Complementary Therapies in Clinical Practice 42 (2021) 101299

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Complementary Therapies in Clinical Practice

journal homepage: http://www.elsevier.com/locate/ctcp

Effect of rosa damascene aromatherapy on anxiety and sleep quality in

cardiac patients: A randomized controlled trial
Kurosh Jodaki a, b, Kamel abdi c, Masoumeh-Sadat Mousavi d, Razieh Mokhtari e,
Hamid Asayesh f, Vijayaraddi Vandali c, Mohamad Golitaleb g, *
a
Departments of Anesthesia, School of Paramedicine, Qom University of Medical Sciences, Qom, Iran
b
School of Nursing and Midwifery, Tehran University of Medical Sciences, Tehran, Iran
c
Nursing Department, Faculty of Medicine, Komar University of Science and Technology, Sulimaniya, Kurdistan Region, Iraq
d
Nursing and Midwifery Care Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
e
Department of Medical Surgical Nursing, School of Nursing, Arak University of Medical Sciences, Arak, Iran
f
Spiritual Health Research Center, Department of Medical Emergencies, School of Paramedicine, Qom University of Medical Sciences, Qom, Iran
g
Department of Critical Care Nursing, School of Nursing, Arak University of Medical Sciences, Arak, Iran

A R T I C L E I N F O A B S T R A C T

Keywords: Introduction: Anxiety and sleep disorders are the most common disorders of patients admitted to the cardiac care
Sleep quality units. The purpose of this study is to investigate the effect of Rosa damascene fragrance on anxiety and sleep
Anxiety quality of hospitalized patients in the cardiac care units.
Aromatherapy
Methods: In this Randomized clinical trial, 60 patients who had the inclusion criteria were conveniently sampled
Intensive care units
Rosa
and randomly allocated to the experimental and control groups. Patients were enrolled in the study 24 h after
hospitalization. Those diagnosed with dysrhythmia, ACS, and CHF were included. Patient recruitment lasted
from October 2018 to December 2019. In these groups, in addition to the routine care, the intervention was
performed for three consecutive nights from 22:00 to 06:00. In the experimental group, patients inhaled five
drops of Rosa damascene essence 40% in distilled water, while in the control group, patients inhaled five drops of
distilled water as placebo. In both groups, anxiety and sleep quality were examined before and after three
consecutive nights using the St. Mary’s Hospital Sleep Quality Questionnaire (SMHSQ) and the Spiel Berger
State-Trait Anxiety Inventory (STAI) questionnaire.
Results: The results of this study showed that the use of Rosa damascene aroma in patients hospitalized in the
cardiac care unit significantly reduces anxiety and increases the improvement of sleep quality in the experi­
mental group compared to the control group (P < 0.05). The significance level for anxiety and sleep quality was
(P = 0.001).
Conclusion: Aromatherapy with Rosa damascene reduces anxiety and increases the sleep quality of patients
hospitalized in the cardiac care unit. Therefore, along with other treatment measures, Rosa damascene can be
used as a complementary method to reduce anxiety and improve sleep quality.

Author agreement statement
We the undersigned declare that this manuscript is original, has not
been published before and is not currently being considered for publi­
cation elsewhere. We confirm that the manuscript has been read and
approved by all named authors and that there are no other persons who
satisfied the criteria for authorship but are not listed. We further confirm
that the order of authors listed in the manuscript has been approved by
all of us. We understand that the Corresponding Author is the sole
contact for the Editorial process. He is responsible for communicating
with the other authors about progress, submissions of revisions and final
approval of proofs Signed by all authors as follows:

* Corresponding author. Basij Square, Arak, Iran.

E-mail addresses: kuroshjodaki@gmail.com (K. Jodaki), kamel.abdi@komar.edu.iq (K. abdi), ms_mousavi@nm.mui.ac.ir (M.-S. Mousavi), razieh.mokhtari91@
gmail.com (R. Mokhtari), asayeshpsy@gmail.com (H. Asayesh), vijayaraddi@komar.edu.iq (V. Vandali), M.golitaleb@arakmu.ac.ir, m.golitaleb@arakmu.ac.ir
(M. Golitaleb).

https://doi.org/10.1016/j.ctcp.2020.101299
Received 20 October 2020; Received in revised form 17 December 2020; Accepted 22 December 2020
Available online 29 December 2020
1744-3881/© 2020 Elsevier Ltd. All rights reserved.
K. Jodaki et al.
1. Introduction
Cardiovascular diseases (CVD) are the leading cause of death in
developing countries. According to the World Health Organization
(WHO), CVD are accountable for 31% of deaths [1,2]. Acute conditions
and hospitalization in the cardiac care units (CCU) cause psychological
reactions such as denial, anger, hopelessness, guilt, fear, anxiety and
depression in patients. Anxiety is the most common psychological re­
action that 50% of inpatients experience in the CCU [3]. Studies over the
past 20 years have also shown that anxiety is a risk factor for fatal
cardiovascular events, such as sudden cardiac death. For patients with
acute coronary syndrome (ACS), most physicians seek treatment to
reduce anxiety by using medications [4]. The side effects of anti-anxiety
medications include heart rhythm dysfunction, sudden death, and the
risk of drug dependency. In addition, high cost of the drug, and the time
drug takes to effect are additional problems. Aromatherapy using rosa
can be used as a complementary treatment along with routine phar­
maceutical therapies to reduce anxiety and increase sleep quality in
patients with cardiac diseases [5,6]. Sleep is a physiological need and a
quality sleep is essential for health. Patients admitted to CCU are con­
sciousness and are more likely to have disturbed sleep due to environ­
mental factors such as loud noises, constant light, unpleasant odors,
recurrent care procedures, their critical condition, and fear of the dis­
ease [7]. Accordingly, Bagheri et al. reported that 93.3% of patients with
ACS had poor sleep quality during the first 24 h of hospitalization [7,8].
Lack of sleep and rest with increased sympathetic system activity in­
crease blood pressure and heart rate and thus, increase the risk of heart
attack. Lack of sleep also increases release of catecholamine. Lack of
sleep and increment of plasma catecholamine leads to restlessness and
increased risk of delirium [9–12]. Aromatherapy has been used as a
complementary method in most countries around the world anciently. In
addition to pharmacological methods, aromatherapy is recommended as
a method without side effects, non-invasive, cheap and painless to
reduce anxiety and increase the sleep quality of cardiac patients. The
smell of aromatherapy by affecting the limbic part of the brain can in­
crease the patient’s sense of calmness [9,13,14]. Rosa damascene is one
of the most important roses in the world and the most famous plant in
the history of horticulture.The scent of Rosa damascene is hypnotic,
analgesic and sedative and has anticonvulsant effects on the central
nervous system [13,15].
According to the findings, sleep disorders and high level anxiety are
common among cardiac patients. Alongside with decreasing anxiety and
increasing relaxation, Rosa damascene increase the quality of sleep too
[16,17]. Sleep deprivation affects hemodynamic status negatively that
cause delays in recovery and increase the length of hospitalization [18,
19]. Some studies have evaluated the effects of Rosa damascene on sleep
quality and anxiety separately and reported contradictory results.
However, no study has been dedicated to simultaneously evaluate the
effects of rosemary aromatherapy on sleep quality and anxiety in hos­
pitalized patients with cardiac problems using the St. Mary’s hospital
sleep quality questionnaire, which served as the primary objective of the
current study. So, the research team decided to evaluate the effect of
Rosa damascene fragrance on anxiety and sleep quality of hospitalized
patients in the CCU.
2. Methods
2.1. Designing
The present study was blind a randomized controlled trial conducted
from October 2018 to December 2019 on 60 patients admitted to the
CCU of Shahid beheshti Hospital, affiliate to Qom University of Medical
Sciences Qom, Iran.
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Complementary Therapies in Clinical Practice 42 (2021) 101299
2.2. Participants
In this Randomized clinical trial, the study population comprised all
patients hospitalized in the study setting. The Inclusion criteria were
orientation to the person, place and time, not consuming psychiatric
drugs, having a cardiac ejection fraction of at least 40%, no underlying
disease that affect sleep (such as rheumatoid arthritis and migraine),
lack of known sleep disorders according to the patient, no history of
asthma condition, not having allergy to flowers and plants and their
fragrance, not taking opium drugs for 6 h before bedtime, lack of vision
problems, not having a care or treatment plan during bedtime (from
22:00- to 06:00), lack of orthopnea and respiratory conditions, and
spending 24 h of hospitalization [9, 20]. The exclusion criteria included
patient’s reluctance to remain in the study, developing allergy to
aromatherapy, developing orthopnea or any other nocturnal respiratory
problems, hemodynamic instability, using over-the-counter tranquil­
izers or hypnotic-sedative agents and developing respiratory conditions
during the study [9, 21, 22]. In this study, sample size was calculated
according to the study of Haji Bagheri et al. [9].
α1 = 0.05, β1 = 0.15, μ1 = 9.26, μ2 = 5.63, s1 = 3, s2 = 5.13, effect
size = 3.63, statistical power 0.8
( )2
( 2 )
Z1− α2 + Z1− β S1 + S22
(1.96 + 0.85)2 (9 + 26.31)
N= = = 21
2
(μ1 − μ2 ) (3.63)2
The primary variable used to calculate the sample size was sleep
quality. According to previous studies, the sample size was estimated as
21. Based on a statistician’s guide on the second variable, for compen­
sating probable attritions and achieving more reliable results, we
recruited 30 patients for each group. Patients were recruited to the study
by using the convenience sampling method. (Fig. 1).
2.3. Randomization
Patients who fulfilled the above criteria were enrolled in the study
using convenience sampling. Then the samples were randomly divided
into two groups of experimental and control using a randomized block
design. Four blocks were considered which half of them as the E code
and another half as the C code, then they were assigned to the experi­
mental and control group respectively. The codes were placed non-
repeatedly in each block and the blocks were randomly chosen one by
one blindly and without any replacement [23].
2.4. Outcome measures
The study instrument comprised three parts including a demographic
questionnaire and the St Mary’s Hospital Sleep Quality Questionnaire
(SMHSQ) and the Spiel Berger State-Trait Anxiety Inventory (STAI)
questionnaire Index. The demographic questionnaire consisted of
questions about participants’ demographic and clinical data (including
age, gender, marital status, employment, educational level, previous
history of hospitalization, and medical diagnosis).
The SMHSQ was designed to assess the sleep quality of hospitalized
patients. It contains 11 questions that assess the length and mental
quality of a person’s sleep during the last night. This scale evaluates
sleep issues such as delayed falling asleep, restless during sleep, waking
up at night, and waking up early. The Questionnaire scores range from
11 to 44, given that, to the option with the answer never score 1, very
low score 2, to some extent score 3, and high score 4 were assigned. The
lowest score of sleep disorder is 11, that is interpreted as lack of sleep
disorder; the score 44 is the highest rate of sleep disorder. Scores 11–21
show slight disorders of sleep, scores 22–32 show moderate sleep dis­
orders and 33–44 Indicate severe sleep disorders [23]. The reliability of
the questionnaire has been examined in some studies; Bagheri-Nesami ‘s
study has confirmed the reliability and validity of the questionnaire by
K. Jodaki et al.
Fig. 1. The CONSORT Follows diagram of the study.
using Cronbach’s alpha that was 91% and r = 0.99, respectively [24].
The STAI is a 40-item self-completed questionnaire that aims to
assess separately state anxiety (a temporary state influenced by the
current situation) and trait anxiety (a general propensity to be anxious)
with 20 items each [25].
In this study, we used the state subscale that evaluates the current
state of anxiety, asking how respondents feel “right now”, using items
that measure subjective feelings of apprehension, tension, nervousness,
worry, and activation/arousal of the autonomic nervous system. Options
for this test include four scoring options in the Likert range, which are: 1
= not at all, 2 = somewhat, 3 = moderately so, and 4 = very much. This
test score ranges from 20 to 80; that varies from without anxiety [20],
mild (21–39), moderate (40–59) and severe anxiety 60–80 groups [21].
The standardization and cross-cultural adaptation of this questionnaire
(STAI) was performed by Roohy et al., in 2005 and reported a reliability
of 90% [26].The reliability coefficient of the questionnaire in the pre­
sent study was calculated as 0.96 using the Cronbach’s alpha statistical
test.
2.5. Intervention
After assigning the samples to the two control and experimental
groups (in the second day of hospitalization), we asked all the patients in
both study groups to complete the SMHSQ and STAI questionnaire.
3
Complementary Therapies in Clinical Practice 42 (2021) 101299
Moreover, we gathered patients’ demographic and clinical data from
their medical records. The onset of intervention was in the second night
of hospitalization.
In both group, patients received the sleep care routinely provided in
the study setting. The routine sleep care included of reducing ambient
noises, reducing ambient light, and providing nursing care during the
day as far as possible were performed to prevent disturbing patient’s
sleep at night.
Patients in the experimental group received routine sleep care as well
as aromatherapy. Each night, researcher dipped five drops of Rosa
damascene essence 40% (prepared by Barij essence Company, Kashan,
Iran) on an absorbent cloth napkin measuring 10 × 10 cm, which was
attached to the collar of the patient’s shirt with a pin. The fabric was far
about 20 cm from the nose. The napkin remained in place for 8 h
(22:00–06:00).
In the control group, 5 drops of distilled water were used as a placebo
for patients with the same method [9,13,27]. In order to blind the nose,
the researcher’s nose was covered with a fragrant face mask, without the
researcher’s insight of the control and intervention group [13]. in the
morning of the fourth day of the study (i.e. after the third aromatherapy
session), we asked patients in both groups to fill out SMHSQ and STAI
questionnaire again. For illiterate patients, the questionnaires’ items
were read to them by the researcher, and patients’ choices were marked
on the questionnaires. should be noted that, Sleep quality and anxiety
K. Jodaki et al. Complementary Therapies in Clinical Practice 42 (2021) 101299

data were collected simultaneously before starting the intervention and Table 1
in the morning of the fourth day of the study. Comparison of demographic characteristics in control and intervention groups.
The patients were kept in separate partitioned rooms so that they ACS = Acute coronary syndrome, CHF= Congestive heart Failure *chi-square
could not see other patients, so those in the control and experimental test.
groups were not in contact with each other. Three members of the Variable Experimental Control p-
research team had aromatherapy license, one of them performed the group (N = 30) group (N value*
No% = 30)
intervention.
No%

2.6. Data analysis Sex Male 16 (53.3) 15 (50) 0.67

Female 14 (46.6) 15 (50)
Age category 25–35 1 (3.3) 1 (3.3) 0.47
After collecting data, SPSS software, version 21 was used for (year) 36–45 1 (3.3) 2 (6.7)
analyzing them. In assessing demographic details, quantitative variables 46–55 5 (16.7) 5 (16.7)
were reported as averages and qualitative variables as percentages. The 56–65 23 (76.7) 22 (73.3)
Marital Status Single 3 (10) 5 (16.6) 0.82
Kolmogorov-Smirnov test was used for the normal distribution of
Married 22 (73.3) 21 (70)
quantitative data. The results of this test showed that the data were in Divorced 3 (10) 2 (6.7)
the normal range, so we used parametric tests. For data analysis, t-test, widow 2 (6.7) 2 (6.7)
chi-square tests were used. P-value <0.05 was considered statistically job status Jobless 2 (6.7) 5 (16.7) 0.88
significance in all tests. Employed 16 (53.3) 13 (43.3)
Housewife 8 (26.7) 7 (23.3)
Retired 4 (13.3) 5 (16.7)
2.7. Ethical considerations Previous history of NO 16 (53.3) 18 (60) 0.12
hospitalization One Time 8 (26.7) 7 (23.3)
Prior to the start of the study, an ethical confirmation was obtained More than one 6 (20) 5 (16.7)
time
from the Ethics Committee of Qom University of Medical Sciences with
Medical diagnosis ACS 13 (43.3) 15 (50) 0.73
the ethical number IR.MUQ.REC.1396.119. The present study with the Dysrhythmia 7 (23.3) 8 (26.7)
code IRCT20170516033998N3 was registered in the International CHF 10 (33.4) 7 (23.3)
Center for Clinical Trials Registration of Iran. All participants were Education Illiterate 1 (3.3) 2 (6.7) 0.82
informed of the study method and the objectives of the study, as well as Elementary 2 (6.7) 4(13.3)
Guidance 8 (26.7) 6(20)
their voluntary participation in the study so that they could leave the High school 16 (53.3) 11 (36.7)
study at any stage. Then a written informed consent was obtained from University 3 (10) 7 (23.3)
all of them. They also were assured that their personal information
would be kept confidential. Moreover, all ethical principles of the
Declaration of Helsinki for medical research involving human subjects
Table 2
were observed during the study. Comparison of anxiety score and sleep quality score in two groups of control and
intervention before and after the intervention.
3. Results
variable Experimental Control p-
group group valuea
In this study, 60 patients were included in two intervention groups
Mean ± SD Mean ± SD
that received the aromatherapy of Rosa damascene and the control
group that inhaled placebo (distilled water). At the beginning of the anxiety Before 58.99 ± 11.03 57.99 ± 0.531
intervention 10.55
study, 103 patients entered the study but 43 of them were excluded
After 41.77 ± 10.04 57.39 ± 0.001
(Fig. 1). The average age of samples in control and intervention groups intervention 10.50
were 61.5 ± 12.75 and 62.8 ± 11.8, respectively. In this study, most of p-valuea 0.001 0.463
the samples were male (70%), married (88.3%), literate (85%), were Sleep Before 29.02 ± 2.33 24.73 ± 0.602
diagnosed with acute coronary syndrome (ACS) (80%) and with a his­ quality intervention 2.55
After 18.99 ± 1.04 24.31 ± 0.001
tory of one-time hospitalization (60%). The results of independent t-test intervention 2.31
and chi-squared test showed that the samples of both groups in terms of p-valuea 0.001 0.584
age, sex, education, history of hospitalization and medical diagnosis a
T-Test.
were identical P > 0.05. (Table 1).
The mean score of sleep quality in the two groups before the inter­
vention was not statistically significant (P > 0.05), while after the undergoing coronary angiography. In another study, Barati et al.[28],
intervention it was different and statistically significant (P < 0.05). Also, reported that inhalation aromatherapy with rose significantly reduced
the T-Test result showed that The mean score of anxiety in the two anxiety in hemodialysis patients. So, the findings of these studies are
groups before the intervention was not statistically significant (P > consistent with our observations.
0.05), while after the intervention it was different and statistically sig­ Dehkordi et al.[29], also reported in a study that was conducted on
nificant P < 0.05) (Table 2). In the present study, intervention has led to hemodialysis patients that aromatherapy with Rosa damascene
a reduction in the anxiety score and an increase in the quality of the fragrance reduces anxiety in these patients.
sleep score in the experimental group compared to the controlled group In addition, Abdelhakim et al. [1], in a systematic review and
(Fig. 2 and Fig. 3). meta-analysis reported that aromatherapy after heart surgery reduces
pain and anxiety. However, in a study conducted by Fazlollahpour et al.
4. Discussion [30], different results from our study were obtained. They reported that
aromatherapy with the Rosa damascene fragrance has no effect on the
The aim of this study was to examine the effect of aromatherapy with level of anxiety of patients. The reason for this can be related to the
Rosa damascene on anxiety and sleep quality of patients hospitalized in method and length of their study; because they performed aromatherapy
the cardiac care unit. with the Rosa damascene fragrance the night before the surgery for 10
In a study, Bikmoradi et al.[21], reported that inhalation aroma­ min and 1 h before the operation, while in our study we performed the
therapy with 40% rose essential oil could reduce anxiety in the patients intervention for 3 consecutive nights and for 8 h (from 22 to 6 in the

4
K. Jodaki et al.
Fig. 2. Anxiety level.
Fig. 3. Sleep quality.
morning).In another study conducted by Kheirkhah et al. [31], on the
anxiety of the early stage of delivery among first-delivery of women
were found that aromatherapy with Rosa damascene significantly
reduced anxiety in these patients. Aromatherapy is one of the medical
complementary methods that by using fragrance and provoking olfac­
tory system, induces relaxation and decreases anxiety. However, scien­
tific researchers have not approved its effect completely, but it is
hypothesized that, like medications, aromatherapy can affect central
nervous system (CNS). Aromatherapy increases neurotransmitters, and
in this way, decreases pain and induces relaxation [31,32].
Studies have shown that rose aromatherapy relieves anxiety and
promotes relaxation [12,27]. Considering the negative and detrimental
effects of anxiety on sleep quality and the direct relationship between
these two entities (i.e. more severe anxiety correlating with poorer sleep
quality), it is understandable that sleep quality increases following a
reduction in anxiety. In addition, the findings of our study showed that
aromatherapy with Rosa damascene is effective in improving the sleep
quality of cardiac patients. In one study, Hajibagheri et al. [9], reported
5
Complementary Therapies in Clinical Practice 42 (2021) 101299
that aromatherapy with rose significantly increased sleep quality in the
patients admitted to the intensive cardiac care units. Also, in another
study by Babaei et al. [20], rose scent was reported to improve the sleep
quality of the patients admitted to the intensive cardiac care unit. The
results of these studies are also in accordance with our findings.
On the other hand, the results of the study of Sanatkaran et al. [33],
showed that aromatherapy with Rosa damascene does not have a sig­
nificant effect on the quality of sleep of female students. The reasons for
this inconsistency can be due to the difference between the methods and
number of samples. They studied 9 people, while in our study, 60 people
were examined. Apart from the three above studies, Hajibagheri [9],
Babai [20], and Sanatkaran [33], no other study has examined the effect
of aromatherapy with Rosa damascene fragrance on quality of sleep.
While many studies have been performed with different scents such as
bitter orange, lemon, and lavender on the sleep quality of cardiac and
non-cardiac patients; the results of all of them have shown a positive
effect of aromatherapy on sleep quality [1,7,27,34–36]. In a study by
Rakhshandash et al. [37], Rosa damascene fragrance was compared to
K. Jodaki et al.
diazepam because of its hypnotic properties. At the end of the study,
they reported that Rosa damascene fragrance could prolong the duration
of sleep induced by phenobarbital compared to diazepam. According to
the results of this study, aromatherapy with Rosa damascene fragrance
has a positive effect on anxiety and improves the quality of sleep of
cardiac patients. Therefore, it is recommended to use the scent of Rosa
damascene for people with sleep disorders and anxiety. The important
point to be considered is to use this method with modern medicine to
control anxiety and improve the quality of sleep. The results of our study
suggest that physicians and nurses use a non-pharmacological approach
to control anxiety and improve the quality of the patients’ sleep.
5. Conclusion
The overall results of this study revealed that the use of Rosa
damascene fragrance is effective in reducing anxiety and improving the
sleep of cardiac patients admitted to the cardiac care unit. Therefore,
based on these findings, physicians and nurses can safely use Rosa
damascene perfume as a supplement along with routine treatments or as
an alternative therapy to improve sleep quality and reduce anxiety in
patients with cardiac diseases. Nevertheless, further studies with larger
sample sizes are recommended in this field. It is also suggested to
conduct a study to compare the effects of Rosa damascene aromatherapy
with those of conventional drug therapies on the sleep quality and
anxiety of patients with cardiac diseases.
Limitations of our study
Factors such as ambient light, the sound of alarms, and the envi­
ronment of the intensive care unit may affect the quality of sleep of
hospitalized patients. This environmental factors are limitations of our
study and are out of researcher’s control. It should be noted that the
above conditions are the same for both intervention and control groups.
A limitation of our study was the relatively low sample size, so it is
recommended to conduct studies with larger sample sizes. Another
limitation was the early discharge (less than 3 days) of patients.
Funding
The present study received financial support from the Qom Univer­
sity of Medical Sciences.
Declaration of competing interest
The authors have no financial or nonfinancial conflicts of interest.
Acknowledgements
The vice Chancellor for research of Qom University of Medical Sci­
ences, the Vice Chancellor for Research of Arak University of Medical
Sciences and all the patients and staff of the Cardiovascular Care
Department of Shahid Beheshti Hospital in Qom will be commended and
thanked.
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