Journal of PeriAnesthesia Nursing xxx (xxxx) xxx

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Journal of PeriAnesthesia Nursing

journal homepage: www.jopan.org

Research

A Randomized Prospective Placebo-Controlled Study of the Effects of

Lavender Aromatherapy on Preoperative Anxiety in Cataract Surgery
Patients
Philip Francis Stanley, MD, MBA, FACS *, Lai Foon Wan, RN, Rostihar Abdul Karim, RN
Department of Ophthalmology and Visual Sciences, Khoo Teck Puat Hospital, Singapore

a b s t r a c t
Keywords: Purpose: To determine if lavender aromatherapy can reduce preoperative anxiety in cataract surgery
cataract surgery patients.
aromatherapy
Design: Single-center prospective randomized placebo-controlled trial.
anxiety
Methods: Seventy-five patients awaiting cataract surgery were randomized to lavender essential oil or
grape seed oil (control) and administered the State-Trait Anxiety Inventory. Vital signs were also
recorded.
Findings: Patients in the lavender group showed greater improvements in self-reported anxiety using
the State-Trait Anxiety Inventory (P ¼ .023, two-sample t test). Compared with the control group, the
effects of lavender on the reduction of anxiety were statistically significant when adjusting for age,
gender, and baseline scores (P ¼ .012, analysis of covariance).
Conclusions: Lavender aromatherapy reduced anxiety in preoperative cataract surgery patients.
© 2019 American Society of PeriAnesthesia Nurses. Published by Elsevier, Inc. All rights reserved.

When facing cataract surgery, patients can understandably be
anxious. Fear of their vision not completely recovering, complica-
tions, the operation itself, the operation failing, and becoming blind
are concerns in the preoperative period.1 Lavender is a traditional
herb used for its analgesic, relaxing, antibacterial, and antifungal
properties.2 It has been studied for anxiety reduction in patients
with cancer, abdominal surgery, coronary artery angiography, and
menstrual cramps.3
Lavender essential oil has been granted safe status by the US
Food and Drug Administration, is well tolerated, and often
applied topically or administered orally in an undiluted form.4
Lavender oil has a low incidence of irritation with the most
common adverse effect being dermatitis.5 In aromatherapy, a
vaporizer evaporates the lavender essential oil, and when
inhaled, it enters the systemic circulation. The lavender plant
contains linalool and linalyl acetate. Linalyl acetate is recognized
as a narcotic, whereas linalool acts as a sedative.6 The
Conflict of interest: None to report.
* Address correspondence to Philip Francis Stanley, Khoo Teck Puat Hospital,
Department of Ophthalmology and Visual Sciences, 90 Yishun Central, Singapore
768828.
E-mail address: philip.stanley@ktph.com.sg (P.F. Stanley).
mechanism of action of lavender oil centrally seems to be
related to inhibition of voltage-gated calcium and sodium
channels and interaction with N-methyl-D-aspartate or g-ami-
nobutyric acid receptors.6 The mechanism of action of lavender
oil peripherally is demonstrated as increased parasympathetic
activity and decreased hemodynamic parameters in rats, dogs,
and humans.4
Secondary to its effects on sympathetic nerve activity, lavender
aromatherapy effectively reduced blood pressure and heart rate in
patients admitted to the open heart surgery intensive care unit.7 A
study of 150 preoperative patients showed lower anxiety during
operating room transfer when lavender was sniffed and topically
applied compared with sham or standard care.8 Lavender aroma-
therapy can reduce the levels of anxiety and plasma cortisol levels
in open heart surgery patients before surgery.3 Lavender aroma-
therapy lowered sympathetic nervous system activity in patients
with essential hypertension as demonstrated by a decrease in
systolic blood pressure (SBP) and improved heart rate variability.9
Another study showed that inhaled lavender essential oil
decreased stress and the pain level during needle insertion pre-
operatively.10 Critics of aromatherapy cite that systemic reviews
had a high risk of bias, small sample sizes, and inadequate
controls.11

https://doi.org/10.1016/j.jopan.2019.12.004
1089-9472/© 2019 American Society of PeriAnesthesia Nurses. Published by Elsevier, Inc. All rights reserved.

Please cite this article as: Stanley PF et al., A Randomized Prospective Placebo-Controlled Study of the Effects of Lavender Aromatherapy on
Preoperative Anxiety in Cataract Surgery Patients, Journal of PeriAnesthesia Nursing, https://doi.org/10.1016/j.jopan.2019.12.004
2 Stanley et al. / Journal of PeriAnesthesia Nursing xxx (xxxx) xxx

Table 1
Summary of Baseline Characteristics of the Study Population

Total (n ¼ 75) Lavender (n ¼ 39) Control (n ¼ 36) P*

Agey 62.4 (7.4) 61.6 (7.0) 63.25 (7.7) .222

Gender, n (%)
Malez 33 (44) 17 (44) 16 (44) 1
Femalez 42 (56) 22 (56) 20 (56)
SBP (mm Hg)y 141.5 (18.3) 141.4 (18.7) 141.6 (18.1) .719
DBP (mm Hg)y 81.2 (10.5) 81.8 (11.4) 80.6 (9.6) .522
Pulse (beat/min)y 76.6 (11.9) 76.8 (12.2) 76.3 (11.8) .873
Respirations (breathes/min)y 18.3 (3.3) 18.4 (3.6) 18.1 (3.1) .757
Baseline STAIy 39x (10.3) 38.4 (10.8) 39.6 (9.4) .617

SBP, systolic blood pressure; DBP, diastolic blood pressure; STAI, State-Trait Anxiety Inventory.
*
P < .05 indicates a significant difference between groups.
y
Data are presented as mean and SD; two-sample t test was used.
z
Data are presented as number and percent; c2 test was used.
x
Moderate anxiety.

We hypothesized that the use of lavender aromatherapy before
cataract surgery would reduce preoperative anxiety as assessed by
the Speilberger State-Trait Anxiety Inventory (STAI) questionnaire.
Blood pressure, pulse, and respiratory rate were also used to assess
sympathetic activity.
Patients and Methods
Seventy-five patients scheduled for cataract surgery between
January 10, 2017 and December 17, 2018 were randomized into a
lavender aromatherapy group or control group. Randomization was
ongoing as patients were recruited (subject 1 would be lavender
group, subject 2 would be control group, with odd numbers
assigned to lavender and even numbers assigned to control).
Informed consent was obtained from all participants, and the study
was reviewed and approved by the National Healthcare Group
Domain Specific Review Board.
Inclusion criteria were aged between 21 and 75 years, and
subjects were excluded if they had a history of mental illness, used
sedatives, and could not read and write English. Asthma, chronic
obstructive pulmonary disease, or bronchitis, contact dermatitis
and allergies to cosmetic fragrances, liver or kidney disorders, and
significant laboratory abnormalities were other exclusion criteria.
Procedure
After registration in the day surgery operating theater, study
patients were administered the STAI and vital signs were taken.
In the preoperative area, patients were exposed to lavender
essential oil or grape seed oil (control) for 20 minutes. Subjects
then took the STAI again and vital signs were taken. After this,
they were brought to the operating room and underwent cata-
ract surgery.
In the lavender group, 20 drops of lavender aromatherapy
containing lavender essential oil were placed in the aromatherapy
vaporizer near the patient's chair in the lounge holding area. The
aromatherapy electric oil vaporizer was from Australia and is
approved by the Australian government. Two separate vaporizers
were used to avoid any hint of aromatherapy in the control group.
The lavender oil was steam distilled from the flowers of Lavandula
officinalis. It was purity tested/quality assured and certified organic
by Quality Assurance International. For a control patient (on a
different day to avoid any hint of aromatherapy), the second
vaporizer was used with 20 drops of grape seed oil. In each case, the
patient was asked to breathe normally for 20 minutes, and then
vital signs and the STAI were repeated.
The STAI takes less than 5 minutes to complete and can be
scored in less than 2 minutes.12 There are 20 questions where
people rate their anxiety from one (not at all) to four (very much
so), and scores range from 20 to 80. For example, low anxiety is 20
to 37, moderate anxiety is 38 to 44, and high anxiety is 45 to 80. The
STAI has an overall median alpha coefficient of 0.92 in normative
samples and slightly higher (0.92 to 0.94) when given under con-
ditions of psychological stress. Psychologists, anesthesiologists, and
allied health investigators use it as the gold standard in measuring
anxiety.13

Table 2 Statistical Analysis

Comparison of the Mean Changes in Anxiety Scores and Vital Signs Between Lav-
ender and Control (n ¼ 75) If the true difference in the lavender and control effect size is
Mean Change Lavender Control P* Effect Sizey 0.74, we needed to study at least 29 experimental subjects and 28
From Baseline control subjects to be able to reject the null hypothesis that the
Mean (SD) Mean (SD)
population means of the experimental and control groups are equal
SBP change 6.9 (13.5) 4.1 (12.2) .35 0.218
with a power of 0.8. This estimate was calculated using an unpaired
DBP change 2.3 (11.7) 2.7 (9.1) .87 0.039
Pulse change 7.1 (9.9) 5.1 (7.8) .35 0.218
two-tailed t test assuming a significance level of 0.05. With 39
Respirations change 1.3 (2.3) 0.4 (2.0) .08 0.409 experimental subjects and 36 control subjects recruited, the power
STAI change 4.5 (8.0) 0.8 (5.9) .023z 0.517 increased to 0.87.
NOTE. Bold text indicates statistical significance. Descriptive statistics were used to express baseline character-
SBP, systolic blood pressure; DBP, diastolic blood pressure; STAI, State-Trait Anxiety istics of the participants for the lavender group and control group.
Inventory. Continuous variables were summarized into mean and SD, and the
*
P < .05 represents a statistical difference between groups.
y
two-sample t test was used. The categorical variable of gender was
Cohen's d where a commonly used interpretation is to refer to effect sizes as
small (d ¼ 0.2), medium (d ¼ 0.5), and large (d ¼ 0.8) based on benchmarks sug-
summarized into count and percentage, and the c2 test was used
gested by Cohen. (Table 1). Differences between the lavender and control groups at
z
Two-sample t test was used. baseline were compared using the two-sample t test (Table 2). The

Please cite this article as: Stanley PF et al., A Randomized Prospective Placebo-Controlled Study of the Effects of Lavender Aromatherapy on
Preoperative Anxiety in Cataract Surgery Patients, Journal of PeriAnesthesia Nursing, https://doi.org/10.1016/j.jopan.2019.12.004
 Stanley et al. / Journal of PeriAnesthesia Nursing xxx (xxxx) xxx 3

Table 3
Comparison of the Mean Changes in Anxiety Scores and Vital Signs at Baseline and After Lavender (n ¼ 39)

Mean Change From Baseline Baseline After Lavender Delta P*

Mean (SD) Mean (SD) Mean (SD)

SBP (mm Hg) 141.38 (18.7) 134.5 (22.1) 6.9 (13.5) .003
DBP (mm Hg) 81.8 (11.4) 79.3 (11.8) 2.5 (11.7) .200
Pulse (beats/min) 76.8 (12.2) 69.1 (11.3) 7.8 (9.3) <.001
Respirations (breathes/min) 18.4 (3.6) 17.1 (3.2) 1.3 (2.3) .001
STAI 38.4 (10.8) 33.9 (10.5) 4.5 (8.0) .001

NOTE. Bold text indicates statistical significance.

SBP, systolic blood pressure; DBP, diastolic blood pressure; STAI, State-Trait Anxiety Inventory.
*
P < .05 indicates a significant change from baseline; paired sample t test was used (two-tailed).

effect size was measured using Cohen's d and interpreted as small
(d ¼ 0.2), medium (d ¼ 0.5), and large (d ¼ 0.8). Within the lavender
group (Table 3) and control group (Table 4), the paired t test was
used to compare mean STAI and vital signs at baseline and after the
experiment. Finally, STAI scores and vital signs between the lav-
ender and control groups were compared while adjusting for age,
gender, and baseline scores using analysis of covariance (Table 5).
The two-tailed analysis was considered significant at P < .05.
Results
The two groups were lavender essential oil (n ¼ 39) and control
(n ¼ 36), for a total of n ¼ 75 (Table 1). The two groups were
comprised of 56% females and had similar baseline characteristics
that included moderate anxiety and vital signs (P > .05) (Table 1).
The mean change in the STAI score was 4.5 in the lavender group
and 0.8 in the control group, which was statistically significant
(P ¼ .023, two-sample t test). Coincident with this decrease in
anxiety, all the vital signs improved except for diastolic blood
pressure (DBP). The mean SBP change was 6.9 mm Hg in the
lavender group and 4.1 mm Hg in the control group. The mean
DBP change was 2.3 mm Hg in the lavender group and 2.7 mm
Hg in the control group. The mean change in pulse was 7.1 beats
per minute in the lavender group and 5.1 beats per minute in the
control group. The mean change in respirations was 1.3 breaths
per minute in the lavender group and 0.4 breaths per minute in
the control group. These vital sign differences did not reach sta-
tistical significance (Table 2). In the lavender group, the mean SBP
decrease was 6.9 mm Hg from baseline. The mean DBP decrease
was 2.5 mm Hg. The mean pulse change was 7.8 beats per
minute. The mean respiration change was 1.3 breaths per minute.
The mean STAI score change was 4.5. All these changes were
statistically significant (P ¼ .003 for SBP, P < .001 for pulse, P ¼ .001
for respirations and STAI, all using paired sample t test) except the
DBP (P ¼ .2, using paired sample t test) (Table 3). Examining the
control group compared with its baseline, the mean SBP decrease
was 4.1 mm Hg. The mean DBP decrease was 2.6 mm Hg. The
mean pulse change was 5.4 beats per minute. The mean respi-
ration change was 0.4 breaths per minute. The mean STAI score
change was 0.8. None of these changes were statistically signifi-
cant except for heart rate (P < .001 using paired sample t test)
(Table 4). Compared with the control group when adjusting for age,
gender, and baseline scores, the effects of lavender on the STAI
score (coefficient of 3.9) were statistically significant (P ¼ .012
using analysis of covariance), whereas changes in SBP, DBP, heart
rate, and respirations did not reach statistical significance (Table 5).
The effect size comparing lavender and control was medium for
STAI (0.517) and small for SBP (0.218) and DBP (0.039), respirations
(0.409), and pulse (0.218) (Table 2). There were no adverse effects in
either the lavender or the grape seed oil groups.
Discussion
This is the first randomized placebo-controlled study on
aromatherapy for preoperative anxiety reduction in cataract sur-
gery patients we are aware of.
This study has several limitations. The first is that the lavender
aromatherapy and grape seed oil are odors that both the investi-
gator and study subjects can detect. Therefore, it cannot be a truly
double-blind study. The second limitation is the potency and de-
livery of the aromatherapy. We chose a heated vaporizer with 20
drops of essential oil or control, whereas other studies have used
ultrasound diffusers commonly used in health spas.12 Still other
studies have used a cloth infused with aromatherapy for direct
inhalation.2 As a result, it is hard to assess the optimum delivery
system and dose until further studies are done.
Conclusion
Lavender is an inexpensive, well-tolerated,4 and easy interven-
tion to lower anxiety in patients getting ready for cataract surgery.

Table 4
Table 5
Comparison of the Mean Changes in Anxiety Scores and Vital Signs at Baseline and
ANCOVA for Comparing the Control Group With the Lavender Group on Score
After Control (n ¼ 36)
Changes in Anxiety and Vital Signs While Adjusting for Age, Gender, and Baseline
Mean Change From Baseline Baseline After Control Delta P* Scores (n ¼ 75)

Mean (SD) Mean (SD) Mean (SD) Outcome Coefficient 95% CI P*

SBP (mm Hg) 141.6 (18.1) 137.6 (18.8) 4.1 (12.3) .053 Score change in SBP 2.7 8.3, 2.9 .35
DBP (mm Hg) 80.6 (9.6) 77.9 (9.7) 2.6 (9.1) .092 Score change in DBP 1.1 3.3, 5.4 .63
Pulse (beats/min) 76.3 (11.8) 70.9 (12.0) 5.4 (7.5) <.001 Score change in pulse 2.1 5.8, 1.6 .27
Respirations (breathes/min) 18.1 (3.1) 17.7 (2.9) 0.4 (2.0) .26 Score change in respirations 0.8 1.7, 0.02 .056
STAI 39.6 (9.8) 38.8 (10.9) 0.8 (5.9) .44 Score change in STAI 3.9y 6.9, 0.9 .012

NOTE. Bold text indicates statistical significance. NOTE. Bold text indicates statistical significance.
SBP, systolic blood pressure; DBP, diastolic blood pressure; STAI, State-Trait Anxiety ANCOVA, analysis of covariance; 95% CI, 95% confidence interval; SBP, systolic blood
Inventory. pressure; DBP, diastolic blood pressure; STAI, State-Trait Anxiety Inventory.
* *
P < .05 indicates a significant change from baseline; paired sample t test was P < .05 indicates a significant change from baseline.
y
used (two-tailed). Lavender significantly reduced the STAI score 3.9 more than control.

Please cite this article as: Stanley PF et al., A Randomized Prospective Placebo-Controlled Study of the Effects of Lavender Aromatherapy on
Preoperative Anxiety in Cataract Surgery Patients, Journal of PeriAnesthesia Nursing, https://doi.org/10.1016/j.jopan.2019.12.004
4 Stanley et al. / Journal of PeriAnesthesia Nursing xxx (xxxx) xxx

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Please cite this article as: Stanley PF et al., A Randomized Prospective Placebo-Controlled Study of the Effects of Lavender Aromatherapy on
Preoperative Anxiety in Cataract Surgery Patients, Journal of PeriAnesthesia Nursing, https://doi.org/10.1016/j.jopan.2019.12.004