INTEGRATED CARE
LEE, RN, MS, AOCN
Clinical Aromatherapy Part II: Safe Guidelines
for Integration Into Clinical Practice
CDR Colleen O. Lee, RN, MS, AOCN
Clinical Aromatherapy Part I: An Intro-
duction Into Nursing Practice (see page 595)
provided an overview of aromatherapy, guide-
lines for selecting quality products, and the po-
tential risks associated with essential oils. This
article, Clinical Aromatherapy Part II: Safe
Guidelines for Integration Into Clinical Prac-
tice, describes the credentialing process for
aromatherapists and holistic nursing, relevant
clinical research regarding aromatherapy, and
suggested guidelines for safe integration into
nursing practice.
What Does Becoming
Certified in Aromatherapy
or Holistic Nursing Require?
Certification programs should provide sci-
entific knowledge, technical skills, and treat-
ment methods to ensure competent and appro-
priate services as professional practitioners.
Program content and clinic practicum must
meet individual state board requirements for
participants to graduate and apply for licen-
sure to practice as professionals in that state
and other states. Aromatherapy can be prac-
ticed in combination with massage therapy
and holistic nursing care programs. Certifica-
tion in aromatherapy is available through vari-
ous schools that comply with National Asso-
ciation for Holistic Aromatherapy Standards
of Aromatherapy Training (see Figure 1).
Schools offering this certification must pro-
vide 200 hours of training in the fields of aro-
matherapy, essential oil studies, anatomy, and
physiology. In addition, students must submit
a research paper, complete a minimum of 10
case histories, and pass a written examination.
Certification in holistic nursing is available
through the American Holistic Nurses Cer-
tification Corporation, the credentialing body
for holistic nursing (see Figure 1). The cre-
dential HNC (certification in holistic nursing)
is given to nurses who possess a baccalaure-
CLINICAL JOURNAL OF ONCOLOGY NURSING VOLUME 7, NUMBER 5 INTEGRATED CARE: PART II
CDR COLLEEN O.
National Association for Holistic
Aromatherapy
http://www.naha.org
American Holistic Nurses Certification
Corporation
http://ahna.org/edu/certification.html
FIGURE 1. ORGANIZATIONS THAT OFFER
CERTIFICATION IN AROMATHERAPY AND HOLISTIC
NURSING
ate degree in nursing, complete 48 hours of
continuing education in the previous two
years, complete one year of practice imple-
menting the principles of holistic nursing,
and pass a quantitative written examination.
Certification in aromatherapy or holistic
nursing does not qualify a nurse to work in-
dependently, nor does it necessarily meet in-
stitutional requirements for practice.
Are Randomized Controlled
Trial Data Available to Develop
Evidence-Based Practice?
Published data on dosing, comparative
methods of administration, and therapeutic
outcomes in the use of essential oils in aroma-
therapy are limited. Many anecdotal accounts
of aromatherapy are individual cases or expe-
riences, and unclear dosing and concentrations
that are difficult to replicate further complicate
study design. Aromatherapy often is practiced
with massage, thereby confounding results,
whether positive or negative (Robins, 1999).
Cooke and Ernst (2000) conducted a sys-
tematic review of the literature on aroma-
therapy to identify clinical indications for its
use. Twelve trials were located, of which six
had no independent replication. The remain-
ing six trials suggested that aromatherapy mas-
sage has a relaxing effect. Cooke and Ernst
ASSOCIATE EDITOR
cautioned that, based on a critical assessment
of the six latter studies, the effects of aroma-
therapy probably were not strong enough to
be considered as independent treatment for
anxiety.
Using the gold standard in clinical trial de-
sign, Graham, Browne, Cox, and Graham
(2003) conducted a placebo-controlled,
double-blind, randomized clinical trial (RCT)
to determine whether inhalation aromatherapy
during radiotherapy reduced patient anxiety.
Three hundred patients undergoing radio-
therapy were assigned randomly to receive ei-
ther carrier oil with fractionated oils, carrier
oil only, or pure essential oils of lavender, ber-
gamot, and cedarwood administered by inha-
lation concurrently with radiation treatment.
Patients completed the Hospital Anxiety and
Depression Scale (HADS) and the Somatic
and Psychological Health Report (SPHERE)
at baseline and at the completion of treatment.
No significant differences were found among
HADS or SPHERE scores between the
groups. The HADS anxiety scores, however,
were lower at completion of treatment in the
carrier oil group as compared to either of the
fragrant arms (p = 0.04). The authors con-
cluded that aromatherapy was not beneficial
as administered in the study design.
CDR Colleen O. Lee, RN, MS, AOCN , is a
commander in the U.S. Public Health Service
and a practice assessment program manager
at the National Cancer Institutes Office of Can-
cer Complementary and Alternative Medicine
in Rockville, MD. (Mention of specific prod-
ucts and opinions related to those products
do not indicate or imply endorsement by the
Clinical Journal of Oncology Nursing or the
Oncology Nursing Society.)
Key Words: complementary therapies, aroma-
therapy
Digital Object Identifier: 10.1188/03.CJON.597-598
597
 Other researchers have published findings
in the clinical use of aromatherapy. According
to Westcombe, Gambles, Wilkinson, Barnes,
and Fellowes (2003), aromatherapy massage
is used in palliative care settings to improve
quality of life for patients with cancer but with-
out evidence of effectiveness. Louis and
Kowalski (2002) measured the responses of
17 patients with cancer to humidified water
and humidified lavender oil. Results showed
positive changes in blood pressure, pulse, pain,
anxiety, depression, and sense of well-being
after both the humidified water treatment and
humidified lavender treatment. Dunwoody,
Smyth, and Davidson (2002) identified eight
themes when exploring patient experiences
with aromatherapy using a focus group inter-
view format. The themes included destressing
effects of aromatherapy, the counseling role
of the aromatherapist, patient empowerment,
aromatherapy as a reward, and communication
through touch. Olleveant, Humphris, and Roe
(1999) undertook a small study comparing
drop sizes of six essential oils. They reported
that the bottles differed in their methods of de-
livery of drops of oil and recommended a uni-
versal standardization of measure to ensure
equity and safety in administration.
Overall, a lack of published validation ex-
ists in many areas of aromatherapy practice.
Areas of future research should focus on stan-
dardizing the acquisition of plant oils and de-
livery routes of essential oils, toxicity data,
regulation of practice, and comparisons among
essential oils. Further inquiry should include
cost analyses of each aspect of aromatherapy
practice, perceived role versus actual role of
aromatherapy in symptom management, and
in-depth patient interviews. Placebo-con-
trolled, double-blind RCTs should further as-
sess aromatherapys clinical efficacy and de-
velop evidence-based practice guidelines.
Guidelines for Safe Integration
of Aromatherapy Into Practice
Campbell, Pollard, and Roeton (2001) of-
fered the following suggestions.
Identify certified staff members who have
aromatherapy or holistic nursing experi-
ence to serve as resource personnel and
educators.
Select essential oils with low known risk
potential.
Develop a range of essential oils and meth-
ods of application that can be used consis-
tently in a practice setting.
When blending essential oils, consider
symptoms, patient allergies, and prefer-
ence of aroma.
Choose one supplier with stringent expec-
tations of quality and consistent testing of
product quality.
598
The use of and nursing in-
volvement in aromatherapy
likely will continue to ex-
pand. The Oncology Nurs-
ing Society believes that on-
cology nurses should provide
credible information regard-
ing therapies, assess patients
for the use of therapies, and
seek to establish evidence-
based practice in oncology
care (Oncology Nursing So-
ciety, 2002).
Obtain consent for treatment.
For patients in shared rooms, use the inha-
lation method by placing essential oils on
tissues.
Document progress and outcomes of aro-
matherapy interventions in patient
progress notes.
Avis (1999) suggested other guidelines.
Avoid the use of vaporizers in clinical ar-
eas because aromas of particular essential
oils can be released in indiscriminate ways.
Essential oils should be used on an indi-
vidual basis after careful assessment that
includes evaluation of all of the effects of
the oils used.
Where Do We Go From Here?
In summary, nurses must educate patients
and staff members regarding specific treat-
ment plans and potential risks in the clinical
use of aromatherapy. Education should in-
clude clear communication that the use of
aromatherapy is based on patient preferences
and largely not supported by clinical trial
data. Additionally, the marketing of essen-
tial oils is not governed by the U.S. Food and
Drug Administration, which implies that no
standard criteria regulate the growth process
of plants to be used for essential oil acquisi-
tion, the acquisition process itself, the level
of purity of essential oils, toxicity reporting,
batch-to-batch consistency of individual oil
preparations, and postmarket surveillance. A
final issue in the marketing of essential oils
is cost. Prices vary, as does product quality.
Insurance companies currently do not reim-
burse for aromatherapy treatment, leaving
patients to pay out of pocket. The use of and
nursing involvement in aromatherapy likely
will continue to expand. The Oncology Nurs-
SEPTEMBER/OCTOBER 2003 VOLUME 7, NUMBER 5 CLINICAL JOURNAL OF ONCOLOGY NURSING
ing Society believes that oncology nurses
should provide credible information regard-
ing therapies, assess patients for the use of
therapies, and seek to establish evidence-
based practice in oncology care (Oncology
Nursing Society, 2002).
Author Contact: CDR Colleen O. Lee, RN,
MS, AOCN , can be reached at leeco@
mail.nih.gov.
References
Avis, A. (1999). Aromatherapy in practice. Nurs-
ing Standard, 13(24), 1415.
Campbell, L., Pollard, A., & Roeton, C. (2001).
The development of clinical practice guide-
lines for the use of aromatherapy in a cancer
setting. Australian Journal of Holistic Nursing,
8(1), 1422.
Cooke, B., & Ernst, E. (2000). Aromatherapy: A
systematic review. British Journal of General
Practice, 50, 493496.
Dunwoody, L., Smyth, A., & Davidson, R.
(2002). Cancer patients experiences and
evaluations of aromatherapy massage in pallia-
tive care. International Journal of Palliative
Nursing, 8, 497504.
Graham, P.H., Browne, L., Cox, H., & Graham, J.
(2003). Inhalation aromatherapy during radio-
therapy: Results of a placebo-controlled
double-blind randomized trial. Journal of
Clinical Oncology, 21, 23722376.
Louis, M., & Kowalski, S.D. (2002). Use of aro-
matherapy with hospice patients to decrease
pain, anxiety, and depression and to promote
an increased sense of well-being. American
Journal of Hospice and Palliative Care, 19,
381386.
Olleveant, N.A., Humphris, G., & Roe, B. (1999).
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299304.
Oncology Nursing Society. (2002). Oncology
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Robins, J.L. (1999). The science and art of aroma-
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Westcombe, A.M., Gambles, M.A., Wilkinson,
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