Applied Nursing Research 37 (2017) 28–35

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Applied Nursing Research

journal homepage: www.elsevier.com/locate/apnr

Original article

Effect of aromatherapy via inhalation on the sleep quality and fatigue

level in people undergoing hemodialysis☆
Gamze Muz a,⁎, Sultan Taşcı b
a
Nevsehir Haci Bektas Veli University, Semra and Vefa Küçük Health College, Department of Nursing, 50300, Nevşehir, Turkiye
b
Erciyes University, Faculty of Health Sciences, 38039, Kayseri, Turkiye

a r t i c l e i n f o a b s t r a c t

Article history: The most common problems in hemodialysis patients are sleep disorders and fatigue. This randomized-con-
Received 30 January 2017 trolled experimental study was conducted to determine the effect of aromatherapy applied by inhalation on
Revised 20 May 2017 sleep quality and fatigue level in hemodialysis patients. The study was completed in five hemodialysis centers
Accepted 30 July 2017
settled in two provinces with 27 intervention group patients and 35 controls, being totally 62 patients, recruited
with simple randomization. Ethical approval, informed consent from the individuals and institutional permission
Keywords:
Hemodialysis
were obtained. Data were collected with a questionnaire form and Visual Analogue Scale (VAS) for fatigue, Piper
Aromatherapy fatigue scale, Pittsburgh Sleep Quality Index (PSQI), and follow-up forms for the patient and the researcher. Aro-
Nursing matherapy inhalation (sweet orange and lavender oil) was performed before going to bed every day for one
Fatigue month to the intervention group patients. No other application has been made to the control group patients ex-
Sleep quality cept for standard hemodialysis treatment. All of the forms were performed at baseline and at follow-up at the end
of the four weeks (baseline and last follow-up), VAS and Piper fatigue scale were performed during follow-ups at
the end of every week (the first, second and third follow-ups). Data were statistically analyzed with Independent
Samples t-test, one way analysis of variance, Pearson correlation analysis, chi-square test, Friedman and Mann
Whitney U tests and Bonferroni test. p b 0.05 was set as statistically significant in comparisons. Mean total and
sub-dimension scores of VAS, Piper fatigue scale and PSQI (except for daytime sleepiness dysfunction sub-dimen-
sion) of the intervention and control groups at baseline were not significantly different (p N 0.05). It was found
that mean total and sub-dimension scores of VAS, Piper fatigue scale and PSQI of the intervention group signifi-
cantly decreased in other follow-ups compared to the control group (p b 0.05). Consequently, it was determined
that aromatherapy applied by inhalation improved sleep quality, decreased fatigue level and severity in hemodi-
alysis patients. Accordingly, aromatherapy prepared with sweet orange and lavender oil may be recommended
to increase sleep quality and to decrease fatigue level of the hemodialysis patients.
© 2017 Elsevier Inc. All rights reserved.

1. Introduction
Recent progress in technology may improve hemodialysis (HD) by
extending the lifespan of patients undergoing dialysis, which can
cause some physical and mental problems (e.g., fatigue, pain, itching,
sleepiness, and depression) (Eti Arslan and Karadakovan, 2010). Iliescu
et al. determined that 71% of dialysis patients suffer from poor sleep
(Iliescu et al., 2003). Given that sleep disorders occur depending on psy-
chological factors and stress, anxiety and depression can affect the sub-
jective sleep quality of people undergoing dialysis. By contrast, sleep
problems may improve because of certain problems as limited lifespan,
metabolic changes, pain, diet limitations, excess liquid, dyspnea, fatigue,
☆ This study was supported with TDK-2014-5222 coded project by Erciyes University
Scientifical Research Projects Unit.
⁎ Corresponding author.
E-mail addresses: gucakan@nevsehir.edu.tr (G. Muz), sultant@erciyes.edu.tr (S. Taşcı).
cramp, advanced age, hypocapnia with chronic metabolic acidosis, and
peripheric neuropathy that affects upper respiratory ways (Kuzeyli
Yildirim, Fadiloglu, and Durmaz Akyol, 2004; Parker, 2003; Uzun, Kara,
and Iscan, 2003). Fatigue can occur because of sleep disorders among
patients undergoing HD. Dialysis and disease progress can affect the
quality of life (Liu, 2006; McCann and Boore, 2000; Mollaoglu and
Arslan, 2003; O'Sullivan and McCarthy, 2009).
Fatigue is the most common problem that affects daily life function
and quality of life in patients with end-stage renal failure (Karakoç,
2008; Liu, 2006; McCann and Boore, 2000; Mollaoglu and Arslan,
2003; Murtagh, Addington-Hall, and Higginson, 2007; O'Sullivan and
McCarthy, 2009; Williams, Crane, and Kring, 2007; Yurtsever and
Beduk, 2003). People define fatigue as becoming tired quickly, apathy,
weakness, and exhaustion. Fatigue decreases physical abilities, in-
creases dependency levels, and affects the quality of life of people by
influencing daily life activities, work lives, social life, sexual life, and
treatment progress (Karakoç, 2008; Swain, 2000; Yurtsever, 2004). To

http://dx.doi.org/10.1016/j.apnr.2017.07.004
0897-1897/© 2017 Elsevier Inc. All rights reserved.
 G. Muz, S. Taşcı / Applied Nursing Research 37 (2017) 28–35
cope with fatigue and insomnia, complementary and integrative
methods should be used besides pharmacologic interventions (Chang,
Chu, Kim, and Yun, 2008; Imura, Misao, and Ushijima, 2006; Karadag
and Karadakovan, 2015; Mitchell and Berger, 2006; Mustian et al.,
2007; Tsay, 2004). Integrative treatment methods include yoga, aroma-
therapy, massage, energy therapy, music therapy, reflexology, acupunc-
ture, and acupressure (Chang et al., 2008; Imura et al., 2006; Karadag
and Karadakovan, 2015; Mitchell and Berger, 2006; Mustian et al.,
2007; Tsay, 2004). Previous studies have shown that aromatherapy
can effectively control some symptoms such as fatigue, insomnia, ure-
mic pruritus, anxiety, and stress (Hsu, Chen, Hwu, Chanc, and Liu,
2009; Imura et al., 2006; Itai et al., 2000; Shahgholian, Dehghan,
Mortazavi, Gholami, and Valiani, 2010). In our country, the effect of aro-
matherapy through sweet orange and lavender oil on sleep problems
and fatigue in patients undergoing dialysis has not yet been determined.
Thus, this study was conducted to determine the effect of aromatherapy
practiced by inhalation (sweet orange and lavender oil) on the sleep
quality and fatigue level in people undergoing HD.
1.1. Hypothesis of the study
H_01: Aromatherapy (sweet orange and lavender oil) that practiced
by inhalation during one month, for 2 min before sleeping is not effec-
tive on increase the sleep quality in patients treated with hemodialysis.
H_11: Aromatherapy (sweet orange and lavender oil) that practiced
by inhalation during one month, for 2 min before sleeping is effective on
increase the sleep quality in patients treated with hemodialysis.
H_02: Aromatherapy (sweet orange and lavender oil) that practiced
by inhalation during one month, for 2 min before sleeping is not effec-
tive on decrease fatigue level in patients treated with hemodialysis.
H_12: Aromatherapy (sweet orange and lavender oil) that practiced
by inhalation during one month, for 2 min before sleeping is effective on
decrease fatigue level in patients treated with hemodialysis.
H_03: Aromatherapy (sweet orange and lavender oil) that practiced
by inhalation during one month, for 2 min before sleeping is not effec-
tive on decrease fatigue severity in patients treated with hemodialysis.
Fig. 1. Sample diagram.
29
H_13: Aromatherapy (sweet orange and lavender oil) that practiced
by inhalation during one month, for 2 min before sleeping is effective on
decrease fatigue severity in patients treated with hemodialysis.
2. Methods
2.1. Study design and sample
This randomized controlled study was conducted with five HD units
in two cities in Turkey. This study involved 62 patients: 27 patients com-
prised the experimental group, whereas 35 patients comprised the con-
trol group. These patients were studied between 17.08.2014 and
29.02.2015 (Fig. 1). According to power analysis, α = 0.05 and β =
0.20, and the power of the study was 99.9%.
Inclusion criteria of the study:
➢ Patients aged 18 and above,
➢ No eye or hearing disabilities,
➢ Voluntary participation in the study,
➢ To undergo HD for 3 months,
➢ To continue dialysis in the same unit/center,
➢ To undergo HD treatment for three sessions in one week,
➢ Not to take any sleeping pill before aromatherapy and during the
course of the study,
➢ To have average or severe fatigue symptoms (Visual Analogue Scale
(VAS) fatigue score should be 3 or more)
➢ To have a score of 5 or more from the Pittsburgh Sleep Quality Index
(PSQI),
➢ To speak Turkish.
Exclusion criteria of the study:
➢ To have any respiratory system disease,
➢ To have any allergy to essential oils used,
30 G. Muz, S. Taşcı / Applied Nursing Research 37 (2017) 28–35
➢ To have any obstacle to smell,
➢ Use of other integrative medicine applications during treatment.
Random selection of samples was performed. We believed that pa-
tients undergoing dialysis in the same session could affect each other,
so we chose the control and study groups according to their session
times. Patients who met the criteria were grouped according to the
time of their HD sessions. The ballot method was used to determine
which group would start the study. After balloting, HD patients in the
morning session were considered the control group, whereas those in
the afternoon session were regarded as the study group.
Complementary or supportive treatment was not administered for
insomnia, fatigue, and other problems reported by the patients under
treatment in the units/centers that participated in the study. However,
for the patients who only had fatigue and sleep problems, medical treat-
ment directed to the etiology (e.g., hypoglycemia, headache, hypoten-
sion, and anemia) was performed under a doctor's orders. The most
common medicines used by the patients were phosphorus bonding
agents, erythropoietin, and ferrum drugs. Such drugs were not used to
evaluate the sleep and fatigue status of patients in HD units.
Group 1: Aromatherapy group (sweet orange oil and lavender oil)
via inhalation for one month for 2 min before sleeping in patients un-
dergoing standard HD treatment (study group).
Group 2: Group that did not practice aromatherapy, except standard
HD treatment (Control group).
2.2. Data collection
2.2.1. Patient information form
The patient information form was developed by the researchers by
screening the literature (Eglence, Karatas, and Tasci, 2013; Karadag
and Karadakovan, 2015; Korkut, 2008; Lee, Kim, Sa, Moon, and Kim,
2011; Yurtsever and Beduk, 2003). This form consisted of 18 questions
that included sociodemographic characteristics; levels of hemoglobin
(Hb), hematocrit (Htc), albumin, urea, creatinine clearance; and charac-
teristics of the disease of the patients. Information was obtained from
face-to-face interviews and from patients' documents.
2.2.2. Visual Analog Scale (VAS)
The scale developed by Price, McGrath, Rafii, and Buckingham
(1983) was used to evaluate the intensity of pain, which is perceived
as subjective. This scale was deemed valid and reliable. The patients
were told that “0” meant “I don't feel fatigue”, and increased numbers
indicated rising fatigue levels; “10” meant “I feel very fatigued”. After
the patients rated their fatigue severity using the VAS, the distance be-
tween the marked point and the lowest point of the line (0 = I don't
feel fatigue) was measured with a ruler (in centimeters). This value
was determined as the fatigue score of the patients.
2.2.3. Piper fatigue scale-PFS
This scale that was developed by Piper et al. (1998) consisted of 27
items, and it evaluated fatigue of the patient with four subdimensions.
Answers for every item were evaluated from 0 10. The total fatigue
score was calculated by adding points of 27 items and dividing the
total score to the item number. A high score indicated a high perceived
fatigue level. Reliability and validity studies for Turkish society was con-
ducted by Can, and Cronbach's alpha was determined as 0.94 (Can,
2001). Cronbach's alpha for the study group in this study was 0.98,
whereas that for the control group was 0.97 before practice of aroma-
therapy. By contrast, Cronbach's alpha was 0.99 in the study group
and 0.98 in the control group after practice.
2.2.4. Pittsburgh Sleep Quality Index-PSQI
The PSQI was developed in 1989 by Buysse, Reynolds, Monk,
Berman, and Kupfer (1989). Reliability and validity studies were con-
ducted by Agargun and colleagues, and Cronbach's alpha was 0.80
(Agargun, Kara, and Anlar, 1996). The scale comprised 18 items and 7
component scores. Every component was evaluated from 0 to 3. The
total of these component points yielded the total score of the scale,
which ranged from 0 to 21. A high score (5 or above) indicated poor
sleep quality. Sleep quality was classified as good (0–4) and poor (5–
21). In the study, before the practice; Cronbach's alpha was 0.76 and
0.74 for the study group and control group, respectively, before aroma-
therapy practice, but became 0.78 and 0.71 in the study group and con-
trol group, respectively, after practice. Given that a study criterion was
the consumption of any sleeping pill before and during the study, the
subdimension of the use of a sleeping pill (component 6) was not
used for calculation.
2.2.5. Patient Follow Schedule–I (patient form)
This period was used to record the progress of the patients or care-
givers about when (day and time) and what they did during four weeks.
2.2.6. Patient Follow Schedule–II (researcher form)
For this schedule, the researchers called the patients before sleeping
and asked if they experienced any problems regarding aromatherapy
practice. Answers were recorded on the form, and necessary support
was provided.
Health team members were informed about the aim and content of
this study. Forms were filled in via face-to-face interviews and using pa-
tient documents. Similarities were noted between groups in terms of
age, gender, education status, duration of renal failure and HD, hemo-
globin and hematocrit values, scores of VAS, fatigue, Piper fatigue
scale, and PSQI (p N 0.05). During sample selection, randomization
was not performed for some factors such as Hb and Htc values, weight,
and residual renal function. During the study, intervention was not per-
formed for the routine treatments of patients in the two groups.
2.3. Process
2.3.1. Control group
Only routine care was practiced in this group. During the initial fol-
low-up of patients, the information form, VAS score, Piper fatigue
scale, and PSQI were determined via face-to-face interview and patient
documents. In the first week (the first follow-up), second week (second
follow-up), and third week (third follow-up), VAS score and Piper fa-
tigue scale were obtained by the researcher. After aromatherapy prac-
tice for four weeks (the last follow-up after one month), patient
information form, laboratory results, VAS score, Piper fatigue scale,
and PSQI were collected.
2.3.2. Study group process
In the study group, the first (the first interview before starting aro-
matherapy) patient information form was completed and VAS, Piper fa-
tigue scale, and PSQI were obtained by the researchers through face-to-
face interview during dialysis sessions. As seen in Fig. 2, aromatherapy
practice guide was prepared by the research group with the aid of an ex-
pert who specialized in aromatherapy (Aycemen, 2008; Buckle, 2003;
Dabirian, Sadeghim, Mojab, and Talebi, 2013; Lee, 2004; Lee et al.,
2011; Ozdemir, 2012).
In practice, lavender and sweet orange oils (1:1) were dropped to a
gauze bandage, which was placed 5 cm away from under the nose. Pa-
tients had to smell the aromatic mixture at this distance for 2 min.
They were asked to take deep breaths three times after smelling the
mixture was completed. The patients followed this procedure before
sleeping every day for a month.
Education about aromatherapy via inhalation was provided to the
patients. When the patients were ready for independent practice,
 G. Muz, S. Taşcı / Applied Nursing Research 37 (2017) 28–35
Fig. 2. Aromatherapy practice guide.
“Inhalation Practice Guidance” prepared by the researchers was given to
the patients. The participants were informed about how to fill in the
“patient follow-up schedule” form. They were asked to record their
daily practice during the study. A message was sent to their cellphones
daily to remind them to apply aromatherapy every evening. At the first,
second, and third follow-up sessions, interviews were conducted to de-
termine any problems within the dialysis session at the included dialy-
sis centers every week. After telephone interviews and visits during
dialysis sessions, any problem that was noted was recorded, and the re-
searchers scheduled another follow-up session. VAS fatigue scores and
Piper fatigue scale were determined at the first week (first follow-up),
second week (second follow-up), and third week (third follow-up).
After practice for four weeks (the last follow-up of the participants
after one month), patient information forms were completed and labo-
ratory results, VAS fatigue, Piper fatigue scale, and PSQI were collected.
2.4. Aromatherapy practice
Aromatic oils (sweet orange and lavender oil) that were given to the
patients in the aromatherapy group were supplied from essential oils
produced by the same company. Oils (10 mL) were stored in dark col-
ored glass bottles with a dropper. They were closed with safety covers
that could open only when pressed strongly. Oils were kept in appropri-
ate conditions according to expert views, and patients were instructed
to ensure proper storage and handling of the oils. During the study, rou-
tine treatments of the patients in the control and study groups were not
interfered with. For management of sleep and fatigue, aromatherapy
practice was performed following the evidence-based aromatherapy in-
halation practice guide (Aycemen, 2008; Buckle, 2003; Dabirian et al.,
2013; Lee, 2004; Lee et al., 2011; Ozdemir, 2012).
2.5. Data analysis
Data were evaluated using IBM SPSS Statistics package program.
Normal distribution of the data was tested by Shapiro–Wilk test. Homo-
geneity of variances was tested by the Levene test. The two groups were
31
compared via independent samples t-test, and the paired sample t-test
was used in nonparametric (Mann–Whitney U test) evaluations. To
evaluate more than two variances, the Bonferroni post-hoc test and
Friedman test (Dunn–Bonferroni) were used. Categorical variables
were compared via chi-square analysis, whereas scales were compared
using Pearson correlation analyses. In the study, statistical significance
was set at p b 0.05. Mean values of laboratory results were evaluated.
2.6. Ethical considerations
The study was conducted with permission from the University Eth-
ical Institute (Decision No: 2013.02.02). Written consent was obtained
from all centers. The aim of the study was explained to the participants,
and informed consent forms from the participants were collected.
2.7. Limitation
The sleep and fatigue levels of individuals were determined for only
one month. However, the effects of aromatherapy practice on sleep and
fatigue levels for more than a month remain unknown.
3. Results
Of the patients in the study group, 66.7% were men with an average
age of 52.26 ± 14.50 years. Approximately 74.1% of the patients gradu-
ated from primary school. Moreover, their mean duration of dialysis
was 6.29 ± 3.91; 96.3% were adaptable for medicine treatment and
59.3% were adaptable for diet treatment. However, of the participants
in the control group, 54.3% were women with an average age of 59.26
± 12.43 years. Approximately 62.9% of the control participants graduat-
ed from primary school. In addition, the mean dialysis duration was 6.24
± 5.27; 91.4 were adaptable for medicine treatment and 51.4% were
adaptable for diet treatment. In terms of disease characteristics, the
participants in the study and control groups were similar (p N 0.05;
Table 1).
32 G. Muz, S. Taşcı / Applied Nursing Research 37 (2017) 28–35

Table 1
Descriptive and disease characteristics of participants in the study and control groups.

Characteristics Groups p

Study group (n = 27) Control group (n = 35)

n % n %

Gender
Female 9 33.3 19 54.3 0.166
Male 18 66.7 16 45.7
Education status
Illiterate 3 11.1 8 22.8 0.174
Literate 0 0.0 3 8.6
Primary school 20 74.1 22 62.9
High school and over 4 14.8 2 5.7
Accommodation to medicine treatment 0.626
Adaptable 26 96.3 32 91.4
Not adaptable 1 3.7 3 8.6
Accommodation to diet
Adaptable 16 59.3 17 48.6 0.562
Not adaptable 11 40.7 18 51.4
Mean age (X ± SD, years) 52.26 ± 14.50 59.26 ± 12.43 0.248
Mean of dialysis duration (month) (X ± SD, month) 6.29 ± 3.91 6.24 ± 5.27 0.965
Mean Hb (X ± SD) 11.30 ± 1.56 11.80 ± 1.95 0.285
Mean Htc (X ± SD, %) 34.90 ± 5.19 35.94 ± 6.19 0.484
Mean Cr/clirens (X ± SD) 1.75 ± 0.33 1.66 ± 0.41 0.360
Mean albumin (X ± SD) 4.00 ± 0.43 3.81 ± 0.46 0.109

The first (6.50; 5.30–8.00), second (5.00; 4.00–6.30), third (3.60;
2.00–4.80), and final follow-up (2.00; 1.00–4.20) scores of the VAS fa-
tigue scale decreased significantly according to the initial recorded
score of 9.00 (7.00–10.00; p b 0.001). Multiple comparison analysis re-
vealed a significant difference between some VAS fatigue scores be-
tween the beginning and second, third, and last follow-up visits (p b
0.001) in the study group. However, of the participants in the control
group, the first (8.00; 7.00–9.60), second (8.00; 7.00–9.60), third
(8.00; 7.00–9.60), and last follow-up (8.00; 7.00–9.60) VAS fatigue
scores increased significantly compared with the initial score of 7.80
(7.00–9.50; p b 0.05). Multiple comparison analysis indicated a signifi-
cant difference between the beginning and last follow-up session in
the control group (p b 0.05). The VAS fatigue scores at follow-up (first,
second, third, and last follow) in the study group were significantly
lower than those in the control group (p b 0.001; Table 2).
The total Piper Fatigue scale and all subscale mean scores significant-
ly decreased in the study group at follow-up compared with those at the
beginning of the treatment period (p b 0.001). The difference between
follow-up sessions (first, second, third, and last follow-ups) was signif-
icant (p b 0.001). In the control group, the total Piper Fatigue scale and
all subscale mean scores increased in the first, second, third, and last fol-
low-ups, but the difference was not statistically significant (p N 0.05).
The results showed that all total and subscale mean scores of the
study group were lower than those of the control group at follow-up,
and this decrease was statistically significant (p b 0.001; Table 3).
Table 2
Distribution of mean, median scores of VAS fatigue scores of the participants in study and
control groups according to measurement time.
Measurement time Study group (n = 27) Control group (n = 35)
Median (%25p–%75p) Median (%25p–%75p)
Beginning 9.00 (7.00–10.00)a 7.80 (7.00–9.50)a
First follow 6.50 (5.30–8.00)a 8.00 (7.00–9.60)a
Second follow 5.00 (4.00–6.30)b 8.00 (7.00–9.60)a
Third follow 3.60 (2.00–4.80)c 8.00 (7.00–9.60)a
Last follow 2.00 (1.00–4.20)c 8.00 (7.00–9.60)b
p⁎ b0.001 0.002
a,b,c
According to multiple compare test (post-hoc: Dunn-Bonferroni) results, this different
letters define that there was a significant difference between scale scores.
⁎ Friedman test.
⁎⁎ MU test for independent variables.
All subscales (subjective sleep quality 0.85 ± 0.90, sleep latency 0.81
± 1.00, sleep duration 0.22 ± 0.42, habitual sleep efficiency 0.62 ± 0.63,
sleep disturbance 1.11 ± 0.50, daytime dysfunction 1.03 ± 0.97, and
global sleep quality scale 4.66 ± 3.66) of PSQI in the study group were
lower than the scores of the control group (subjective sleep quality
2.60 ± 0.65, sleep latency 2.94 ± 0.23, sleep duration 2.74 ± 0.50, habit-
ual sleep efficiency 2.68 ± 0.79, sleep disturbance 2.02 ± 0.38, daytime
dysfunction 2.62 ± 0.49, and global sleep quality scale 15.62 ± 1.81),
and this decrease was statistically significant (p N 0.001). A significant
relation was found between the PSQI mean score differences at the be-
ginning and the last follow-up in both groups (p b 0.001; Table 4).
4. Discussion
Some symptoms, such as pain, spasm, pruritus, fatigue, and insom-
nia, caused by HD treatment negatively affect the quality of life and
daily life activities of people with chronic renal failure. (Akca, Tasci,
and Karatas, 2013; Eglence et al., 2013; Eti Arslan and Karadakovan,
2010; Farese et al., 2008; Su, Wu, Lee, Wang, and Liu, 2009; Tsay, Cho,
and Chen, 2004; Usta Yıldırım and Demir, 2014). For the management
of fatigue, some integrative medicine practices including massage,
yoga, reflexology, and acupressure are suggested as effective (Chang
et al., 2008; Eglence et al., 2013; Imura et al., 2006; Mitchell and
Berger, 2006; Mustian et al., 2007; Sood, Barton, Bauer, and Loprinzi,
2007; Tsay, 2004). Aromatherapy, one of the integrative methods, has
been found to reduce the level and severity of fatigue (Aycemen,
2008; Buckle, 2003; Eglence et al., 2013; Kohara et al., 2004; Lee,
2004; Lee et al., 2011; Ozdemir and Oztunc, 2013). In particular, aroma-
therapy via inhalation is an easy, quick, and effective treatment for cer-
p⁎⁎ tain physical and physiological problems, such as lower and upper
respiratory infections, fever, headache, sinusitis, fatigue, depression,
0.315 and insomnia (Buckle, 2003). In our study, no difference was found in
b0.001 the VAS fatigue scores between the study and control groups at the be-
b0.001 ginning of the study (p N 0.05). The VAS fatigue score of the study group
b0.001 significantly decreased in all follow-up sessions after aromatherapy
b0.001
practice with inhalation (p b 0.001), but it increased in the control
group from the beginning to the last follow-up (p b 0.001). Moreover,
the total and all subscale mean scores of PFS decreased according to
the initial values in the study group (p b 0.001). However, these scores
increased in all follow-up sessions in the control group (p N 0.05).
 G. Muz, S. Taşcı / Applied Nursing Research 37 (2017) 28–35 33

Table 3
Piper fatigue scale sub-dimensions scores of the participants in the study and control groups.

PFS Study group (n = 27) Control group (n = 35) p⁎⁎

(x ± SD) (x ± SD)

Behavioral/severity
Beginning 8.27 ± 1.34a 7.31 ± 1.40 0.009
First follow 6.46 ± 1.34b 7.38 ± 1.42 0.012
Second follow 5.17 ± 1.30c 7.41 ± 1.46 b0.001
Third follow 3.89 ± 1.65d 7.40 ± 1.51 b0.001
Last follow 3.19 ± 2.10e 7.40 ± 1.50 b0.001
p⁎ b0.001 0.415

Affective meaning
Beginning 8.40 ± 1.32a 7.33 ± 1.27 0.002
First follow 6.49 ± 1.30b 7.38 ± 1.24 0.008
Second follow 5.15 ± 1.27c 7.44 ± 1.29 b0.001
Third follow 3.85 ± 1.47d 7.44 ± 1.35 b0.001
Last follow 3.10 ± 1.95e 7.44 ± 1.40 b0.001
p⁎ b0.001 0.415

Sensory
Beginning 8.54 ± 1.31a 7.49 ± 1.16 0.001
First follow 6.59 ± 1.43b 7.57 ± 1.16 0.008
Second follow 5.28 ± 1.43c 7.64 ± 1.21 b0.001
Third follow 3.95 ± 1.67d 7.64 ± 1.29 b0.001
Last follow 3.17 ± 2.12e 7.65 ± 1.32 b0.001
p⁎ b0.001 0.244

Cognitive/mood
Beginning 7.76 ± 1.36a 6.93 ± 1.08 0.010
First follow 6.10 ± 1.29b 7.00 ± 1.02 0.003
Second follow 4.98 ± 1.39c 7.09 ± 1.14 b0.001
Third follow 3.65 ± 1.56d 7.09 ± 1.22 b0.001
Last follow 2.93 ± 1.93e 7.09 ± 1.28 b0.001
p⁎ b0.001 0.269

PFS sub-dimensions scores of the participants in the study and control (continuing).

PFS Study group (n = 27) Control group (n = 35) p⁎⁎

(x ± SD) (x ± SD)

Total fatigue scale

Beginning 8.22 ± 1.27a 7.25 ± 1.16 0.003
First follow 6.40 ± 1.28b 7.32 ± 1.14 0.004
Second follow 5.14 ± 1.30c 7.38 ± 1.21 b0.001
Third follow 3.83 ± 1.56d 7.37 ± 1.28 b0.001
Last follow 3.09 ± 2.01e 7.38 ± 1.33 b0.001
p⁎ b0.001 0.320
a,b,c,d,e
According to multiple compare test (post-hoc: Bonferroni) results, this different letters define that there was a significant difference between scale scores.
⁎ Variance analysis was conducted for repeated measurement.
⁎⁎ Two sample t-test in independent groups was conducted.

Table 4
PSQI sub scales scores of the participants in the study and control groups.

PSQI Study group (n = 27) Control group (n = 35) pa Study group (n = Control group (n = pa
(x ± SD) (x ± SD) 27) 35)
(x ± SD) (x ± SD)

Beginning Last follow pb Beginning Last follow pb Beginning Last Difference between PSQI measurementsc
(x ± SD) (x ± SD) (x ± SD) (x ± SD) follow (x ± SD)

Subjective sleep 2.81 ± 0.39 0.85 ± b0.001 2.68 ± 0.47 2.60 ± 0.65 0.324 0.246 b0.001 1.96 ± 0.97 0.08 ± 0.50 b0.001
quality 0.90
Sleep latency 2.88 ± 0.32 0.81 ± b0.001 2.85 ± 0.35 2.94 ± 0.23 0.083 0.717 b0.001 2.07 ± 0.99 −0.08 ± 0.28 b0.001
1.00
Sleep duration 2.85 ± 0.36 0.22 ± b0.001 2.74 ± 0.44 2.74 ± 0.50 1.000 0.291 b0.001 2.62 ± 0.49 0.00 ± 0.42 b0.001
0.42
Habitual sleep 2.85 ± 0.36 0.62 ± b0.001 2.77 ± 0.42 2.68 ± 0.79 0.585 0.435 b0.001 2.22 ± 0.64 0.08 ± 0.91 b0.001
efficiency 0.63
Sleep disturbance 2.03 ± 0.43 1.11 ± b0.001 2.05 ± 0.41 2.02 ± 0.38 0.324 0.834 b0.001 0.92 ± 0.38 0.02 ± 0.16 b0.001
0.50
Daytime dysfunction 2.92 ± 0.26 1.03 ± b0.001 2.65 ± 0.48 2.62 ± 0.49 0.324 0.007 b0.001 1.88 ± 0.97 0.02 ± 0.16 b0.001
0.97
Global sleep quality 16.37 ± 4.66 ± b0.001 15.74 ± 15.62 ± 0.669 0.140 b0.001 11.70 ± 3.39 0.11 ± 1.56 b0.001
1.52 3.66 1.72 1.81
a
Two sample t-test in independent groups was conducted.
b
Paired t-test was done.
c
PSQI score differences; score taken from last follow subtracted from score taken from the beginning follow.
34 G. Muz, S. Taşcı / Applied Nursing Research 37 (2017) 28–35
The fatigue levels of the two groups before the intervention were
similar based on VAS scores, but they differed according to Piper. This
difference may be because the PFS measures multi-dimensional fatigue
levels, whereas the VAS fatigue scale only measures one dimension of
fatigue level.
These results were similar to the literature (Imura et al., 2006; Kang
and Kim, 2002; Kang and Kim, 2008; Kohara et al., 2004; Lee et al.,
2011). In a previous study on mothers with postpartum depression
who wore a necklace with lavender and eucalyptus oil to supply inhala-
tion, fatigue levels of mother decreased significantly; however, the dif-
ference in sleep quality between groups was not significant. In
another study, aromatherapy practices were found to be effective on fa-
tigue (Imura et al., 2006; Kang and Kim, 2002). According to Eglence et
al. (2013), the application of acupressure for 1 month decreases the fa-
tigue severity of patients. Lavender oil exerts positive effects on insom-
nia in various diseases (Buckle, 2003; Chien, Cheng, and Liu, 2012;
Dabirian et al., 2013; Keshavarz Afshar et al., 2015; Lee et al., 2011;
Moeini, Khadibi, Bekhradi, Mahmoudian, and Nazari, 2010). In this
study, all subscale and total mean scores of PSQI for the last follow-up
in the study group were lower than the score means of the control
group (p N 0.001). A significant relation in PSQI score mean differences
was found between the beginning and last follow-up in the study and
control groups (p b 0.001). Steflitsch and Steflitsch reported that
Weihbrecht practiced lavender oil with inhalation in 10 people with
chronic insomnia (Steflitsch and Steflitsch, 2008). Two drops of laven-
der oil were dropped onto paper tissue or pillows, and inhalation was
practiced. Eight of the participants stated that they woke up feeling re-
laxed. In the study of Moeini et al., the practice of lavender inhalation
among patients with ischemic heart disease was found to improve the
quality of sleep (Moeini et al., 2010). In the study of Choi and Lee
(2012), a significant decrease was determined in sleep disorders
among participants with essential hypertension after inhalation of a
mixture of lavender, marjoram, and ylang ylang (4:3:3) for two weeks
(three times in a day for 3 min). The results of our study were similar
to results of aromatherapy practices in different diseases (Chien et al.,
2012; Cho, Min, Hur, and Lee, 2013; Choi and Lee, 2012; Ju et al.,
2013; Keshavarz Afshar et al., 2015; Moeini et al., 2010; Soden,
Vincent, Craske, Lucas, and Ashley, 2004; Steflitsch and Steflitsch, 2008).
Unwanted side effects related to inhalation of essential oils are rare
(Alkanat Ozdemir, 2015). After aromatherapy, one person reported of
nausea and vomiting, and two people presented increased blood pres-
sure levels.
5. Conclusion
Inhalation of lavender and sweet orange mix (1:1) through the
month once a day for 2 min yielded the following results:
➢ Increased sleep quality in dialysis patients (H_11 hypothesis was ac-
cepted)
➢ Decreased fatigue level and severity (H_12 and H_13 hypotheses
were accepted).
As a result,
➢ The patients who reported high fatigue levels and sleep quality
scores should be studied to determine the effects.
➢ Double-blind randomized controlled studies should be conducted
and repeated to increase the evidence level of the study. Long-
term research should be conducted and repeated.
➢ Objective evaluation tools (e.g., polysomnographic recording) for
evaluating sleep after aromatherapy practices should be used.
Conflicts of interest
No conflict of interest has been declared by the authors.
Acknowledgement
This study was announced as verbal announcement at 2. Integrative
Medicine Congress (Abstract:0110) and oral presentation the first prize
award. Moreover, this study was supported, in part, by a grant from the
Erciyes University Scientific Research Projects Coordination Unit (no.
TDK-2014-5222). The authors are grateful to Associate Professor Ahmet
Ozturk (Department of Biostatistics at Erciyes University) for
supporting statistical analysis.
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