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Quantitative Research Article analysis
Name: _________________________________ Date: ______________________
APA Reference:_______________________________________________________
This analysis is on a quantitative research article. Choose ONE of the quantitative research articles provided in Workshop Four. Do not write a narrative paper. Use the worksheet to complete this assignment. Use your own words to paraphrase information from the article. You can use direct quotes, but use them sparingly. Cite all paraphrases and direct quotes; each box must be cited. Use the grading rubric for guidelines on how to answer each of the questions on the worksheet. When you have completed the assignment, save a copy for yourself and submit a copy to the 4.3 Dropbox by the end of the workshop.
Problem Statement
&
Purpose Statement
Assessment of Literature Reviewed
(Background information)
Research Question(s)
(The findings answer the Research question)
Research Design (Experimental, Quasi-Experimental, Correlational, Exploratory,
Descriptive)
Sample, Setting
&
Sampling Method
Data Collection
&
Data Analysis
Ethical Issues
(Informed Consent, Anonymity, Confidentiality, IRB)
Limitations
&
External Validity
Findings
Implications for Nursing Practice
Recommendations for Further Research
January-February 2018 • Vol. 27/No. 138
Hillary Jenson, BSN, RN, PCCN, is Registered Nurse, Providence Portland Medical Center,
Portland, OR; and DNP-FNP student, University of Portland, Portland, OR.
Sandra Maddux, DNP, APRN, CNS-BC, is Senior Regional Director, Providence Health and
Services, Oregon Region, Portland, OR.
Mary Waldo, PhD, RN, GCNS-BC, CPHQ, is Regional Director, Providence Health and
Services, Oregon Region, Portland, OR.
Improving Oral Care in Hospitalized
Non-Ventilated Patients:
Standardizing Products and Protocol
P
atients who develop ventila-
tor-acquired pneumonia have
estimated attributable mor-
tality rates of approximately 10%
(Klompas et al., 2014). To reduce
these rates, healthcare advocacy
groups have endorsed a prevention
bundle that includes routine oral
care (Centers for Medicare &
Medicaid Services, 2017). In a hall-
mark study, DeRiso, Ladowski,
Dillon, Justice, and Peterson (1996)
demonstrated use of the oral anti-
septic chlorhexidine reduced rates
of hospital-acquired pneumonia in
ventilated patients undergoing
coronary artery bypass surgery.
Although routine oral care histori-
cally has been a part of daily patient
care, its significance in preventing
non-ventilator hospital-acquired
pneumonia (NV-HAP) has emerged
as an important preventive meas-
ure. Maeda and Akagi (2014) linked
poor oral health with an increased
risk for infection and thus NV-HAP.
Research also has demonstrated
that without regular oral hygiene,
bacteria remain in the oral cavity
and become more pathogenic over
time (Ikeda et al., 2014). Despite
these risks, research suggests imple-
mentation of regular, high-quality
oral care by nursing staff often is
neglected due to barriers in practice
(Letsos, Ryall-Henke, Beal, &
Tomaszewski, 2013). These barriers
include limited time, resource con-
straints, challenging patient behav-
iors, and staff knowledge gaps
regarding appropriate frequency in
oral care.
Although every patient benefits
from routine oral care, some groups
are at higher risk of developing NV-
HAP. These include recently extu-
bated persons, postoperative pa –
tients, and patients managed on
progressive care units (Scheel,
Pisegna, McNally, Noordzij, &
Langmore, 2016); and patients
strictly receiving nothing by mouth
or with dysphagia (Maeda & Akagi,
2014). These patients, who are seen
commonly in the medical-surgical
setting, require heightened aware-
ness and sensitivity to their oral
care needs.
NV-HAP develops when patients
micro-aspirate oropharyngeal path –
ogens into the lungs (Di Pasquale,
Aliberti, Mantero, Bainchini, &
Blasi, 2016). Organ isms responsible
for the development of NV-HAP
include Staphy lococcus aureus and
gram-negative bacteria, which are
increasingly antibiotic resistant
(Weiner et al., 2016). This knowl-
edge of escalating antibiotic resist-
ance in conjunction with previous-
ly discussed studies demonstrating
the relationship between oral care
and reduction of NV-HAP high-
lights the urgency for nurses to take
action (Kaneoka et al., 2015; Maeda
& Akagi, 2014). Medical-surgical
nurses are in a position to influence
outcomes related to oral care. This
fundamental nursing intervention
warrants further investigation to
ensure these actions become an
essential part of daily patient care.
Purpose
The purpose of this study was to
determine if staff education, imple-
mentation of an oral care protocol,
and alterations to bedside oral care
tools improved the frequency of
oral care in patients who were non-
ventilated and did not have a tra-
cheostomy. A secondary purpose
was to determine if a difference
existed in the frequency of oral care
provided to high-risk populations,
defined as those who had orders to
take nothing by mouth, were tube-
Research for Practice
Research for Practice
Hillary Jenson
Sandra Maddux
Mary Waldo
Medical-surgical nurses are in a position to influence outcomes
related to oral care. In this study, educating nurses on the impor-
tance of routine oral care and moving tools to the bedside improved
the frequency of oral care.
January-February 2018 • Vol. 27/No. 1 39
fed or diagnosed with dysphagia, or
had been extubated recently.
Review of the Literature
A review of the literature from
2013-2017 was conducted in MED-
LINE using search terms oral care in
acute care and oral care in long-term
care.
To determine the effect of oral
care on incidence of pneumonia or
related mortality in adult patients
in hospitals or long-term care facili-
ties, Kaneoka and co-authors (2015)
conducted a comprehensive litera-
ture review and meta-analysis of
primary, randomized controlled tri-
als. Five studies met defined inclu-
sion criteria; one of them had no
reported pneumonia during the
data collection period and was not
included in the meta-analysis.
Authors concluded the pooled
effect of oral care with topical
chlorhexidine or mechanical oral
care contributed to significantly
reduced risk for developing pneu-
monia compared to control
(p=0.02). Additionally, the effect of
oral care on reducing fatal pneumo-
nia was significant (p=0.02). This
meta-analysis dem onstrated routine
oral care positively correlates to
improved outcomes among non-
ventilated patients.
To reduce complications second-
ary to pneumonia, Maeda and Akagi
(2014) evaluated the effect of regular
oral care among 63 immobile older
adult patients (mean age=81.7, + 2.5
years) who received nutrition solely
via tube feedings and nothing by
mouth. Authors noted lack of oral
intake can alter the pathogenicity of
the oral cavity and, combined with
higher rates of aspiration in elders,
lead to increased risk of NV-HAP. A
year-long intervention study includ-
ed control and oral care interven-
tion groups; the intervention group
received mechanical oral care using
chlorhexidine, a mouth moisturizer
with glyceryl gel, and salivary gland
massage. The intervention group
had significant reduction in the
incidence of pneumonia, number of
febrile days, number of days with
antibiotics, and rate of blood and
radiological tests (p<0.05). This
study underscores the importance of
regular oral care on health to
improve outcomes in high-risk per-
sons.
Despite evidence of a correlation
between oral care and improved
outcomes, Pettit, McCann, Schneid –
erman, Farren, and Campbell
(2012) identified a knowledge gap
when surveying a random sample
of 98 registered nurses. The mailed
50-question survey assessed oral
care knowledge, practices and per-
ceptions of importance, and barriers
to providing oral care. Results indi-
cated 95% of respondents (n=93)
believed oral care was important
and 79% (n=77) felt responsible for
providing oral care; however, 52%
(n=51) indicated oral care was
addressed minimally in their nurs-
ing education. Although the per-
ceived lack of education, 67%
(n=66) reported being knowledgeable
or very knowledgeable about oral
care. Participant scores on survey
questions related to oral care knowl-
edge did not correspond to the per-
ceived knowledge reported (mean
test score 50.5%, SD=0.132). Per –
ceived barriers to performing oral
care included low priority, lack of
time, lack of resources, and no
employer mandate for its provision.
These responses reflected a knowl-
edge gap regarding oral care and
identified potential barriers to rou-
tine, nurse-driven oral care. Creat –
ing an intervention that educates to
deficits in nursing knowledge and
Background
Daily oral care is known to reduce microorganisms in the oral cavity and
may reduce the risk of infection caused by aspiration (Kaneoka et al.,
2015). This practice may be overlooked among non-ventilated patients.
Purpose
To determine if staff education, a standardized protocol, and bedside
tools improved frequency of oral care.
Method
A pre-post design was used in a study of patients who were non-ventilat-
ed and without tracheostomies. Chart reviews determined the frequency
of oral care pre-intervention compared to weeks 5, 7, and 9 following
intervention. Oral care knowledge and perceived barriers to oral care were
assessed and analyzed.
Findings
Oral care documentation improved from pre-intervention rates com-
pared to weeks 5 and 9 (p<0.01); from weeks 5 to 7 (p=0.00); and main-
tained through week 9 (p=0.00). Nurses demonstrated increased aware-
ness after intervention for oral care need (p=0.005), high-risk populations
(p=0.001), benefits to patient’s self-esteem (p=0.026), and opportunity to
assess oral health (p=0.006).
Limitations and Implications
An inability to generalize findings to other populations due to inaccessi-
ble demographics on patients was a limitation of the study. Results imply
an existing knowledge gap among nurses regarding need for oral care in
high-risk patients.
Conclusion
Educating nurses on the importance of routine oral care and moving tools
to the bedside improved the frequency of oral care. Longitudinal studies
are needed to determine if oral care prevents aspiration pneumonia.
Improving Oral Care in Hospitalized Non-Ventilated Patients: Standardizing Products and Protocols
January-February 2018 • Vol. 27/No. 140
reduces barriers in delivering oral
care may result in more effective
adoption of the practice.
Quinn and Baker (2015) also
conducted a gap analysis on nurs-
ing oral care practice in the inpa-
tient setting. While results of the
gap analysis were not reported,
authors created an evidence-based,
multi-pronged intervention to
determine the effect of quality, rou-
tine oral care on patient outcomes.
The first aspect of the intervention
addressed inadequate and inappro-
priate supplies within the system,
including toothbrushes that did not
comply with American Dental
Association guidelines and lack of
availability of suction toothbrushes.
The second component of the inter-
vention involved updating the sys-
tem’s oral care protocol to include
patients of all acuities, from those
independent in oral care to those
with complete dependency. The
third prong of the intervention
incorporated modification of exist-
ing documentation to enable prop-
er charting of oral care perform-
ance. Finally, nursing staff knowl-
edge was surveyed before and after
the intervention. Information from
the baseline survey was used to
develop an educational program for
nursing staff. In the following year,
hospitalized patients were less likely
to acquire NV-HAP (49% decline,
p<0.001). In addition, an estimated
$2.4 million were saved secondary
to reduced hospital stays; return on
investment was an estimated $2.28
million. This study demonstrated
education plus easy-to-use and
ready-to-go equipment are effective
in reducing healthcare costs,
improving patient outcomes, and
effecting change among clinical
providers in an inpatient setting.
This review of the literature sup-
ports the need for providing oral
care to non-ventilated, hospitalized
patients. A need exists for a low-
cost, highly effective means of
enhancing medical-surgical nurses’
delivery of regular oral care.
Ethics
This study received approval
from the Institutional Review Board
at Providence Health and Services
(Portland, OR). A conflict of interest
agreement was established with the
manufacturer of the oral care kits
prior to implementation of the
study. The staff received an invita-
tion to participate in completion of
the survey, which indicated their
willingness to participate in the
study. Because patient data were
extracted from existing medical
records, consent was not required.
Sample Selection
Patient Sample
Through a retrospective chart
review, baseline oral care data were
gathered from a convenience sam-
ple of 50 patients admitted in June
2015. Patients were included if they
did not have a ventilator or a tra-
cheostomy. Post-intervention data
were collected using the same exclu-
sion criteria for patients admitted
August-Septem ber 2015.
Staff Sample
All regularly scheduled staff on
the medical-surgical progressive
care unit (PCU) were invited via
email to participate in the online
pre-intervention survey during June
2015. A reminder email was sent 1
week after the initial invitation.
Consent was implied through sur-
vey completion, and all responses
were anonymous. After the inter-
vention was implemented, regular-
ly scheduled staff again were invit-
ed to participate in a post-interven-
tion survey.
Design and Method
This pre- and post-interventional
study was conducted at a metropol-
itan, not-for-profit, Magnet®-desig-
nated facility in the northwestern
United States. Registered nurses
(RNs) and certified nurse assistants
(CNAs) from a medical-surgical
PCU were invited to participate.
The intervention included an edu-
cational in-service for nursing staff,
implementation of an oral care pro-
tocol, and adoption of a daily oral
hygiene kit located at the bedside.
Data were collected via retrospec-
tive chart audit for patients who
met inclusion criteria. Staff knowl-
edge was assessed using an online
questionnaire developed by the
investigators.
The seven-item multiple-choice
questionnaire was used to deter-
mine staff knowledge regarding the
importance of oral care practices on
the unit and barriers encountered
in providing regular oral care. The
questionnaire was developed after
team members conducted an exten-
sive literature review. A master’s-
prepared nurse manager with ex –
pertise in the care of high-acuity
patients with respiratory disorders
determined face validity of the staff
survey. In addition, the survey was
evaluated for readability and clarity
by content experts from among
clinical staff not participating in the
study as well as staff from the
Speech Pathology Department. It
was determined to be appropriate
for administration to nursing staff.
An external clinical nurse special-
ist (CNS) with national recognition
in acute and critical care was invited
to provide the intervention educa-
tion. After the literature re view, the
research team suggested content
and collaborated with the CNS in
development of the education inter-
vention. This CNS conducted an
original 1-hour presentation on the
impact of oral hygiene practices in
eliminating NV-HAP in the acute
care setting. Included were methods
to ease adoption of practice im –
provements. The session was record-
ed and a digital video disc copy
made available to staff members
who were unable to attend. The
CNS also provided personalized edu-
cation to staff members who were
involved in direct patient care at the
time of the presentation.
A convenience sample of pat –
ients was selected from the daily
census before the intervention and
at 5, 7, and 9 weeks after interven-
tion. An electronic health record
data collection tool was developed
to assess the frequency of patient
refusal and completion of oral care
documentation by nursing staff.
Inter-rater reliability for chart audits
was established after researchers
independently reviewed charts and
Research for Practice
January-February 2018 • Vol. 27/No. 1 41
achieved 100% agreement. Addit –
ionally, the data collection tool was
used to identify the frequency of
factors that place patients at higher
risk for aspiration pneumonia:
being unable to take anything by
mouth, having a modified diet tex-
ture or liquid consistency, and/or
using a tube feeding (Maeda &
Akagi, 2014).
To enhance the ability of staff
members to deliver oral hygiene,
the study site trialed a pre-packed
kit (Q•Care®; Sage Products LLC)
consisting of four tear-off oral
hygiene kits to be used throughout
a 24-hour period. All four sections
contained a combination antiseptic
cleanser and mouth moisturizer.
Two of the kits contained a suction
toothbrush and the other two kits
contained a suction swab. The
product was placed at the head of
the patient’s bed each morning by
night staff to provide a visual cue
for oncoming staff to perform oral
hygiene. A representative from the
manufacturer was trained on the
study protocol and provided just-
in-time training over 1 week for day
and night shift staff before imple-
mentation of the intervention.
An oral hygiene guideline
(adapted with permission from
Quinn & Baker, 2015) was imple-
mented for patients without a tra-
cheostomy or who were not ventila-
tor-dependent. This protocol speci-
fied patients were to receive oral
hygiene using the oral care kits four
times a day. Patients who were
capable of self-administering hy –
giene were encouraged to use the
product with supervision. Staff were
trained to document completion of
oral hygiene or patient refusal. The
protocol was posted strategically
around the unit, emailed to staff,
and kept at the charge nurse station
for easy access and reference. See
Table 1 for the protocol.
Findings
Data were entered into Statistical
Package for Social Sciences (SPSS),
version 22. Chi-square was used to
compare perceived frequency, barri-
ers and benefits of performing oral
care, and populations at risk for de –
veloping NV-HAP. One-way ANOVA
was performed to determine the dif-
ferences in documentation of oral
care between the baseline and 5, 7,
and 9 weeks after education. A priori
significance was determined to be
p<0.05. A power analysis deter-
mined the appropriate sample size
to detect significance to be at least
40 patients per collection period.
Analysis on role differences was not
conducted as no CNAs completed
the post-intervention survey.
Survey results found no statisti-
cally significant difference after
intervention in staff perception of
the importance of ensuring regular
oral care (chi-square p=0.22). Using
Pearson’s chi-square, researchers
analyzed barriers to performing oral
care, and staff understanding of
benefits and patients at risk to
determine differences in responses
in before- (n=23) and after-educa-
tion surveys (n=16) (see Table 2).
Significant differences were found
in the following areas: awareness of
an oral care protocol for patients
without a tracheostomy and not
ventilated, and increased risk of
TABLE 1.
Oral Care Protocol
Dental Condition Supplies Procedure Frequency
No dentures Oral Care Kit
• Use brush
attachment before
breakfast and dinner.
• Use swab
attachment before
lunch and at bedtime.
Moisten suction toothbrush in antiseptic oral rinse.
Connect suction toothbrush to continuous suction.
Brush teeth for 1-2 minutes.
Suction debris from mouth.
Discard disposable equipment in appropriate
receptacle.
Before each meal
and at bedtime
Dentures Labeled denture cup
Soft toothbrush
Denture cleaner for
soaking only
Two swabs
Alcohol-free antiseptic
rinse
Denture adhesive
(optional)
Remove dentures and place in labeled denture cup.
Brush palate, buccal surfaces, gums, and tongue
with swab.
Have patient swish and spit antiseptic rinse or use
swab to apply rinse.
Carefully brush dentures with warm water. Do not
use toothpaste, which may scratch dentures.
Help patient insert dentures in mouth.
After bedtime mouth care, soak dentures in
commercial cleanser in denture cup.
If patient needs adhesive to hold dentures firmly in
place, follow manufacturer directions.
Before each meal
and at bedtime
Source: Adapted from Quinn & Baker, 2015
Improving Oral Care in Hospitalized Non-Ventilated Patients: Standardizing Products and Protocols
January-February 2018 • Vol. 27/No. 142
TABLE 2.
Chi-Square
Question df
Pre-Intervention
Replied “No”
Post-Intervention
Replied “No”
Chi-Square
Result
Exact
Significance
(two-sided)
On a typical day, which of the following are
barriers to performing regular oral care with
your patients (No/Yes):
• Lack of time
• Lack of supplies
• Other tasks take priority
• Lack of support staff
• Patient refusal
• Not something I give much thought to
1
1
1
1
1
1
n = 6
n = 22
n = 5
n = 11
n = 16
n = 18
n = 6
n = 15
n = 4
n = 10
n = 8
n = 15
0.58
0.07
0.06
0.82
1.53
1.74
p = 0.50
p = 1.0
p = 1.0
p = 0.52
p = 0.32
p = 0.37
Are you aware of a protocol in place for oral
care among non-trached, non-ventilated
patients? (Not aware/Aware)
1 n = 8 n = 6 6.24 p = 0.018*
What benefits do you see to performing regular
oral care with non-trached, non-ventilated
patients (Yes/No)
• Improved self-esteem
• Increased oral intake
• Reduced chance for infection
• Opportunity to assess patient’s oral health
1
1
1
1
n = 8
n = 10
n = 2
n = 9
n = 3
n = 8
n = 3
n = 3
1.20
0.16
0.85
1.84
p = 0.47
p = 0.75
p = 0.63
p = 0.29
Which of the following patients are most at risk
for developing non-ventilator hospital-acquired
pneumonia? (Yes/No)
• NPO patients
• Post-surgical patients
• Dysphagia patients
• Tube feeding patients
• Critically ill patients
1
1
1
1
1
n = 8
n = 3
n = 1
n = 3
n = 0
n = 0
n = 0
n = 0
n = 2
n = 0
7.00
2.26
0.71
0.002
NA
p = 0.01**
p = 0.26
p = 1.0
p = 1.0
NA
NPO = nothing by mouth
*p ≤ 0.05, **=0.00
Variable Sum Squares df Mean Square F Significance
Patient age B = 1173.3
W = 27538.1
3
156
391.11
176.5
2.216 0.088
Documentation: Number of times oral care refused B = 11.42
W = 108.8
3
156
3.8
0.70
5.459 0.001*
Documentation: Number of times oral care charted B = 69.2
W = 159.0
3
156
23.1
1.0
22.634 0.000*
NPO B = 0.17
W = 8.3
3
156
0.06
0.05
1.054 0.0370
Diet texture B = 22.8
W = 713.4
3
156
7.6
4.6
1.663 0.177
Liquid consistency B = 18.6
W = 693.1
3
156
6.2
4.4
1.393 0.247
Presence of tube feeding B = 0.6
W = 7.0
3
156
0.2
0.05
4.457 0.005*
TABLE 3.
Differences in Means Among the Four Data Collection Periods, ANOVA
B = between, NPO = nothing by mouth, W = within
*p ≤ 0.05
Research for Practice
January-February 2018 • Vol. 27/No. 1 43
patients allowed nothing by mouth
(NPO) of developing NV-HAP.
Analysis of variance (ANOVA)
was used to compare changes in
patients’ documented oral care over
time. No significant differences
were found in patient age, orders
for nothing by mouth, diet texture,
and liquid consistency (see Table 3).
Statistically significant findings in
number of times oral care was
refused (p=0.001) or charted
(p=0.000), and the presence of tube
feedings (p=0.005) were analyzed
further using the Scheffe test (see
Table 4). This test identified a signif-
icant increase in number of times
oral care was refused from baseline
compared to weeks 7 (p=0.018) and
9 (p=0.006). Further analysis deter-
mined the number of charted oral
care occurrences improved signifi-
cantly from baseline to weeks 5
(p=0.000) and 9 (p=0.007). Signif –
icant improvement in documenta-
tion occurred be tween weeks 5 and
7 (p=0.000), and between weeks 5
(p=0.000) and 9 (p=0.000), but not
between weeks 7 and 9. Six patients
had tube feedings at week 5; this
was a significant change from base-
line (p=0.021) and from week 9
(p=0.021). At baseline and week 9,
no patients had tube feedings.
TABLE 4.
Post Hoc Analysis: Difference in Means Among Four Data Collection Periods (Scheffe Test)
Dependent Variable
Data Collection
Period
Data
Collection
Period
Mean
Difference Std Error Sig.
95% Confidence Interval
Lower
Bound
Upper
Bound
Documentation:
Number of times oral
care refused
Pre-intervention 5 weeks
7 weeks
9 weeks
-0.3000
-0.6000
-0.6750
0.187
0.187
0.187
0.463
0.018*
0.006*
-0.83
-1.13
-1.2
0.228
-0.07
-0.15
5 weeks
post-intervention
0 weeks
7 weeks
9 weeks
0.3000
-0.3000
-0.3750
0.187
0.187
0.187
0.463
0.463
0.262
-0.23
-0.83
-0.90
0.83
0.23
0.15
7 weeks
post-intervention
0 weeks
5 weeks
9 weeks
0.6000
0.3000
-0.075
0.187
0.187
0.187
0.018*
0.463
0.984
0.07
-0.23
-0.60
1.13
0.83
0.45
9 weeks
post-intervention
0 weeks
5 weeks
7 weeks
0.6750
0.3750
0.0750
0.187
0.187
0.187
0.006*
0.262
0.984
0.15
-0.15
-0.45
1.20
0.90
0.60
Documentation:
Number of times oral
care charted
Pre-intervention 5 weeks
7 weeks
9 weeks
-1.8250
-0.6000
-0.8000
0.226
0.226
0.226
0.000**
0.074
0.007*
-2.47
-1.24
-1.44
-1.19
0.04
-0.16
5 weeks
post-intervention
0 weeks
7 weeks
9 weeks
1.825
1.225
1.025
0.226
0.226
0.226
0.000**
0.000**
0.000**
1.19
0.59
0.39
2.46
1.86
1.66
7 weeks
post-intervention
0 weeks
5 weeks
9 weeks
0.6000
-1.225
-0.2000
0.226
0.226
0.226
0.074
0.000**
0.853
-0.04
-1.86
-0.84
1.24
-0.59
0.44
9 weeks
post-intervention
0 weeks
5 weeks
7 weeks
0.8000
-1.025
0.2000
0.226
0.226
0.226
0.007*
0.000*
0.853
0.16
-1.66
-0.44
1.44
-0.39
0.84
Presence of tube
feeding
Pre-intervention 5 weeks
7 weeks
9 weeks
-0.1500
-0.0500
0.0000
0.047
0.047
0.047
0.021*
0.774
1.000
-0.28
-0.18
-0.13
-0.02
0.08
0.13
5 weeks
post-intervention
0 weeks
7 weeks
9 weeks
-0.1500
0.1000
0.1500
0.047
0.047
0.047
0.021*
0.221
0.021*
0.02
-0.03
0.02
0.28
0.23
0.28
7 weeks
post-intervention
0 weeks
5 weeks
9 weeks
0.0500
-0.1000
0.0500
0.047
0.047
0.047
0.774
0.221
0.774
-0.08
-0.23
-0.08
0.18
0.03
0.18
9 weeks
post-intervention
0 weeks
5 weeks
7 weeks
0.0000
-0.1500
-0.0500
0.047
0.047
0.047
1.000
0.021*
0.774
-0.13
-0.28
-0.18
0.13
-0.2
0.08
*p ≤ 0.05; **=0.00
Improving Oral Care in Hospitalized Non-Ventilated Patients: Standardizing Products and Protocols
January-February 2018 • Vol. 27/No. 144
Discussion
Tada and Miura (2012) noted reg-
ular oral care improves a patient’s
ability to eat, drink, and swallow.
However, the current survey found
staff understanding of this relation-
ship did not increase after educa-
tion. In retrospect, the educational
sessions did not emphasize the rela-
tionship between oral care and the
mechanics of swallowing. Prior to
education, staff already demonstrat-
ed insight to the relationship
between oral care and infection.
This remained high after the educa-
tional intervention. Staff perception
improved regarding the impact of
oral care on self-esteem and the
opportunity to assess a patient’s oral
health, but results were not signifi-
cant. The lack of significance is like-
ly due to a smaller sample on the
follow-up survey. Education ap –
peared effective in improving the
ability of staff to identify patients
who were NPO as at higher risk for
developing NV-HAP. Staff demon-
strated increased awareness be –
tween pre- and post-surveys of the
risk of patients developing NV-HAP
if they have dysphagia, or are tube-
fed or critically ill.
The interventions used in this
study did not reduce or remove
known barriers to providing oral
care identified by Letsos and col-
leagues (2013). In the current study,
survey results did not identify
access to supplies and patient coop-
eration as barriers. The greatest bar-
riers to performing oral care for staff
were time availability and task pri-
oritization. The ability to manage
time associated with oral care and
prioritize it among other nursing
demands remained problematic
before and after the intervention.
Interestingly, perception of ade-
quate staffing as a barrier to oral
care did not change; it also was not
perceived to be a strong barrier.
After the intervention, a statisti-
cally significant finding was staff
improvement of their documenta-
tion of oral care performance as
well as patient refusal of oral care.
Baseline data demonstrated limited
documentation in these areas. Staff
education included standardized
documentation requirements for
oral care. The improvement after
intervention may be related to the
increased value placed on oral care
documentation during this study,
or it may indicate practice changed
because of this intervention.
Limitations
The lack of demographic data
collected on the nursing staff and
the patient sample hindered gener-
alizability to other staff and patient
groups. In addition, the lack of CNA
participation in the post-study sur-
vey affected the interpretation of
results. The staff survey was devel-
oped expressly for this study and
therefore does not have demonstrat-
ed reliability or validity. Another
limitation was the un known rate of
education completion by nursing
staff. This study also did not deter-
mine which intervention was most
effective in improving oral care
practices. Finally, patient acuity may
have increased in the post-interven-
tion phase, as demonstrated by the
increased number of patients with
tube feedings. This may have influ-
enced the ability of staff to perform
oral care or their failure to docu-
ment its occurrence over time.
Recommendations for
Future Research
Additional longitudinal studies
are needed to determine if regular
oral care will prevent NV-HAP.
Future research should focus on
higher-risk patients with the pres-
ence of tube feedings, a diagnosis of
dysphagia, and difficulty managing
secretions after extubation, as well
as those who are NPO, to determine
frequency and efficacy of routine
oral care. Future studies also could
include assessment of the feasibility
and effectiveness of different meth-
ods of targeted staff and patient
education.
Nursing Implications
A knowledge gap was identified
for RNs and CNAs concerning the
importance of patient oral care.
Providing comprehensive staff edu-
cation, using a clearly defined pro-
tocol, and having easily accessible
tools ensured standardization of
practice and elevated the impor-
tance of oral care. On busy medical-
surgical units, nurses may not be
able to provide oral care for every
patient. However, they are responsi-
ble for delegating oral care and they
maintain accountability for its com-
pletion when they are unable to
perform the task themselves. Und –
erstanding the importance of oral
care is a first step toward changing
practice.
Poor oral care is associated with
higher rates of NV-HAP, extended
hospital stays, and the development
of multi-drug resistant organisms
(Kaneoka et al., 2015). Nurses may
be distracted by non-patient related
tasks and lose focus on fundamen-
tal interventions such as oral care,
which is known to minimize
patient complications and hospital
costs (Quinn & Baker, 2015). The
value of providing oral care goes
beyond preventing complications.
Regular oral care offers another
opportunity for the RN to assess the
patient’s self-care ability and pro-
vide health education. This addi-
tional time spent at the bedside
may enhance the nurse-patient
experience.
Nurses in this study voiced frus-
tration over the large list of tasks to
be completed each shift. Partici –
pants had difficulty prioritizing oral
care among other nursing func-
tions. Importantly, nurse leaders
must remain aware of nursing inter-
ventions on their units that con-
tribute to the best patient out-
comes; oral care should be among
those tasks. RNs need support and
proficiency in prioritizing, delegat-
ing, and ensuring performance of
tasks that enhance safety. The cur-
rent study found patients may have
a stronger influence on the frequen-
cy of oral care practices than previ-
ously understood. This finding sug-
gests nursing staff and patients
should be partners in ensuring com-
pletion of oral care. Nurses also
must be competent in coaching
patients regarding the importance
of oral health habits.
Research for Practice
January-February 2018 • Vol. 27/No. 1 45
Conclusion
Previous research recommended
overcoming barriers to routine oral
care hygiene as a strategy for reduc-
ing NV-HAP (Letsos et al., 2013).
Barriers found in the literature
include limited time, resource con-
straints, patient behaviors, and staff
knowledge gaps. This study reduced
the barrier of limited time and
resources through CNA, RN, and
patient use of a bedside oral hygiene
kit, contributing to improved oral
care documentation. Although the
study did not determine the impact
of patient behavior as a barrier to
the frequency of oral care, it identi-
fied the existence of gaps in staff
knowledge regarding oral care.
Targeted education to overcome this
barrier likely had clinical signifi-
cance.
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Improving Oral Care in Hospitalized Non-Ventilated Patients: Standardizing Products and Protocols
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www.aana.com/aanajournalonline AANA Journal February 2018 Vol. 86, No. 1 19
Temperature monitoring is a standard of anesthesia
care as listed in Standard V of the American Asso-
ciation of Nurse Anesthetists Standards of Nurse
Anesthesia Practice. The purpose of this quantitative
correlational study was to examine which temperature
modality (tympanic vs temporal) best correlates with
pediatric surgical patients’ core rectal temperature.
Data were from a sample of 106 intraoperative pedi-
atric surgical patients with ASA physical classifica-
tion 1 or 2 who were scheduled for elective surgical
procedures.
Findings from this study support that tympanic tem-
perature correlates more to core rectal temperature
both before (Pearson r = 0.36 vs 0.16) and after surgery
(Pearson r = 0.57 vs 0.33) and had less bias with core
rectal temperature (r = 0.37 vs 0.55) than temporal
temperature. Multiple regression analyses further sup-
ported tympanic temperature as the best predictor of
core rectal temperature both before surgery (R2 = 0.17,
R2adj = 0.13, F(5, 100) = 4.18, P = .0007) and after sur-
gery (R2 = 0.34, R2adj =0 .30, F(7, 99) = 7.47, P = .001).
Although generalizations are limited beyond this study
population, the findings add support to recommend
tympanic temperature as the temperature modality of
choice in the pediatric surgical population.
Keywords: Core temperature, pediatric surgical
patients, temperature, temporal temperature, tym-
panic temperature.
Relationship of Tympanic and Temporal
Temperature Modalities to Core Temperature
in Pediatric Surgical Patients
Debra J. Minzola, PhD, MSN, CRNA
Rebecca Keele, PhD, PHCNS-BC
T
emperature is one of the oldest monitored vital
signs used to measure human physiology and
the body’s response to stress and illness. One
responsibility of Certified Registered Nurse
Anesthetists (CRNAs) in the operating room
(OR) is patient temperature monitoring. The historical
timeline of thermometers began in the 16th century by
Galileo, but the method changed in 1709 when Daniel
Fahrenheit developed an alcohol-filled thermometer and
a mercury-filled thermometer.1,2 William Squire, a medi-
cal student in London in 1846, was the first to use these
thermometers to monitor his patients under anesthesia.1
Squire concluded through his seminal research that
activity increases body temperature and rest lowers body
temperature.3
Developments in temperature monitoring and anes-
thesia during the 1800s and early 1900s made it possible
to observe the effects of anesthesia on patients’ body
temperature.1,2,4 In 1868, Carl Wunderlich developed
the clinical thermometer used in medicine for the next
130 years.2 Throughout the 1900s, an ongoing rise in
morbidity and mortality occurred in surgical patients.
Hypothermia led to coagulopathy, surgical wound infec-
tions, delayed recovery, and death in surgical patients.1,2,4
The hazards of hypothermia and hyperthermia led to rec-
ognizing the importance of routine temperature monitor-
ing and early identification of temperature extremes in
the OR.5-7 The development of the thermometers in use
in the 21st century occurred in the 1800s by measuring
the heat conducted from mucous membranes or skin
by direct contact.8 Seminal research indicated concerns
regarding the imbalance of patient thermoregulation due
to clinical conditions in the OR.
One measure that may reduce the risk of surgical com-
plications is temperature monitoring and accurate main-
tenance of normothermia in surgical patients. General an-
esthesia impairs thermoregulation; both inhalation agents
and nitrous oxide inhibit thermoregulatory vasoconstric-
tion in the surgical patient. This measure signifies the
importance of the study in monitoring pediatric patients’
intraoperative temperature with the best temperature
modality correlating with the pediatric patients’ core
temperature as they transition through the surgical suite.
The Surgical Care Improvement Project (SCIP), formed in
2003, consists of numerous nationally recognized organi-
zations: the American Hospital Association, the Agency for
Healthcare Research and Quality, the Centers for Disease
Control and Prevention, the Institute for Healthcare
Improvement, the Centers for Medicare and Medicaid
Services (CMS), the Joint Commission, and the Veterans
Health Administration.9 The primary objective of the SCIP
is to reduce the risk of surgical complications.9
The goal of this national campaign and partnership
is a 25% reduction in surgical complications. The SCIP
20 AANA Journal February 2018 Vol. 86, No. 1 www.aana.com/aanajournalonline
is an extension of CMS, which funded the previous
initiative: the Surgical Infection Prevention Project.9
To receive 100% of the annual payment, updated by
CMS, hospital leaders must participate in the Medicare
Hospital Inpatient Quality Reporting Program.10
Previous studies have focused on obtaining con-
tinuous recordings of adult patients’ temperatures using
esophageal and tympanic temperature monitors while
patients were under anesthesia.11 This emphasis on the
importance of temperature measurement intraoperatively
supports the need for the current study with its focus on
the pediatric surgical population, which is more vulnera-
ble than adults.11 Pediatric patients are a population with
an increased risk of complications related to extremes of
temperature intraoperatively because of their proportion-
ately large body surface area.12-14 These intraoperative
and postoperative complications include coagulopa-
thy, surgical wound infections, delayed recovery time,
prolonged neuromuscular blockade, increased surgical
wound infections, and death.1,2,4 Pediatric patients are
considered a vulnerable patient population because of
the potential risk of impaired body temperature regula-
tion stemming from their large body surface area.12-14
Prevention of complications in pediatric surgical patients
related to temperature variation is critical for patient
safety and positive outcomes. Since the early 1990s, tech-
nological innovations have helped healthcare providers
detect and measure the infrared energy radiated from
the human body.8 Both temporal and tympanic ther-
mometries are standards of care in the OR suite, require
minimum patient cooperation, and are quick and easy to
use, but healthcare providers often question the accuracy
of both methods.15
There is continued controversy over which non-
invasive temperature monitoring method used in the
preoperative and postoperative units most closely relates
to core body temperature of pediatric surgical patients.
Although rectal or pulmonary artery catheter tempera-
ture measurement is an appropriate method to measure
core temperature, it is often not feasible to use because of
the level of invasiveness, type of surgical procedure, and
potential risk of contamination. Thus, it is important to
explore the relationship between noninvasive methods
and core body temperature. The most widely used non-
invasive temperature measuring methods during the
surgical experience from preoperative to perioperative to
recovery room are the tympanic and temporal tempera-
ture measurements. Research has been saturated with
focus on temperature measurement in the adult patient
population in various settings. However, limited research
exits on which temperature modality most closely relates
to core body temperature in the pediatric surgical patient.
Therefore, current research has yielded mixed find-
ings regarding which modality is best for the pediatric
population in general. Intraoperatively, esophageal and
nasal temperature measurements are often performed.
Esophageal temperature methods were not applicable to
the present study because the esophagus is not always
accessible in many surgical cases in this patient popula-
tion. However, tonsillectomy and adenoidectomy were
among the procedures evaluated in this study. The use
of irrigation in the oral pharynx created the concern for
unreliable temperature measurements; therefore, esopha-
geal and nasopharyngeal temperature measurement was
not considered for the dependent variable in this study.
The purpose of the current study was to determine which
method of temperature measurement most closely re-
flects core temperature by comparing rectal temperature
measurement to the less invasive tympanic and temporal
temperature measurements in children during the peri-
operative period.
Methods
Because the focus of this study was on examining the
relationship between rectal temperature and tympanic/
temporal temperature measurements, a quantitative cor-
relational research design was chosen. Eligibility criteria
for this study included ASA classes 1 and 2, age 3 to
17 years, and elective surgical procedure scheduled
at Geisinger Medical Center or Geisinger Woodbine
Outpatient Surgery in Danville, Pennsylvania. Healthy
pediatric outpatients were the target sample for this
study. Patients excluded from this study were any who
required emergency surgery, sustained trauma, or had
an ASA classification greater than class 2 because of con-
genital defects or ear or rectal anomalies.
There were 2 primary research questions: (1) How
do tympanic and temporal temperatures relate to rectal
temperature in the pediatric surgical patient population?
(2) Which temperature modality (tympanic or temporal)
commonly used in the pediatric surgical patient popu-
lation most accurately reflects rectal temperature after
controlling for age, gender, type and length of surgery,
and OR temperature?
Institutional review board approval was obtained
at Geisinger Medical Center for all pediatric patients
undergoing surgery at Geisinger Medical Center or
Geisinger Woodbine Outpatient Surgery who satisfied
the eligibility criteria. A researcher’s contact information
was given to the patients and families if they wanted their
study data to be removed from the study after their surgi-
cal experience.
• Study Participants. Participation for this study re-
quired written parental or guardian consent. Information
on the consent form included the title of the study, an
explanation of the voluntary involvement of the partici-
pant, the lead researcher’s (D.J.M.) contact information,
and the parental authorization form for the Geisinger
Health System. Study description included the tempera-
ture methods the researcher would use, a description of
www.aana.com/aanajournalonline AANA Journal February 2018 Vol. 86, No. 1 21
the data the researcher would collect, and the study’s
purpose and procedure. Parental consent form included
the presence of any risks, such as an alteration in an-
esthetic technique, and the benefits, such as additional
patient temperature methods. The permission form in-
cluded provisions for patient anonymity. After receiving
an informed parental consent form for participation, the
researcher placed a coded alphanumeric index card on
the head portion of the OR stretcher; this code indicated
consent to participate in the study for the data collector.
The code on the index card matched the alphanumeric
code on the signed parental consent and child assent
forms. In addition, the index card informed the data col-
lector of the correct code to list on the data collection
chart intraoperatively. The researcher shredded each
participant’s index card and discarded it in the OR trash
can immediately after completion of the surgery.
The current study had 7 variables, and assuming =
.05 and power = .80, moderate effect size with R = 0.13,
and 7 predictor variables, Tabachnick and Fidell16 sug-
gested estimating sample size using the formula 50 +
(8 × Number of predictors). Using this guideline with 7
predictors, the sample size should be at least (50 + [8 ×
7]) = 106. One surgical procedure was canceled before
data collection because the child vomited on induction
of anesthesia, and the researcher recruited an additional
participant to meet the requirement for 106 participants.
• Data Collection. Data collection involved taking
tympanic temperature (Braun ThermoScan PRO 4000 ear
thermometer, Welch-Allyn, Skaneateles Falls, NY) and
temporal temperature (Exergen thermometer, Exergen
Corp, Watertown, MA) at the start and the end of the
patient’s surgery. Timing of the collection of the tym-
panic and temporal temperature measurements was
important because it best reflected the pediatric surgical
patients’ temperature in the preoperative and postop-
erative units where nursing staff use the noninvasive
temperature monitors. For data collection purposes, the
start of surgery was defined as after induction of general
anesthesia and intravenous access placement; the end of
surgery was defined as completion of surgical procedure
and removal of surgical drapes. Because of variability in
the length of surgeries, measuring tympanic and tempo-
ral temperatures at the start and end of the case allowed
for the best reflection of patients’ temperature in the
preoperative and postoperative care units where these
monitors are normally used during assessment for base-
line measurements to guide the plan of care. The data
collection for the study took place at the start and end of
the surgical procedure in the OR by the anesthesia pro-
vider assigned to the room; the researcher was present to
ensure consistency in data collection among subjects.
The anesthesia provider received information on the
data collection sequence before the procedure and had re-
search study guidelines, including timing and procedural
approach of temperature measurements, available for ref-
erence on the morning of the surgical procedures. Rectal
temperature was documented on the data collection tool
10 minutes after insertion to account for adjustment
of body temperature and measured continuously after
induction of general anesthesia using a standard-sized
9F level 2 esophageal/rectal temperature probe (Smiths
Medical, Dublin, OH). All temperature monitoring ceased
at the end of the surgical case before extubating the
patient to prevent patient awareness and discomfort.
The CRNAs collected temperature measurements
for 106 pediatric patients on the day of their scheduled
surgery. Data collection extended throughout an 11-
week, 4-day period to obtain the required sample size
of 106 pediatric surgical participants. The data included
participants’ demographic data, which were age, gender,
surgical procedure, and operating room temperature.
After the induction of general anesthesia and secured
endotracheal tube, the anesthesia provider monitored
a constant core temperature rectally in each individ-
ual patient for the length of the surgical case using a
Smiths Medical ER400-9, TAT-5000 temporal monitors
by Exergen, and Braun PRO 4000 tympanic monitors by
Welch-Allyn. Every patient received room-temperature
intravenous fluids. According to the Geisinger Infoweb,17
the surgical OR temperature remained at 20.0° to 23.9°C
(68°F to 75°F) in every OR according to the hospital in-
fection control guidelines.
• Data Analysis. The study involved collecting 3 tem-
perature measurements (tympanic, temporal, and rectal)
from each pediatric surgical patient enrolled in the study
during the data collection period at the start and end of
the surgical case. Because there were no missing tempera-
ture measurements, all temperature measurements for
the 106 pediatric surgical patients were included in the
analysis. Data analysis for this study was performed using
SAS software version 9.2 (SAS Institute Inc, Cary, NC).
Results
Of the 106 study participants, 48 (45.3%) were female
and 58 (54.7%) were male. The ages of the participants
ranged from 3 to 17 years, with the mean age being 7.67
years (SD = 3.95 years). Most cases were ear, nose, and
throat procedures (45.28%), which lasted an average of
47.99 minutes with a mean OR room temperature of
21.94°C. Mean temperatures at the start of surgery were
36.93°C (rectal), 37.30°C (tympanic), and 37.31°C (tem-
poral). At the end of surgery mean temperatures were
36.82°C (rectal), 37.05°C (tympanic), and 37.37°C (tem-
poral). No significant differences were found in mean OR
room temperature from start of surgery (21.67°C) to end
of surgical procedure (22.2°C).
To answer the research questions, the investigators
used Pearson r correlational analysis to examine the re-
lationship between tympanic, temporal, and rectal tem-
22 AANA Journal February 2018 Vol. 86, No. 1 www.aana.com/aanajournalonline
peratures. Correlation between tympanic temperature and
rectal temperature at the end of the surgical procedure was
significant, with P < .0001 and a correlation coefficient
of 0.57. Correlation between temporal temperature and
rectal temperature at the end of the surgical procedure
was also significant, with P = .0007 and a correlation coef-
ficient of 0.33. Results of the correlation analysis are pre-
sented in Tables 1 and 2. The coefficient of determination
of the tympanic-rectal temperature (r = 0.57, R2 = 0.32)
revealed that 32% of the total variation can be explained
by the linear relationship between the tympanic and rectal
temperature measurements. However, the coefficient of
determination of the temporal-rectal temperature (r =
0.33, R2 = 0.10) indicated that only 10% of the total varia-
tion in temperature can be explained by the linear relation-
ship between the temporal and rectal temperature mea-
surements. Therefore, the relationship between temporal
temperature and rectal temperature was uniformly weaker
than the relationship between tympanic temperature and
rectal temperature (Tables 1 and 3).
Bland-Altman analysis indicated the bias between the
mean differences and the agreement interval between
tympanic, temporal, and rectal temperature methods.
The differences between the tympanic and rectal tem-
perature and the temporal and rectal temperature are
plotted against the average measurement of the 2 tem-
perature devices. Bland-Altman plot analysis revealed a
bias of only 0.37 with 95% limits of agreement ranging
from to 1.35 to 0.62 when comparing the measurements
of tympanic and rectal temperature at the start of surgery
(Figure 1).
Plot analysis of the tympanic and rectal temperatures at
the end of surgery revealed a bias of .37 with 95% limits
of agreement ranging from 1.54 to 0.79 (Figure 2). The
data results indicated tympanic temperature and rectal
temperature were consistently similar, both at the start
and end of the surgical case. In comparison, the Bland-
Altman plot between temporal temperature and rectal
temperature methods at the start of surgery revealed a bias
of -0.37 with 95% limits of agreement ranging from 0.79
to 1.5 (Figure 3).
In addition, plot analysis of the temporal temperature
and rectal temperature at the end of surgery revealed a
bias of 0.55 with 95% limits of agreement ranging from
0.97 to 2.07. This finding indicated the 2 temperature
measures provided similar measures at the start of the
surgical case but had a larger bias at the end of the surgi-
cal case (Figure 4).
The difference in bias between temperature measure-
ments at the start of the surgical case was 0.37, whereas
the difference in bias between temperature measurements
at the end of the surgical case was 0.55. Both tympanic
Table 1. Pearson Correlation of Tympanic, Temporal, and Rectal Temperatures at End of Surgerya
aN = 106 for all analyses.
bP = .0001.
Variable Tympanic Temporal Rectal
Tympanic 1.0
Temporal 0.63 1.0
Rectal 0.57b 0.33 1.0
Table 2. Temperature Measurements at Start and End of Surgerya
aN = 106 for all analyses.
Percent
Limits of agreement within limits
Temperature method Bias SD Lower Upper of agreement
Tympanic–rectal, start of surgery – 0.37 0.49 – 0.62 1.35 95
Tympanic–rectal, end of surgery – 0.37 0.65 – 0.79 1.54 95
Temporal–rectal, start of surgery – 0.37 0.58 – 0.79 1.5 95
Temporal–rectal, end of surgery – 0.55 0.76 – 0.97 2.07 95
Table 3. Pearson Correlation of Tympanic, Temporal, and Rectal Temperatures at Start of Surgerya
aN = 106 for all analyses.
bP = .0002.
Variable Tympanic Temporal Rectal
Tympanic 1.0
Temporal 0.45 1.0
Rectal 0.36b 0.16 1.0
www.aana.com/aanajournalonline AANA Journal February 2018 Vol. 86, No. 1 23
and temporal temperature measurements are lower than
the core rectal temperature both at the start and end of
surgery. However, tympanic temperature measurements
had smaller (less negative) bias than temporal temperature
compared with the core rectal temperature (see Table 2).
Although both tympanic and temporal temperatures
were positively correlated to core rectal temperature,
tympanic temperature was more strongly correlated both
at the start and end of surgery. Furthermore, results of
the Bland-Altman analysis supported less bias and greater
levels of agreement between tympanic temperature and
core rectal temperature vs temporal temperature and core
rectal temperature. Although differences between both
tympanic and temporal temperature measurements and
core rectal temperature were small, a greater bias and
wider limits of agreement existed between temporal and
core rectal temperature measurements.
Two separate multiple regression analyses were per-
Ty
m
p
a
n
ic
T
e
m
p
e
ra
tu
re
–
R
e
ct
a
l T
e
m
p
e
ra
tu
re
Mean
Mean of Tympanic and Rectal Temperatures
Figure 1. Bland-Altman Plot of Tympanic and Rectal Temperature Before Surgery
Ty
m
p
a
n
ic
T
e
m
p
e
ra
tu
re
–
R
e
ct
a
l T
e
m
p
e
ra
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re
Mean
Mean of Tympanic and Rectal Temperatures
Figure 2. Bland-Altman Plot of Tympanic and Rectal Temperature at End of Surgery
24 AANA Journal February 2018 Vol. 86, No. 1 www.aana.com/aanajournalonline
formed using the general linear model because the dataset
included both continuous and categorical variables. In
the first analysis examining temperature measurements
at the start of the surgical procedure, the predictor vari-
ables were tympanic and temporal temperatures at the
start of surgery and the criterion variable was core rectal
temperature. Covariates include patient age, gender, and
temperature of the OR. Results of regression analysis
examining which temperature modality (tympanic vs
temporal) is the most accurate predictor of core rectal
temperature at the start of the surgical procedure indi-
cated an overall model of 1 independent variable (tym-
panic temperature, P = .001) that significantly predicted
core rectal temperature, R2 = 0.17, R2adj = 0.13, and F(5,
100) = 4.18, P = .0007. This model accounted for 17% of
variance in core rectal temperature (Table 4).
To examine the influence of length of surgery and type
of surgery on core rectal temperature, the researchers
Te
m
p
o
ra
l T
e
m
p
e
ra
tu
re
–
R
e
ct
a
l T
e
m
p
e
ra
tu
re
Mean
Mean of Temporal and Rectal Temperature
Figure 3. Bland-Altman Plot of Temporal and Rectal Temperature Before Surgery
Te
m
p
o
ra
l T
e
m
p
e
ra
tu
re
–
R
e
ct
a
l T
e
m
p
e
ra
tu
re
Mean
Mean of Temporal and Rectal Temperature
Figure 4. Bland-Altman Plot of Temporal and Rectal Temperature at End of Surgery
www.aana.com/aanajournalonline AANA Journal February 2018 Vol. 86, No. 1 25
conducted a separate regression analysis using end-of-
surgery tympanic and temporal temperatures as predic-
tor variables and core rectal temperature as the criterion
variable. This model added the length of surgery and type
of surgery covariates to the regression analysis because
increased length of time in the OR environment while the
patient was under general anesthesia could significantly
affect the anesthetized pediatric patient’s core rectal tem-
perature. Type of surgery can increase exposure of the
patient to the OR environment and negatively affect core
rectal temperature. Results indicated that tympanic tem-
perature was the only variable that significantly predicted
core rectal temperature, R2 = 0.34, R2adj = 0.30, F(7, 99)
= 7.47, P = .001. This model accounted for 34% of vari-
ance in core rectal temperature. A summary of regression
coefficients appears in Table 5 and indicates that the
tympanic temperature at the end of surgery (P = .00001)
was the only variable that contributed significantly to the
model after adjustment for age, gender, temperature of
the OR, length of surgery, and type of surgery.
Discussion
The results of this study showed that neither tympanic
nor temporal temperature measurement were a perfect
analog to core rectal temperature. In this study, tym-
panic temperature measurement seems to be second best
compared with rectal temperature measurement in the
pediatric surgical patient but is not ideal.
The study had a few potential limitations. Several
factors such as OR (room) temperature, body weight
and size of the patient, and skin exposure during surgery
may affect a surgical patient’s temperature. However,
OR temperature was not a significant predictor of body
temperature in this study. Furthermore, most cases were
ear, nose, and throat cases, thus reducing the possible
limitation caused by skin exposure during surgery. Very
young patients were excluded from the study, decreasing
the impact of body size on temperature measurements.
However, the impact of these potential confounding vari-
ables could be examined in future research.
Results from this study may lead to the promotion of
developing a standardized temperature protocol in pre-
operative and postoperative areas of the surgical suite.
Findings of this research study support recommending
that the protocol for temperature measurement during
the pediatric surgical patient experience include using
the tympanic temperature modality throughout the OR
suite. The most effective measure that practitioners can
provide to protect surgical patients from undetected
temperature change is accurate temperature monitor-
ing. Although the results of this study’s findings indicate
tympanic temperature measurement is inferior to core
rectal temperature measurement, it remains the next best
noninvasive measurement in the preoperative and post-
operative settings.
Table 4. Regression Table With Five Predictor Variables at Start of Surgery
Variable 95% CI Partial correlation t P
Age .02 6.91-8.43 0.006 1.92 .058
Gender .02 – 0.15- – 0.19 0.592 0.25 .805
Temperature of operating room .02 71.01-71.96 0.00002 1.45 .151
Tympanic temperature .36 37.22-37.38 0.009 3.33 .001
Temporal temperature .01 37.22-37.39 0.006 0.13 .896
Table 5. Regression Table With Seven Predictor Variables at End of Surgery
Variable 95% CI Partial correlation t P
Age .002 6.91-8.43 0.006 0.12 .904
Gender – .09 – 0.09-0.25 0.592 – 0.89 .378
Temperature of operating room .01 71.01-71.96 0.00002 0.64 .526
Tympanic temperature .39 36.90-37.19 0.280 4.65 .00001
Temporal temperature – .03 37.23-37.51 0.002 – 0.39 .694
Length of surgery .002 41.2-54.8 0.149 1.72 .089
Type of surgery .009 – 0.26- – 0.05 0.021 0.13 .898
26 AANA Journal February 2018 Vol. 86, No. 1 www.aana.com/aanajournalonline
AUTHORS
Debra J. Minzola, PhD, MSN, CRNA, is an assistant professor at Blooms-
burg University of Pennsylvania and program director of the Geisinger
Health System/Bloomsburg University of Pennsylvania Nurse Anesthesia
Program. She completed this research study for her dissertation and
graduate requirements from University of Phoenix. Email: djminzola@
geisinger.edu.
Rebecca Keele, PhD, PHCNS-BC, is a professor at Texas Woman’s
University in the College of Nursing, Denton, Texas. She served as the
dissertation chair for Dr Minzola during the completion of this research
study. Email: bkeele@nmsu.edu.
DISCLOSURES
The authors have declared no financial relationships with any commercial
entity related to the content of this article. The authors did not discuss
off-label use within the article.
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APRIL2018, VOL. 22 NO. 2 CLINICAL JOURNAL OF ONCOLOGY NURSING 203
CJON.ONS.ORG
E
Aromatherapy
The effect of lavender on anxiety and sleep quality in patients
treated with chemotherapy
Ayse Özkaraman, RN, PhD, Özlem Dügüm, RN, Hülya Özen Yılmaz, MSc, and Öznur Usta Yeşilbalkan, RN, PhD
ESSENTIAL OILS ARE CHEMICALS EXTRACTED FROM PARTS OF PLANTS that have a
unique aroma and complex chemical properties (National Cancer Institute
[NCI], 2018; Worwood, 2016). Essential oils can be inhaled, digested, or
applied topically, and they are eliminated from the body through urine and by
respiration (Maddocks-Jennings & Wilkinson, 2004; NCI, 2018). They were
introduced to nursing care by Florence Nightingale, and their use grows daily
by nurses with certification in the use of essential oils (Gnatta, Kurebayashi,
Turrini, & Silva, 2016; Smith & Kyle, 2008).
Lavender is a member of the mint family and contains linalyl acetate,
linalool, and caryophyllene. Lavandula angustifolia increases the effect of
gamma-Aminobutyric acid on the amygdala and has narcotic and sedative
effects similar to those of benzodiazepines (Conrad & Adams, 2012; Fismer
& Pilkington, 2012; Maddocks-Jennings & Wilkinson, 2004). In addition,
Lavandula hybrida has relaxing and sedative properties (Price & Price, 2011).
In addition to its antibacterial, antifungal, and carminative characteristics,
which increase wound healing and the detoxification of enzymes associated
with insect bites, lavender has no known contraindications and is safe to
use (Braden, Reichow, & Halm, 2009; Howard & Hughes, 2008; Kritsidima,
Newton, & Asimakopoulou, 2010; Muzzarelli, Force, & Sebold, 2006).
Inhaling lavender has been reported to have an immediate effect, and topical
administration takes effect in 10–90 minutes and lasts a few days (Worwood,
2016).
Lavender is used for spiritual relaxation, for therapeutic purposes (to
build physical and emotional well-being), and for regulation of sleep disor-
ders (Koulivand, Khaleghi Ghadiri, & Gorji, 2013; Kritsidima et al., 2010).
In a study conducted by Franco et al. (2016), 2% lavender oil was admin-
istered to one group of women and odor-free aromatic oil was given to
another group for 10 minutes through an oxygen mask before all under-
went a breast biopsy. Women who inhaled lavender oil reported decreased
negative feelings, and the aromatherapy was shown to be effective in
the management of preoperative anxiety (Franco et al., 2016). Another
study showed that smelling four drops of 10% lavender oil for four weeks
improved sleep quality in postpartum women (Keshavarz Afshar et al.,
2015). Kritsidima at al. (2010) observed the diagnosis and treatment
procedures carried out on a group of patients who visited an outpatient
clinic for dental treatment in a room where a 10-cc cup of water with 5
drops of lavender oil was located. They observed the procedures con-
ducted on another group in an odor-free room. At the end of the study,
KEYWORDS
aromatherapy; lavender; sleep quality;
anxiety; PSQI; STAI; chemotherapy
DIGITAL OBJECT IDENTIFIER
10.1188/18.CJON.203-210
BACKGROUND: A cancer diagnosis is a serious
stressor that is associated with anxiety, depression,
sleep disorders, and inability to fulfill daily routines.
Many pharmacologic and nonpharmacologic
options are available to help patients with cancer
manage anxiety.
OBJECTIVES: This randomized, controlled trial
examined the effects of lavender oil aromatherapy
on anxiety and sleep quality in patients undergoing
chemotherapy.
METHODS: 70 patients were randomly assigned
to a lavender oil group, a tea tree oil group, and a
control group with no oil. A patient identification
form, the State-Trait Anxiety Inventory, and the
Pittsburgh Quality Sleep Index (PSQI) were used to
measure anxiety and sleep quality before and after
chemotherapy.
FINDINGS: State anxiety before and after chemo-
therapy did not vary among groups. The authors
compared trait anxiety values before and after
chemotherapy and found a significant difference in
the lavender group. In addition, a significant change
in PSQI measurements before and after chemother-
apy was observed.
204 CLINICAL JOURNAL OF ONCOLOGY NURSING APRIL 2018, VOL. 22 NO. 2 CJON.ONS.ORG
AROMATHERAPY
“The use of lavender
oil significantly
increased the sleep
quality of patients
with cancer.”
they found that the anxiety levels of the patients undergoing
procedures in the room with the lavender aromatherapy were
lower (Kritsidima et al., 2010). Although lavender oil is used
for the management of anxiety and sleep disorders in varied
populations, no studies to date have reported on the efficacy
of lavender oil to better manage anxiety and sleep disorders in
patients undergoing chemotherapy.
Patients with cancer experience symptoms from their disease
and treatment, including fear of death, poor quality of life, and
damaged relationships, which can cause a feeling of a loss of con-
trol, anxiety, and sleep disorders (Chandwani et al., 2012; Chang
& Lin, 2017; Delsigne, 2013; Graci, 2005; NCI, 2016; Palesh et al.,
2010; Yaranoğlu, 2015). Oncology nurses play an important role in
the pharmacologic and nonpharmacologic management of anxiety
and sleep disorders. Many pharmacologic treatments are used to
manage anxiety and sleep disorders, but they can lead to adverse
effects and economic loss (NCI, 2016). Nonpharmacologic treat-
ments that are effective in treating anxiety and sleep disorders
include participating in relaxation exercises, listening to music,
shifting attention, practicing sleep hygiene, and using aroma-
therapy (Cramer, Lauche, Langhorst, Dobos, & Paul, 2013; Dóro,
Neto, Cunha, & Dóro, 2017; Emberly, 2008; Firmeza et al., 2017;
Gallagher, Lagman, & Rybicki, 2017; Ovayolu, Seviğ, Ovayolu,
& Sevinç, 2014; Zupanec et al., 2017). The current study was
designed to evaluate the effects of lavender oil on anxiety and
sleep quality in patients receiving chemotherapy.
Methods
Participants
The study sample consisted of patients with cancer who were
receiving chemotherapy in outpatient units. Inclusion criteria
were as follows: patients with cancer aged 18 years or older who
had the ability to smell, were receiving paclitaxel weekly, agreed
not to use scented products, and volunteered to participate in the
study. The exclusion criteria included having a chronic disease
(cardiovascular disease, asthma), being diagnosed with a psychi-
atric disease (anxiety, panic attacks, depression), having a known
history of allergies, and using anxiolytic drugs.
Outcome Measures
For the collection of data, the researchers used a patient iden-
tification form created for the study, The State-Trait Anxiety
Inventory (STAI), and the Pittsburgh Sleep Quality Index (PSQI).
The patient identification form included questions about
patients’ socio-demographic characteristics (age, sex, educa-
tional status, marital status, information about caregivers), sleep
characteristics (room temperature, sound, light, day and night
sleep durations), and disease characteristics (diagnosis, treat-
ment, and duration of disease).
The STAI is a self-evaluation questionnaire that uses short
statements to evaluate how participants feel in a certain time
or under a certain condition. It was adapted to Turkish by Öner
and Le Compte (1985) and was used in this study. It has two sub-
scales, the State Anxiety Scale (S-Anxiety) and the Trait Anxiety
Scale (T-Anxiety), which are measured by a four-point Likert-
type scale ranging from 1 (never) to 4 (always). According to
reliability analysis, the Cronbach alpha internal consistency coef-
ficients are from 0.94–0.96 for the S-Anxiety and from 0.83-0.87
for the T-Anxiety, respectively (Kara & Acet, 2012; Şirin, Kavlak,
& Ertem, 2003). The STAI clearly differentiates between the
temporary condition of state anxiety and the more general and
long-standing quality of trait anxiety, helping professionals dis-
tinguish between feelings of anxiety and depression.
The PSQI was developed by Buysse, Reynolds, Monk, Berman,
and Kupfer (1989), and Ağargün, Kara, and Anlar (1996) performed
its validity and reliability analyses in Turkey. The Turkish version
was used in this study. Although the PSQI consists of 24 items, it
is scored using 19 items. It includes open-ended questions, such
as “During the past month, when have you usually gone to bed
at night?” as well as multiple-choice questions, such as “During
the past month, how would you rate your sleep quality overall?”
with answers ranging from 0 (very good) to 3 (very bad) or 0 (not
during the past month) to 3 (three or more times a week). It has 7
components, each scored from 0–3. Total scores range from 0–21
points. Scores lower than five points indicate good sleep quality,
and scores higher than five points indicate poor sleep quality
(Ağargün et al., 1996).
Data Collection
Before initiating this study, the researchers obtained written per-
mission from the ethical committee and administration of the
Private Ümit Hospital in Eskişehir, Turkey. After the researchers
recruited patients who met the criteria, they obtained written
consent. Using the random-number method on a computer, the
authors randomized participants to one of three groups (lavender
oil group, tea tree oil group, or control group). The patients were
homogeneously distributed across groups, and the data were
collected by a nurse who was independent of the research team.
The patients’ records and group numbers were delivered to the
APRIL 2018, VOL. 22 NO. 2 CLINICAL JOURNAL OF ONCOLOGY NURSING 205CJON.ONS.ORG
CJON.ONS.ORG
administering nurse in a closed envelope. Numbered labels were
affixed to the bottles of aromatic oils to blind the contents of the
bottles to patients and the administering nurse.
The researchers bought the lavender essential oil (Lavandula
hybrida) from an herbal product firm with quality certifications,
consisting of business registration G06-3231 from the Ministry
of Food, Agriculture, and Livestock, and ISO 9001:2008 from
the International Organization for Standardization. The tea tree
oil used in the current study was bought from the same herbal
product firm. In their study, Howard and Hughes (2008) used
tea tree oil, which does not have a sedative or relaxing effect, to
create a placebo effect, as it was used in the current study.
In the first and second stages of the study, lavender oil and tea
tree oil were administered to the respective intervention groups,
and no aromatherapy was administered to the control group.
Three drops of lavender or tea tree oil were put onto a piece of
cotton that was placed on each patient’s neck and shoulders,
about 10 inches below the nose.
FIRST ASSESSMENT: The authors used a patient identification
form, the STAI (T-Anxiety and S-Anxiety), and the PSQI for the
first evaluation of all groups just before the first cycle of chemo-
therapy. During chemotherapy, the nurse administered lavender
and tea tree oil to the respective intervention groups. No aroma-
therapy was administered to the patients in the control group.
When the patients completed chemotherapy, the S-Anxiety was
readministered to all patients.
SECOND ASSESSMENT: The nurse gave written and verbal
information about the use of lavender or tea tree oil at home to
patients in the respective intervention groups when they were
discharged after chemotherapy. For one month, the lavender
group patients and tea tree oil patients smelled the oil every
night at 9 pm for five minutes at home. After chemotherapy, the
T-Anxiety and PSQI were readministered, and a second evalua-
tion was performed.
Statistical Methods and Data Analysis
Descriptive statistics for quantitative variables were calculated
and presented as a mean and standard deviation. Frequencies
and percentages were given for qualitative variables, and the
Shapiro-Wilk test was used to evaluate the normality of quan-
titative variables. Scores from the scales were assessed with
two-way mixed analysis of variance (ANOVA) using general
linear models for repeated measures procedure from IBM SPSS
Statistics, version 21.0. The model included group and time as
main effects and a group * time interaction effect term. Post
hoc testing was carried out only for significant interactions and
was performed using a simple effect analysis with Bonferroni
adjustment. The relationship between categorical variables was
evaluated using Pearson chi-square analysis. A probability value
of less than 0.05 was considered significant, unless otherwise
noted.
Findings
Sample Characteristics
Of the participants, 30 were in the lavender group, 20 were in the
tea tree oil group, and 20 were in the control group. The mean
age of the participants was 58.22 years. Most were women and
were married, and about half were graduates of primary school.
The distribution of patients by age, sex, educational status, mar-
ital status, and income level was homogeneous (p < 0.05) (see
Table 1). In addition, 10 expressed that their income met their
expenses, most had breast cancer, 22 were undergoing paclitaxel-
carboplatin treatment, and 7 had not experienced any symptoms
in the past week.
State-Trait Anxiety Inventory Scores
According to the S-Anxiety and T-Anxiety scores from the first
assessment before chemotherapy, all patients had moderate
state and trait anxiety. In the second assessment, S-Anxiety and
T-Anxiety mean scores decreased in all groups.
Table 2 shows descriptive statistics. In terms of S-Anxiety
values, no difference was found among groups (F[2.67] = 1.16 , p =
0.32). The authors did not find a significant change in S-Anxiety
values from the first to second assessment (F[1.67] = 1.981, p =
0.164). The change that occurred between S-Anxiety values from
the first to second assessment did not vary by group (F[2.67] =
0.826, p = 0.442). The authors did not perform power analysis
because no significant difference existed in group, time, or
group * time interaction.
The model established for T-Anxiety showed that no dif-
ference existed among all groups (F[2.67] = 1.246, p = 0.294);
however, considering all participants, a significant change in
T-Anxiety values was observed from the first to second assess-
ment (F[1.67] = 9.595, p = 0.003), which also differed among
groups (F[2.67] = 11.002, p < 0.001). The researchers examined
reasons for this difference and determined that, when the groups
were compared at the first and second assessments, there was a
difference only between the lavender and tea tree oil groups at
the second assessment (p = 0.046). However, when comparing
group measurements at the first and second assessments, a sig-
nificant difference was found only between measurements for the
lavender group (p < 0.001). The posterior power of these compar-
isons performed in terms of the group * time interaction was 98%.
Pittsburgh Sleep Quality Index Scores
In the first assessment performed before chemotherapy, the
PSQI mean score for each group was higher than five points; in
the second assessment after chemotherapy, the PSQI mean score
decreased only in the lavender and tea tree oil groups (PSQI: L =
3.86 [SE = 0.58], T = 5.9 [SE = 0.722], C = 7.15 [SE = 0.722]).
Given all measurements obtained in this study, no differ-
ence existed among groups in terms of PSQI (F[2.67] = 1.721,
p = 0.187); however, the researchers found a significant change
206 CLINICAL JOURNAL OF ONCOLOGY NURSING APRIL 2018, VOL. 22 NO. 2 CJON.ONS.ORG
AROMATHERAPY
TABLE 1.
SAMPLE CHARACTERISTICS
LAVENDER GROUP
(N = 30)
TEA TREE GROUP
(N = 20)
CONTROL
(N = 20)
TOTAL
(N = 70)
CHARACTERISTIC
—
X SE
—
X SE
—
X SE
—
X SE p
Age (years) 57.73 12.81 57.55 12.87 59.65 13.37 58.22 12.83 > 0.05
CHARACTERISTIC n n n n
Sex (c2 = 0.917) 0.653
Female 24 17 18 59
Male 6 3 2 11
Educational status (c2 = 0.633) 0.386
Primary school 15 7 11 33
Secondary school 7 9 5 21
High school 4 2 4 10
Literate 4 2 – 6
Marital status (c2 = 0.243) 0.877
Married 24 15 15 54
Single 6 5 5 16
Income level (c2 = 3.118) 0.596
Income meets expenditure 23 15 17 55
Income exceeds expenditure 6 3 1 10
Income does not meet expenditure 1 2 2 5
Cancer type
–
Breast 18 12 16 46
Lung 6 3 2 11
Urothelial 1 – 1 2
Ovarian 3 2 1 6
Gastrointestinal 2 – – 2
Unknown origin – 2 – 2
Renal – 1 – 1
Chemotherapy –
Paclitaxel and carboplatin 11 7 4 22
Paclitaxel and trastuzumab 10 7 7 24
Continued on the next page
APRIL 2018, VOL. 22 NO. 2 CLINICAL JOURNAL OF ONCOLOGY NURSING 207CJON.ONS.ORG
between the first and second measurement values (F[1.67] =
33.162, p < 0.001), which also differed among groups (F[2.67] =
8.991, p < 0.001). In terms of measurement time, this study
revealed a significant difference in measurements between the
lavender and control groups only at the second assessment. The
group comparisons showed a significant difference between
measurements at the first and second assessments for the lav-
ender and tea tree oil groups (p < 0.001). The posterior power
of these comparisons in terms of the group * time interaction
was 95%.
Discussion
The use of lavender oil in different therapeutic activities has
been explored by various studies (Kianpour, Mansouri, Mehrabi,
& Asghari, 2016; Koca Kutlu, Yılmaz, & Çeçen, 2008; Maddocks-
Jennings & Wilkinson, 2004; Ovayolu et al., 2014; Smith & Kyle,
2008; Takeda, Watanuki, & Koyama, 2017). Several studies sup-
port the ongoing use of lavender oil as part of an integrated
approach to invasive interference (Karadag, Samancioglu, Ozden,
& Bakir, 2017; Trambert, Kowalski, Wu, Mehta, & Friedman,
2017). Aromatherapy massage with lavender oil has had positive
effects on patients with cancer (Ovayolu et al., 2014). In the cur-
rent study, trait anxiety was reduced and sleep quality improved
with the use of lavender oil.
The first assessment revealed that the sleep quality of each
group was poor prior to the use of the oils and that partici-
pants experienced a moderate level of state and trait anxiety.
The present study evaluated the immediate anxiety levels of
the patients and revealed that the medium level of state anx-
iety observed in the control group before chemotherapy did not
change, along with the state anxiety levels of the two groups that
smelled lavender oil and tea tree oil during chemotherapy. No
difference was found the state anxiety levels among groups. A
study examining the effects of one drop of Lavandula hybrida oil
before surgical operations by Braden et al. (2009) revealed that
it reduced patients’ state anxiety. Other studies have also found
that the inhalation of lavender oil reduces state anxiety (Koca
Kutlu et al., 2008; Kritsidima et al., 2010). However, the current
study revealed no effect of Lavandula hybrida oil (three drops) on
participants’ state anxiety, which was largely in agreement with
the findings of other studies (Howard & Hughes, 2008; Perry,
Terry, Watson, & Ernst, 2012).
A study by Bikmoradi et al. (2015) revealed that smelling
lavender for 20 minutes two days per week did not reduce par-
ticipants’ anxiety, and these researchers suggested increasing the
duration of aromatherapy to determine the effect of lavender. In
the current study, results did not indicate a significant difference
in state anxiety levels because the S-Anxiety was administered to
patients before and after chemotherapy, the time between these
two administrations was short according to chemotherapy pro-
tocols (a minimum of one hour and a maximum of four hours),
and the patients may have given the same responses at the first
and second assessments because they remembered their prior
answers. The time invariance of scales defines the relationship
TABLE 1. (CONTINUED)
SAMPLE CHARACTERISTICS
LAVENDER GROUP
(N = 30)
TEA TREE GROUP
(N = 20)
CONTROL
(N = 20)
TOTAL
(N = 70)
CHARACTERISTIC n n n n p
Chemotherapy (continued) –
Paclitaxel 3 5 4 12
Paclitaxel, trastuzumab,
and carboplatin
5 – 5 10
Paclitaxel and gemcitabine 1 1 – 2
Symptoms experienced in the past
week
–
Fatigue and weakness 11 15 8 34
Anorexia, fatigue, and pain 15 2 4 21
Numbness in hands and feet 1 1 5 7
None 3 2 3 8
SE—standard error
208 CLINICAL JOURNAL OF ONCOLOGY NURSING APRIL 2018, VOL. 22 NO. 2 CJON.ONS.ORG
among datasets obtained by measuring anything in different time
periods under similar conditions (Karasar, 2005). In the current
study, the time invariance criterion of the S-Anxiety was not met.
The current study also showed no difference in trait anx-
iety levels among patients in the tea tree oil and control groups
at the first and second assessments, whereas the trait anxiety
levels of patients in the lavender group decreased by the second
assessment. Published studies have reported that, because of its
anxiolytic and sedative effects (Conrad & Adams, 2012; Fismer
& Pilkington, 2012; Kianpour et al., 2016; Maddocks-Jennings &
Wilkinson, 2004; Woelk & Schläfke, 2010), lavender provides
spiritual comfort and physical and emotional well-being (Franco
et al., 2016; Hur, Song, Lee, & Lee, 2014; Koulivand et al., 2013;
Redstone, 2015). Ovayolu et al. (2014) found that aromatherapy
massage and aromatherapy with lavender oil maintain physical
comfort in the short term and that lavender oil can be used to
manage psychological problems in the long term. Essential com-
pounds, such as linalool and linalyl acetate in lavender oil, are
linked to receptors in the olfactory bulb by smelling, and a ther-
apeutic effect arises in the area where actions and moods, such
as fear and anger, are controlled and motivated in the limbic
system (Huang & Capdevila, 2017; Koulivand et al., 2013; Lis-
Balchin & Hart, 1999; Maddocks-Jennings & Wilkinson, 2004;
NCI, 2018). The current study determined that lavender oil is
effective in managing anxiety if it is regularly used every day
for a month. Patients expressed satisfaction with the pleasant
aroma of lavender in the room when administered during
chemotherapy.
The current study revealed that the use of lavender signifi-
cantly increased the sleep quality of patients with cancer based
on the assessment time compared to the other two groups. The
sleep quality of patients in the tea tree oil group increased in the
second assessment compared to the first assessment; however,
no statistical difference was found between the lavender and con-
trol groups. As with other studies (Karadag et al., 2017; Keshavarz
Afshar et al., 2015), the current study revealed that the use of lav-
ender oil improved sleep quality.
Otaghi, Qavam, Norozi, Borji, and Moradi (2017) found that
essential lavender oil was not effective in improving sleep quality.
However, Otaghi et al. (2017) did not report on the anxiety level
of patients. There is a negative relationship between sleep quality
and anxiety. In the current study, patients began to relax, revealed
by a decrease in trait anxiety, and their sleep quality improved.
Tea tree oil had no effect on state and trait anxiety levels but did
increase sleep quality. The current authors hypothesized that tea
tree oil had a placebo effect; statistical analyses confirmed the
superiority of lavender oil in improving sleep quality.
Limitations
The study is limited to patients who were treated with weekly
paclitaxel and who completed the STAI and PSQI. The effects
TABLE 2.
DESCRIPTIVE STATISTICS OF STAI AND PSQI SCORES BY GROUP AND TIME
LAVENDER GROUP TEA TREE GROUP CONTROL p
GROUP AND TIME
—
X SE
—
X SE
—
X SE TIME GROUP GROUP * TIME
S-Anxiety 0.164 0.320 0.442
First assessment 41.4 1.49 45.3 1.82 42 1.82
Second assessment 42.36 1.53 45.3 1.88 42.4 1.88
T-Anxiety 0.003 0.294 < 0.001
First assessment 44.8 1.27 45.4 1.556 45.4 1.556
Second assessment 40.833 1.123 45.25 1.376 45.25 1.376
PSQI < 0.001 0.187 < 0.001
First assessment 7.63 0.82 9.15 1.009 7.05 1.009
Second assessment 3.86 0.58 5.9 0.722 7.15 0.722
PSQI—Pittsburgh Sleep Quality Index; S-Anxiety—State Anxiety Scale; SE—standard error; STAI—State-Trait Anxiety Inventory; T-Anxiety—Trait Anxiety Scale
IMPLICATIONS FOR PRACTICE
ɔ Evaluate patients’ anxiety and sleep states during treatment.
ɔ Use lavender oil, which has a pleasant smell, has no adverse effects,
and is inexpensive, in the management of patients’ anxiety and
sleep disorders.
ɔ Apply knowledge about the use of aromatherapy in nursing
practice.
AROMATHERAPY
APRIL 2018, VOL. 22 NO. 2 CLINICAL JOURNAL OF ONCOLOGY NURSING 209CJON.ONS.ORG
of lavender oil inhalation on anxiety and sleep quality should
be evaluated in a larger population who receive other chemo-
therapy protocols. Although the authors tried to blind the nurse
and patients to the aromatic oils used in the study, blinding
failed because participants were familiar with the scent of
lavender.
Implications for Nursing and Conclusion
The current study showed that the patients treated with che-
motherapy had a medium level of state and trait anxiety and a
low level of sleep quality. The patients treated with tea tree and
lavender oil had no complaints associated with the application
of oils in the study. This study determined that three drops of
lavender oil inhaled nightly before sleep reduced patients’ trait
anxiety levels and improved sleep quality.
As a result, oncology nurses should regularly assess patients’
anxiety and sleep status, learn about complementary treatment
methods for the management of anxiety and sleep disorders,
and include lavender oil during care. Lavender oil has no adverse
effects, and it is more cost effective than other complementary
methods.
Ayse Özkaraman, RN, PhD, is a lecturer in the Faculty of Health Sciences and
Department of Nursing at Eskişehir Osmangazi University; Özlem Dügüm, RN, is
a charge nurse at the Private Ümit Hospital in Eskişehir; Hülya Özen Yılmaz, MSc,
is a research assistant in the Faculty of Medicine and Department of Biostatistics
at Eskişehir Osmangazi University; and Öznur Usta Yeşilbalkan, RN, PhD, is an
associate professor in the Faculty of Nursing and Department of Internal Diseases
at Ege University in İzmir, all in Turkey. Ozkaraman can be reached at aozaydin26@
hotmail.com, with copy to CJONEditor@ons.org. (Submitted May 2017. Accepted
August 9, 2017.)
The authors take full responsibility for this content. This research was funded in part by the
Scientific Research Project Coordination Unit at Eskişehir Osmangazi University. The article has
been reviewed by independent peer reviewers to ensure that it is objective and free from bias.
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