturbed sleep patterns. The research question was: How do nurses experience and
perceive lavender augustofolia aromatherapy with dementia patients who experienced anxiety
and disturbed sleep patterns?
2. Method and implementation
Considering the purpose of this study and the limited experience in Norwegian nursing
homes of using aromatherapy, an action research method was chosen. Action research is a
process that generates knowledge within an organization. It requires the researcher to make
their knowledge available and for participants in their practice to share their understanding of
what they are doing available to the researcher. The most important and useful results are
action, change, development and liberation [23]. Thus, Action research is a strategy where
we work for change while we use the process to learn and develop new knowledge [22, p.
156].
The principle aim of the project was to implement the use of aromatherapy, whilst
concurrently monitoring and evaluating the change in practice process. Thus evaluation
sought to describe and analyze the implementation and contextualize these outcomes within
existing knowledge in the field. Action and research occurred simultaneously throughout the
entire process. Action research is also characterized by the direct involvement of the
researcher to implement and monitor the change process and ultimately, to ensure the
participants e in this case the nurses owned the change in nursing practice. This closeness
between the researcher and the field can be both a strength and a challenge with positive
collegiate collaboration. However, it is also essential for the researcher to ensure that each
step of the action research process is monitored and staff encourages done to resolve issues
that may arise. Thus the researcher does not provide solutions to problems, but encourages
and monitors staff as they implement change [22].
An invitation to participate in the project was sent to the eight nursing homes in the region.
Four nursing homes agreed to participate, this included 12 nurses and 24 patients.
2.1. Ethical considerations
People with dementia are a vulnerable group who were unable to provide informed consent to
participate in the project. Any participation requires thorough ethical assessment [24]. The
responsible nurses together with the relatives of each resident acted as the residents advocate
and gave consent on their behalf. In some cases, participation was discussed with the doctor.
The Regional Ethics Committee ruled that ethical approval was not required for the project
because essential oil of lavender was considered a scent associated with well-being, and not
medication.
The nurses chose freely to join the project and signed an informed consent form to
acknowledge they had been made aware of their right to withdraw and remain anonymous.
2.2. Problem identification
The project consisted of following seven steps prescribed by Malterud [22, p. 157]:
1. Problem identification: Nurses report residents with dementia suffering from anxiety and
disturbed sleep patterns (walking around at night, frequently calling for staff at night, patients
tired and falling asleep during the daytime).
2. Summary of past experience: Nurses experienced and recognized that existing treatments
(most commonly drugs) are not working effectively with this client group.
3. Formulate a goal: Conduct and document the use of aromatherapy using Lavender
Augustofolia for selected residents experiencing anxiety and disturbed sleep.
4. Project planning: The researcher and staff discussed the procedure and decided to use an
aromatherapy fan diffuser2 with lavender. They made plans for implementation in
cooperation with an aromatherapist and selection, criteria and a survey form were developed
for residents. Selection criteria included residents who were regularly ambulatory or awake
during the night and who slept during daytime despite medication. Twenty-four residents
from four nursing homes met the criteria and were selected for participation. Information
sheets for employees, relatives and physicians were printed and reporting forms and
folders for each resident were prepared by the researcher and participating nurses. Full
information was provided and information forms completed and signed where appropriate.
Other colleagues were given information about the project both orally and in writing.
5. Procedure: 12e15 drops of essential oil of lavender augustofolia was placed into a fan
diffuser at a particular time each evening and diffusers were standardized and monitored to
ensure each patients received similar exposure to the essential oil.
6. Implementation: The nurse on night duty was responsible for monitoring fan diffusers and
these were commenced 30 min before bedtime. Night staff regularly checked diffusers during
the period they were in use and turned them off each morning.
A short night report was completed. The procedure was repeated every night over a three
month period. Day staff also monitored patients and completed a daily report on each
resident, regarding, patient perceived anxiety, alertness and mood.
7. Redefining the problem: The procedure is dependent on the continuity and motivation of
nurses involved in the project. The staff involved in the project were monitored by the
researcher and any issues associated with use of the specific oils were addressed and
discussed. Similarly discussion also focused on the opportunity to reduce individual residents
drug regimens.
2.3. Action research
As in any form of research, the research question determines which methods can provide
relevant knowledge. In action research, this commonly involves qualitative methods [22].
Data were collected in the form of field notes, reports, logbooks and focus group interviews.
Field notes were written during the entire process. Nurses completed daily reports on each
resident. Unrest, activity, mood, sleep and drug use were the most important factors recorded
and evaluated. The researcher visited each nursing home every 14 days. This resulted in field
notes focusing on the experiences of all the nurses. On completion of the implementation, the
responsible nurses were interviewed in three focus groups and one individual interview.
Focus groups are particularly well suited to learning about the experiences, attitudes or
viewpoints in an environment where many people interact [22, p. 133]. The focus group
interview is guided by a moderator who ensures that all are heard, maintains the group
process and contributes to the conversation to ensure that the actual theme is fully explored
[22, p. 134]. The primary theme focused upon experiences of the nurses in using the
aromatherapy fan diffuser with specific nursing home residents. It encompassed planning and
implementation, use of essential oils, cooperation with colleagues and relatives, support from
management/leaders and participating in the project.
Analysis of the resident reports was made by the researcher and the responsible nurses.
Reports for each resident were read and discussed among the responsible nurses. They had
different experiences, but they agreed on four categories:
1. Residents who had a good effect form experiencing essential oils via the diffuses.
2. Those for whom a moderate effect was experienced.
3. Residents who were not perceived to have changed who had an unclear effect.
4. Residents for whom the essential oil did not appear to have any effect.
The field notes and the interviews were analyzed by the researcher alone. A systematic
content analysis [22] of the collected data revealed two main categories:
1. The use of essential oils was stimulating.
2. Good preparation and follow-up was essential.
3. Results
3.1. Nurses found that lavender had an overall good effect
Nurses experienced a positive effect of the lavender scent on the majority of residents. Those
on night shift observed fewer residents wandering or troubled and several slept well. Nurses
on morning duty found that these residents were more alert and improved in mood. For a
minority of residents, the effect of lavender was only slightly noticeable. Table 1 shows the
distribution of the 24 residents after the nurses had analyzed the reports for the 90 days.
Below are some examples of how the nurses concluded the reports for some of the residents
in the four categories:
3.1.1. Experiences of good effect
Resident A now has a much better and structured sleep. Previously, she slept very little, she
used to be very uneasy and worrisome and called frequently for the staff. Now this habit is
channeled to day and evening instead and it leaves the night quiet. She sleeps little during the
day now that she is more alert and relaxed. On average, she is very much quieter and has a
better nights sleep than before. She has reduced the use of Sobril.
Resident B used to walk around during the night, and often fell asleep during the day. Now
he has good nights sleep, he is more alert and ready in the morning, less anxious during the
day and more able to attend social activities. He has stopped taking sleeping pills.
3.1.2. Experiences of moderate effect
Resident C is now sleeping pretty much all night, but how long he sleeps varies. He is more
social in the afternoon and can now participate in activities. The night nurse reports he is
sleeping better than before.
Resident D is up every night on the toilet, but now he falls asleep quickly again. He did not
do this before the lavender trial. Night nurses used to give him medication because of his
frequent waking, but often this did not have the desired effect. In general, the resident has a
better quality of sleep with the combination of lavender and medication.
3.1.3. Experiences of an unclear effect
Resident E is basically a very anxious resident. At first, he was somewhat quieter at night.
The reports showed that he slept longer than usual, but that changed over time and he became
restless and awake again. He has changed in several ways and has vague symptoms that are
being observed and he gets more painkillers.We dont really know what is bothering him.
3.1.4. Experiences of no effect
Resident F cannot find peace, she iswalking around all the time. We thought at first that
lavender helped her, but it turned out that it was too much medication that made her blunt and
sleepy. We do not see any changes in connection with the lavender project.
In all four nursing homes, the responsible nurses had received requests for lavender from the
night nurses because residents had gone back to old habits and were turbulent at nighttime
once the project period was concluded. For one of the residents, the change was not apparent
until the project had finished. Because of this, the responsible nurse revised the conclusion
from a moderate to good effect.
3.2. The use of essential oils upon staff
The project staff perceived the use of essential oils positively. They also questioned the lack
of knowledge about natural products in nursing asking, Why has not anyone taught us about
essential oils before? They had not learned anything about this in their nursing education,
and were critical of the predominance placed upon pharmacological medications in their
education. Many were skeptical of the extensive use of drugs with the aged general and
people with dementia in particular. For example, they observed that residents who took
sleeping pills had problems associated with falls or tiredness during the day and wanted to
know about other options. The initial introductory day course on essential oils was viewed by
all as interesting and professionally valuable. One group said: We are so glad that essential
oils are natural products and that they are so easy to relate to and use.
Several commented on the pleasurable smell of herbs and expressed interest in learning more
about essential oils. They felt that the essential oils were spreading joy. The good smell and
the ease of use led to several employees using oils in private. One group had also begun to
use lavender in other ways. According to one nurse: We were able to keep a woman with
very challenging behaviors quiet with a dose of lavender on the palm of her hand and her
neck. This is done every two hours. We also have lavender in creams, soaps and bath oils.
In the focus groups, nurses also told of colleagues who asked for advice on residents whom
they believed would benefit from lavender. The majority of nurses involved in the project
wished to use essential oils after the project had completed. Two groups reportedtheir interest
had expanded to trying different oils such as citrus oils for depression and tea tree for nail
fungus and infected wounds. The group of nurses decided to organize a seminar on natural
remedies as a conclusion to the project in order to learn more about alternatives to
medication. They also suggested inviting the doctors to the seminar, because they had
experienced that doctors expressed skepticism and lack of knowledge towards CAM. Only
one nurse reported that the doctor was very interested in the project.
3.3. Preparation and follow-up
All groups were satisfied with the project preparations and the one-day course on essential
oils. They also viewed their ability to be able to actively participate in the planning of the
implementation positively as well as being able to provide input during the implementation
period. The nurses stated that they valued employees being invited to a training and
information meeting prior to commencement of the project. They agreed that follow-up by
the researcher every 14 days was good, as was availability by email.
In summary, introduction of a new procedure requires cooperation and support in the nursing
group. Essential oils are considered as CAM, and it was recognized by staff that some nurses
were negative about this. One focus group participant said: We had many negative
colleagues, so in our nursing home, it was fun because it worked so well for the residents
involved, and this changed the attitude among most of the negative nurses.
Some nurses initially experienced problems with implementation and the follow-up
procedure. Others pointed out colleagues had changed their attitudes after the project had
finished because they believed turmoil among residents had returned. One nurse reported:
Three of the night nurses have reported residents are sleeping worse since the lavender
project ended.
The importance of support from the nurse leaders was clear, as one focus group participant
commented: It was good and positive with the full support from management and fun with a
medical doctor who was interested. Another participant commented: The management
here is very positive. We can also use refreshing oils in the living rooms, and they supported
us with lavender after the project had completed. Three groups said they had meetings with
their leaders and received funding to purchase oils and continue with lavender after the
project was completed.
4. Discussion
Many factors come into play in the management residents with dementia. This project
examined nurses experiences with the introduction of a simple addition to daily care: that of
aromatherapy. Staff overall perceived lavender as a positive intervention assisting residents to
calm down and sleep more fully. The use of lavender in this study found similar benefits to
those reported in previous research [10,19,20]. Field notes indicated that residents used many
different drugs, and some experienced side effects form particular medications. Studies
confirm that residents in nursing homes who use quantities of medications drugs are exposed
to drug-related problems [25,26,27,4]. Measures are being implemented to reduce potentially
inappropriate use of drugs in nursing homes [27], but there is a need for further research in
this arena.
One Swedish study indicated that t psychiatric residents using CAM reduce their drug
dosages [28]. Whilst Lavender Augustofolia oil is not defined as a drug, there is a lack of
knowledge about how specific medications may interact with lavender. An Iranian study
shows that lavender in combination with imipramine had a positive effect on residents with
depression [29], however there is a need for re[placation and additional research.
Reducing psychotropic drugs is considered to be positive for residents with dementia.
Therefore, the nurses considered the idea of greater use of essential oils positively [5] and
that this could be a means by which drug use and their side effects could be reduced. For
example, there is a connection between falls and fractures and the use of neuroleptics and
sleeping pills (especially pills with benzodiazepines) [30]. Dewing [3] claims that nondrug
interventions should always be the first choice for this group of residents.
Aromatherapy is a nonpharmacological intervention, but it may lie in the gray area between
medicine and care along with a number of other complementary therapies [17,18,31].
Research on the effects of lavender is primarily published in medical journals, and periodicals
focusing on CAM. Little is found in nursing journals, although the international literature has
integrated CAM and nursing in a way that is novel in the Scandinavian countries [32].
Integrating aromatherapy in nursing care will expand the caring/healing repertoire of nurses,
but could lead to competition with physicians.
Nurses in the Norwegian health care system are largely assistants to biomedical doctors and
administer drugs prescribed by them. The use of essential oils may be an independent nursing
action in caring for residents with anxiety and sleep problems, but for it to be a natural part of
caring, it must be included in nursing education and curriculum. Nurses in this study
expressed their skepticism towards drugs. However, in a study of decision making around
treatment with antidepressants among doctors and nurses in nursing homes, doctors reported
relying on nurses observations and rarely carried out systematic diagnostic work and follow-
up of residents [33]. If nurses had knowledge and skills in the use of aromatherapy, one might
assume that this could reduce the demand and use of medication.
Research indicates that in addition to health workers expertise, enthusiasm can affect the
type of treatment residents receive [34]. Natural remedies such as essential oils created
enthusiasm among nurse participants and they wanted to expand their use to enhance positive
environment and well-being. The researcher in an action research study recognized that such
enthusiasm could t affect the objective distance, thus it was felt necessary to ask critical
questions.
In this project, implementation was facilitated, with nursing homes accommodating the
project. Leaders attended meetings and eagerly followed the projects progress. Studies show
that leaders are the most important link in developing new skills and professional
development [35]. The use of lavender in an aromatherapy fan diffuser was a new and
different way to meet residents needs, and nurse participants were enthusiastic. However,
negative feedback from a few nurse colleagues was experienced relating to the smell of
lavender described as heavy and described the use of lavender as not evidence based.
Attitudes toward CAM in the Norwegian health care system vary; many argue that CAM is
still insufficiently evidence based and should not be offered to residents. However, recent
surveys have indicated growing interest in the use of CAM [31] and CAM and its perceived
value in the public health service is increasing [36]. Knowledge and experience will have
positive effects on attitudes towards CAM, and new nursing literature develops the
foundation of evidence based CAM [37].
Research addressing patients suffering from dementia is challenging, as is the ability to
measure the effects of scent [5]. In this study, nurses shared their experiences using aromatic
oil of lavender in their daily care of persons suffering from dementia. Qualitative findings in
this study support and expand findings from previous quantitative studies. The goal of this
study was not to measure effects, this might be considered as a limitation. It must also be
taken into consideration that many things can influence how nurses describe their
experiences. A positive response in the work environment might support positive
descriptions, but it may also inhibit the negative ones. It is considered a strength that the four
different workplaces (twelve different nurses) had similar experiences.
5. Conclusion
Nurses in nursing homes experienced aromatherapy diffuser fan with lavender a simple and
effective caring modality for residents with dementia suffering from anxiety and disturbed
sleep patterns. As a natural remedy, lavender was viewed as an effective tool in the care of
this particular cohort of patients. There is a need for nurses to learn more about using
aromatherapy and CAM in care. With the support of their leaders, nurses in this study will
continue to use lavender. In collaboration with physicians and aromatherapists, the use of
aromatherapy in nursing care should be examined more closely. There is also a need to study
how smell affects nurses when using aromatic oils in care.

Conflict of interest statement

There is no conflict of interest.

Acknowledgments
Many thanks to the nurse and aromatherapist Anna Srnmo and to all the nurses who made it
possible to conduct the study. The study was funded by the University of Agder in
cooperation with the Grimstad and Songdalen municipalities in Norway.