Debra Reis, MSN, RN, CNP, Tisha Throne Jones, MSW, Glenna Frey, MSN, RN
Vol. 6 Issue 2 Fall 2017 IJPHA, pages 21 – 25.
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The purpose of this article is to share the process used for the development and implementation of an Aromatherapy program in a multisite cancer center. Essential oils are a simple method of support and can be part of a holistic treatment approach to care. Clinical Aromatherapy is becoming very popular in cancer centers across the United States (Buckle, 2015; Seely et al., 2012) and is being integrated into health system–wide acute care nursing (Joswiak et al., 2016).
The Aromatherapy program was created to support the management of stress response in patients with a cancer diagnosis. Stress often manifests in patients due to the diagnosis, the impact on lifestyle, treatment side effects and more (National Cancer Institute, 2012). Research shows that stress can create greater detriment to the body, causing more anxiety and pain (Payne, 2014). The aim was to have staff use Aromatherapy safely to promote a system balance to the mind, body and spirit through olfactory stimulation.
ProMedica Cancer Institute (PCI), part of ProMedica (a locally owned, nonprofit healthcare system), is a multisite outpatient oncology center committed to providing comprehensive, quality care to pediatric and adult patients at multiple rural and urban locations across northwest Ohio and southeast Michigan. In addition to superior clinical care, multiple supportive services are provided, including Healing Care. The Healing Care Program provides supportive therapies such as Aromatherapy, energy therapy, relaxation breathing, guided imagery and gentle movement therapy to assist patients and families during their cancer experience. The Healing Care Program is staffed by two registered nurses and one licensed practical nurse (approximately one and a half full time positions) with over 30 years of experience providing complementary therapies to patients. Two of the three Healing Care nurses are certified in clinical Aromatherapy, and all have extensive education and experience with essential oils. The Healing Care Program is the primary resource for essential oils and diffusers throughout PCI. The Aromatherapy service has been very popular with patients, families and staff. It was recognized that one and a half full time positions would not be able to cover the needs of patients and families dealing with the stress of a cancer diagnosis across all the cancer center locations, resulting in a need to expand capacity.
Obtaining administrative support
Introducing Aromatherapy into a clinical setting requires administrative support. Administration was provided with an overview of the benefits of Aromatherapy for stress reduction, citing current research. To reduce concerns about potential harmful effects by patients, families or staff, education on essential oils safe practices and use of quality oils was provided. Having a certified clinical Aromatherapist as part of the team gave credibility to the scientific rationale for Aromatherapy (Joswiak et al., 2016). In addition to garnering administrative support, early discussions with clinical staff about essential oils as a supportive therapy for relaxation and stress reduction were also happening. As with any program, costs were part of the conversations. Each of the cancer center sites were responsible for identifying funding to support the costs related to implementation (i.e. diffusers and essential oils); some locations incorporated the costs into their department budget while others obtained support through other means.
Using essential oils
Most clinical Aromatherapy programs include inhalation and diffusion methods (Lillehei et al., 2015). Humans can smell between four and ten thousand different scents, and inhalation of a scent can affect behavior, the autonomic nervous system, mental and emotional conditions, and body function (Angelucci
et al., 2014). In addition, when smelling an aroma, those molecules move into the nose, the olfactory bulb and the midbrain area known as the limbic system. This is the area associated with emotions and memory, which may explain why people find aromas to be relaxing and some scents reminiscent of a past event or person.
Inhalation was selected as the delivery method to be used at the various cancer centers. Inhalation provides a very easy way to deliver the benefits of essential oils for the purpose of relaxation and stress management. Further, inhalation, as an application method, also presents a very low-level of risk to most people (National Association for Holistic Aromatherapy, 2017). There are direct and indirect methods of inhalation; using a few drops of oil placed on a cotton ball, tissue or inhaler is a form of direct inhalation while the use of a diffuser, where essential oils are dispersed into the air, is indirect inhalation (Allard and Katseres, 2016).
Diffusion is used primarily in the radiation treatment rooms. If any patient needs additional relaxation, inhalation on a tissue is provided. Diffusion is not done in the infusion centers due to concerns related to nausea, which many patients experience with chemotherapy. These patients are offered essential oils on a tissue for their own personal use.
Diffusion disperses the oils into the air, allowing for better absorption through the mucosa (Stewart, 2005). The diffusers selected for the centers cover a space over 200 square feet. They were examined by the biomedical engineering staff and they have a “TriMedex Clinical Engineering Approved for Use” sticker.
The radiation therapists are responsible for the filling, cleaning, and maintenance of the diffusers. Distilled water is added to the diffuser according to directions, followed by five to eight drops of the selected essential oil. The water and oil are refilled after about four hours. At the end of the work day, the diffuser is emptied, wiped with a clean cloth, and allowed to dry, to help prevent harboring of microorganisms. The cleaning process was reviewed and endorsed by the Infection Prevention and Control nurse for the sites.
The second method of delivery is to place one to two drops of the essential oil directly on a plain tissue and mark it with the common name of the oil, date, and time. This allows the patient to choose a specific essential oil that best fits their need at the time and control over when they choose to inhale the oil scent. Inhalers or Aromasticks in the clinical setting have been shown to be an effective Aromatherapy method for inhalation (Dyer et al., 2014; Johnson et al., 2016; Joswiak et al., 2016); however, the use of a tissue was chosen as the preferred method. This decision was based on ease of use in a busy unit and cost effectiveness. Often, patients will choose an aroma for one-time use or may wish to use another aroma the next day. The tissue is provided to the patient to hold and inhale as desired. Many patients choose to place the tissue on their chest (without touching their skin) during radiation or chemotherapy infusion while reclined.
It is highly recommended that any essential oil used in a clinical setting be evaluated for its source, how it is distilled and if it is of genuine quality (Life Science, 2011; Reis and Jones, 2017). Four single essential oils are being used in the outpatient cancer centers: Lavender (Lavandula angustifolia), Peppermint (Mentha
x piperita), Orange (Citrus sinensis), and Lemon (Citrus limon). These oils were selected because they are common and have a familiar scent to most individuals, are cost effective and are supportive in stress management and relaxation. Table 1 provides the indication of use for each of these oils. The essential oils may be used alone or in combination with other interventions such as relaxation breathing, guided imagery, and/or Healing Touch.
Some patients have a specific scent they prefer and that oil can be used. There is no “wrong” decision when selecting the oil. Any of these oils can provide benefit, if the patient finds the scent pleasant. If a patient prefers not to use essential oils, that decision is always respected. Diffusers can be turned off and an essential oil tissue would not be used. To date, there have been patients who refused to accept an oil but no patient nor family member has expressed concerns over the use of essential oils in the clinical setting.
All patients are assessed for respiratory concerns such as asthma before inhalation is promoted. Precautions are taken with patients that may have a history of airway or lung disease, and deep inhalation is a concern. The nurse will assess the patient’s response to an oil by gently waving the scent near the patient’s nose, rather than having the person inhale directly from the tissue. If the patient has any irritation or an unpleasant experience, the nurse assesses for another oil or does not use oils.
Although inhalation is a low-risk application method, it is important to understand safety issues for all application methods, including topical, baths and internal (National Association for Holistic Aromatherapy, 2017). Further, awareness of contraindication of any essential oil should always be evaluated, as there are essential oils that may affect the effectiveness of some medications and cancer treatment protocols, specifically with topical application or internal use (Buckle, 2015; Reis and Jones, 2017). Precautions for Lavender, Peppermint, Orange and Lemon are included in Table 1.
It is important for staff to have safe, clear standards and guidelines for how to use the oils. A policy was felt to be the best method of delivering this information for all the cancer centers. Because the Aromatherapy program is specific to inhalation, the policy is not all-encompassing. If topical or internal methods will be used as part of an Aromatherapy program, additional language specific to topical or internal use of essential oils should be added to the policy. National Association for Holistic Aromatherapy (NAHA) and Alliance of International Aromatherapists (AIA) documents along with evidence from the literature were used to guide the policy development as well as the education plan. As part of policy development, staff at PCI, as well as areas outside of PCI, such as infection control, pediatrics, inpatient, extended care facility, hospice, NICHE (Nurses Improving Care for Healthsystem Elders), and Joint Commission, were consulted. The policy was presented and approved by the operations committee, which consists of the management team at the cancer center.
The policy includes the previously mentioned description of how to use the essential oils with the diffuser and inhalation with tissue. The policy also addresses documenting the use of Aromatherapy. This includes patient assessment, intervention of the essential oil for relaxation, and patient response. Documentation is done in the medical record.
Safety precautions are a very important aspect of the policy and indicate what to do for ingestion, spills, eye contact, and skin reaction. Material Safety Data Sheets were obtained from the company from which the essential oils were purchased. These were placed on the facility website, which is accessible to all staff. Hand hygiene is indicated prior to handling of the essential oil bottles. Other important safety aspects include: place lid securely on the essential oil bottle immediately after use; store in a locked, cool, dry place; keep away from light and heat; keep away from direct contact with flames; and original label must be on bottle and legible (Buckle, 2015; Price and Price, 2012). Staff who have questions or safety concerns are directed to contact the Healing Care Program.
An educational program was developed and approved by administration. All agreed that education was required before using Aromatherapy with patients. Education was open to all outpatient oncology staff including nurses, medical assistants, radiation therapists, social workers, physicians, and support staff. The cancer center manager at each site made the decision of who could attend the educational program and permitted time away from scheduled clinical work.
One hour of education was provided by the Healing Care nurses. Personal classroom instruction was used in order to guide the staff in use of the oils and address any questions or concerns they might have during the class. The Aromatherapy topics included: general description of essential oils (history, characteristics, quality, extraction, benefits), application method of inhalation (effects on brain and limbic system), safety concerns, review of the policy and procedure, discussion of each of the four essential oils, integration of the oils with other interventions, clinical studies using essential oils, and documentation in the medical record. The staff smelled each of the four essential oils and talked through each step of the policy. They were shown how to fill and clean a diffuser and demonstrated use of the tissue application method. This hands-on experience with supervision was important to show competency that included proper handling of the bottles of oil.
The addition of an Aromatherapy program has provided many benefits to patients and families dealing with the stress of a cancer diagnosis, and has been a wonderful complement to other supportive therapy services. Successful integration of the Aromatherapy program across multiple outpatient oncology centers required administrative and staff support throughout the entire process; education and ongoing communication were significant factors to obtaining and maintaining this support. It was imperative that consistent and safe practices were used across all sites and for all patients. To accomplish this an Aromatherapy policy and educational program were developed. A certified clinical Aromatherapist provided the background and knowledge needed to ensure that safe practice standards and quality essential oils and diffusers were being used. The process of developing and implementing the program was a positive experience, resulting in more options being available to support patients experiencing stress in the outpatient cancer setting.
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