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Delivering aromatherapy and massage in a day centre

A project that provided hand and foot treatments proved successful. Christine Cole and Jennifer Burt discuss the potential for health professionals to develop a similar scheme
Abstract
A massage and aromatherapy therapy group was set up at a day centre for people who have learning disabilities. The authors describe the involvement of clients and staff, the positive results and how carers and health professionals could develop massage and aromatherapy groups in various settings. Challenges to the continuation of the project, because of national changes in policy and practice, are also examined. The initiatives development potential is limited but similar undertakings, possibly employing private practitioners, may emerge elsewhere. Keywords Aromatherapy, day centre services, epilepsy, learning disabilities, massage therapy
Correspondence christine.cole@barnet.nhs.uk Date of acceptance November 3 2011 Peer review This article has been subject to double-blind review and has been checked using antiplagiarism software Author guidelines www.learningdisabilitypractice.co.uk

are physically disabled. This therapy also introduces positive social interaction and benefits relationships between everyone involved (Fowler 2007). The type and quality of touch used helps people with learning disabilities gain understanding and awareness of their environment and relationships, particularly when they have sensory deficits (harrison and ruddle 1995, Gates and Barr 2009). croghan (2009) described how staff were able to interpret a clients non-verbal communication during a course of aromatherapy massage.

Massage for complex needs

In 2001 the authors met with a staff member from a specialist needs unit in a day centre to discuss setting up therapeutic aromatherapy massage sessions for clients with complex health needs and who are fully dependent on their wheelchairs for mobility. The day centre staff had already developed skills in supporting service users with mobility and exercise. In this initiative the physiotherapist was able to offer staff further training in basic massage techniques, which would complement the aromatherapy, that was taught by the nurse. A person-centred approach and equality of access (sanderson 2000, Department of health (Dh) 2001) remained central to the planning process. A literature review was carried out so that the clinicians could inform clients and carers about acceptable massage practice and aromatherapy treatment for this population. The cumulative Index to Nursing and Allied health Literature, PsycINFO, British Nursing Index and Association for Management education and Development from 1985 to 2009 databases were searched using the terms: mental retardation; learning disabilities; intellectual disability; developmental disability and
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reseArchers hAve emphasised that people with learning disabilities benefit from productive activities (Mansell et al 2002, crites and howard 2011). People with intellectual disabilities are frequently deprived of meaningful touch (Gates 2007). contact with this client group is often functional, involves touch or is organisational, for example washing and dressing. Massage can help develop communication through gentle interaction in a non-verbal and non-threatening way. This therapy is a good way of introducing a socially therapeutic interaction (Fowler 2007). In aromatherapy, massage is used to aid the absorption of essential oils through the skin and via the nasal route, conferring varied physical and psychological benefits (McGuinness 2004, Fontaine 2011), including two-way communication with clients who otherwise find communication difficult (Wray 1998). Feeling cared for and cosseted promotes relaxation, concentration, satisfaction and trust (harrison and ruddle 1995, rosser 2000), and tension stored in the muscles is eased. regular foot and hand massage improves local blood supply and helps keep the limbs in good condition (evans et al 2008), which is particularly valuable for those who

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learning difficulties. Authors such as harrison and ruddle (1995) and Wray (1998) explored the use of aromatherapy with a group of clients with profound learning disabilities. Their papers highlighted the improvements of communication, interaction and relationships when using this therapy which prompted the clinicians to carry out this intervention. Aromatherapy, complementary therapy and alternative therapy were also explored, but evidence relating to these was scarce. The aims of the project were to: Provide massage and aromatherapy sessions in a day centre for clients with learning disabilities and complex physical health needs. Instruct support workers on the basics of aromatherapy and essential oils, their usage and contraindications, and the physical and psychological outcomes of safe and effective treatment (Avis 1999, McGuinness 2004). Train support workers in correct positioning of clients for treatment to increase comfort and reduce muscle tension (rennie 2001). staff wash their hands before and after each session to prevent any risk of cross infection and to guarantee a high standard of hygiene in accordance with infection control regulations (OKeefe A 2007, Dh 2009a). Teach support workers to massage clients hands and feet. hand massage was chosen initially as hands are the easiest to access (Maxwell-hudson 1988), and swedish (muscular) massage was chosen because of its soothing and relaxing effects and the resulting improvements in postural awareness and circulation (rosser 2000). Because of the clients physical disabilities, head, neck and shoulder massage were not considered. Also, the time needed to carry out this therapy in a day service setting would have made it unviable. Information sheets and consent forms were sent to the families of six service users who were selected from clients who participated in physiotherapy sessions and who it was deemed would gain value from additional tactile therapy. signed approval for participation was obtained on behalf of the clients by their parents. Their GPs were asked for approval to ensure that there were no medical contraindications to inclusion (sanderson et al 2002). As photographs could illustrate the best positions for the clients and where to position cushions and other aids during massage, consent for photography was sought from individuals and families in line with local guidelines. Objectives were tailored to each service user and details of therapy and outcomes were recorded in their health files and individual assessment and care plans. staff training was based on observation and modelling of the basic massage techniques using a schedule guidance form. This method of teaching, advocated by croghan (2009), ensured correct procedures and helped maintain continuity of the sessions. During training, clinicians emphasised a caring, calm approach when carrying out this therapy to ensure that clients were relaxed. The importance of this approach was made clear to all the staff involved.
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Government review
The house of Lords science and Technology committee report (2000) reviewed all complementary alternative medicine therapies, including massage and aromatherapy, and the setting of standards for practice, public information and public assurance (Mills 2001). since 2009, massage and aromatherapy have been regulated by the complementary and Natural health care council and the General regulatory council for complementary Therapies. The blending of essential aromatherapy oils is now covered by the Medicines Act (1968). research continues to explore and strengthen the evidence base for massage and aromatherapy in the healthcare setting (Kessler et al 2006). royal college of Nursing guidance (rcN) (2003) says that any sessions providing massage and aromatherapy in the clinical setting should be managed by a clinician with the relevant complementary skills and qualifications. The nurse involved in the current project had professional certification from the International council of holistic Therapy and the physiotherapist observed the chartered society of Physiotherapy (2000) core standards of Practice. The nurse and physiotherapist had access to the medical and health backgrounds of the clients, and further history taking and consultations were carried out in accordance with current standards of practice (chartered society of Physiotherapy 2000, 2005, Nursing and Midwifery council (NMc) 2008). The community nurse with the physiotherapist offered and provided preliminary training in aromatherapy massage to identified staff. The staff were selected from the day centre and worked with the physiotherapist who managed the mobility sessions for the clients. This meant that staff were aware of each persons needs before they started each massage session. When staff were familiar with the concept, procedures and benefits of the therapy, they could carry out sessions unsupervised to ensure continuation of treatment (rcN 2003, Pigram et al 2006). 26 December 2011 | Volume 14 | Number 10

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A cascade training strategy was used across the workforce in the day centre to develop skills in, and appreciation of, the practice as beneficial in care and treatment (rcN 2003). The sessions were scheduled for an hour a week in a room that would allow the privacy and dignity of the clients to be maintained throughout. equipment included pillows and pillowcases, the clients own fire retardant sheepskin draped over the beanbags, cleaning wipes, containers for the oils and a burner for essential oils such as lavender. These fragrances were purely for enjoyment. sweet almond carrier oil was used for massage because it is almost odourless and suitable for all skin types (McGuinness 2004). essential oils can have undesirable effects (Price and Price 1999), so it was decided not to add any to the massage oil. The clients attended on a rotational basis with two or three individuals at each session. however, because this is a one-to-one therapy, the number of clients at each session depended on the availability of staff (Wray 1998, Gates 2009). A scheme of a typical massage and aromatherapy session delivered to the group is shown in Box 1. regular consultation meetings of the staff group followed on a three monthly basis and further guidance was offered by the clinicians when required. Box 1 Scheme of a typical massage and aromatherapy session Aroma burner is lit, producing a fragrance. This helps clients recognise that the session is taking place. Good ventilation is ensured. Appropriate classical music was used during the session to create a relaxing atmosphere. Staff wash their hands, before and after each session, to prevent any risk of cross infection and to guarantee a high standard of hygiene is delivered in accordance with infection control regulations (Department of Health 2009a). Clients are helped onto mat, armchair or beanbag as appropriate. Staff refer to posture photographs to check positioning, then ensure that each client is comfortable, relaxed and supported. Staff sit down on the floor alongside the client to carry out the massage. Oil is placed in a small container for each client. One hand is massaged first, allowing ten minutes for each hand or foot. Staff sit on the floor alongside the client to carry out the massage. Clients are aware when the staff have finished applying specific massage strokes on the limbs and they associate this with the end of the session. The music stops and the clients have a recovery/quiet period. Notes are completed after the session for each client. Room is cleared and equipment cleaned and put away (oils protected from heat and light). recognise the clients displays of satisfaction or discontentment with the therapy via their non-verbal signs and behaviour. evaluation of the sessions was based on mainly non-verbal client responses (Lindsay et al 2001, croghan 2009). Many individuals appeared and were reported to be more relaxed and calmer after the interventions. They indicated their pleasure by their known communication methods, which included body language, smiling and vocalisation. clients seemed to convey that they liked the therapy, which helped ascertain that their choice to attend was real and in accordance with the government strategy valuing People (Dh 2001). Massage relaxes and aids correct positioning of the body, and helps with mobility because it is a form of passive exercise (Price and Price 1999). After the sessions, it was noted by staff at the day centre that during personal care, clients became more supple and more flexible to manage. This was acknowledged by staff who regularly attend to all the clients requirements, which include assisting them in and out of their wheelchairs. staff were able to monitor their progress The staff involved acknowledged that through the one-to-one sessions they became more familiar with the clients individual styles of communicating and relating, and thus interaction with them generally was improved (Fowler 2007). hegarty (1996) mentioned that massage as a social therapeutic method can establish relationships through touch and make communication a positive experience.
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Good practice
A number of sources advocate good clinical sequences for delivering massage and aromatherapy (hogg and cavet 1995, Fowler 2007) which are useful references when reviewing this type of project. In addition, Fowler (2007) discusses in addition the rewards of sensory stimulation, the assessment of the clients reactions and any responses by observing engagement, visual expression and general behaviour. One of the clients in the group had epilepsy and experienced seizures during the sessions. The seizure recording chart showed that the seizure events were associated with the massage sessions (cole et al 2009). Good observation and monitoring of the seizures and the awareness of support staff linked the aroma from the burner, which was used initially to symbolise the start of the massage session, as the cause. Fowler (2007) highlighted the importance of recording a persons reaction to stimuli; that is, their behaviour when they have communication challenges. When forms of sensory stimulation, for example, massage, are being used as an activity, the effects can later be assigned meaning, for example, like and dislike. The massage sessions enabled staff to
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reviews were carried out by the community nurse and physiotherapist in consultation with day centre staff and the physiotherapy assistant. The issues associated with obtaining the relevant equipment aids and staffing levels were dealt with. The project was reassessed after 18 months because of staffing changes; the senior physiotherapist left and the physiotherapy assistant took over, under supervision (chartered society of Physiotherapy 2002), accompanied by two unit support workers who alternated on a monthly rotation. At a second formal review of the project the group proposed painting the room white to create a better environment, fitting blackout window blinds and installing an extractor fan and improved lighting. Additional large beanbags and replacement pillow cases were needed to ensure comfort, which is a fundamental requirement of therapeutic massage (OKeefe 2006). One client in the group had a number of epileptic seizures during the sessions, apparently triggered by the smell of lavender from the aroma burner. The seizures were prevented by removing the burner. certain essential oils are contraindicated in a number of conditions such as epilepsy (Price and Price 1999, radford 1999) or anecdotally that some may prevent seizures (Appleton et al 2004). Kelly (2002) noted that modern drugs undergo extensive testing for adverse effects but that no such controls exist for the majority of herbal remedies. however, statutory regulation of herbal medicine and the blending of essential oils is being considered. The day centre manager was supportive of the project and proposed that additional staff were identified for participation. A formal training structure was suggested to equip them to carry out the massage sessions, supervised by the health professionals (rankin-Box 2002). The originators of the project examined the sessions regularly and remained familiar with current practice and developments. This supported their continuing professional development in accordance with statutory requirements (chartered society of Physiotherapy 2000, 2005, NMc 2008). A number of unpredictable factors brought this project to an end. Foremost, the reorganisation of day services resulted in the centre closing and the clients moving to other services. however, in 2009 the nurse received a request from the new day service to set up massage and aromatherapy sessions. several of the clients identified were participants from the original group. second, government guidelines advocate for these therapies to be carried out in clients homes by paid private practitioners in line with equity for all (Dh 2007, 2009b). social services are embracing this approach, enabling clients to have more choice and independence in their lives through their individualised budgets to receive such therapies. This type of day service activity is being implemented in the community for this client group when the day service package is reviewed by social services. Third, clinicians wishing to introduce a therapy need to consider the Mental capacity Act 2005. clients with sensory, verbal and non-verbal deficits rely on other people perceiving their needs and interpreting their wishes. If people with a learning disability are judged to lack capacity to consent to a treatment, the approach that is in their best interest should be applied (hardy and Joyce 2009). This can be time consuming, but the issues are not insurmountable and perseverance can enable people, regardless

References
Appleton R, Chappell B, Beirne M (2004) Epilepsy and Your Child. second edition. class Publishing, London. Avis A (1999) Aromatherapy in practice. Nursing Standard. 13, 24, 14-15. Chartered Society of Physiotherapy (2000) Core Standards of Practice. csP, London. Chartered Society of Physiotherapy (2002) Physiotherapy Assistants Code of Conduct. csP, London. Chartered Society of Physiotherapy (2005) Core Standards of Physiotherapy Practice. revised. csP, London. Cole C, Pointu A, Mahadeshwar S et al (2009) community survey of carers: individual epilepsy guidelines for rescue medication. Seizure. 18, 3, 220-224. Crites S, Howard B (2011) Implementation of systematic instruction to increase client engagement in a day rehabilitation programme. Journal of Intellectual and Developmental Disability. 36, 1, 2-10. Croghan P (2009) The therapeutic effects of hand massage. Learning Disability Practice. 12, 5, 29-32. Department of Health (2001) Valuing People A New Strategy for Learning Disability for the 21st Century. Dh, London. Department of Health (2004a) Agenda for Change: What Will it Mean for You. A Guide for Staff. Dh, London. Department of Health (2004b) The NHS Knowledge and Skills Framework and the Development Review Process. Dh, London. Department of Health (2007) Independence, Choice and Risk. A Guide to Best Practice in Supported Decision Making. Dh, London. Department of Health (2009a) The Max4Health Hand Hygiene Campaign. crown copyright. Department of Health (2009b) Valuing People Now from progress to transformation. Dh, London. Evans M, Franzen S, Oxenford R (2008) Step by Step Massage and Aromatherapy. Anness, Wigston. Fontaine K (2011) Complementary and Alternative Therapies for Nursing Practice. Third edition. Pearson, Upper saddle river NJ. Fowler S (2007) Sensory Stimulation. Sensory Focused Activities for People with Physical and Multiple Disabilities. Jessica Kingsley, London. Gates B (2007) Learning Disabilities: Toward Inclusion. elsevier, Kidlington. Gates B, Barr O (2009) Oxford Handbook of Learning and Intellectual Disability Nursing. Oxford University Press, Oxford. Harding J (2006) Secrets of Aromatherapy. Ivy Press, Lewes. Hardy S, Joyce T (2009) The Mental capacity Act: practicalities for health and social care professionals. Advances in Mental Health and Learning Disabilities. 3, 1, 9-14. Harrison J, Ruddle J (1995) An introduction to aromatherapy for people with learning disabilities. British Journal of Learning Disabilities. 23, 1, 37-40. Hegarty JR (1996) Touch as a therapeutic medium for people with challenging behaviours. British Journal of Learning Disabilities. 24, 1, 26-32. Hogg J, Cavet J (1995) Making Leisure Provision for People with Profound Learning and Multiple Disabilities. chapman hall, London.

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of their disability, to participate in a therapy if it is in their best interest. Fourth, there is a lack of integrated cohesive strategies at national, Nhs trust and primary care trust levels to undertake or fund complementary therapies (rcN 2003) or even to define parameters for effective safe practice. When health professionals working practices were reviewed in preparation for the Agenda for change pay system (Dh 2004a) and the Nhs Knowledge and skills Framework (Dh 2004b), it was questioned whether or not this therapeutic work was within the health professionals job description and work remit. Therefore it was advised not to continue with the project at that time. Last, increasing size of complex caseloads prevented the health practitioners involved in this aromatherapy massage initiative from being innovative and taking on new projects. All these concerns have resulted in the primary aromatherapy massage group not resuming. a variety of settings and encourage others to develop massage and aromatherapy sessions, particularly for people with learning disabilities. As mentioned above, it has been proposed that independent aromatherapists could be employed via social services in day centres or other services, using individual client budgets. These clients would then have the opportunity to participate in an effective and pleasant therapeutic pursuit that also benefits their relationship with their carers. This approach would be in line with valuing People Now (Dh 2009b).

Find out more

Betts T (2003) Use of aromatherapy. Seizure. 12, 8, 534-538. Buckle J (2007) Literature review: should nursing take aromatherapy more seriously? British Journal of Nursing. 16, 2, 116-120. Department of Health (2009) Impact Assessment of a Code of Practice for Health and Adult Social Care and Guidance. Department of Health, London. National Society for Epilepsy (2011) Epilepsy Complementary Therapies. www.epilepsynse.org.uk (Last accessed: November 15 2011.) Preen C (2009) Guide for Aromatherapists. What Can You Say on Your Advertising/marketing Literature? www.aromatherapycouncil.org.uk (Last accessed: November 15 2011.) Ray J, Paton K (2007) Complementary therapies in learning disability settings. In Gates B (Ed) Learning Disabilities: Towards Inclusion. Elsevier, Kidlington. Smallwood C (2006) Role of complementary and alternative medicine in the NHS. Nursing Science Quarterly. 19, 3, 265-271.

Online archive
For related information, visit our online archive of more than 6,000 articles and search using the keywords Acknowledgement Our thanks go to all clients involved in this project and to Alison Pointu, Mary Kabagambe, Libby Christie, Patricia Harris, Douglas Lloyd, Claire Melvin, Debra Egan and David Sewell Conflict of interest None declared Jennifer Burt is a specialist physiotherapist and Christine Cole is an epilepsy specialist nurse both at Barnet Learning Disability Services, London Borough of Barnet

Conclusion
Touch can be pleasant and useful when words may be difficult to find. hand massage can be offered to people who do not often experience touch and can help individuals gain confidence (harding 2006). This aromatherapy massage group was productive, inclusive and rewarding for all involved. It was a learning experience for staff, it established multidisciplinary working, and a variety of health and wellbeing benefits followed. however, further research is required into the properties of essential oils in relation to particular disorders (Appleton et al 2004, Fontaine 2011). It is hoped that this description of the project will inform carers and staff groups in

House of Lords Science and Technology Committee Report (2000) House of Lords Science and Technology Committee on Complementary Alternative Medicine from the Sixth Report, 1999-2000. HL paper 123. stationery Office, London. Kelly J (2002) Toxicity and adverse effects of herbal complementary therapy. Professional Nurse. 17, 9, 562-565. Kessler J, Marchant P, Johnson M (2006) A study to compare the effects of massage and static touch on experimentally induced pain in healthy volunteers. Physiotherapy. 92, 4, 225-232. Lindsay W, Black E, Broxholme S et al (2001) effects of four therapy procedures on communication in people with profound intellectual disabilities. Journal of Applied Research in Intellectual Disabilities. 14, 2, 110-119.

Mansell J, Elliott T, Beadle-Brown J et al (2002) engagement in meaningful activity and active support of people with learning disabilities in residential care. Research in Development Disabilities. 23, 5, 342-352. Maxwell-Hudson C (1988) The Complete Book of Massage. Dorling Kindersley, London. McGuinness H (2004) Aromatherapy Therapy Basics. hodder and stoughton, London. Mills S (2001) The house of Lords report on complementary medicine: a summary. Complementary Therapies in Medicine. 9, 1, 34-39. Nursing and Midwifery Council (2008) The Code 2008. NMc, London. OKeefe A (2007) The Official Guide to Body Massage. second edition. Thompson Learning, London.

Pigram J, Simpson R, Hopkins S et al (2006) Supervision, accountability and delegation of activities to support workers. A guide for registered practitioners and support workers. royal college of Nursing, London. http:// tinyurl.com/cv2duv9 Price S, Price L (1999) Aromatherapy for Health Professionals. second edition. churchill Livingstone, London. Radford J (1999) Family Aromatherapy. Foulsham, slough. Rankin-Box D (2002) ethics and quality in complementary therapy education. Nursing Times. 98, 2, 40-46. Rennie J (2001) Learning Disability, Physical Therapy, Treatment and Management. A Collaborative Approach. Whurr Publishers, London.

Rosser M (2000) Body Massage Therapy Basics. hodder and stoughton, London. Royal College of Nursing (2003) Complementary Therapies in Nursing, Midwifery and Health Visiting Practice. rcN, London. Sanderson H (2000) Person-centred Planning. Key Features and Approaches. Joseph rowntree Foundation, York. Sanderson H, Harrison J, Price S (2002) Aromatherapy and Massage for People with Learning Difficulties. hands-on Publishing and Training, Birmingham. Wray J (1998) complementary therapies in learning disabilities: examining the evidence. Journal of Learning Disabilities for Nursing Health and Social Care. 2, 1, 10-15.

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