INTEGRATIVELITERATUREREVIEWSANDMETA-ANALYSESAromatherapypracticeinnurs - PDF document

INTEGRATIVELITERATUREREVIEWSANDMETA-ANALYSESAromatherapypracticeinnursing:literaturereviewWendyMaddocks-JenningsBAMARGONLecturerinComplementaryHealth,UniversalCollegeofLearning,andNurseClinician/TraineeNursePractitioner,AcutePainServices,MidcentralHealth,PalmerstonNorth,NewZealandJennyM.WilkinsonBScPhDGradDipFETSeniorLecturerinPhysiology,SchoolofBiomedicalSciences,CharlesSturtUniversity,WaggaWagga,AustraliaSubmittedforpublication11November2003Acceptedforpublication10March2004Correspondence:WendyMaddocks-Jennings,FacultyofHealthSciences,PrivateBag11066,NewZealand.E-mail:w.maddocks-jennings@ucol.ac.nzMADDOCKS-JENNINGSW.&WILKINSONJ.M.(2004)MADDOCKS-JENNINGSW.&WILKINSONJ.M.(2004)JournalofAdvanced(1),93–103Aromatherapypracticeinnursing:literaturereviewTheuseofaromatherapyinnursingcarecontinuestobepopularinmanysettings.Mostofthenursingliteraturerelatestotheuseofessentialoilsinlowdosesformassageoruseoftheoilsasenvironmentalfragrances.Informationfromthewiderliteraturemayaddtotheevidencebaseforuseofthistherapyinnursing.Thispaperreportsaliteraturerelatingtotheuseofaromatherapybynursesandcriticallyevaluatestheevidencetosupportthispractice.Medline,CINAHL,MANTISandEBSCOHostdatabasesweresearchedforpapersrelatedtouseofessentialoilsand/oraromatherapy.Paperswerealsoobtainedthroughcross-checkingofreferencelists.Atotalof165articleshavebeenincludedinthisreview.Nursingpaperswerepublishedsince1990wereincluded,butsomereferencesfrom1971onwardsrelatingtoscienticresearchconductedonessentialoilswerealsoincluded.Theseremainvaluableastheyareprobablytheonlyreferenceavailableforaspecicoilorproperty,orshowthedevelopmentofknowledgeinthisarea.Paperswereexcludediftheyconsistedonlyofbriefcasestudiespresentedinabstractform.Thereviewcoverskeyprofessionalissuesandtheprincipalareasofclinicalpracticewherearomatherapyisused.Despitecallsformoreresearchinthe1980sand1990s,thereisstilllittleempiricalevidencetosupporttheuseofaromatherapyinnursingpracticebeyondenhancingrelaxation.Itspopularityneedstobebalancedagainstthepotentialrisksrelatedtoallergies,safetyandinappropriateusebyinexperiencedusers.Thereisgreatpotentialformorecollaborativeresearchbynursestoexploretheclinicalapplicationsingreaterdetailandtomovebeyondthelowdoseparadigmofapplicationofessentialoils.:aromatherapy,essentialoils,nursing,professionalpractice,literatureSincethe1990snurseshaveconsideredthattheincreasedtechnologyofhealthcarethreatenstheirabilitytopractiseholisticcare,whichispositivelyentrenchedinthephilosophyofnursing(Keeganetal.1994).Hence,manyareattractedtothenotionofintegratingtherapeuticinterventionssuchasaromatherapyintomanyaspectsofpatientcare(Grainger2004BlackwellPublishingLtd 1991,Owen1995,Trevelyn1996,Rankin-Box1997,Baum1998,Chadwick1999,Wilkinson&Simpson2002).Despitetheconceptofintegratedcarebeingwellestablishedinmanyhospitalsworldwide(Richardson1996,Ernst&White2000,Furnham2000,Bermanetal.2001),manyprofessionalandpracticalissuesneedtobeconfrontedinrespectoftheuseofaromatherapyinnursingpractice.Thispapercriticallyreviewscurrentpracticeagainstexistingevidence.SearchmethodsTheMedline,CINAHL,MANTISandEBSCOHostandtheCochraneCollectiondatabasesweresearchedforpapersrelatedtouseofessentialoilsand/oraromatherapy.Key-wordsusedforsearchingwerearomatherapy,essentialoils,aroma,massage,fragrant,fragrance,volatileoil,essence,plantessenceandphytotherapy.ThesearchwaslimitedtoarticlespublishedinEnglish.Nodatelimitationswereusedexceptfornursing-relatedliterature,whereitwassetat1990orlater.Paperswerealsoobtainedthroughcross-checkingofreferencelists.Over250citationswereretrievedthroughelectronicandmanualsearching.Exclusioncriteriawere:paperwasnotwritteninEnglish;notavailablebyinterloanservicesinNewZealandwithoutconsiderableexpense;lackofreferencelistunlessthepaperinvolvedsomedescriptivecomment;orwasonlyabriefclienthistorywritteninanon-nursingcontextsuchasexistsinmanyaromatherapyjournalsandnewsletter-typepublications.Inclusioncriteriawerethattheapplicationofaromatherapyrelateddirectlytonursingpractice;thesurveyordiscussionincludedaromatherapy;orthattheactualpropertiesofessentialoilswereexploredinascienticmanner.Atotalof165paperswereincludedinthereview.Eachpaperwasbrieyreviewedtoensurethatitmettheinclusioncriteriaandwasthencategorizedaccordingtoitscontent.Twenty-oneofthepapersreportedquantitativenursingresearch,64concernedquantitativenon-nursingresearch,29wasdiscus-sionordescriptive(includingsurveys),and51didnotfallintotheaboveclassication,includingbooksandcomments.Somenon-nursingreferencesfrom1971onwardswereincludedbecausetheydiscussedscienticresearchconductedontheessentialoils.Theseremainvaluableastheyarelikelytobetheonlyreferenceforaspecicoilorproperty,ortoshowthedevelopmentofknowledgeinthisarea.Theliteraturewascategorizedintothefollowingsections:professionalissues(educationandresearch)andpracticalapplicationofaromatherapy(pharmacokineticsandphysio-logicaleffects;maternalandchildhealth;criticalcareenvironment;painrelief,skinandhairconditions;medicalProfessionalissuesWhilenursesmayhavehadsomeexposuretoaromatherapyintheirundergraduateeducation,manywhouseessentialoilshavenotundergoneformalpreparation(Morganetal.etal.2001,Wilkinson&Simpson2002).Thedebateisongoingastowhatisanacceptablelevelofaromatherapytrainingfornurseswhowishtousearomatherapy(Gaydos2001,Tovey&Adams2002).Thisdebatewillnodoubtcontinueastheroleofthenursewithprescribingrightsgainsprominence.Nursesinthisrolewillneedtoapplythesameprinciplesofprescribingtoessentialoilsastheydotocon-ventionalpharmaceuticals.Asregulatoryrequirementsvaryinternationally,theyarerecommendedtocontacttheirownprofessionalandregulatorybodiesaswellastoconrmwiththeiremployerstheacceptedparametersforpractice(Morganetal.1998,Stone1999,Frisch2001a,2001b,Sparber2001).Mostimportantly,itiscrucialthatapersondoesnotimplythattheyhavealevelofcompetencetheydonotactuallypossess,regardlessofthetherapybeingused(Campbelletal.Withfewempiricalstudiesthatdemonstrateefcacyandsafetyofessentialoilswithhumans,thereislittletoguidepractice,exceptperhapsinanxietyreduction(Lis-Balchin1997,Vickers1997,Cooke&Ernst2000,Longetal.Continuedcallsarebeingmadeformorenurse-ledresearchandlargerrandomizedcontrolledtrialstoguideevidence-basedpractice(Wilkinson1995,Ernst1997,Biley&Freshwater1999,Lancet2001,Ribeaux&Spence2001,White&Ernst2001).Giventhecomplexityoftheissuesrelatingtoeducationandresearch,itisrecommendedthatnurseswhohavenotundergoneformalpreparationinaromatherapythatmeetsnationalacceptedstandardsofpracticeshouldadoptonlyalimitedroleintheuseofessentialoils.Thisuseshouldbesupervisedandguidedbyinstitutionalpolicy,andthereremainsthepotentialforerrororharmwithinformalusethatisnotbasedonsoundunderstandingofessentialoils.PracticalapplicationofaromatherapyPharmacokineticsandphysiologicaleffectsofessentialoilsEssentialoilsarelipidsolubleandrapidlyabsorbedintothebloodstreamwhenappliedexternally,inhaledoringested,W.Maddocks-JenningsandJ.M.Wilkinson2004BlackwellPublishingLtd,JournalofAdvancedNursing(1),93–103 andareexcretedviatheurinarysystemandinexpiredCOThereis,however,limitedunderstandingofthepharmaco-kineticsofmanyessentialoilsandtheirpotentialforinter-actionwithconventionalpharmaceuticals(Bronaughetal.1990,Hotchkissetal.1990,Jirovetzetal.1992,Buchbauer1993,Bureld2000,Kohlertetal.2000).Variousfactorsinuencetheactivityofessentialoils,forexamplemetabo-lismoftheconstituentspriortoexcretion(Jageretal.2001),afunctiondependentonhepaticcytochromeP450enzymes(Miyazawaetal.2001).Althoughtheuseofessen-tialoilsbynursesdoesnotgenerallyinvolveingestion,inFrancemedicalaromatherapyisalsopractisedandinvolvestheinternaluseofessentialoils(Franchommeetal.Withinternaluse,thepHofgastricjuiceswillalsoaffectabsorption(Szentmihalyietal.2001).Themainpracticalissuesfornursesarecorrectstorageandhandlingofessentialoilstopreventoxidation,bacterialcontaminationoraccidentaloverdose(Tibballs1995,Gouin&Patel1996,Anapalahan&LeCouteur1998,Darbenetal.Maudsley&Kerr1999,Botmaetal.2001).Althoughmoststudiesarebasedonanimalmodels,whichmaynotneces-sarilytranslatetoclinicalhumanpractice,thereareconsistentndingsthatessentialoilsarereadilyclearedanditisunlikelythatoilsortheircomponentchemicalsaccumulatewithinbodytissue(Kohlertetal.2000).Cautionisadvisedthoughinpatientswhohaverenalorhepaticdisorders.Animalstudieshavedemonstratedthatsomeessentialoilshavespasmogeniceffectsonsmoothmuscle,andothershavespasmolyticeffectsonsmoothandskeletalmuscle.Itisthoughtthattheseeffectsmaybemediatedbyareductioninavailablecellularcalcium(Lis-Balchinetal.1997a,1997b,Lis-Balchin&Hart1997).Otherexploratoryresearchintothetherapeuticpotentialofessentialoilsincludesthehepatoprotective,antioxidant,anti-inammatory,hypergly-caemicandinsulininhibitingeffects,andantimutagenicpropertiesinbothhumanandanimalcellsofvariousdifferentextractsofRosmarinusofÞcinalisetal.1987,Englbergeretal.1988,Schwarzetal.1992,al-Haderetal.1994,Huangetal.1994,Haraguchietal.1995,Fahim&Esmat1999).Humaninvitrohavefoundthatboswellicacids,fromfrankincenseessentialoil,havestronganti-inammatorypropertiesthroughin-hibitinghumanleukocyteelastase(HLE)action.Thisenzymehasbeenimplicatedinseveralrespiratorydiseases,includingcysticbrosis,acutebronchitis,glomerularnephritisandrheumatoidarthritis(Safayhietal.Collectively,therangeofexperimentalworkthatisbeingundertakentoexplorethetherapeuticpotentialofessentialoilscontributestogreaterknowledgeandunderstandingoftheiractions.Itisunclearatthisstage,however,whattheimplicationsareforhumanclinicalsituations,particularlythroughthedermalapplicationmainlyusedbynurses.MaternalandchildhealthThemainconcernsformaternalandchildhealtharewhetheressentialoilshaveahormone-likeeffectonthemother,whethertheyareabortifacientorwhethertheymaycausemalformationtothedevelopingfoetus(Battaglia1996).Whilstclaimsexistthataromatherapymayalsohelpwithsomeoftheminorsymptomsassociatedwithpregnancy,suchasmorningsickness,stretchmarks,varicoseveins,heartburn,haemorrhoids,backacheandexhaustion,nonearesupportedbyempiricalevidence(Guenier1992,Smith1993,Mason1996,Mercer1996).Anumberofstudieshaveexplorethevalueofaromatherapyinlabourandfoundthatwomenwhousedarangeofessentialoilsoftencopedbetterandrequiredlessanalgesia(Burns&Blamey1994,Jeffries1996,Burnsetal.2000).Althoughthesestudiesdidnotincludemassageasanintervention,isworthwhilenotingthatthereiscon-ictingevidenceastothebenetsofmassageduringlabourwhencomparedwithotherinterventionssuchastranscuta-neouselectricalnervestimulation(TENS),sterilewaterinjectionsandmobilization(Labrecqueetal.1999,Brownetal.2001).However,Fieldetal.(1997)foundthatmassagewasmoreeffectivethanbreathcoachinginreducingpainandanxietylevels.Clearly,moreresearchisneededinthisareatoascertaintheeffectivenessofmassageandalsotostudyotherwaysofusingessentialoils.Theevidenceremainsinconclu-siveastowhetherlavenderoilinlowdosesismoreeffectivethanconventionaltreatmentinassistingperinealrepair;however,womenwhouseitreportittobecomforting(Cornwell&Dale1995).CriticalcareenvironmentIntheUnitedKingdom(UK),approximately50%ofcriticalcareunitsusesomeformofcomplementarytherapy,withneonatalunitshavingthehighestratewithbabymassage(Hayes&Cox1999).Earlierevidencesuggeststhatshortmassageofthelegs,feetorback,withorwithoutessentialoils,hassomemeasurablebuttransientrelaxationeffectswhichhavenotreachedstatisticalsignicance;however,subjectivepatientfeedbackhasbeenpositiveandnoadversereactionshavebeennoted(Stevenson1992,Woolfson&Hewitt1992,Buckle1993,Dunnetal.1995).Largeclinicaltrialshaveyettobeconductedinthisarea,particularlywithrespecttodoseandmethodofdilutionoftheoils.PainreliefAsmassagehasbeendemonstratedtostimulateendorphinproductionforpeoplewhoareinpainithasvalueasaIntegrativeliteraturereviewsandmeta-analysesAromatherapypracticeinnursing2004BlackwellPublishingLtd,JournalofAdvancedNursing(1),93–103 pain-relievingtool,especiallyinchronicormuscularpainetal.1986,Dayetal.1987,Kaada&Torsteinbø1988,Shipton1995).Whethertheadditionofessentialoilsincreasesthepain-relievingbenetsbeyondananxietyreductionvaluehasyettobedemonstrated.Lavenderanditsmainconstituents,linalylacetateandlinalool,havebeenidentiedashavinglocalanaestheticeffectsinanimalinvitromodels(Ghelardinietal.1999).Oxides,whicharepresentinmanyessentialoilsincludingeucalyptusspeciesandcajeput,alsohaveananaestheticeffect(Ghelardinietal.2001).Theeffectsoflinaloolalsoincludeanti-convulsantactivitiesduetoinhibitionofseveralchemicalpathways(Brumetal.Whilstitisnotpossibletoextrapolateresultsfromtheseanimalstudiestoahumanclinicalenvironment,theremaybepotentialtouseessentialoilssuchaslavenderintheman-agementofpain;however,furtherinvivopatientresearchisneededtoconrmdoses,routesofapplicationandtreatmentCancercareSeveralstudiessupporttheongoinguseofaromatherapyaspartofanintegratedapproachtocancerandpalliativecare(Crowther1991,Madelin1994,Cooper1995,Corneretal.1995,Wilkinson1995,Gurba1996,Bell&Sikora1996,Millar1996,Peace&Simons1996,Kiteetal.etal.1999,Abel2000,DeValois&Clarke2001).Aromatherapyisprimarilyusedtohelpcopewithanxietyandfearandtosupportsymptomcontrol,ratherthanasanalternativetoconventionaltreatment(Lampicetal.Forexample,patientswhoarediagnosedwithabraintu-mouroftenhaveapoorerdiagnosisandmoredebilitatingsymptomsthanthosewithotherformsofcancer,andusingtherapiessuchasmassageandaromatherapymayhelpsuffererstodealwithsuchseriousissuesandcopewiththeemotionaleffectsofthehighdosesofsteroidsrequiredetal.1996,Fox&Lantz1998,Hadeld2001).Whilstspecializedlymphmassageiswellacceptedtoreducelymphoedema(Mortimeretal.1990,Ikomietal.LeVu&Mourisse1997),thereisnoevidencethataddingessentialoilswillimprovethephysicaleffectsofthemassage.Patientsmayexperienceuncomfortablesideeffectsrelatedtocancertherapy,andthetreatmentforthesesideeffectscanbequiteunpleasant.Variousessentialoilshavebeenexploredaspossiblealternativesintreatingsomesideeffects,buthavehadmixedeffects.Althoughablendofteatreeandbergamotoilwasjustaseffectiveasaconventionalmouthwashformucositis,ithadhigherpatientcomplianceduetothepleasanttasteandaroma(Gravettetal.1995).However,aromatherapywasnotusefulinrelievingskinrashes,infectionsornauseaassociatedwithhighdosechemotherapyetal.1995).Laterstudiessuggestthatessentialoilsmayhelpreducethatthedurationofgastrointestinalsymp-toms(Gravett2001a);however,theyarenomoreeffectivethanconventionaltreatmentforinfectedHickmanlines(Gravett2001b).SkinandhairconditionsAsthemainrouteofadministrationforessentialoilsisviatheskin,thereispotentialfortheirusetotreatorpreventexacerbationofcommonskinconditions,orforapplicationtothehair.Someevidenceexiststhatessentialoilscanhelpwithhairlosswhenmassagedregularlyintothescalp(Hayetal.1998).Intwowell-designedtrials,severaldifferentessentialoilshavealsobeenfoundtohaveeffectonheadlice,especiallywhenusedinconjunctionwithavinegarrinse(Veal1996,Lahlouetal.2001).Animalstudieshavefoundthatalpha-bisabololfromchamomileessentialoil,hasstronganti-phlogistic(anti-inammatory)effectswithverylowtoxicityandlowsensitivitywhenappliedtotheskin(Isaac1979,Jakovlevetal.1979,Lawrence&Reynolds1987).However,thefewhumantrialsexploringskinhealingeffectsofessentialoilsareinconclusiveorpoorlydesigned.Forexample,whilstonecontrolledtrialsuggestedthatessentialoilmighthelpchildrenwithatopiceczema,somanyessentialoilswereusedthatitwasunclearwhichwereeffective,orwhethertheeffectswereaspontaneousremissioninthesymptoms.Thosewhohadusedtheessentialoilsalsohadahigherreturnrateoftheeczemaafterthetrial,possibleduetoallergicreactionstotheessentialoils(Lis-Balchin2000).Ofnoteisthatmassagewithoutessentialoils,whengivenonaregularbasis,hasbeenfoundtoreducethesymptomsofatopicdermatitisinchildren(Schacheretal.1998).Theuseofessentialoilsoflavender(Lavandulaangustifolia)andGermanchamomile(Matricariarecutita)wasexploredinasmalltrialwitheightpatientswithchroniclegulcers.Threereceivedconventionalwoundcareandvereceivedtwicedailydressingsofa6%mixtureoftheaboveoilsingrape-seedoil.Duetothesmallsamplesizeandinabilitytohaveamatchedcontrolgrouptheauthorswereunabletodrawanydenitiverecommendations.Theynoted,however,thatfourofthevearomatherapy-treatedwoundshealedcompletelyandthefthwoundwasprogressingtowardshealing.Thoseintheconventionalwoundcaregrouphadvariablehealingtimesduetoanumberoffactors,suchaspoorpatientcompliance(Hartman&Coetzee2002).Theuseofessentialoilsinthemanagementofpsoriasishasbeenexploredbyvariousauthors.Thecasestudiesandsmalltrialsinvolvedalluseddifferentessentialoilsappliedwithmassage,andallhadinconclusiveresults.Ofnoteisthatbergamot,orCitrusbergamia,wasusedforanxietyreductionW.Maddocks-JenningsandJ.M.Wilkinson2004BlackwellPublishingLtd,JournalofAdvancedNursing(1),93–103 inallcases(Weaver1991,Walsh1996,Darrell1997).Bergamotcontainsbergapten,apsoralen,whichisphoto-toxicwhentheskinisexposedtosunlight(Zaynounetal.1977,Naganumuetal.1985).Psoralensaresometimesusedinpsoriasistoenhancetheeffectsofthephototherapybyreducingbasalcellmitosis(MantikLewis&CoxCollier1987).Thispossibleuseofbergamotoilhasnotbeenexploredinpsoriasistreatment.MedicalconditionsWhiletherearenumerouscasestudiespresentedintheliteratureinvolvingtheuseofessentialoilstotreatvariousmedicalconditions,thesealoneareinsufcienttoguideevidence-basedpractice.Thepotentialagainseemstobeinreductionofstress,especiallyinchronicconditionssuchbromyalgia,Guillain-BarresyndromeandAIDS(Wilson1989,Styles1997,Buckle1998,Grace2001,ShirreffsNeurologicalconditionsAstudybyBetts(1995)highlightedthepotentialtouseessentialoilsinseizurecontrolaspartofaconditionedresponseforpeoplewhoknowtheirtriggers.Essentialoilscanalsoassistincopingwiththesocialandemotionalaspectsofsuchacondition(Asjes1993).Datainthisareaarecon-icting,withoneauthorsuggestingthatrosemaryreducedseizuresinapatient(Crouton1991)whileanimalstudiesfoundthatrosemaryessentialoilhasbeenusedtoinducetonic-clonicseizures[attributedtothehigheucalyptol(1,8-cineole)content].Invitroanimalstudieshavealsoshownthatcamphor,whichisamajorconstituentofrose-maryessentialoil,lowerssodiumandpotassiumconcentra-tionsincerebralcortextissue,whichaffectsoxygenconsumptionbythebrainandthusincreasestheriskofconvulsions(Steinmetzetal.1987).Accidentalingestionofcamphorinvariousformshasbeenimplicatedinseizuresinchildren(Weiss1973).Peppermintoilandeucalyptusoilhavebeenshowntohavemusclerelaxingeffectsaswellasanalgesiceffectsforthereliefofheadaches.Theyaremosteffectivewhenusedincombinationtorelievemuscleactivity,andpeppermintismosteffectiveasananalgesicwhencom-binedwithethanol.Bothoilsalsohavetheabilitytoimprovecognitivefunctioning(Gobeletal.RespiratoryconditionsEssentialoilsarefrequentlyusedtoalleviaterespiratoryconditions,andthereissomeevidencethatanumberhavebroncholytic,antispasmodicandsecretolyticproperties(Schafer&Schafer1981,Goeb1995).Oilsfromeu-calyptusspeciesarepopularforthispurpose;however,thereissomecontroversyabouttheiractualeffectivenessasbronchodilators,decongestantsandantitussives.Thereisalsoconcernatthenumberofaccidentalpoisoningsasso-ciatedwitheucalyptusoil(Tibballs&James1995).Inresponsetothesecriticisms,Balacs(1997)critiquedmanyarticlesoneucalyptusandconcludedthatthereremainsgreattherapeuticpotentialfortheexternaluseofcineole-richeucalyptusoils,suchasE.globulusE.smithiiE.polybracteaE.radiataInvitrostudieshavefoundthateucalyptusoil(typeunstated)hasthepotentialforuseinneonatalrespiratorydistresssyndrome,duetoitsabilitytoimprovesurfactantfunction(Zankeretal.1980,Banerjee&Bellare2001).Theoxidativepropertiesofeucalyptusoilsmaybeexploitedwhenusedtotreatrespiratorypathogensetal.2000).Measurementofciliarybeatfre-quency(CBF)isonewayofassessingtheeffectivenessofaninhaledsubstanceontherespiratorysystem.Inhaledpine,mentholandeucalyptusoils(typesunstated)signicantlyreduceCBFbothincombinationandalone;however,thetherapeuticrangeislimitedbythepotentialtodamageciliarycells(Riechelmannetal.1997).AnimalstudiesalsosuggestthatRosmarinusofÞcinalisessentialoilinhibitstrachealmusclecontraction(Aqel1991)andinvitrousinghumanbronchialcellsshowedthatrosemaryextractshadasignicantroleininhibitingcarcinogenicactivityetal.DigestivedisordersPeppermintessentialoilhasbeenwidelyresearchedforitspotentialingastro-intestinaldisorders,includingreducingcolonicspasmduringcolonoscopy(Asaoetal.2001)andforthesymptomsofirritablebowelsyndrome(Pittler&Ernst1998,Jailwalaetal.2000).Astheseinvolveinternalapplications,theyarebeyondthescopeofnursingandaromatherapypractice;however,thedataaresuggestivethatpeppermintmaybeusefulasadigestiveanti-spas-modic(Lechetal.1988,Nolen&Friend1994,Beesleyetal.1996,Cerrato1999,Freise&Kohler1999,Klineetal.AromatherapyandmentalhealthSeveralhumantrialsinmentalhealthsettingshaveindi-catedthattherearepositiveemotionaleffectsofusingaromatherapyand,giventhatatleast60%ofvisitstodoctorsarestress-related(Charlesworth1995),thereisgreatpotentialinthisarea;severalmentalhealthservicesalreadyincorporatearomatherapyintopatientcare(Garnett-Ore1996,Moore1999).Inhaledessentialoilsmayincreasealertnessandreduceanxiety(Morrisetal.1995,Lehrneretal.2000,Ilmbergeretal.2001),aswellIntegrativeliteraturereviewsandmeta-analysesAromatherapypracticeinnursing2004BlackwellPublishingLtd,JournalofAdvancedNursing(1),93–103 ashavingpositiveeffectsonphysicalparametersoftheauto-nomicnervoussystem,enhancingrelaxation(Heubergeretal.2001).Inhaledchamomileoil(typeunstated)hasbeenfoundtoreduceadrenocorticotrophichormone(ACTH)inrats,leadingtoinducedstress(Yamadaetal.1996),andstudiesinhumanshavesuggestedthatinhaledchamomileoilhasapositiveeffectonmoodwhencomparedwithaplacebo(Roberts&Williams1992).Inhalinglavenderormelissaessentialoilshasalsobeenfoundtoreducesomesymptomsassociatedwithdementia,especiallyrestlessness(Burnsetal.2000).Severaldementiacareunitshavereportedregularuseofvariousaromatherapymeasures(Henry1993,Mitchell1993,Moate1995,Kobbe1996,Brookeretal.Reductionsinagitationhavealsobeennotedinchildrenwithattentiondecit-hyperactivitydisorder(ADHD),whichaffectsbetween4and20%ofschoolagechildrenintheWesternworld(Godfrey2001).Ithasalsobeenfoundtobecalminginpatientswithseriouslearningandsensorydisor-ders(Callis1993,Sanderson1993).Theuseofata005%dilutiongivesaweakrelaxationresponse,aswellasincreasedperipheralcirculation,demonstratedthroughseveralchangesincardiovascularparameters(Saeki2000).Whilstitisclearthatthereisagrowingbodyofevidenceaboutthepracticeofaromatherapy,thereremainfewempiricaldatatoguidenursingpracticeinlargenumberofareas.First,nursesneedtobeabletounderstandandinterpretthescienticresultsfromstudiesconductedinotherprofessions.Thesethenneedtobetranslatedintoaclinicalapplication,possiblythroughfurtherresearch.Methodsofapplicationanddosesmayneedtobechanged,dependingonthecontext.Thereislittleevidencethataddingessentialoilsatalow(2%orless)dilutionintensiestheeffectsofmassage.Studiesneedtobeconductedtoexploretheeffectsofhigherdoses,compareblendsofoilswithsingleformu-lations,studythevolatilenatureoftheoilsmoreintheclinicalenvironment,andinvestigatetheapplicationofoilsdirectlytoaspecicbodyarea.Thelackoflarge-scaleclinicaltrialsmeasuringpatientoutcomesremainsastumblingblockforwidespreadadoptionofaromatherapyinnursingpractice.Manystudieshavebeenhamperedbysmallsamplesizes,imprecisemeasuringtools,difcultiesinblindingparticipantsandresearcherstotreat-ments,incorrectorabsentstatisticalanalysis,andvarieddosesormethodsofapplicationoftheessentialoil.However,thesestudiesdoprovidevaluableinformationforfutureresearchersinthattheyhelpnarrowthefocus,exploredifferingdosesorusevariouswaysofcollectingdata.Itcertainlyseemsclearthatmorethanoneresearchapproachisused.Nursesneedtobeabletoprovideevidencetoguidetheirpracticeinallaspectsofpatientcare,andcanbeguidedbyexistingpracticeguidelines(Campbelletal.2001,Frisch2001a,2001b).Thereisclearindicationthatthescienticcommunityistakingseriousinterestinthepotentialhealingpropertiesofessentialoils,andthiswillfurtheraddtotheinformation-basefromwhichnursescandraw.Whetherthendingsofthesestudiesbecomeincorporatedintoholisticaromather-apy,orwhethertheessentialoilsbecomefragmentedintotheirisolatedconstituentswhichthenbecomepartofpharmacotherapy,isonlyconjectureatthisstage.Never-theless,thereisenormouspotentialforresearchinthisarea.Whileatthistimethereareinsufcientdatatowarrantameta-analysis,itisenvisagedthatthistypeofanalysiswill,inthefuture,providefurtherevidenceaboutwhichusesofaromatherapyarebestaspartofnursingpractice.Thiswouldbeespeciallyvaluableintheinter-pretationofresearchinmentalhealth,duetothenumberofstudiesexploringtheanxiety-reducingeffectsofessentialWhilethereisinconclusiveevidenceaboutwhethertheadditionofessentialoilsat25%orlowerimprovesthephysiologicaleffectsofmassage,aromatherapyhasbeenshowntoimproveanxietyandstress-relatedsymptomsandtheagitationassociatedwithdementia.Withthisinmind,aromatherapymayhaveparticularuseinmentalhealthandagedcareenvironments.Cineole-richessentialoils,suchaseucalyptus,havethepotentialtoassistwithanumberofminorrespiratoryconditionsthroughtheirexpectorantandanti-tussiveproperties.Thereisalsosomeevidencethattheinternaluseofessentialoilshasgreatpotentialwithincertainclinicalareas;however,thisrequiresconsiderablymoreresearchbeforeifcanbeincorporatedintonursingNursesshouldatleasthaveabasicunderstandingofthechemicalstructureandphysicalpropertiesofessentialoils,aswellasknowledgeofthesafeapplicationofafewcommonlyavailableoils,iftheyplantousetheminanywayintheirpractice.Ideally,ifnursesplantouseessentialoilswithpatientsorclientsratherthanjustasenvironmentalfra-grances,thentheyshouldconsiderundergoingformaledu-cationasaromatherapists.Atalltimestheyshouldbeguidedbytheprofessionalandlegislativerequirementsoftheregisteringbodyintheirstateorcountry.W.Maddocks-JenningsandJ.M.Wilkinson2004BlackwellPublishingLtd,JournalofAdvancedNursing(1),93–103 AbelJ.(2000)ComplementarytherapyprogrammeatStLuke’shospice,Plymouth.ComplementaryTherapiesinNursing&,116–119.al-HaderA.A.,HasanZ.A.&AqelM.B.(1994)HyperglycaemicandinsulinreleaseinhibitoryeffectsofRosmarinusofÞcinalisofEthnopharmacology(3),217–221.AnapalahanM.&LeCouteurD.G.(1998)Deliberateselfpoisoningwitheucalyptusoilinanelderlywoman.AustraliaNewZealandJournalofMedicine(1),58.Anonymous(2001)EditorialComplementarymedicine:timeforcriticalengagement.(9247),2023.AqelM.B.(1991)RelaxanteffectofthevolatileoilofRosmarinusofÞcinalisontrachealsmoothmuscle.JournalofEthnopharma-(1–2),57–62.AsaoT.,MochikiE.,SuzukiH.,NakamuraJ.,HirayamaI.,Mori-nagaN.,ShojiH.,ShitaraT.&KuwanoH.(2001)Aneasymethodfortheintraluminaladministrationofpeppermintoilbe-forecolonoscopyanditseffectivenessinreducingcolonicspasm.GastrointestinalEndoscopy(2),172–177.AsjesE.(1993)Managingepilepsy.TheInternationalJournalofAromatherapy(3),16–19.BalacsT.(1997)Cineolericheucalyptus.InternationalJournalofAromatherapy(2),15–21.BanerjeeR.&BellareJ.R.(2001)Invitroevaluationofsurfactantswitheucalyptusoilforrespiratorydistresssyndrome.Physiology(2),141–151.BattagliaS.(1996)Essentialissues:pregnancy:howsafeareessentialAromatherapyToday,16–18.BaumM.(1998)Whatisholism?Theviewofawell-knowncriticofalternativemedicine.ComplementaryTherapiesinMedicineBeesleyA.HardcastleJ.,HardcastleP.T.&TaylorC.J.(1996)Influenceofpeppermintoilonabsorptiveandsecretoryprocessesinratsmallintestine.(2),214–219.BellL.&SikoraK.(1996)ComplementarytherapiesandcancerComplementaryTherapiesinNursingandMidwifery,57–BermanB.M.,OwenD.K.,LewithG.&StephensC.R.(2001)Candoctorsrespondtopatients’increasinginterestincomplementaryandalternativemedicine?BritishMedicalJournalBettsT.(1995)Practicalexperienceofusingaromatherapyinpeoplewithepilepsy;aneffectivecountermeasure.AROMAÕ95Con-ferenceProceedings.AromatherapyPublications,Brighton.BileyF.C.&FreshwaterD.(1999)TrendsinnursingandmidwiferyresearchandtheneedforchangeincomplementarytherapyComplementaryTherapiesinNursingandMidwiferyBotmaM.,Colquhoun-FlanneryW.&LeightonS.(2001)Laryngealoedemacausedbyaccidentalingestionofoilofwin-tergreen.InternationalJournalofPediatricOtorhinolarynology(3),229–232.BronaughR.L.,WesterR.C.,BucksD.,MaibachH.I.&SarasonR.(1990)Invivopercutaneousabsorptionoffragranceingredientsinrhesusmonkeysandhumans.FoodandChemicalToxicology,369–374.BrooknerD.J.R.,SnapeM.,JohnsonE.,WardD.&PayneM.(1997)Singlecaseevaluationoftheeffectsofaromatherapyandmasageondisturbedbehaviourinseveredementia.BritishJournalofClinicalPsychology,287–296.BrownS.T.,DouglasC.&FloodL.P.(2001)Women’sevaluationofintrapartumnon-pharmacologicalpainreliefmethodsusedduringJournalofPerinatalEducation(3),1–8.BrumL.F.,ElisabetskyE.&SouzaD.(2001)Effectsoflinaloolon[(3)H]MK801and[(3)H]musimolbindinginmousecorticolmembranes.PhytotherapyResearch(5),422–425.BuchbauerG.(1993)Molecularinteraction:biologicaleffectsandmodesofactionofessentialoils.InternationalJournalofAromatherapy(1),11–14.BuckleJ.(1993)Aromatherapy:doesitmatterwhichlavenderessentialoilisused?NursingTimes(20),32–36.BuckleJ.(1998)Fibromyalgiaandaromatherapy.Aromatherapy,26–29.BurfieldT.(2000)Safetyofessentialoils.TheInternationalJournalofAromatherapy(1/2),16–29.BurnsE.&BlameyC.(1994)Soothingscentsinchildbirth.InternationalJournalofAromatherapy(1),24–28.BurnsE.,BlameyC.,ErsserS.J.,BarnestonL.&LloydA.J.(2000)Aninvestigationintotheuseofaromatherapyinintrapartummidwiferypractice.JournalofAlternativeandComplementary(2),141–147. WhatisalreadyknownaboutthistopicAromatherapyiswidelyusedwithinbothcommunityandhealthcaresettings,butmanytherapeuticclaimsaboutessentialoilsarenotsupportedbyempiricalSomeessentialoilshavebeendemonstratedtoenhancerelaxation,reduceanxietyortohaveantimicrobialTheuseofessentialoils,indilutionsof1–5%,doesnotappeartoimprovesignicantlytheoutcomeofmassagewhencomparedwithmassagewithaplaincarrieroil.WhatthispaperaddsNursesneedtobeawareofpractisingwithintheirscopeaccordingtolegislativerequirements.Furtherstudiesareneededtobuildoninvivotrialstoenhanceclinicalrelevanceparticularlyintheareasofwoundcare,inammatoryandrespiratorydisorders.Validatesneedforcautionofsomeessentialoilsalthoughitisunlikelythatindividualconstituentsaccumulateforlongperiodsoftimewithinthebody.Mostpositiveeffectsarerecordedintheelevationofmoodandreductionofstressespeciallyinwomen’shealthandmentalhealthareas.Integrativeliteraturereviewsandmeta-analysesAromatherapypracticeinnursing2004BlackwellPublishingLtd,JournalofAdvancedNursing(1),93–103 CallisL.(1993)Feelniceandgotosleepteachingaromatherapytothosewithlearningdifficulties.TheInternationalJournalofAromatherapy(1),6–7.CampbellL.,PollardA.&RoetonC.(2001)ThedevelopmentofclinicalpracticeguidelinesfortheuseofaromatherapyinacancerAustralianJournalofHolisticNursing(1),14–22.CerratoP.(1999)Peppermintoilcansootheirritablebowel.(1),84.ChadwickD.(1999)Whatarethereasonsfornursesusingcomple-mentarytherapyinpractice?ComplementaryTherapiesinNursingandMidwifery,144–148.CharlesworthH.(1995)AromatherapyandstressrelatedhealthTheAromatherapist(4),9–23.CookeB.&ErnstE.(2000)Aromatherapy:asystematicreview.BritishJournalofGeneralPractice,493–496.CooperE.(1995)Theuseofaromatherapyinpalliativecareforpatientswithadvancedcancer.TheAromatherapist(3),26–36.CornerJ.,CawleyN.&HildebrandS.(1995)Anevaluationoftheuseofmassageandmassagewiththeadditionofessentialoilsonthewellbeingofcancerpatients.AROMAÕ95Conference.AromatherapyPublications,Brighton.CornwellS.&DaleS.(1995)Lavenderoilandperinealrepair.ModernMidwifeCroutonT.(1991)Oilsforepilepsy.TheInternationalJournalofAromatherapy(3),22–23.CrowtherD.(1991)Complementarytherapyinpractice.(23),25–27.DarbenT.,CominosB.&LeeC.T.(1998)Topicaleucalyptusoilpoisoning.AustralasianJournalofDermatology(4),265–DarrellN.(1997)Psoriasis.TheAromatherapist(1),26–29.DayJ.A.,MasonR.R.&ChesrownS.E.(1987)Effectofmassageonserumlevelof-endorphinand-lipotropininhealthyadults.PhysicalTherapy(6),926–930.DeValoisB.&ClarkeE.(2001)Aretrospectiveassessmentof3yearsofpatientauditforanaromatherapymassageserviceforcancerpatients.TheInternationalJournalofAromatherapyDunnC.,SleepJ.&CollettD.(1995)Sensingandimprovement:anexperimentalstudytoevaluatetheuseofaromatherapy,massageandperiodsofrestinanintensivecareunit.JournalofAdvanced,34–40.EnglbergerW.,HaddingU.,EtschenbergE.,GrafE.,LeyckS.,WinkelmannJ.&ParnhamM.J.(1988)Rosmarinicacid:anewinhibitorofcomplementC3-convertasewithanti-inflammatoryInternationalJournalofImmunopharmacologyErnstE.(1997)Evidencebasedcomplementarymedicine.mentaryTherapiesinNursingandMidwifery,42–45.ErnstE.&WhiteA.(2000)TheBBCsurveyofcomplementaryuseintheUK.ComplementaryTherapiesinMedicine,32–36.FahimF.A.&EsmatA.Y.(1999)AlliedstudiesontheeffectofRosmarinusofÞcinalisL.onexperimentalhepatotoxicityandInternationalJournalofFoodSciencesandNutrition(6),413–428.FieldT.,Hernandez-ReifM.,TaylorS.,QuintinoO.&BurmanI.(1997)Laborpainisreducedbymassagetherapy.JournalofPsychosomaticObstetricsandGynaecology,286–291.FoxS.&LantzC.(1998)Thebraintumourexperienceandqualityoflife:aqualitativestudy.JournalofNeuroscienceNursingFranchommeP.,JolloisR.&PelD.(2001)LÕaromathe.RogerJollie,Bayeux,France.FreiseJ.&KohlerS.(1999)Peppermintoil-carawayoilfixedcom-binationinnon-ulcerdependentdyspepsia-comparisonoftheeffectsofentericpreparations(abstract).Pharmazie(3),210–215.FrischN.C.(2001a)Standardsforholisticnursingpractice:awaytothinkaboutourcarethatincludescomplementaryandalternativeOnlineJournalofIssuesinNursing(2),http://www.nursingworld.org/ojin/topic15/tpc15_4.htm,lastaccessed18May2002.FrischN.C.(2001b)Nursingasacontextforalternative/comple-mentarymodalities.OnlineJournalofIssuesinNursinghttp://www.nursingworld.org/ojin(retrieved18May2002)FurnhamA.(2000)Howthepublicclassifycomplementarymedicine:afactoranalyticstudy.ComplementaryTherapiesin,82–87.Garnett-OreL.(1996)Aromatherapywithinmentalhealthservices.TheAromatherapist(1),17–33.GaydosH.L.B.(2001)Complementaryandalternativetherapiesinnursingeducation:trendsandissues.OnlineJournalofIssuesinNursing(2),http://www.nursingworld.org/ojin/topic15/tpc15_5.htm,lastaccessed18May2002.GhelardiniC.,GaleottiN.&MazzantiG.(1999)LocalanaestheticactivityoftheessentialoilofLavandulaangustifolia,700–703.GhelardiniC.,GaleottiN.&MazzantiG.(2001)Localanaestheticactivityofmonoterpenesanphenylpropanesofessentialoils.PlantaMedica(6),564–566.GobelH.,SchmidtG.&SoykaD.(1994)Effectofpeppermintandeucalyptusoilpreparationsonneurophysiologicalandexperimentalalgesimetricheadacheparameters.(3),228–234.GodfreyH.(2001)Theroleofessentialoilsinthetreatmentandmanagementofattentiondeficithyperactivedisorder.InternationalJournalofAromatherapy(4),193–199.GoebP.(1995)Broncho-pulmonarypathologies.LeCahiersdelÕaromatherapierecords,67–81.GouinS.&PatelH.(1996)Unusualcauseofseizure.EmergencyCare(4),298–300.GraceU.-M.(2001)TreatingfibromyalgiasyndromewithessentialTheInternationalJournalofAromatherapy(1),20–25.GraingerK.(1991)Thealternativeapproach.(46),9–11.GrassmannJ.,HippeliS.,DornischK.,RohnertU.,BeuscherN.&ElsnerE.(2000)Antioxidantpropertiesofessentialoils.(2),135–139.GravettP.(2001a)AromatherapytreatmentforpatientswithHick-manlineinfectionfollowinghighdosechemotherapy.tionalJournalofAromatherapy(1),18–19.GravettP.(2001b)Treatmentofgastrointestinalupsetfollowinghigh-dosechemotherapy.TheInternationalJournalofAroma-(2),84–86.GravettP.J.,FinnM.&HalleseyS.(1995)Aninvestigationoftheuseofessentialoilsforthetreatmentofchemotherapy-inducedsideeffectsinagroupofpatientsundergoinghighdosechemotherapy,withstemcellrescueforbreastcancer.AROMAÕ95Conference.AromatherapyPublications,Brighton.W.Maddocks-JenningsandJ.M.Wilkinson2004BlackwellPublishingLtd,JournalofAdvancedNursing(1),93–103 GuenierJ.(1992)Essentialobstetrics.TheInternationalJournalofAromatherapy(1),6–8.GurbaS.(1996)NonpharmacologicpainmanagementinterminalClinicsinGeriatricMedicine(2),301–311.HadfieldN.(2001)Theroleofaromatherapymassageinreducinganxietyinpatientswithmalignantbraintumours.InternationalJournalofPalliativeNursing(6),279–285.HaraguchiH.,SaitoT.,OkamuraN.&YagiA.(1995)InhibitionoflipidperoxidationandsuperoxidegenerationbyditerpenoidsfromRosmarinusofÞcinalisPlantaMedicaHartmanD.&CoetzeeJ.C.(2002)TwoUSpractitioners’experi-encesofusingessentialoilsforwoundcare.JournalofWound(8),317–320.HayI.C.,JamiesonM.&OrmerodA.D.(1998)Randomizedtrialofaromatherapy.Successfultreatmentforalopaeciaareata.ofDermatology(11),1349–1352.HayesJ.A.&CoxC.L.(1999)TheintegrationofcomplementarytherapiesinNorthandSouthThamesRegionalHealthAuthorities’criticalcareunits.ComplementaryTherapiesinNursingand,103–107.HenryJ.(1993)DementiaaromagroupsimprovethequalityoflifeinAlzheimer’sdisease.InternationalJournalofAromatherapyHeubergerE.,HongratanaworakitT.,BohmC.,WeberR.&Buch-bauerG.(2001)Effectsofchiralfragrancesonhumanautonomicnervoussystemparametersandself-evaluation.ChemicalSenses(3),281–292.HoeflerC.,FleurentinJ.,MortierF.,PeltJ.M.&GuillemainJ.(1987)CompartivecholereticandhepatoprotectivepropertiesofyoungsproutsandtotalplantextractsofRosmarinusofficinalisinJournalEthnopharmacology(2),133–143.HotchkissS.A.,ChidgeyM.,RoseS.&CaldwellJ.(1990)Percuta-neousabsorptionofbenzylacetatethroughratskininvitro.Validationofaninvitromodelagainstinvivodata.FoodandChemicalToxicology,443–447.HuangM.T.,HoC.T.,WangZ.Y.,FerraroT.,LouY.R.,StauberK.,MaW.,GeorgiadisC.,LaskinJ.&ConneyA.H.(1994)Inhibitionofskintumorigenesisbyrosemaryanditconstituentscarnasolandursolicacid.CancerResearch(3),701–708.IkomiF.,HuntJ.,HannaG.&Schmid-SchonbeinG.W.(1996)Interstitialfluid,plasmaprotein,colloid,andleukocyteuptakeintoinitiallymphatics.JournalofAppliedPhysiology(5),2060–IlmbergerJ.,HeubergerE.,MahrhoferC.,DessovicH.,KowarickD.&BuchbauerG.(2001)Theinfluenceofessentialoilsonhumanattention.I:alertness.ChemicalSenses(3),239–245.IsaacV.O.(1979)PharmacologicalinvestigationswithcompoundsofchamomileI.Onthepharmacologyof()-alphabisabololandbisabololoxides[abstract].PlantaMedica,118–124.JagerW.,MayerM.,PlatzerP.,ReznicekG.,DietrichH.&Buch-bauerG.(2000)Stereoselectivemetabolismofthemonoterpenescarvonebyratandhumanlivermicrosomes.JournalofPharmacyPharmacology(2),191–197.JagerW.,MayerM.,ReznicekG.&BuchbauerG.(2001)Percuta-neousabsorptionofthemonoterpenecarvone:implicationofstereoselectivemetabolismonbloodlevels.JournalPharmacyandPharmacology(5),637–642.JailwalaJ.,ImperialeT.F.&KroenkeK.(2000)Pharmacologictreatmentofirritablebowelsyndrome;asystematicreviewofrandomized,controlledtrials.AnnalsofInternalMedicineJakovlevV.,IsaacO.,ThiemerK.&KundeR.(1979)Pharmacolo-gicalinvestigationsofcamomilecomponents.PlantaMedicaJeffriesJ.(1996)Aholisticapproachtochildbirth.Aromatherapy,19–20.JirovetzL.,BuchbauerG.,JagerW.,WoidichA.&NikiforovA.(1992)Analysisoffragrancecompoundsinbloodsamplesofmicebygaschromatography,massspectrometry,GCFTIRandGCAESafterinhalationofsandalwoodoil.BiomedicalChromatography(3),133–134.KaadaT.&TorsteinbøO.(1988)Increaseofplasma-endorphinsinconnectivetissuemassage.GeneralPharmacology,487–489.KeeganL.,RosenS.&MesservyL.(1994)HolisticnursinginNewJournalofHolisticNursing(3),343–349.KiteS.,MaherE.J.,AndersonK.,YoungT.,YoungJ.,WoodJ.,HowellsN.&BradburnJ.(1998)Developmentofanaromatherapyserviceatacancercentre.PalliativeMedicineKlineR.M.,KlineJ.J.,DiPalmaJ.&BarberoG.J.(2001)Entericcoated,pHdependentpeppermintoilcapsulesforthetreatmentofirritablebowelsyndromeinchildren.JournalofPediatrics(1),125–128.KobbeG.(1996)Abetterqualityoflife.AromatherapyQuarterly,9–11.KohlertC.,vanRensenI.,MarzR.,SchindlerG.,GraefeE.U.&VeitM.(2000)Bioavailabilityandpharmacokineticsofnaturalvolatileterpenesinanimalsandhumans.PlantaMedica(6),495–505.LabrecqueM.,NouwenA.,BergeronM.&RancourtJ.F.(1999)Arandomizedcontrolledtrialofnonpharmacologicapproachesforreliefofpainduringlabour.JournalofFamilyPracticeLahlouM.,BerradaR.,AgoumiA.&HmanouchiM.(2001)ThepotentialeffectivenessofessentialoilsinthecontrolofhumanheadliceinMorocco.TheInternationalJournalofAromatherapy(3/4),108–122.LampicC.,WennbergA.,SchillJ-E.,BrodinO.,GlimeliusB.&SjodenP-O.(1994)Anxietyandcancerrelatedworryofcancerpatientsatroutinefollow-upvisits.ActaOncologicaLawrenceB.M.(1987)Progressinessentialoils.Perfumerand,35–52.LawrenceB.&ReynoldsR.J.(1987)Chamomileoil.Perfumer&(1),35–389.LeVuB.&MourisseH.(1997)Efficatiedumassageetdelamobilisationdumembresuperieuraprestraitementchirurgicalducancerdusein(abstract).BulletinCancer(10),957–961.LechY.,OlesenK.M.,HeyH.,Rask-PedersenE.,VilienM.&OstergaardO.(1988)Treatmentofirritablebowelsyndromewithpeppermintoil.Adouble-blindstudywithaplacebo(abstract).UgeskrLaegar(40),2388–2389.LehrnerJ.,EckersbergerC.,WallaP.,PotschG.&DeeckeL.(2000)Ambientodoroforangeinadentalofficereducesanxietyandimprovesmoodinfemalepatients.PhysiologyBehaviorIntegrativeliteraturereviewsandmeta-analysesAromatherapypracticeinnursing2004BlackwellPublishingLtd,JournalofAdvancedNursing(1),93–103 Lis-BalchinM.(1997)Essentialoilsand‘aromatherapy’:theirmodernroleinhealing.JournalofRoyalSocietyofHealthLis-BalchinM.(2000)Evaluationofmassagewithessentialoilsonchildhoodatopiceczema.PhytotherapyResearch(6),452–456.Lis-BalchinM.&HartS.(1997)Apreliminarystudyoftheeffectofessentialoilsonskeletalandsmoothmuscleinvitro.JournalofEthnopharmacology(3),183–187.Lis-BalchinM.,DeansS.G.&HartS.(1997a)Astudyofthevariabilityofcommercialpeppermintoilsusingantimicrobialandpharmacologicalparameters.MedicalScienceResearch,151–Lis-BalchinM.,HartS.&RothG.(1997b)ThepharmacologicalactivityoftheessentialoilsofscentedPelargoniums(Geraniaceae).PhytotherapyResearch(8),583–584.LongL.,HuntleyA.&ErnstE.(2001)Whichcomplementaryandalternativetherapiesbenefitwhichconditions?Asurveyoftheopinionsof223professionalorganisations.ComplementaryTherapiesinMedicine,178–185.MadelinL.(1994)Anintegratedcareprogramme.TheInternationalJournalofAromatherapy(4),8–10.MantikLewisS.&CoxCollierI.(1987)MedicalSurgicalNursingAssessmentandManagementofClinicalProblems,2ndedn.McGraw-Hill,NewYork.MasonM.(1996)Aromatherapymidwifery.AromatherapyQuar-,17–19.MaudsleyF.&KerrK.G.(1999)Microbiologicalsafetyofessentialoilsusedincomplementarytherapiesandtheactivityofthesecompoundsagainstbacterialandfungalpathogens.CancerCare(2),100–102.MercerB.(1996)Aromatherapyduringpregnancy–afragrantandnurturingexperience.AromatherapyToday,7–8.MillarR.(1996)Theuseofaromatherapyinhospitalsforpatientswithcancer.TheAromatherapist(2),14–29.MitchellS.(1993)Dementiaaromatherapy’seffectivenessindis-ordersassociatedwithdementia.TheInternationalJournalofAromatherapy(2),20–23.MiyazawaM.,ShindoM.&ShimadaT.(2001)Oxidationof1,8-cineole,themonoterpenecyclicetheroriginatedfromeucalyptuspolybractea,bycytochromeP4503Aenzymesinratandhumanlivermicrosomes.DrugMetabolismDisposition(2),200–205.MoateS.(1995)Anxietyanddepression.TheInternationalJournalofAromatherapy(1),18–21.MooreJ.(1999)Complementarytherapyinmentalhealth.tionalJournalofAlternativeandComplementaryMedicine,20–21.MorganD.,GlanvilleH.,MarsS.&NathansonV.(1998)Educationandtrainingincomplementaryandalternativemedicine;apostalsurveyofUKuniversities,medicalschoolsandfacultiesofnurses’ComplementaryTherapiesinMedicine,64–70.MorrisN.,BirtwistleS.&TomsM.(1995)Anxietyreduction.InternationalJournalofAromatherapy(2),33–37.MortimerP.S.,SimmondsR.,RezvaniM.,RobbinsM.,HopewellJ.W.&RyanT.J.(1990)Themeasurementofskinlymphflowbyisotopeclearance-reliability,reproducibility,injectiondynamics,andtheeffectofmassage.TheJournalofInvestigativeDermatol-,677–682.NaganumuM.,HiroseS.,NakayamaY.,NakajimaK.&SomeyaT.(1985)Astudyofthephototoxicityoflemonoil.ArchivesofDermatologicalResearch(1),31–36.NolenH.W.III&FriendD.R.(1994)Menthol-beta-D-glucuronide:apotentialprodrugfortreatmentoftheirritablebowelsyndrome.PharmacyResearch(12),1707–1711.OffordE.A.,MaceK.,RuffieuxC.,MalnoeA.&PfeiferA.M.A.(1995)Rosemarycomponentsinhibitbenzopyrene-inducedgenotoxicityinhumanbronchialcells.CarcinogenesisOwenA.(1995)Surveyingthealternatives.NursingTimesPeaceG.&SimonsD.(1996)Completingthewhole.NursingTimes(25),52–54.PittlerM.H.&ErnstE.(1998)Peppermintoilforirritablebowelsyndrome;acriticalreviewandmeta-analysis.AmericanJournalofGastroenterology(7),1131–1135.PuustjarviK.,HanninenO.&LeppaluotoJ.(1986)Effectofmassageonendorphinlevelsandsomephysiologicalparameters.PhysiologicaHungarica,243.Rankin-BoxD.(1997)Therapiesinpractice:asurveyassessingnurses’useofcomplementarytherapies.ComplementaryTherapiesinNursingandMidwifery(4),92–99.RibeauxP.&SpenceM.(2001)CAMevaluation:whataretheresearchquestions?ComplementaryTherapiesinMedicineRichardsonJ.(1996)Non-conventionaltherapyintheNHS:canitInternationalJournalofAlternativeandComplementary,20–21.RiechelmannH.,BrommerC.,HinniM.&MartinC.(1997)Responseofhumanciliatedrespiratorycellstoamixtureofmenthol,eucalyptusoilandpineneedleoil[abstract].(9),1035–1039.RobertsA.&WilliamsJ.M.(1992)Theeffectofolfactorystimula-tiononfluency,vividnessofimageryandassociatedmood:apreliminarystudy.BritishJournalofMedicalPsychology(pt2),SaekiY.(2000)Theeffectoffootbathwithorwithouttheessentialoiloflavenderontheautonomicnervoussystem:arandomizedComplementaryTherapiesinMedicine,2–7.SafayhiH.,RallB.,SailerE.R.&AmmonH.P.(1997)Inhibitionbyboswellicacidsofhumanleukocyteelastase.TheJournalPhar-macologyandExperimentalTherapeutics(1),460–463.SalanderP.,BergenheimT.&HenrikssonR.(1996)Thecreationofprotectionandhopeinpatientswithmalignantbraintumours.SocialScienceandMedicine(7),985–996.SandersonH.(1993)Interactivemassage.AromatherapyQuarterly,3–4.SchacherL.,FieldT.,Hernandez-ReifM.,DuarteA.M.&KrasnegorJ.(1998)Atopicdermatitissymptomsdecreasedinchildrenfollowingmassagetherapy.PediatricDermatology(5),390–395.SchaferD.&SchaferW.(1981)Pharmacologicalstudieswithanointmentcontainingmenthol,campheneandessentialoilsforbroncholyticandsecretolyticeffects[abstract].(1),82–86.SchwarzK.,TernesW.&SchmaudererE.(1992)AntioxidativeconstituentsofRosmarinusofÞcinalisSalviaofÞcinalisW.Maddocks-JenningsandJ.M.Wilkinson2004BlackwellPublishingLtd,JournalofAdvancedNursing(1),93–103 Stabilityofphenolicditerpenesofrosemaryextractsunderther-malstressasrequiredfortechnologicalprocesses[abstract].ZeitschriftfurLebensmittel-untersuchungund-forschungShiptonH.(1995)Strokingawaythepain.TheInternationalJournalofAromatherapy(1),4–5.ShirreffsC.M.(2001)AromatherapymassageforjointpainandconstipationinapatientwithGuillanBarre.ComplementaryTherapiesinNursingandMidwifery,78–83.SmithR.H.(1993)Lavenderhelpsburnedboy.InternationalJournalofAromatherapy(4),6–9.SparberA.(2001)Stateboardsofnursingandscopeofpracticeofregisterednursesperformingcomplementarytherapies.JournalofIssuesinNursing,availableathttp://www.nursingworld.org/ojin/topic6/tpc.htm.SteinmetzM.D.,VialM.&MilletY.(1987)Actionsofessentialoilsofrosemaryandcertainofitsconstituents(eucalyptolandcam-phor)onthecerebralcortexoftheratinvitro.JournalTox-icologicalClinicalExperiments(4),259–271.StevensonC.(1992)Orangeblossomevaluation.InternationalJournalofAromatherapy(3),22–25.StoneJ.(1999)Usingcomplementarytherapieswithinnursing:someethicalandlegalconsiderations.ComplementaryTherapiesinNursingandMidwifery,46–50.StylesJ.L.(1997)TheuseofaromatherapyinhospitalisedchildrenwithHIVdisease.ComplementaryTherapiesinNursingand(1),16–20.SzentmihalyiK.,ForgacsE.,HajduM.&ThenM.(2001)Invitrostudyonthetransferofvolatilecomponents.JournalofPharma-ceuticalBiomedicalAnalysis(5–6),1073–1080.TibballsJ.(1995)Clinicaleffectsandmanagementofeucalyptusoilingestionininfantsandyoungchildren.MedicalJournalofAus-(4),177–180.TibballsJ.&JamesA.(1995)Eucalyptusoil:medicinaltherapyorfolkremedy?AustralianJournalofHospitalPharmacy(6),516–ToveyP.&AdamsJ.(2002)TowardsasociologyofCAMandnursing.ComplementaryTherapiesinNursingandMidwiferyTrevelynJ.(1996)Atruecomplement?NursingTimes(5),42–44.VealL.(1996)Thepotentialeffectivenessofessentialoilsasatreatmentforheadlice,Pediculushumanuscapitis.Complement-aryTherapiesinNursingandMidwifery,97–101.VickersA.(1997)Yes,butdoweknowit’strue?Knowledgeclaimsinmassageandaromatherapy.ComplementaryTherapiesinNursingandMidwifery,63–65.WalshD.(1996)Usingaromatherapyinthemanagementofpsori-NursingStandard(13/14),53–56.WeaverJ.(1991)Chronicpsoriasis.TheInternationalJournalofAromatherapy(1),20–21.WeissJ.(1973)Camphoratedoilintoxicationinpregnancy.,713–714.WhiteA.&ErnstE.(2001)Thecaseforuncontrolledclinicaltrials:astartingpointfortheevidencebaseforCAM.TheInternationalJournalofAromatherapy(4),201–205.WilkinsonS.(1995)Aromatherapyandmassageinpalliativecare.InternationalJournalofPalliativeNursing(1),21–30.WilkinsonJ.M.&SimpsonM.D.(2002)PersonalandprofessionaluseofcomplementarytherapiesbynursesinNSW,Australia.ComplementaryTherapiesinNursing&Midwifery(3),142–WilkinsonS.,AldridgeJ.,SalmonI.,CainE.&WilsonB.(1999)Anevaluationofaromatherapymassageinpalliativecare.,409–417.WilsonL.(1989)AromatherapyinthecareofAIDSpatients.nationalJournalofAromatherapy(3),12.WoolfsonA.&HewittD.(1992)Intensivearomacare.InternationalJournalofAromatherapy(2),12–13.YamadaK.MiuraT.,MimakiY.&SashidaY.(1996)EffectofinhalationofchamomileoilvapouronplasmaACTHlevelinovarectomized-ratunderrestrictionstress.BiologicalPharmacy(9),1244–1246.ZankerK.S.,TolleW.,BlumelG.&ProbstJ.(1980)Evaluationofsurfactant-likeeffectsofcommonlyusedremediesforcolds.Respiration(3),150–157.ZaynounS.T.,JohnsonB.E.&Frain-BellW.(1977)Astudyoftheoilofbergamotanditsimportanceasaphototoxicagent.JournalofDermatology,475–482.Integrativeliteraturereviewsandmeta-analysesAromatherapypracticeinnursing2004BlackwellPublishingLtd,JournalofAdvancedNursing(1),93–103