Purpose:  Summarize and appraise an article for bias and validity in a collaborative environment. Assessment: The DBs are wo

Research Discussion Board Rubric Course: NUR4440-02:Research in Nursing (2021 Fall Term 2)-14108

Criteria Advanced Proficient Developing Incomplete Unsatisfactory Criterion Score

Word Count: 100

word minimum

(artificial filler

(adding citations,

thank you’s to

peers, etc. will not

be counted)

/ 3

Number of posts

(Posts must meet

quality criterion

to count for this

criterion.)

/ 5

Clustering of

posts (Post must

meet quality

criterion to count

for this criterion.)

/ 10

3 points

Criterion met for ALL

posts

0 points 0 points 0 points 0 points

Criterion NOT met

for ANY ONE post.

5 points

at least 3 posts

4.5 points

at least 2 posts

4 points

at least 1 post

0 points 0 points

no posts

10 points

posts made on 3

separate days

9 points

posts made on 2

separate days

8 points

posts made on 1 day

0 points 0 points

no posts

Total / 38

Criteria Advanced Proficient Developing Incomplete Unsatisfactory Criterion Score

Posts meet ALL of

the following:

answers part of

the prompt not

previously

answered;

rationale is given;

not repetitive

with own or

others’ posts;

stays on topic of

thread;

information

relates to the

article; attempts

to apply concepts

intro’d in lecture

/ 2020 points

3 posts meet criteria

17 points

2 posts meet criteria

14 points

1 post meets criteria

10 points

no posts meet

criteria, but posts are

made

0 points

no posts made

Overall Score

Advanced 35 points minimum

Proficient 32 points minimum

Developing 29 points minimum

Unsatisfactory 28 points minimum

ORIGINAL ARTICLE

Essential Oils to Reduce Postoperative Nausea and Vomiting

Maxine A. Fearrington, MS, RN-BC, Brandon W. Qualls, MPA,

Mary G. Carey, PhD, RN, FAHA, FAAN

Purpose: The purpose of this study was to determine if using essential oil

Maxine A. Fearr

University of Roch

don W. Qualls, MPA

sity of Rochester M

Carey, PhD, RN, FA

ter, University of R

Conflict of intere

conflict of interest

research because s

dustry selling essen

However, for this

from a company

Qualls and Mary G

Address corresp

Surgical Center, U

Elmwood Avenue

maxine_fearringto

Published by Els

PeriAnesthesia Nu

1089-9472/$36.

https://doi.org/1

Journal of PeriAnesth

products for adult patients reduced the need for antiemetics for postoper-

ative nausea and vomiting (PONV). Design: A prospective and retrospective cross-sectional design using a con-

venience sample. Methods: Double blinded to the type of essential oil, subjects randomly

selected a nasal inhaler containing peppermint, ginger, or a combination

of both. A prophylactic dose was given preoperatively, and during the

postoperative period nausea was assessed using verbal descriptive scale. Findings: Overall 322 same day surgical patients were analyzed (control

group [n 5 179] and intervention group [n 5 143]). The intervention group had a greater history of PONV but received fewer doses of anti-

emetics postoperatively compared with the control group. There was no

significant difference in the effectiveness of the three types of inhalers. Conclusions: Aromatherapy demonstrated a statistically significant (P , .05) reduction in the need for antiemetics to treat PONV.

Keywords: aromatherapy, postoperative nausea, hospital, surgical center.

Published by Elsevier, Inc. on behalf of American Society of PeriAnesthesia

Nurses

ington, MS, RN-BC, Strong Surgical Center,

ester Medical Center, Rochester, NY; Bran-

, Clinical Nursing Research Center, Univer-

edical Center, Rochester, NY; and Mary G.

HA, FAAN, Clinical Nursing Research Cen-

ochester Medical Center, Rochester, NY.

st: Maxine A. Fearrington has an apparent

which may question the objectivity of the

he in an independent consultant to the in-

tial oils, the intervention for this protocol.

protocol, the intervention product comes

she has no association with. Brandon W.

. Carey have no conflicts of interest.

ondence to Maxine A. Fearrington, Strong

niversity of Rochester Medical Center, 601

, Rochester, NY 14642; e-mail address:

[email protected]

evier, Inc. on behalf of American Society of

rses

00

0.1016/j.jopan.2019.01.010

esia Nursing, Vol -, No – (-), 2019: pp 1-7

PATIENTS ANTICIPATING SURGERY typically experience some degree of anxiety related to the potential for experiencing unpleasant side effects

such as postoperative nausea and vomiting

(PONV). Traditional interventions to treat PONV

involve administering intravenous (IV) antiemetics.

However, pharmacologic therapies can be accom-

panied by adverse consequences including seda-

tion, alterations in heart rate or rhythm, decreased

level of consciousness, and an increased demand on nursing care.

1-3 Aromatherapy offers an

alternative or complimentary therapy that can be

either nurse or patient administered.

Literature Review

Currently, aromatherapy is used in a variety of

clinical settings and for a variety of purposes. Also referred to as essential oils, aromatherapy is

most frequently used to manage nausea, 1-10

1

2 FEARRINGTON, QUALLS, AND CAREY

pain, 6

insomnia, 6

and stress or anxiety. 11,12

Essential oils are concentrated essence extracted

from plants using a distillation process. 13

Reis

and Jones caution that not all essential oils are

created equally; consumers (nurses) should pur- chase and use oils that meet the criteria for thera-

peutic or medicinal quality. Many oils may be

certified pure and organic, which means they

may meet established guidelines, yet the therapeu-

tic effect may be in question. 13

When the right oils

are used for the right reason, and in the right way,

many beneficial outcomes can be realized.

One example of a beneficial use of aromatherapy is

to reduce anxiety. Stress and anxiety are often pre-

sent in many hospitalized patients and can lead to

undesirable outcomes. Bikmoradi et al studied the

effects of inhaled lavender essential oils on the vital

signs of 60 patients undergoing coronary bypass

surgery. 11

This study examined changes in mental

stress using both a Depression Anxiety Stress Scale (DASS-21) questionnaire and changes in vital signs.

The results were not statistically significant for the

intervention group, except for an increase in sys-

tolic blood pressure at 5 and 30 minutes postinter-

vention. At the 5-minute mark on the third day

postprocedure, systolic blood pressure for the con-

trol group (114 6 20) was lower than the interven- tion group (127 6 25), and at the 30-minute mark, similar results were noted (116 6 22 and 131 6 25, respectively). Despite the lack of positive evidence, Bikmoradi et al

11 recommended lavender

as a low cost, minimal risk intervention for use that

may help in decreasing anxiety and mental stress.

These contradictory results demonstrate the need

for further studies in this area.

Another study examined women undergoing breast

biopsies (n 5 87) and the effects of aromatherapy on anxiety levels. Trambert et al

12 compared

lavender-sandalwood and orange-peppermint

essential oils against a placebo, which revealed sta-

tistically significant results for women in the

lavender-sandalwood blend group at reducing anxi-

ety. This study was a randomized three-arm study measuring anxiety levels using the State-Trait Anxi-

ety Inventory, with the lavender-sandalwood group

being both statistically and clinically significant in

the reduction of postprocedure anxiety.

Johnson et al 6 reported on a retrospective study

(n 5 5,837) where nurses in a large health system

in the mid-west were trained in the use of various

essential oils for use as ‘‘therapeutic interventions’’

as deemed appropriate by the nurses. Symptoms

such as pain, anxiety, and nausea were addressed

using essential oils of sweet marjoram, lavender, mandarin, and ginger, respectively. This study of

nurse-delivered aromatherapy revealed a decrease

in score among the three outcomes; however, pain

scores decreased an average of three points on a

0 to 10 scale, which demonstrated strong evidence

(statistically significant, yet the actual results were

not provided) to support the use of essential oils as

a complement to standard of care in a holistic patient care environment.

6

PONV is a relatively common side effect of surgery;

yet the exact causation is not fully understood. 3 A

number of factors have been identified that can

lead to an increased incidence of PONV, such as fe-

male gender, nonsmoker, a history of PONVor mo-

tion sickness, and surgical procedures lasting greater than 1 hour.

3 Several studies have been

conducted using peppermint, ginger, or various

other combinations for use as prevention or treat-

ment of PONV. 1-10

Two systematic reviews were

published in 2012 examining the use of various

types of inhaled aromatherapy for PONV, 14,15

demonstrating encouraging but not yet

convincing results. However, most of the studies reviewed were small or lacking in rigor. Since

2012, several larger and more compelling studies

have been conducted. Three of the four studies

that tested the use of peppermint oil

demonstrated positive results in reducing

PONV. 1,2,7,10

Similarly, three other studies using

inhaled ginger oil 4,6,8

and three using a

commercially prepared product QueaseEASE 3,9

or a combination of several oils 5 also showed

favorable results in reducing PONV. Despite these

findings, many practitioners still hesitate to

embrace this treatment modality, likely because

of the need for additional research that is more

rigorous in design, 7,8

a larger sample size, 2,3

or

longer in duration. 1,10

Purpose

The purpose of this study was to determine if

aromatherapy (peppermint, ginger, or a combina-

tion) for adult hospital ambulatory or 23-hour

surgical patients would reduce the need for anti-

emetics to treat PONV.

ESSENTIAL OILS FOR NAUSEA AND VOMITING 3

Sample and Setting

The study took place in the surgical center of a

large urban teaching hospital. The target popula-

tion was adult patients scheduled for same day or

short-stay surgical procedures. The intervention

group was a convenience sample, selected from

the operating room schedule that met the initial

criteria of being scheduled for ambulatory surgery

or a 23-hour stay. Most (94.4%) of surgical proced- ures targeted patients in six services including or-

thopaedics, urology, general and trauma, plastics,

neurosurgery, and ear, nose, and throat, with less

than 6% being colorectal and gynecologic sur-

geries. They were then screened using the inclu-

sion criteria of being at least aged 18 years, able

to understand and follow directions, able to give

informed consent, and understand, read, and write English. Patients were excluded if they had a his-

tory of chronic obstructive pulmonary disease,

asthma, or other respiratory disorder that could

be exacerbated by strong odors, inability to smell

fragrances (before or after surgery), allergic or sen-

sitive to either peppermint or ginger, or sensitive

to any strong odors. The control group was a retro-

spective chart review of prior year’s surgeries that met the same initial inclusion criteria (same-day or

23-hour stay) as the intervention group.

Protection of Human Subjects

After receiving Institutional Review Board

approval and registering as a Phase II trial on

clinicaltrials.gov, recruitment of subjects began.

All data were recorded on an encrypted portable

device, and none of the stored data contained

any identifiable information about the research

subjects. Paper copies were stored in a secure loca-

tion, and once all pertinent data were captured, the papers were shredded.

Figure 1. Plastic nasal inhaler sealed in plastic

with unique four-digit number. This image is available

in color online at www.jopan.org.

Methods

For the retrospective chart review, initial selection

of patients was accomplished by the first author by

reviewing retained hard copies of operating room

schedules from July through December 2017, of

patients who had ambulatory surgery or stayed in

the 23-hour unit postoperatively. Once identified,

the patients’ electronic medical records were ac- cessed using a unit-based computer. Data collected

included age, gender, race, type of surgery, length

of stay, history and episodes of PONV, and type and

number of both intraoperative and postoperative

doses of antiemetics administered. These patients

comprised the control group as they received the

standard IV antiemetic medication for any PONV.

Intervention: Essential Oils

The inhalers were premade by designated

personnel (not associated with the surgical center

patients) and contained four drops of essential

oils of peppermint or ginger, or a combination con-

taining two drops of each of the two oils. The in- halers were sealed in plastic shrink-wrap and

marked with a four-digit number, which was re-

corded on a log and held in a separate secure loca-

tion in the surgical center until the study was

complete (Figure 1). The inhalers all looked the

same and the fragrance was undetectable; there-

fore, the study was double blinded to the type of

essential oil.

For the prospective study, all providers and nurses

in the postanesthesia care unit and surgical center

were provided training and material to inform

them of the study protocol. Potential subjects

were identified from the operating room schedule

as meeting the initial criteria. These subjects were

then approached to determine initial interest in study participation. Subjects were then given an

information sheet, and the study protocol ex-

plained. Investigators offered the subjects the

informed consent to read, ask questions, and sign

if participation was desired. Consent forms were

placed in a secure location in the surgical center.

4 FEARRINGTON, QUALLS, AND CAREY

After obtaining informed consent, a color-coded

(blue) wristband was applied to the subject’s wrist

as a visual aid that designated the patient as a study

subject. Several blue dot stickers were also applied

to various locations in the paper chart that accom- panied the subject throughout their hospital stay

as another way to flag the patient as a study sub-

ject. All data were deidentified, and the following

variables were collected: age, gender, race, type

of surgery, length of stay, history and episodes of

PONV, and type and number of doses of anti-

emetics administered. The numeric number from

the blue wristband served as the subject’s unique identifier and was in no way tied to the patient’s

medical record. The subject then selected at

random a nasal inhaler from a basket. The subjects

were instructed to use the inhaler for one dose

(two to three slow deep inhalations from the nasal

inhaler) before receiving any sedating medication

preoperatively. The inhaler was then placed inside

the patient’s paper chart, which accompanied the patient throughout their stay in the hospital.

The nurses in the postanesthesia care unit were

trained to assess nausea with every set of vital

signs, using a 0 to 3 verbal descriptive scale, 5 and

for any score of 1 to 3, offer the subject the nasal

inhaler as the first intervention. Nausea was then

reassessed 5 minutes after inhaler was used, and if nausea was not yet relieved, the subject would

be offered a second dose from the inhaler. The sub-

jects were advised that they could, at any time,

request a dose of ordered medication with or in

place of the nasal inhaler without being unen-

rolled in the study. Any patient who was actively

vomiting was given a dose of ordered medication

without using the inhaler; however, any subse- quent episodes of nausea were encouraged to

use the nasal inhaler before receiving additional

medication.

Analysis Plan

All analyses were conducted using Statistical

Package for the Social Science (SPSS v25 for Windows) and statistical significance was set to P

, .05. Continuous measures (eg, age) were reported as mean 6 standard deviation and categorical variables (eg, gender) as a count (n,

%). Demographic and clinical characteristics of

the groups (ie, control vs intervention) were

compared using Student’s t test to determine if

there were differences between the groups. Statis-

tical significance was set at P , .05. Model 1 used a repeated measures analysis to compare changes

in nausea score preintervention and postinterven-

tion. Model 2 examined total length of stay in relation to inhaler fragrance and intraoperative

medications. Unadjusted analysis of variance

was also conducted to determine any changes in

preoperative and postoperative nausea assessment

scores between the three intervention arms. A

power analysis was conducting using a 5 0.05 and b 5 0.20 determined a sample size of 190 was needed; therefore this study was adequately powered.

Results

Overall 322 same day surgical patients were analyzed (control group [n 5 179] and interven- tion group [n 5 143]). Among the eight hospital adult services, most patients (70%) came from

three services including urology, neurosurgery,

and general or trauma.

Among the six variables (age, gender, race, epi-

sodes of PONV, total hours in the operating room, and average number of doses of antiemetics

administered) all were statically different between

the control and the intervention groups, except

age and gender. It should be noted that subjects

in the intervention group were predominantly

White, had a greater history of PONV, and received

fewer doses of antiemetics postoperatively

(Table 1). Those who used an antiemetic and those who had a history of postoperative nausea had

greater preimprovement to postimprovement in

nausea scores after controlling for the other vari-

ables in the model. This model accounted for

20% of the variance in nausea change scores

(Table 2). Those who spent 2 hours or greater in

the operating room had longer length of stay in

the surgical center compared with those less than 2 hours after controlling for the other vari-

ables in the model. This model accounted for

13% of the variance in length of stay (Table 3).

Within the intervention group (�45% of total sample), the three types of essential oils included

peppermint, ginger, and a combination of both,

the distribution was 16%, 17%, and 12%, respectively, whereas the control group consti-

tuted �55% of the total sample. There was no

Table 1. Control Versus Intervention for Essential Oils to Reduce PONV (n 5 322)

Control (n 5 179) Intervention (n 5 143) P Value

Age x 6 SD 55.18 6 17.53 54.64 6 15.89 .774 Sex Female 5 87 (48.6%) Female 5 71 (49.7%) .85

Male 5 92 (51.4%) Male 5 72 (50.3%) Race (%, n) Caucasian 5 76.5% (137) Caucasian 5 90.9% (130) .002

African American 5 15.1% (27) African American 5 6.3% (9) Hispanic/Latino 5 6.1% (11) Hispanic/Latino 5 0.7% (1) Other 5 2.2% (4) Other 5 2.1% (3)

History PONV Yes 5 4.5% (8) Yes 5 14.0% (20) .003 No 5 95.5% (171) No 5 86.0% (123)

Number of PONV episodes

per patient x 6 SD 0.54 6 0.90 1.72 6 1.80 , .001

Number of doses of antiemetics

per patient x 6 SD 0.53 6 0.85 0.15 6 0.47 , .001

PONV, postoperative nausea and vomiting.

ESSENTIAL OILS FOR NAUSEA AND VOMITING 5

statistically significant difference in the type of

inhaler used (P 5 .62). A separate unadjusted anal- ysis of variance produced similar results, support-

ing the previous findings. During the study, no

complications or adverse reactions occurred.

Although anecdotal information was not systemat-

ically collected or studied, comments from the nurses included ‘‘.patients were happy with their inhaler.,’’ ‘‘.wouldn’t give me the inhaler back, but promised to tell me when it was used.,’’ and ‘‘I’m certain I gave fewer doses of intravenous

antiemetics during the study period.’’ In addition,

on more than one occasion, patients’ comments

included ‘‘I love my inhaler,’’ ‘‘can I do this again

next time I have surgery?’’, and ‘‘I want my (eg, child, niece, husband) to try this for their car sick-

ness.’’ One study participant commented ‘‘I don’t

Table 2. Repeated Measures Analysis—

Variable B (SE) t Va

Age 0.001 (0.01) 0

Sex 0.13 (0.36) 0

Race 0.19 (0.83) 0

Total number of hours OR 20.34 (0.28) 21 Number of intraoperative medicines 20.39 (0.25) 21 History of PONV 0.77 (0.38) 2

Type of inhaler 20.10 (0.20) 20 Antiemetic used 1.25 (0.60) 2

Inhaler 3 antiemetic 20.34 (0.33) 21

CI, confidence interval; OR, operating room; PONV, posto

scale.

Model: R 2 5 0.20, F 5 1.54, P 5 .16.

like the smell, but it seemed to work anyway.’’

Also, several patients that either declined to partic-

ipate in the study or were never approached re-

quested to use a nasal inhaler when they

experienced PONV, and the IV antiemetics were

unsuccessful in relieving their symptoms. In all

cases, those patients experienced decreased symp-

toms and expressed satisfaction with the nasal inhaler. None of those patients were included in

the study data.

Discussion

This nurse-led study demonstrated that patients

who receive aromatherapy postoperatively

for nausea have fewer antiemetics in the adult

hospital ambulatory or 23-hour surgical patient

as compared with the control group; in addition,

Changes in Nausea (VDS) Scale

lue P Value 95% CI Lower 95% CI Upper

.12 .90 20.02 0.02

.38 .71 20.55 0.80

.23 .82 21.47 1.85

.23 .22 20.90 0.22

.56 .13 20.90 0.11

.05 .05 0.02 1.53

.50 .62 20.50 0.30

.08 .04 0.05 2.45

.05 .30 20.99 0.31

perative nausea and vomiting; VDS, verbal descriptive

Table 3. Length of Stay Comparison

Variable B (SE) t value P Value 95% CI Lower 95% CI Upper

Sex 2.09 (2.83) 0.74 .46 23.58 7.77 Ethnicity 2.42 (7.00) 0.35 .73 211.60 16.45 Age 0.06 (0.08) 0.79 .43 20.10 0.23 Total number of hours in OR 4.48 (2.36) 1.90 .06 20.24 9.20 Number of intraoperative medicines 2.98 (2.13) 1.40 .17 21.29 7.25 History of PONV 0.96 (3.19) 0.30 .77 25.44 7.35 Type of inhaler 0.74 (1.70) 0.44 .66 22.67 4.16 Antiemetic used 22.76 (5.07) 20.54 .59 212.91 7.40 Inhaler 3 antiemetic 1.47 (2.75) 0.54 .59 24.03 6.98

CI, confidence interval; OR, operating room; PONV, postoperative nausea and vomiting.

Model: R 2 5 0.13, F 5 0.93, P 5 .51.

6 FEARRINGTON, QUALLS, AND CAREY

all three arms (peppermint, ginger, and a combina- tion) demonstrated a reduction in the need for an-

tiemetics. Among the three types of essential oils,

they were evenly distributed indicating that the

randomization of the inhalers was effective.

The rate for PONV in this study was approximately

27%, which is consistent with national rates,

which is approximately 30%. 16

Thus, it is recom- mended to use a simplified risk score for PONV

created by Apfel et al, 17

which evaluates adults

preoperatively, so that preventive strategies like

essential oils can be offered to high-risk patients.

The components of the simplified risk score

include the following four highly predictive risk

factors: female gender, nonsmoker, history of

PONV, and expected administration of postopera- tive opioids. On the basis of the number of risk fac-

tors present, 0, 1, 2, 3, and 4, the corresponding

risk of PONV is 10%, 20%, 40%, 60%, and 80%,

respectively.

PONV continues to plague many postoperative

patients, with traditional IV medication not always

a reliable option. Aromatherapy has shown suc- cess as an adjunct therapy for managing PONV

symptoms. QueaseEASE is highly promoted in

perianesthesia literature; however, it is at a much

higher price-point than the inhalers used in this

study. The inhalers used in this study were an

inexpensive alternative, albeit, required a trained

nurse to prepare them for patient use.

Strengths and Limitations

This study was a prospective, double-blind

randomized clinical trial that was designed and

implemented by nurses. Neither the subjects nor investigators knew which of the three-arm inter-

vention was to be used until the subject selected

the nasal inhaler. The low cost of the inhalers

and essential oils was also the strength of the study,

with the net cost being approximately $0.50 each,

and the subjects could take it home with them.

In fact, hospital pharmacies may be able to manu-

facture the inhalers at even lower costs. This study was nurse-led and developed and was supported

by the Department of Anesthesia as well as

the hospital-based Nursing Practice Research

Internship.

Limitations in the research design included using a

convenience sample and a retrospective chart re-

view for the control group rather than a placebo, as well as variability within nursing practice.

Nausea is routinely assessed in the postoperative

patient population; however, the measurement

tool used in this study was new, and therefore

there was a certain learning curve associated

with it. There were also inequitabilities between

the two groups, for example race. Because the con-

trol group had no exclusion criteria, as long as they met the inclusion criteria of being a same day or

23-hour stay patient, non-English speaking pa-

tients were included in the control group. Also, it

was not always well documented in the electronic

medical record when patients had a history of

PONV, which may have led to an inequality be-

tween groups. Although the number and type of

intraoperative antiemetics were collected and controlled for, the type of anesthesia agent was

not addressed in the analysis plan. Finally,

selection of patients based on surgical type and

postoperative assignment (same day or 23-hour

ESSENTIAL OILS FOR NAUSEA AND VOMITING 7

stay) excluded many individuals who may have

benefited from the intervention.

Future Studies

Further studies should be conducted to expand

the patient population to include those surgical

patients that are admitted to the hospital. Use

of a placebo group would strengthen the study

design; however, using an inhaler without any

fragrance would alert the subject and may cause

increased patient anxiety. However, use of a

placebo with a scent that is not an essential oil (such as lemon juice) could prove to be more

effective in forthcoming study development. It

may also be beneficial to allow the nasal inhalers

to be patient-controlled, and rather than assessing

the nausea score preintervention and postinter-

vention, simply document the number of doses

of antiemetics administered. In addition, under-

standing nurses, patients, and families’ satisfaction

with nonpharmacologic interventions would

contribute to the literature.

Conclusions

When properly prepared and using the correct

essential oil(s), aromatherapy should be consid-

ered for most of adult postoperative patients. It is

cost effective, reduces the need for nursing time

and costly, often sedating, medications, and in- creases patient satisfaction.

Acknowledgments

This study would not have been possible without a great deal

of support, especially from the Associate Director of Periopera-

tive Services, Janet Remizowski, the entire team of nurses in

the Surgical Center and Postanesthesia Care Unit, statistical sup-

port from Kim Arcoleo, PhD, MPH, with a special thanks to the

small group of nurses who aided in recruitment and consenting

of subjects (Christine Deitrick, Sandra Price, Kim Veil, and

Casey Sehlin) as well