Essential Oil Therapy for Alleviation of Discomfort in Surgical Patients

Practice Problem: Post-surgical pain (PSP) has not been sufficiently managed despite routine opioid use. The adverse effects of opioids led to the search for non-pharmaceutical intervention. PICOT: The PICOT question that guided this project was, "In an acute hospital surgical setting, does essential oil therapy complement pain and discomfort relief comparing to conventional pain management alone after 6 weeks?” Evidence: Seven clinical studies, five systematic or integrative reviews, and four conference proceedings were reviewed. The evidence supported lavender essential oil for the alleviation of PSP and discomfort. Intervention: Patients breathe through a personal lavender essential oil inhaler hourly or every 2 hours. Outcome: The percentage means of pre and post-intervention pain score reduction were 39.5117.73 and 45.7719.45. The post-intervention group's mean pain score changed from 51.53 to 27.71 pre and post-opioids. Opioid usage per patient day in two groups was 26.2 mg and 48.6mg in morphine equivalent. Pain scores pre and post essential oil therapy were 6.13 and 2.7. Conclusion: This project did not confirm the statistical significance of pain score reduction but a higher reduction in the post-intervention group. The results were clinically meaningful to offer lavender essential oil to alleviate PSP and discomfort. ESSENTIAL OIL THERAPY FOR SURGICAL PATIENTS 4 Essential Oil Therapy for Alleviation of Discomfort in Surgical Patients Post-surgical pain (PSP) has been a perennial challenge for healthcare providers. Various pharmaceutical drugs, including opioids, are prescribed and administered as a standard of care for PSP relief (Gan, 2017). The subsequent prolonged prescription opioid overuse or misuse has become a secondary concern (Stratton, Palombi, Blue, & Schneiderhan, 2018). The opioid crisis called for pain treatment options that have fewer side effects. As a result, complementary therapies have been advocated to be a part of individualized pain management strategies (Henningfield, Ashworth, Gerlach, Simore, & Schnoll, 2019). The Joint Commission (TJC) requires that at least one non-pharmaceutical therapy be offered for problematic symptoms and encourages the exploration of a variety of therapies. Aromatherapy is a significant complementary therapy because "it is easy to understand, as many of today's drugs originally came from plants" (Buckle, 2013, p. 564). The Massachusetts Board of Registration in Nursing was the first state board to accept complementary therapy as part of a "holistic model of nursing" and "within the scope" of nursing (Buckle, 1998, p.58). The California Board of Registered Nursing (2000) supports the registered nursing role in providing complementary, alternative therapies as nursing's holistic tradition. Lavender essential oil has been demonstrated in the literature as an effective complementary therapy for PSP (Gorji et al., 2015; Hasanzadeh et al., 2015; Kim et al., 2007; Yu & Seol, 2017). This evidence-based practice (EBP) project was to assess the implementation of lavender essential oil therapy (interchangeable as aromatherapy) as a non-pharmaceutical therapy for alleviating discomfort in surgical patients. The EBP intervention included a training module for nurses working on a post-surgical floor and the implementation of an aromatherapy protocol. Evaluation of aromatherapy implementation was measured by auditing electronic health records ESSENTIAL OIL THERAPY FOR SURGICAL PATIENTS 5 (EHR) to collect pain scores and opioid use per patient per day in morphine equivalents and collecting nurse self-efficacy surveys (paper based) pre, post, and 4 weeks after training. The project was conducted at an acute community hospital in Sacramento, California, on the Acute Surgical Unit (ASU). The primary content areas discussed in this report are the significance of the practice problem, PICOT question, theoretical framework, synthesis of literature review, and practice recommendation. Additionally, the project implementation process is discussed, which include the project setting and overview, project plan, evaluation plan, discussion and implication for nursing and healthcare, dissemination, and conclusion. Significance of the Practice Problem Pain is a significant symptom that hospitalized surgical patients experience despite routine pharmaceutical intervention. Johnson et al. (2016) noted that every group of hospitalized patients have a certain level of pain or risk for pain. Several studies nationally and globally reported a prevalence of PSP: 80% in the U.S., 30% in India, and 50% in Italy (Gan, 2017; Harsoor, 2011; Sansone et al., 2015). In the project hospital, Healthgrade's (2019) report showed that the hospital scored 3% lower than the 68% national average in providing adequate pain relief. Suboptimal or inadequate PSP relief may "result in clinical and psychological changes that increase morbidity and mortality," or cause "impaired quality of life, slowed recovery, prolonged opioid use, and increased cost of care," or "negative physiological and psychological outcomes" (Gan, 2017, p. 2288; Gorgi et al., 2015, Introduction section; Harsoor, 2011, p. 101; Sansone et al., 2015). While care providers are obligated to provide adequate pain relief, prescribing addictive opioids for pain relief should be weighed against the risk of abuse or misuse (Kotalik, 2012). The current opioid crisis has led to an ethical dilemma and inadequate pain control ESSENTIAL OIL THERAPY FOR SURGICAL PATIENTS 6 (Stratton et al., 2018). Data from 2016 showed more than 42,249 overdose fatalities (The New Opioid Problem, 2018, The Scope and Response section). The TJC sets pain management as a standard of quality and requires hospitals to “provide at least one non-pharmacological pain treatment modality" (2018, para. 1). Therefore, healthcare providers' responsibility is not only to offer adequate pain control but also to limit the risk of overuse and addiction to opioids. Aromatherapy can be a safe addition to current pain management with no adverse effects (Lakhan, Sheafer, & Tepper, 2016).


Evidence Search Strategies
To search for evidence to support the implementation of the project, ProQuest, EBSCOHost, Science Direct, and PubMed databases were selected. The keywords used included "aromatherapy" or "essential oils," and "pain," "discomfort," and "hospitalized patient or surgical patients." Research articles included aromatherapy or essential oil therapy used for adult surgical patients. The surgical type was not limited to one or a few but all types of surgeries. The intervention used lavender inhalation with or without supplemental oxygen and compared it to a control group within an evaluation time frame of 2 to 4 months. Studies that were from different settings, measures, and non-English full text were excluded. The measure of pain utilized a visual analog scale or a numeric scale. The search was limited to English from 1990 to 2020.
MeSH headings using "aromatherapy or essential oils," "pain," did not generate relevant results.
However, the searched keywords were also in MeSH terms.

Evidence Search Results and Evaluation
One thousand, one hundred and forty-five articles were generated from the search. One thousand one hundred and forty-one from PubMed, ProQuest, EBSCOHost and Science Direct, and four from conference proceedings. There was a variance of hits among searches at different times. After removing duplicates, abstract only entries, studies using essential oils other than lavender, other measurement tools, or other procedures than surgeries, 25 clinical trials were included in the analysis. Seven clinical studies using lavender for PSP and four clinical experiences shared in a conference proceeding were synthesized for the recommendation. Five systematic or integrative reviews were included in the synthesis, as well. See Figure 1 for detail of the PRISMA flow.

PRISMA Flow Diagram for Aromatherapy
The articles' quality was evaluated using the Johns Hopkins Level and Quality of Research and Non-Research Evidence (Dang & Dearholt, 2018). Experimental studies and randomized controlled trials (RCT) were included in level I evidence. Quasi-Experimental Records identified through database searching (n=1141)

Screening Included Eligibility Identification
Additional records identified through other sources (n = 4 ) Records after duplicates or unrelated removed (n=520) Records screened (n = 312 ) Records excluded (n = 208 ) Full-text articles assessed for eligibility (n =112 ) Full-text articles excluded, with reasons (n = 87 ) Studies included in the qualitative synthesis (n = 25 ) Studies included in the quantitative synthesis (n = 11 ) research was included in level II. Nonexperimental studies were in level III (Dang & Dearholt, 2018). High-quality grade A research evidence is defined as "consistent, generalizable results, sufficient sample size for study design, adequate control, definitive conclusion, consistent recommendations based on comprehensive literature review…" (Dang & Dearholt, 2018, p. 131). Good and low-quality research (grades B and C) have less than defined contents, or a lack of consistent results or a "conclusion cannot be drawn" (Dang & Dearholt, 2018, p. 131).
Four level-I evidence with grade B, good-quality clinical trials examined lavender inhalation for PSP. These studies concluded that lavender essential oil demonstrated a significant reduction of PSP (Gorji et al., 2015;Hasanzadeh et al., 2015;Kim et al., 2007;Yu & Seol, 2017). In addition, Kim et al. (2007) reported that the participants demanded fewer opioids when lavender oil was used. One level I triple blinded low-quality RCT showed affirmative pain relief with the lavender intervention (Olapour et al., 2013). One single-blind level II trial with the low quality found no statistical difference between the intervention and control groups in pain reduction (Salamati, Mashouf, Sahbaci & Mojab, 2014). When this trial was reevaluated for the lavender's effect on vital signs in open-heart surgery, the authors found that lavender significantly lowered blood pressure and heart rates (Salamati, Mashouf, & Mojab, 2017). One level III high-quality retrospective study reported affirmative pain relief with lavender and other essential oil inhalation (or topical application) . Clinician-experiences, classified as level V evidence, was presented in conference proceedings that confirmed the pain relief function of lavender and other essential oils. (Baglien, 2019;Scheidel & Brown, 2019). Dusek (2019) presented a study with his colleagues that integrative modalities offered in their hospital was associated with a reduction in pain and a reduction in total costs of care with cost-savings of $898 per hospital admission (Dusek, Griffin, Finch, Rivard, & Watson, 2019). Aromatherapy administrated by holistic nurses was one of these integrative modalities (Dusek et al., 2019).
One grade A systematic review and one grade A integrative review supported the use of aromatherapy for pain and recommended the therapy (Lakhan et al., 2016;Meghani, Tracy, Hadidi, & Lindquist, 2017). Another grade A synthesis review partially supported the claim that lavender was useful for pain but stated there was an inconsistency of findings in other primary studies they reviewed (Dimitriou, Mavridou, Manataki, & Damigos, 2017). One grade B synthesis review identified the effective results for pain and anxiety relief in the studies but did not recommend aromatherapy (Lederer, Schmucker, Kousoulas, Fichtner-Feigl, & Huber, 2018).
One grade C review found lavender to be useful for anxiety and pain relief and recommended for further research (Stevensen, 1995). A summary of primary research and systematic reviews can be found in Appendices A and B.

Themes from the Literature
Common themes from the literature were the effectiveness and safe use of lavender essential oil for pain and anxiety relief. First, lavender essential oil was used as a CAM in reducing pain (Gorji et al., 2015;Kim et al., 2007;Yu & Seol, 2017 Brown, 2019). The use of aromatherapy has created a valuable opportunity for nurses to "share with the patient a glimpse of a multidimensional world" and to offer this non-pharmacologic therapy complementary to relieve their patients' pain (Buckle, 2013, p.572). The third theme was a variety of other uses for aromatherapy.

The Pain Relief of Lavender Essential Oil
The studies that used inhalation of the essential oil lavender with or without supplemental oxygen resulted in less pain severity or more significant pain relief (Gorji et al., 2015;Hasanzadeh et al., 2015;Kim et al., 2007;Yu & Seol, 2017). Headaches during hemodialysis and labor pain were relieved by aromatherapy (Bicer et al., 2015;Tanvisut, Traisrisilp, & Tongsong, 2018).

Clinical Experience of Aromatherapy
Non-research organizational experience and field experts supported aromatherapy for pain relief (Baglien, 2019;Dusek et al., 2019;Scheidel & Brown, 2019). A study with a sample size of 25 patients also supported aromatherapy for pain relief (Coles, 2019).
Evidence also found that aromatherapy was recommended by dentistry for "the significant impact on wellness" (Pierce, 2019, p. 56). Aromatherapy, when used in midwifery, is "a skill that midwives may benefit from having an understanding of, …and in supporting their patients in the use of aromatherapy oils" (Royal Cornwall Hospital Trust, 2018, p. 3). Lavender inhalation was used in a dental office waiting area for anxiety before treatment leading to a positive outcome (Pierce, 2019).

Other Uses and Safety
Not only was lavender used in surgery, but it also provided benefits to patients for pain and anxiety relief in procedures, such as implanted port access and colonoscopy, and patients with burns (Hozumi et al., 2017;Ilter, Ovayolu & Ovayolu, 2019;Seyyed-Rasooli et al., 2016; Yayla & Ozdemir, 2019; ). Aromatherapy was safely applied to children (Kallush, Riley & Kacker, 2018;Soltani et al., 2013;). A quasi-experimental study identified aromatherapy as one of the effective pain relief holistic care interventions (Rice et al., 2019).

Practice Recommendations
The recommendation of aromatherapy for pain and discomfort relief in surgical patients was generated by applying the process of the Johns Hopkins Nursing Evidence-Based Practice Model (JHNEBP). The JHNEBP model process covers three phases. The three phases are the practice question, evidence, and translation (Dang & Dearholt, 2018). The practice question was raised from critical thinking in clinical experience and the statistics that 80% of patients experience PSP, with half of them not well managed (Dang & Dearholt, 2018;Gan, 2017 Gorji et al., 2015;Hasanzadeh et al., 2015;Kim et al., 2007;Olapour et al., 2013;Scheidel & Brown, 2019;Yu & Seol, 2017 Buckle. The project hospital defined in its guideline that essential oil therapy is within the registered nurse's scope of practice to promote the patient's comfort and well-being. The third phase was translation. The translation process included creating the action plan, securing support and resources to implement the action plan, evaluating outcomes, reporting outcomes to stakeholders, identifying next steps, and disseminating findings that are ongoing and to be fulfilled when opportunity allows (Dang & Dearholt, 2018).
Research and non-research evidence backed the recommendation. Pain is medically defined as "an unpleasant sensory and emotional experience associated with actual or potential tissue damage" (Anselmo, 2013, p. 328). Surgical pain that is caused by actual tissue damage should be addressed sufficiently in addition to a conventional regimen. Lavender essential oil has analgesic and sedative therapeutic actions for pain and related discomfort relief (Battaglia, 2003).
The outcomes from this project suggested that further use and study of essential oil therapy was implicated. Therefore, the recommendation of an aromatherapy program for surgical patients was generated based on a thorough and rigorous search and evaluation of current evidence, as discussed earlier in the JHNEBP model process. The findings from the literature review were consistent with this recommendation. Organizational context and infrastructure were evaluated, and it was deemed feasible to implement this project of aromatherapy for pain and discomfort relief in a surgical unit (Dang & Dearholt, 2018).

Project Setting
This scholarly project was implemented in an acute care community hospital in Sacramento, California. The hospital is a tertiary healthcare facility. It is a nationally recognized cardiac referral center, admitting patients from the local and distant community for their cardiac needs. The hospital has service areas of critical care, medical-surgical, acute surgical unit, neurology, cardiac support unit, oncology, cardiac, woman's health, family birth center, and an emergency department. The clients vary in age group, socioeconomics, ethnic background, and educational level. The organizational structure is set up as a hierarchy, from the president (chief executive officer), vice presidents, senior directors for each service area, unit managers, shift managers, R.N. staff, and supporting departments. A system-wide medical group manages many of the physicians. Physicians are not considered hospital employees but belong to the group.
There are additional private practice physicians who practice at the hospital. The hospital applies the vision and mission of its corporation.
A strength, weakness, opportunity, and threats (SWOT) analysis was performed (see Appendix C). The strengths of this project were the strong collaborative team and the members' enthusiasm. The team members included five persons from different specialties: a certified aromatherapy nurse who was working on her doctorate; a senior director of nursing working as a preceptor, with experience implementing a doctorate level EBP project; a clinical nurse specialist (CNS) who could develop the training curriculum and provide the training; a surgery program coordinator who was trained and available to obtain patient consent; and a pharmacist with a doctoral degree on the pain team who was able to collect the opioid data. All of the team members were motivated to implement the project for quality improvement in patient care. The "opportunities" were represented by the hospital's interest in providing aromatherapy to patients.
The hospital has been adding to the list of available non-pharmaceutical modalities for symptom relief, a TJC requirement. Additionally, research and non-research evidence supported the implementation of aromatherapy. Patients, in general, were requesting care that was costeffective and with fewer side effects. A "weakness" was that several surgeons decided to "optout" or not have their patients participate in the study due to concerns about essential oil therapy.
"Threats" included time constraints for the study, the occurring pandemic, nurse training using a remote video platform versus in-person training, untrained float nurses assigned to study patients, and failure to document correctly or lack of motivation to complete the requested nurse self-efficacy surveys.

Project Overview
This project's vision was to promote the health of the population and support patients' healing through a holistic modality. This vision was congruent with that of the hospital: "to improve the health of all communities served" (Dignity Health, n.d. Our Organization section).
The mission was to utilize the holistic principle and aromatherapy to provide quality health service for people at all levels of societal and economic backgrounds, to alleviate patients' pain and discomfort and improve their health and well-being. The project's mission was the same as that of the hospital to "deliver compassionate, high-quality care" (Dignity Health, n.d. Our Organization section). The project's objectives were the promotion of pain control, the reduction of opioids usage, and improved nurse self-efficacy in managing patients' pain with a complementary modality. The evidence search strategy was to locate research and non-research evidence to support the implementation of complementary therapy in the management of PSP.
Aromatherapy was selected based on the hospital's interest in searching for a non-pharmaceutical modality for PSP and discomfort. The addition of aromatherapy enhanced the strength of the hospital's multimodal pain management strategies. As a result of the hold on elective surgery cases during the COVID-19 pandemic, patient enrollment and nurse self-efficacy responses were less than anticipated. Thus, the unintended consequence of the project was the suboptimal statistical significance for the therapy.

Project Plan-Change Model
This project was an organizational change based on John Kotter's eight-stage process change model. The selection of this model was because the model has been testified across time through a variety of industries (Kotter, 2012). The model is considered a contemporary change theory, stressing the importance of the people involved in the change (White, 2016). The people and their collaboration within and outside of the team were the keys to project success. The eight stages of the model were followed, as described next.

Establishing a Sense of Urgency
An urgency to offer a complementary care modality had been established. The hospital was in the process of researching aromatherapy implementation when this project was initiated.
The hospital and the student had a similar vision to offer complementary modalities for patients' holistic health. A collaborative relationship was initiated within the preceptorship. A sense of urgency for change was communicated among participants and stakeholders at the beginning of this project.

Creating the Guiding Coalition
A guiding coalition was built when the team worked on creating a guideline for the project. The coalition members were from the hospital's education and surgical department, pharmacy, the senior director of nursing, and this doctorate student from another hospital within the corporation. A research nurse scientist and a research coordinator were involved in team activities to provide expertise on research project content and process. Weekly progress meetings (in person and virtually) were conducted to monitor the process and correct the issues when they arose.

Developing a Vision and Strategy
Vision and implementation strategies were generated after discussion within the group.

Communicating the Change Vision and Empowering Broad-Based Action
The change vision was initiated in the group. An essential oil therapy protocol/policy was established. Another hospital within the corporation also was interested in implementing and studying aromatherapy. At an appropriate time, the hospital will apply for approval from the institutional review board (IRB) and implement the project.

Generating Short-Term Wins
A short-term win was nurses receiving training and practicing on themselves. They started to feel empowered with the new therapy available to them. The new approach and knowledge provided to patients created a short-term win for patients and their family members with the new results immediately available.

Consolidating Gains and Producing More Change and Anchoring New Approaches in the Culture
Short-term wins for nurses and patients were transferred to more patients until enough patients for the study's purpose were provided with the essential oil therapy. When the project is disseminated to other units within the hospital or to other hospitals, a new culture will be generated. At the time of this report, the process is on hold due to the COVID-19 pandemic.
During this change process, the doctoral student worked as the project manager with the preceptor's guidance. The leadership quality learned was leading the people and managing the process through listening empathetically and being persistent. The skills gained were mastering four foundational behaviors: "Demonstrate respect, listen first, clarify expectations, and practice accountability" (Kogan, Blakemore, & Wood, 2015, p. 23).

Project Plan-Method
The project design was a pre-post comparison of outcomes of opioid usage, pain scores, and nurses' self-efficacy after nurse training and implementation of aromatherapy. A nurse selfefficacy survey was delivered to nurses as paper forms before and after aromatherapy training and approximately 4 weeks after the training. Electronic health records were examined before and after the implementation of aromatherapy, including demographics, pain scores, and average opioid use per patient per day in morphine equivalents. The implementation of aromatherapy started from the establishment of practice guidelines setting the new standard of care, describing the process for nurses in offering personal aroma inhalers to patients in the post-surgery unit as part of complementary pain relief care to patients who consented. The aromatherapy inhalers are sealed, small, plastic tubes pre-infused with essential oils on a cotton wick. Once the sealed tube is opened, the patient can inhale the essential oil lavender without the scent diffusing broadly around them. Nurses taught patients to breathe through the inhaler for 10 minutes when they felt discomfort or pain. The therapy can occur as often as every hour or 2 hours (see Appendix D).
The General Self-Efficacy (GSE) scale compares nurses' self-efficacy before and after their essential oil therapy training and 4 weeks after completing the training. The GSE score 4 weeks after training helps evaluate the nurses' continued comfort level with essential oil therapy.
The GSE was developed by Schwarzer and Jerusalem in 1979, with a translated English version available in 1995. The GSE measures nurses perceived self-efficacy in performing tasks at various levels of difficulty and while coping with adversity (Schwarzer & Jerusalem, 1995).
With 10 items measured on a 4-point Likert scale, nurses respond to each survey question and generate a final score of 10-40. The score reflects their comfort and confidence in applying essential oil therapy and actualizing its pain/discomfort management feature (see Appendix E).
Numeric pain scores were collected from the EHR. Patients rated their pain during standard of care using a scale of 0-10 with 10 as the "worst" pain. The numeric rating scale is commonly used and easy to document (Karcioglu, Topacoglu, Dikme, & Dikme, 2018). It is broadly validated across patient types and considered as "intuitively interpretable and meet regulatory requirements for pain assessment and documentation" (Karcioglu et al., 2018, p. 708).
Patients' pain scores were assessed in clinical practice before and after opioid administration and before and daily while using lavender essential oil therapy. Documentation of pain scores related to aromatherapy was created explicitly by nurses only for this project (see Appendix F).
Opioid usage data were collected from the EHR and converted to morphine equivalents by a pharmacist. The study site pharmacist/project team member withdrew the opioid utilization for all pre and post-implementation from EHR records through the Omnicell dispensing system and calculated an average per patient per day in morphine equivalents.
Demographics collected from the EHR included medical record number, age, gender, race, marital status, and surgical type. A list of patient medical record numbers was sent via encrypted email to the pharmacist/study team member for those EHR included in the project.
After the project completes, this list was deleted by the pharmacist. All study variables are described in Appendix G.
The implementation timeline was planned and finalized with the preceptor and other team members in the first week. Roles and responsibilities were assigned to each study team member.
There were some modifications to the timeline. The training was completed using a web-based application, which made it possible for nurses to attend the training for one of the four classes The financial measure was the cost of the therapy. This project was carried out within the ASU nursing budget. The hospital purchasing department made the purchase of essential oil and supplies for 200 dollars. The nurse training cost is estimated as follows: 1. Two educators at 10 hours each at $100 per hour=$1,000 2. 38 staff nurses at 1hour education time at $60 per hour=$2280 3. Hand-out costs for surveys and consents=$86.70 The total cost was approximately $3566.70. The cost was included in the nursing department's budget as a nursing EBP project. There was no charge to patients (see Appendix I).

Barriers and Facilitators
The notable barriers this project encountered included the delay of the Institutional Review Board (IRB) approval; IRB approval of research determination required patient informed consent. Nurses who took care of the patients were not eligible to have patients signed consent.
To overcome the barriers, the study team members scheduled a weekly meeting to discuss and update the study protocol and implementation plan. While waiting for the COVID-19 hold on elective surgeries to be lifted, study team members prepared nurse training curriculum and purchased required project supplies. The team recruited a pre-op educator to consent to patients. Other team members presented to the unit and obtained consent.

Project Evaluation
Project evaluation is equally as critical as the implementation. Thomas and Bleich (2020) explained that "project evaluation is an effort to measure the impact of project-based change" (p. 227). This project was planned to evaluate the effect of lavender essential oil on pain or discomfort relief in surgical patients and possible opioid use reduction. The nurse self-efficacy evaluation pre, post, and 4-week post-training were added to examine the impact of this project on nurses' self-efficacy.

Evaluation Tools
The tools to evaluate the pain score and nurse self-efficacy were the numeric rate scale and the GSE scale (Schwarzer & Jerusalem, 1995;Yu & Seol, 2017

Sample Population
The project population was selected among adult post-surgery patients in ASU. Patients were given information on the project and asked to consent for participation if they agreed. The informed consent was obtained in pre-op classes by a research assistant and upon arrival of the floor by other team members. All patients who signed consent and accepted the therapy were included in the project.
Demographic characteristics in pre and post-intervention groups had no statistical difference (p>0.05). A significant level of p value was set at <0.05 (see Table 1).  (1) The pre-intervention group consisted of 35 patients. These 35 charts were reviewed, and demographic information collected, including age, gender, race, marital status, and surgical type.
There were 63% of females and 37% males. Among the race groups, the majority of participants were White (71.4%). The remainder were distributed between Hispanic (8.6%), Black (11.4%), Asian (5.7%), and one other race (2.9%). More than half the patients (54.3%) were married, 29% were single, and 17.2% were divorced or widowed. Regarding surgical types, patients with orthopedic surgery covered 63% of the analyzed population. The rest were 17% with abdominal surgery, 20% of pelvic/urology, 10% of thoracic or vascular surgery, and 2.9% other surgery.
The post-intervention group had similar demographic characteristics with more females than males (64.7% vs. 35.3%), the majority of the White race at 52.9%, and orthopedic surgery at 82.4%.
The project included adult patients at the age of 18-85, admitted to ASU after surgery.
These patients required pain medication, accepted aromatherapy, and consented.
The project excluded those patients who are sensitive to scent or denied aromatherapy.
Patients who needed pain medication on post-op day 3 and beyond were excluded. The exclusion was also applied to patients whose surgeon opted out of the project or did not want to participate.
Based on sample size estimation from previous literature, the goal of this project was to audit 35 EHR records for pre and 35 EHR records for post-implementation of essential oil therapy (70 records total). In earlier studies measuring the implementation of aromatherapy lavender inhalation for the procedure and surgical pain, two groups of authors calculated the minimal sample size as 17 and 21 using a power of 0.08 and significance level of 0.05 for their research (Ilter, Ovayolu, & Ovayolu, 2019;Yu and Soel, 2017). When increasing the power to 0.09, the sample size calculation resulted in 41 for a three-group study applying lavender or eucalyptus compared to a control group (Yayla & Ozdemir, 2019).
To create the pre-implementation patient group, a patient discharge list from January 1, 2020, to February 15, 2020, was created from Discern Analytics 2.0 (report from the hospital EHR application-Cerner). A randomized sample of 35 EHR records that met inclusion criteria were selected using a web-based random number generator tool. The selected records were audited for data collection of baseline demographic information, pain scores, and opioid usage.
MRNs of the 35 selected records were sent to the site pharmacist/study team member via encrypted email. After calculating opioid usage, the list was deleted to maintain patient confidentiality.

Summative Evaluation
The evaluation was implemented to measure whether or not the individual patient outcome, numeral overall outcome measure, and qualitative outcome are demonstrated as expected. Nurse self-efficacy evaluation was added to the project in response to the hospital's intention to improve nurses' efficacy in taking care of patients using complementary modalities.
The evaluation of the project outcome of pain and discomfort relief was a comparison between the baseline and the intervention group. The endpoint for data collection was modified to meet the course deadline and the lack of possible patients' enrollment when many surgeries were canceled due to the current pandemic. Patient enrollment was 3 weeks in duration. The final sample of study patients consisted of 17 patients who were compared with the baseline 35 patients.
The project closure meeting was conducted among the team members to evaluate the project's quality, share what has been learned, and which step of the process needs to improve.
Barriers to the implementation were discussed during and after the project conclusion. The harmonization between the project outcome and the hospital's strategic goal was evaluated to determine its clinical significance for the organization.

Formative Evaluation
The project protocol was approved by the facility's IRB on April 17, 2020 (see Appendix Four weeks after completion of the training, nurses who attended the class were requested to complete a third GSE survey in paper form (see Appendix E). The survey was collected from CNS's dropbox for analysis.
Two weeks after nurses completed the training, aromatherapy was offered to patients who met the inclusion criteria and signed consent. The original plan was to offer aromatherapy to all patients as a new evidence-based program. However, the IRB determined that this study protocol was research, and therefore required informed consent. Additionally, several surgeons requested not to have their patients included in the study. The trained nurses followed the aromatherapy practice guidelines and offered aromatherapy to consenting patients. The postimplementation data collection began concurrently after the implementation of aromatherapy.
The principal investigator audited 22 EHR records in sequential order from the list of patients who used aromatherapy. Five of these patients were excluded from the analysis per study protocol. The collection of opioid use data followed the same procedure as the preimplementation group. At its completion, a team evaluation of the project process confirmed the fidelity and expanded scope to measure nurse self-efficacy. The formative evaluation included weekly process monitoring and reporting. The project's performance was measured "against a planned schedule" and reached the final milestone despite barriers during the process (Meredith, Mantel, Jr., & Shafer, 2017, p.271). Valuable lessons on project management and how to respond to unintended circumstances were learned from the project. Initial professional and personal development goals were met.

Evaluation Results
The results of 17 post-intervention patients were compared with 35 patients' chart review at the baseline (pre-intervention) group (see Table 2). Pain score pre-and post-opioid administration, pain score reduction percentage, and opioid usage data were collected and calculated at baseline and project completion (see Table 2).
On average, pain score changes in pre-and post-intervention groups amounted to a 39.51% reduction in the pre-group and a 45.77% reduction in the post-group. There was no statistically significant difference in pain reduction between the groups. However, when the pre-opioid pain scores in two groups were compared, the result showed a significant difference with a mean of 33.37 at pre-and 51.53 at the post-intervention group. With a higher pre-opioid and an equivalent post-opioid pain score, the result could be interpreted as a positive change with the intervention. The opioid usage results were 26.2mg and 48.66mg morphine equivalents per day per patient in two groups, which showed a statistically significant difference (see Table 2).
Nurse self-efficacy at three time points were evaluated and calculated using SPSS oneway ANOVA repeated measure analysis (see Tables 3-1, 3-2, 3-3).  Mauchly's sphericity test showed that the assumption was met, X 2 (2)=2.32, p=0.313. The assumption was that the relationship between the different pairs of conditions was similar (see Table 3-1). In tests of within-subject effects, F ratio>1 at 2.18 indicated the time points would have had a significant effect on nurse efficacy. However, the significance level>0.05 at 0.156 resulted in no difference between conditions (see Table 3-2). Partial Eta Squared at 0.267, which was higher than 0.14, indicated large effects. Therefore, there was no significant main effect of each time point on nurse efficacy (F(2,10)=2.18, p=0.156, ηp 2 =0.267) (see Table 3-2). There was no significant difference between any of the three pairs (see Table 3-3).
Due to a small sample size of only seven nurses who completed surveys at the three points, the statistical results might not be representative. A paired t-test was performed to evaluate the difference between two time-points pre-and post-training. The test led to a statistically significant difference between pre-training and post-training results (p value=0.04) (see Table 3-4). Pain score of eight patients from essential oil therapy documentation indicated a statistically significant pain relief. (see Table 4). A total of 11 participants expressed subjective positive responses to the therapy.

Data Analysis
The descriptive variable measurement included pre and post-intervention groups' patient demographic information, pre and post-opioid pain scores, opioid usage, and nurse self-efficacy pre, post-training, and 4-week after training. (see Appendix G). The demographic information included: age, gender, race, marital status, and surgical type. (see Table 1).
A statistician from the corporate research institute was consulted about the statistical analysis. He taught how to perform a t-test and sent an interactive Excel template for later use during data analysis. The DNP student was able to conduct statistical calculations and data analysis. Statistical t-test was used to calculate means, standard deviations, and a p-value to determine if there was a statistical difference. If p value was less than 0.05, the result was statistically significant. The measures were pre and post-intervention groups' pain scores, pain score reduction percentage, and opioid usage in morphine equivalence per patient day.
After enrolled patients' data were collected in the data collection Excel file, a t-test was applied to compare the means of two different groups' (baseline and study groups) morphine equivalent opioid usage, pre, and post pain scores. Nurse surveys at three time-points were converted to an SPSS file and analyzed using SPSS software version 26 for a one-way repeated ANOVA analysis for a comparison at pre, post, and 4weeks post-training. The statistical significance of each metric was analyzed and calculated. A paired t-test was used to calculate the mean scores of nurse self-efficacy pre and post-training. The positive statistical difference indicated the effectiveness of the provided therapy was confirmed.
All audited EHR data and nurse surveys were entered into a Microsoft Excel file (See Appendix K). No PHI or MRNs were included in the analytical dataset. The data's privacy and confidentiality have been maintained by storing data in electronic files on a hospital passwordprotected computer. The study lead investigator controlled the access to the Excel files and allowed access for the project team only.
Data were kept and stored on a hospital password-protected computer, safeguarded with a password and locked after use to protect the data and patients' information. The forms identifying the study patients were placed in a secure repository for shredding per the hospital policy after the required data were collected. As previously mentioned, no PHI was included in the analytical dataset. The list with MRNs used for auditing data was destroyed by the pharmacist and deleted to be not connecting to the final analyzed dataset. Patients' right to privacy and confidentiality were protected at all times, following facility and research institute policies.

Discussion and Implications
The outcome measures indicated a meaningful usage of essential oil therapy: 1) Pain scores reduction was found within the pre-intervention group but a more clinically significant reduction in the post-intervention group; however, there is no statistically significant difference in pain reduction between the groups; 2) Opioid usage increased in the post-intervention group.
The result was due to increased patient-controlled analgesia (PCA) use and higher pain severity at the pre-opioid time; Three out of the 17 analyzed patients in the post-intervention group used PCA with a dose of 326mg. Their usages were counted for 38.8% of the total doses. In the baseline group, five patients did not require opioids, and the highest dose used was 132 mg. In the post-intervention group, the range of opioid usages was from 3.3 mg to 124.5mg. The median usage in the two groups was 26.2 in the baseline group and 36.3 in the post-intervention group.
3) Nurse self-efficacy indicated no statistical significance in three timeframes with a very small sample size (n=7). There was statistically significant between pre and post-training with a sample of 18 nurses.
The essential oil therapy-specific documentation was not completed on every patient. The results of the eight included patients with documented pre, and post-assessment pain scores indicated a significant decrease of 55.1%. Some float nurses cared for these patients and had not been trained, but some wrote a regular nursing progress note indicating the use of essential oil therapy. Among the 11 narrative responses of the included patients, the common themes from the documentation were "relaxing," "calming," and "enjoyable scent." One patient commented that the hospital should have provided therapy for everyone a long time ago.
The planned pain reduction was not identified by statistical analysis as the literature review indicated, however, lavender essential oil was effective and safe in managing PSP (Gorji et al., 2015;Hasanzadeh et al., 2015;Kim et al., 2007;Reynolds, Parker, Wells, & Card, 2018;Tisserand & Balacs, 1995;Yu & Seol, 2017). The results could be attributed to the use of PCA and higher severity of pre-surgery pain or physical condition because the post-intervention group included patients who were discharged to a skilled nursing facility instead of home directly.
However, the patient's positive clinical response to the therapy indicated a need to further evaluate usage in an expanded patient population in other units or hospitals. The nurse selfefficacy survey did not result in an improvement of self-efficacy at three time-points. A small sample of only seven nurses (18%) who returned the survey three times might contribute.
Presumably, nurses were not motivated to participate actively. Due to the COVID-19 pandemic, nurses found their patients' acuity was higher than previous hospitalized patients. Patients' care was more demanding. The training was provided over a video application rather than a face-toface format. When calculating those nurses' responses who completed at least two surveys, the results indicated an improvement from pre to post-training. The results warranted a further implementation of the project when the patient population is more stable and predictable.
The limitations of the project were a small patient and nurse sample size, a single nursing unit, and lack of a standardized documentation tool for aromatherapy.
At the beginning of the implementation, there were not enough surgical patients when elective surgeries were on hold due to the COVID-19 pandemic. Some doctors opted out of the project leading to a reduction in eligible patients. The small sample size decreased the reliability of the statistical analysis. The fact that only the team members, instead of floor nurses, could obtain consent changed when patients consented and were offered the therapy. The DNP student could not physically go to the unit every day to provide training to patients and obtain consent.
Other team members might be available during the day but not after regular working hours.
Some consents were collected on the morning of post-op day 1. Patients who were provided the therapy on the day had more than a 12-hour gap without essential oil usage. Therefore, these patients' opioid usage might not be accurate as they were provided therapy immediately postsurgery upon arrival at the unit. Nurse training was through a web-based format that was new to some of the nurses. Not having an in-person class may have impacted the completion of the selfefficacy survey. There was no specific available documentation tool. Nurses in the unit were trained to create one for their documentation. However, when nurses floated from other units and were not trained, they did not know how to document for the study.

Implications for Nursing and Healthcare
PSP has been prevalent in the hospital and all healthcare systems. Essential oil therapy provided a useful tool for nurses to offer to their patients. Nurses' self-efficacy in addressing their patients' pain was improved through the implementation of this project (preand posttraining). Patients with PSP were satisfied with the care and complementary regime they received. In addition to essential oil therapy usage in other healthcare systems, as discussed earlier in this report, this project also offered an essential tool for nurses and their patients for their care needs. Nursing as an instrument of healing was actualized in the project when they practiced the empathy, presence, and empowerment principles of aromatherapy and provided essential oil to their patients.
To expand the evaluation of essential oil use, this study team worked with another hospital in Arizona to duplicate the project using the same protocol. The goal is to combine the data from both facilities. The Arizona hospital has not had an opportunity to implement the protocol due to the current pandemic.
Additional nursing units and additional essential oil options are needed to expand the program. To increase the project's reliability, the Arizona hospital should consider mitigating or eliminating the project's barriers and limitations. If nurse self-efficacy is included in their study, they should have a separate training section. The educator should spend time introducing the survey tool. Making time available for trained nurses to obtain patients' consent could be another strategy. Waiting until surgery volume is more stable may also impact the number of eligible study patients. Surgeons should be well informed and prepared to participate. An essential oil therapy-specific documentation form can be created with the information technology department's assistance before the project implementation.

Dissemination
The results were shared among the group members at the project closure. There are multiple options and forums for further dissemination. Smith-Stoner (2018) suggested traditional and virtual oral methods and traditional and virtual text methods. From the suggestion list, oral presentations to local and regional professional conferences will be one option. Presenting the study results at the study hospital would be an appropriate place to start. Such conferences as The National Association of Holistic Aromatherapy (NAHA) conference, the Academy of Integrative Health & Medicine Annual conference, Surgical Nursing conference, and Holistic Nursing conference will be considered as the next step.
The virtual oral presentation can be carried out via screen capture instructional video (Smith-Stoner, 2018). A nurse learning module for continuing education hours through an organization's distance learning center or a webinar for a broader audience in the profession will be appropriate. Nursing is selected because most of the participants in the project were persons with orthopedic surgery. The submission guidelines will be followed. The project is appropriate for these journals because it promotes holistic nursing and complementary therapy to the current treatment plan of care. There were similar articles published in the selected journals. One example is titled "The Effect of Listening to Music on Postoperative Pain in Adult Orthopedic Patients" by a DNP (Schneider, 2018). The article used a similar pain measurement scale and statistical methods.
A reflective sharing of the journey from start to completion of the project will be written out. What has been learned from the process, and what can be taught to others will be shared.
The virtual text formats for dissemination can be newsletters, and articles for the public (Smith-Stoner, 2018). The hospital and corporate newsletters can be utilized. Writing articles for the public can also be a method to disseminate the project.

Conclusion
By applying the JHNEBP model, a practice question was raised: ""In an acute hospital surgical setting, does essential oil therapy complement pain and discomfort relief comparing to conventional pain management alone after 6 weeks?" A literature search was performed, researched and non-researched evidence was analyzed for a recommendation, which led to the intervention of essential oil therapy for post-surgical pain. The plan for implementation and evaluation was discussed in the paper.
An evidence-based practice change project was established using the JHNEBP model. A matching MRM theory was applied to the project. Kotter's change model guided the implementation of the planned project. The implementation of essential oil therapy demonstrated a clinically significant reduction in pain scores, but not a reduction in average daily opioid use.
Nurse self-efficacy was improved post-training compared with pre-training, but the sample size was too small to demonstrate a statistical significance at three points in time pre-training, posttraining, and four weeks post-training.
Additionally, patients and nurses expressed their satisfaction with essential oil therapy. • Essential oil selection is based on the following: (1) reason for use and desired potential outcome and (2) patient preference in regard to the essential oil. • Assess patient for contraindications. 6. Safety: • Gloves are worn when handling essential oils.
• Essential oils are kept in a cool, dark, and secure location when not in use (medication room).
• Essential oil containers are labeled with supplier's name, common essential oil name, botanical name, date opened, and expiration date. • If essential oil container breaks or spills, use gloves, mask, and eye protection when cleaning up the spill. Refer to Safety Data Sheet (SDS) for specific instructions. • If essential oils come in direct contact with eyes or mucus membranes, wipe the area. If essential oils are ingested, DO NOT induce vomiting. The mouth should be rinsed with water, juice, or milk and follow SDS instructions.

Direct inhalation:
• Perform hand hygiene and apply gloves.
• Place cotton wick inside single patient use applicator.
• Apply two (2) drops of one (1) essential oil on the cotton wick.
• Quickly replace lid on essential oil container and return to storage location. The essential oil container should not leave the medication room. • Remove gloves and perform hand hygiene.
• Add essential oil and patient label to inhalation applicator.
• Place "essential oil therapy" signage outside patient room (Attachment B).
• Instruct the patient to inhale the essential oil by taking slow, deep breaths through the nose for no greater than ten (10) minutes at a time and once per hour. • Instruct the patient to notify staff in regard to any change in condition, including but not limited to, a change in respiratory or cardiac status, headache, or itchy/watery eyes that may represent an adverse effect of the essential oil. • If adverse reactions related to the therapy occur in patients, visitors, or staff, discontinue therapy immediately by removing essential oil inhaler from the room. Affected individuals should be assessed and appropriate interventions taken. • The inhaler lasts approximately 48 hours and is discarded in the regular trash once the aroma is no longer present or detectable by smell. If the patient requests to continue essential oil therapy past 48 hours, then a new inhaler will be used.

Patient and Family Education:
• Educate the patient/family on the essential oil purpose, benefits, and correct use. (Attachment A).
• Place approved signage outside the patient's room to alert staff and visitors to essential oil therapy use (Attachment B).
9. Documentation (on progress note for essential oil therapy • Initial assessment is documented as follows: a. Indication for use, b. Patient agreement or refusal, c. Type of essential oil used, d. Pain/discomfort level, e. Patient response, and f. Education regarding therapy • Reassessment is performed and documented every shift while essential oil therapy is in use as follows: a. Indication for use, b. Type of essential oil being used, c. Pain/discomfort assessment, and