Examination of the Effectiveness

of Peppermint Aromatherapy on
Nausea in Women Post C-Section
Betty Lane, RN, MSN, PhD
Kathi Cannella, RN, MSN, PhD

jhn

90

Journal of Holistic Nursing

American Holistic Nurses Association
Volume 30 Number 2
June 2012 90-104
2012 AHNA
10.1177/0898010111423419
http://jhn.sagepub.com

Clayton State University

Cathy Bowen, RN, AD

David Copelan, PharmD, MPA, FASHP
Southern Regional Medical Center

Grace Nteff, RN, MSN, NP

Katrina Barnes, RN, MSN
Melanie Poudevigne, PhD
Clayton State University

Jacqueline Lawson, RN, MBA

Southern Regional Medical Center

Purpose: This study examined the effect of peppermint spirits on postoperative nausea in women following a scheduled C-section. Design: A pretest-posttest research design with three groups was used.
The peppermint group inhaled peppermint spirits, the placebo aromatherapy control group inhaled an
inert placebo, green-colored sterile water, and the standard antiemetic therapy control group received
standard antiemetics, usually intravenous ondansetron or promethazine suppositories. Methods:
Women were randomly assigned to a group on admission to the hospital. If they became nauseated,
nurses on the mother-baby unit assessed their nausea (baseline), administered the assigned intervention, and then reassessed participants' nausea 2 and 5 minutes after the initial intervention. Participants
rated their nausea using a 6-point nausea scale. Findings: Thirty-five participants became nauseated
post-operatively. Participants in all three intervention groups had similar levels of nausea at baseline.
The nausea levels of participants in the peppermint spirits group were significantly lower than those of
participants in the other two groups 2 and 5 minutes after the initial intervention. Conclusions:
Peppermint spirits may be a useful adjunct in the treatment of postoperative nausea. This study should
be replicated with more participants, using a variety of aromatherapies to treat nausea in participants
with different preoperative diagnoses.
Keywords:peppermint; aromatherapy; postoperative nausea; alternative therapies; c-section; quantitative studies

Women often experience the discomfort of nausea

during the postoperative period following a cesarean
section (C-section). Vagal or sympathetic stimuli,
severe pain, visceral trauma, medications, and anesthesia can stimulate receptors in the medulla resulting in postoperative nausea and vomiting (McCance
& Huether, 2010). Nausea is frequently treated with
pharmacologic therapies to improve patient comfort

and decrease the incidence of vomiting, which may

place stress on the surgical wound. Standard drug
therapies for nausea can be problematic in postpartum women because they can result in sedation,
Authors Note: Please address correspondence to Betty Lane,
RN, MSN, PhD, associate professor/clinical nurse researcher,
Clayton State University, Morrow, GA 30260; e-mail: bettylane@
clayton.edu.

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Peppermint Aromatherapy / Lane et al.91

which can interfere with breast feeding or may not

be effective in short-term nausea (Karch, 2011).
Pharmaceutical treatments are often associated
with unpleasant side effects (Springhouse, 2003).
Peppermint aromatherapy provides a potential alternative therapy for management of nausea without
the side effects of sedation (Springhouse, 2005).
However, lack of research on aromatherapy and
essential oils has been a barrier to their use in the
hospital environment (Stevensen, 2001). Peppermint oil, like a variety of natural remedies, has not
been adequately studied using large randomized
controlled trials. Two challenges of studying herbs
using the medical model are that herbal preparations typically contain a variety of ingredients making them more difficult to study compared with
singular ingredients and that herbs are not usually
financially appealing to drug companies (Freeman,
2009a; Springhouse, 2003). Micozzi (2011) acknowledges the challenges of applying the biomedical
model to explain alternative medicine. He suggests
that the current biomedical paradigm will need to
evolve in order to adequately study the effects of
alternative medicine. In addition, the different
methods and products that are used to administer
aromatherapy in studies have made it difficult to
conduct systematic reviews of the literature.

Background
Traditionally, in our community hospital promethazine (Phenergan) had been used intravenously to
treat postoperative nausea. However, promethazine
was removed from the hospital formulary for intravenous use due to concerns about phlebitis (D. Copelan,
personal communication, December 1, 2009). This
resulted in the use of ondansetron (Zofran) for the
treatment of postoperative nausea. Zofrans safety
has not been established in breast-feeding women, it
is not indicated in acute short-term nausea, and its
effect can last up to 8 hours (Karch, 2011).
The lack of effective medications for short-term
acute nausea that did not cause sedation or interfere
with breast-feeding presented a challenge to the
nurses on the postpartum unit; this resulted in a
search for alternative ways to relieve nausea. A registered nurse on the postpartum unit who specializes
in holistic therapies suggested that aromatherapy
with peppermint spirits be explored as an alternative
intervention that might quickly and safely relieve
nausea without the side effects of sedation.

Significance
The problem addressed in this study is the lack of
effective, economical, safe, and nonsedating therapeutic measures for nausea in women post C-section. This study is significant to holistic nursing
because it evaluates the use of peppermint aromatherapy as an alternative therapy for the treatment of
nausea without the side effects of traditional medications. Treatment of nausea takes on extra significance
in women post C-section since its treatment with
traditional pharmaceutical methods can cause sedation, which can interfere with breast-feeding and are
often contraindicated in breast-feeding. The use of a
natural product such as peppermint spirits also meets
a growing consumer desire to use natural products
that have potential to relieve unpleasant symptoms
with fewer occurrences of side effects (Sierpina,
Gerik, Miryala, & Micozzi, 2011). A review of the
literature revealed three studies that used peppermint
oil aromatherapy for treating postoperative or intrapartum nausea (Anderson & Gross, 2004; Burns, Blamey,
Ersser, Barnetson, & Lloyd, 2000; Tate, 1997). As
cited by Buckle (2009), there are three additional
unpublished reports where Figuenick, Chalifour, and
Piotrowski successfully used peppermint aromatherapy to relieve the nausea of 10 oncology patients
undergoing chemotherapy, inpatients withdrawing
from opiate and crack cocaine, and 17 hospitalized
patients, respectively. No adverse treatment effects
were reported for any of the participants in the studies
by Anderson and Gross, Chalifour, Figuenick,
Piotrowski, or Tate. Burns et al. were unable to determine whether the very minor complaints experienced
by about 1% of the women in labor participating in
their study were caused by the peppermint aromatherapy or by the labor and delivery (L&D) itself.

Purpose
No studies were found that used a product described
as peppermint spirits, which combines peppermint
with an aromatic ethyl alcohol base. The purpose of
this study was to examine the effect of peppermint
spirits aromatherapy on postoperative nausea in
women following a scheduled C-section. A pretest
posttest research design with random assignment to
three intervention groups was used. The three levels
of the independent variable, intervention, were peppermint spirits aromatherapy, sterile water placebo
aromatherapy, and standard antiemetic therapy. The
dependent variable was nausea.

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92Journal of Holistic Nursing / Vol. 30, No. 2, June 2012

Literature Review
Peppermint (Mentha piperita) is an aromatic herb
that is classified as a carminative that can relieve
stomach and intestinal disorders and relieve nausea
and vomiting (Fundukian, 2009; Sweetman, 2009).
Peppermint is also commonly used as a flavoring in
food, teas, lotions, and medications. The menthol in
peppermint is thought to calm the stomach through
relaxing the stomach muscle and acting as an
anesthetic to the stomach wall, which decreases or
reduces nausea and vomiting (Fundukian, 2009).
Peppermint is also thought to have an emotional
calming effect (Cassileth, 1998). In the Herbal
Medicine Handbook, sedation is not listed as a property or side effect of peppermint (Springhouse,
2005). Information on peppermint aromatherapys
physiological effect to decrease nausea and vomiting
is primarily historical and anecdotal. Peppermint is
generally thought to be a relatively safe aromatic herb
for treating gastrointestinal discomfort (Ebadi, 2002).
Buckle (2009, p. 402) asserts that peppermint,
spearmint, and ginger are the classic essential oils to
inhale for nausea and notes the effect from these
oils is immediate if they are going to work. Since
peppermint is not regulated as a drug by the FDA,
scientific studies on pregnant and nursing women
appear to be absent. A limited number of controlled
studies have evaluated peppermints effect using
the administration technique of aromatherapy
(Springhouse, 2003). Buckle believes that, used correctly, essential oils are safe in pregnancy and asserts
that both inhaled and topically applied essential oils are
safer for pregnant women than the pesticides they
ingest with their food. However, she asserts that
undiluted essential oil of peppermint may cause
respiratory distress in infants, so it should not be
used near their nostrils.
Aromatherapy uses the essential oils of plants
for therapeutic purposes. Aromatherapy can be
divided into aesthetic, holistic, and clinical aromatherapy (Harris, 2011). Clinical aromatherapy tends
to be implemented by nurses, is episodic, and
focuses on a specific discomfort. The essential oils
affect the bodymind connection through interaction with the olfactory system (Harris, 2011). Aromatherapy is thought to have an emotional as well as a
physiological effect, which further complicates evaluation of its impact. The aroma from the essential
oil binds with the receptors in the nasal epithelium.
The resulting neurochemical reaction is transmitted

to the olfactory bulb in the brain, the limbic system,

and the thalamus, which causes a release of endorphins and serotonin (Buckle, 2009; Kuhn, 1999).
Very small amounts of essential oils are needed due
to the acuteness of the smell (Buckle, 2009). Aromatherapy with peppermint is thought to be relatively safe although lacking substantial clinical trials
(Ernst, 2001; Guba, n.d.).
Herbs that have been traditionally used without
harm for minor discomforts have been commonly
thought to have demonstrated safety (Ebadi, 2002;
Freeman, 2009a; Springhouse, 2003). As a result,
most of the information on the actions and safety of
herbs such as peppermint are primarily anecdotal.
Less causal research methods should not be dismissed (Ives & Jonas, 2011); however, this has
resulted in difficulty when it comes to making guidelines for alternative medicines in the clinical setting.
The practitioner who administers essential oils
should be aware of potential side effects such as
allergies, photosensitivity, dermatitis, and mucous
membrane irritation (Harris, 2011; Kuhn, 1999;
Springhouse, 2003). Individuals with lung conditions, asthma, or pregnancy should avoid inhalation
of oils (Kuhn, 1999). Also, peppermint should not
be used in people with gallbladder disorders
(Springhouse, 2005). There is limited information on
the safety of peppermint aromatherapy in pregnant
or lactating women; however, for many years aromatherapy with essential oils has been used to treat
nausea and other symptoms in these women (Harris,
2011). It is generally thought that ingestion of peppermint in amounts usually found in food products
or medications is generally safe for these women
(National Institutes of Health, 2011). However, it
should be noted that the level of evidence for recommendations and restrictions for peppermint and
other essential oils requires further development.
Two of the three studies that examined the use of
peppermint oil aromatherapy to treat postoperative/
intrapartum nausea were conducted in different
countriestwo in England (Burns et al., 2000; Tate,
1997) and one in the northeastern United States
(Anderson & Gross, 2004). Tate (1997) compared
the effect of no therapy, peppermint essence aromatherapy (the components of peppermint essence
were not defined) that she defined as a placebo
therapy, and peppermint oil aromatherapy in an
experimental study of postoperative nausea in 18
gynecological patients, who were randomly assigned
to one of the three groups. Although Tate reported

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Peppermint Aromatherapy / Lane et al.93

that most patients only inhaled from the bottle

when feeling nauseous postoperatively (p. 546), she
did not report the specific breathing instructions
given to study patients. Tate used a 5-point descriptive ordinal scale to measure nausea and assessed
nausea levels every 4 hours. The scale ranged from 0
(I am not experiencing any nausea) to 4 (I am so nauseated I feel I am about to vomit). She found a significant
difference in average per person per day levels of
nausea between the experimental and placebo groups
on the day of operation. No adverse effects were
reported during this study. Subjective data and the
decreased use of antiemetics in the experimental
group suggested that the peppermint oil aromatherapy might be useful as a nausea treatment in
women following a gynecological procedure.
Burns et al. (2000) conducted an observational
study comparing aromatherapy using one or more of
10 essential oils, including peppermint (Mentha
piperita), by 8,058 women in labor to 15,700 women
who were not given aromatherapy. Routine data that
had been collected on women in labor who were
seen between 1990 and 1998 were analyzed and
compared with data on a comparison group of
15,799 women in labor obtained from a unit audit.
Peppermint oil aromatherapy was used to treat nausea and/or vomiting in 1,104 of these women in
labor. Forty-nine percent of these women rated the
effectiveness of peppermint oil in reducing nausea
and vomiting as helpful, 37% rated it as equivocal,
and 14% rated it as not helpful. Only 1% of the
8,058 women who received aromatherapy reported
any undesired associated effects. These effects were
reported only for the total group of 8,058 women
and included nausea (n = 60), itchy rash (n = 15),
headache (n = 13), and rapid labor (n = 9). Since
these were usually very minor symptoms that are
often reported during labor, their actual causality is
not known. There were no reports of adverse outcomes to the mother or baby associated with any
essential oils aromatherapy used in this study. This
study demonstrated the clinical effectiveness of aromatherapy and its integration into midwifery practice at a maternity unit in Oxford, United Kingdom.
In a randomized controlled trial, Anderson and
Gross (2004) compared the effect of aromatherapy
using peppermint oil (n = 10), isopropyl alcohol (n = 11),
and placebo isotonic saline (n = 12) on nausea in
33 surgical patients in a postanesthesia care unit
who were randomly assigned to one of the three
groups. Inhalation of isopropyl alcohol is believed to

disrupt the emetic response by affecting the transmission of nausea sensations along neural pathways
(Wang, Hofstadter, & Kain, 1999). All patients in
the three groups were instructed to take three slow
deep breaths and inhale the vapors deeply through
their noses and exhale them through their mouths.
Nausea was measured using a visual analogue scale
at baseline and again 2 and 5 minutes after the initial intervention. All three therapies were found to
be equally effective. No adverse effects were
reported. The researchers attributed the decrease in
nausea levels among the three interventions to the
deep breathing that the subjects were instructed to
perform during the inhalation of the peppermint oil,
isopropyl alcohol, or isotonic saline. This contradicts
the earlier findings of Langevin and Brown (1997),
who conducted a double-blind crossover study of 15
consecutive patients. They found that saline did
not relieve postoperative nausea or vomiting in any
patient (n = 15), whereas isopropyl alcohol inhalation
relieved postoperative nausea or vomiting in 12 of
15 patients.
In addition to Anderson and Gross (2004) and
Langevin and Brown (1997), other researchers
(Merritt, Okyere, & Jasinski, 2002; Smiler & Srock,
1998; Wang et al., 1999; Winston, Rinehart, Riley,
Vacchiano, & Pellegrini, 2003) also studied the
effectiveness of aromatherapy using isopropyl alcohol to treat nausea. There have been few reports of
side effects and no reports of toxicity from the inhalation of isopropyl alcohol (Cotton, Rowell, Hood, &
Pellegrini, 2007; Merritt et al., 2002; Pellegrini,
DeLoge, Bennett, & Kelly, 2009). Spencer (2004)
focused on the effectiveness of isopropyl alcohol inhalation in reducing postoperative nausea/vomiting,
describing the physiology of postoperative nausea
and vomiting, reviewing the above studies, and recommending that nurses use isopropyl alcohol inhalation as a complementary treatment for postoperative nausea/vomiting. Later studies found that the
inhalation of isopropyl alcohol was an effective treatment for postoperative nausea/vomiting in home as
well as hospital settings as well as in patients at high
risk for developing postoperative nausea/vomiting
(Cotton et al., 2007; Pellegrini et al., 2009).
This review of the literature revealed a very limited number of studies on the use of peppermint
aromatherapy in postoperative nausea. No study of
aromatherapy for the treatment of nausea using the
product labeled as peppermint spirits was found.
Three studies investigated peppermint oil (Anderson

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94Journal of Holistic Nursing / Vol. 30, No. 2, June 2012

& Gross, 2004; Burns et al., 2000; Tate, 1997).

Tate also investigated peppermint essence, and
Anderson and Gross also investigated isopropyl
alcohol. Tate used peppermint essence as an inert
placebo, but did not specify the constituents of the
peppermint essence she used. Kress (2010) stated
that essences only differ from spirits in strength,
with essences usually being three times stronger.
She provided a formula for peppermint essence, a
mixture of 1 fluid ounce of peppermint oil with 4
fluid ounces of rectified spirit, that she stated is in
accordance with the British Pharmacopoeia. Isopropyl alcohol inhalation has been shown to
decrease nausea/vomiting in several studies. However, there were no studies that used ethyl alcohol
to treat postoperative nausea. This experimental
study was built on the previous studies and was
unique in that it focused on aromatherapy using
peppermint spirits, capturing the synergistic effect
of both peppermint and ethyl alcohol, which has
not been done in previous studies. The purpose of
this study was to examine the effect of peppermint
spirits aromatherapy on postoperative nausea in
women following a scheduled C-section.
Research Question: Will women who receive peppermint spirits aromatherapy experience a
greater decrease in nausea after the initial
intervention than women who receive either
sterile water placebo aromatherapy or standard antiemetic therapy?

Method
Design
Based on the previous studies and the call for scientific studies of alternative therapies (Koop, 2011;
Lundberg, 2011; Micozzi, 2001) and evidence-based
practice (Guzzetta, 2005), an experimental pretest
posttest research design with random assignment
was used to examine the treatment effects. The three
groups consisted of peppermint spirits aromatherapy,
placebo aromatherapy, and standard antiemetic therapy groups.
The initial interventions were administered
immediately after participants baseline nausea levels were assessed. Each participant in the peppermint spirits aromatherapy group (experimental
group) received aromatherapy using pharmacy grade

peppermint spirits (HUMCO Peppermint Spirit

USP: ethyl alcohol 82%, peppermint oil, purified
water, peppermint leaf extract). Each participant in
the placebo aromatherapy control group (inert placebo control group) received aromatherapy using
sterile water mixed with green food coloring. Each
participant in the standard antiemetic therapy control group (usual care control group) received standard antiemetic therapy in accordance with physicians orders and hospital policy/protocol. The staff
nurse reassessed the nausea level of participants in
all three intervention groups 2 and 5 minutes after
administering the initial intervention.
Specific research questions were identified to
compare each groups nausea levels at 2 minutes
and 5 minutes after the initial intervention to their
nausea levels at baseline and to compare the nausea
levels between groups at the same time points.

Specific Within-Groups
Research Questions
1. Will participants in the peppermint spirits aromatherapy group report a decrease in nausea?
2. Will participants in the placebo aromatherapy
group report a decrease in nausea?
3. Will participants in the standard antiemetic
therapy group report a decrease in nausea?

Specific Between-Groups Hypotheses

1. There are no differences in the baseline nausea
levels of participants who receive peppermint
spirits aromatherapy, placebo aromatherapy,
and standard antiemetic therapy.
2. Participants who receive peppermint spirits aromatherapy experience less nausea at 2 minutes
after the initial intervention than do participants
who receive either placebo aromatherapy or
standard antiemetic therapy.
3. Participants who receive peppermint spirits
aromatherapy experience a greater decrease
in nausea at 2 minutes after the initial intervention compared with baseline than do
participants who receive either placebo aromatherapy or standard antiemetic therapy.
4. Participants who receive peppermint spirits
aromatherapy experience less nausea at 5 minutes after the initial intervention than do participants who receive either placebo aromatherapy or standard antiemetic therapy.

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Peppermint Aromatherapy / Lane et al.95

5. Participants who receive peppermint spirits

aromatherapy experience a greater decrease in
nausea at 5 minutes after the initial intervention compared with baseline than do participants who receive either placebo aromatherapy or standard antiemetic therapy.

Participants and Setting

Women were recruited for this study consecutively
using the hospitals list of scheduled C-sections.
Women were eligible to participate in this study if
they were scheduled for a nonemergency C-section,
English speaking, at least 18 years of age, nonsmoker,
and became nauseated post C-section. Women were
invited to participate in this study by phone. Those
who agreed to participate were sent an enrollment
package and consent form. Women were excluded
from the study if they had an allergy to peppermint or
food colorings, had been diagnosed with persistent
vomiting such as hyperemesis, or had a condition in
which the contraction of abdominal muscles during
vomiting would have been contraindicated such as an
infected wound (McCance & Huether, 2010). Women
were also excluded from the study if they were receiving magnesium sulfate therapy since patients on magnesium sulfate are at greater risks for aspiration due
to its effects of decreased muscle tone and diminished reflexes (Lippincott, 2011).
The setting for this study was a womens center
of a community hospital located in the metropolitan
area of a large city in the southeastern United States.
This hospital primarily provides services to an underserved minority community.

Ethical Protections and

Safety Considerations
Approval to conduct this study was obtained from
the medical centers institutional review board.
There is a lack of literature on the use of peppermint
aromatherapy in postpartum women and nursing
mothers. The study was therefore presented to the
Womens Center Medical Committee, composed of
obstetricians, anesthesiologists, and midwives, for
review and approval. The peppermint spirits contained some of the common ingredients that individuals might be exposed to in daily life, such as
peppermint food and beveragesflavorings in an
alcohol base. The alcohol in the peppermint spirits
was 82% compared with the alcohol in a commonly

available form of peppermint used in cooking

peppermint extract that contains 89% alcohol
(McCormick & Company, 2010). An additional layer
of safety was ensured with the use of pharmacygrade peppermint spirits, which contained ethyl
alcohol instead of the isopropyl alcohol used in previous studies for the treatment of nausea. Several
safety factors were instituted to reduce exposure of
the babies to the peppermint spirits. The babies
were not allowed in the mothers arms when the
aromatherapy was administered, a staff nurse supervised the administration of the aromatherapy, the
aromatherapy was inhaled from a small bag rather
than a diffuser to limit exposure to the surrounding
air, and only 3 inhalations at 3 times (baseline and 2
and 5 minutes postbaseline) were allowed under the
direct supervision of the nurse. There appears to be
very limited scientific information on the effect of
peppermint spirits aromatherapy with regard to its
components of peppermint oil or its ethyl alcohol
base on breast milk. Peppermint oil aromatherapy
has been used to treat nausea in women in labor
with no adverse outcomes to the mother or baby
(Burns et al., 2000). However, it should be noted
that American Academy of Pediatrics Committee on
Drugs (2001) only cautions the avoidance of alcohol
oral ingestion in large amounts in their policy on
the transfer of drugs and other chemicals into
human milk, and the La Leche League International
(2010) provides information from multiple sources
indicating that breast-feeding mothers can drink
some alcohol occasionally without harming themselves or their babies. Alcohol leaves the breast milk
as soon as it leaves the bloodstream (La Leche
League International, 2010). According to Dr.
Thomas Hale (2006), author of Medications and
Mothers Milk, adults usually metabolize 1 ounce of
alcohol in 3 hours.
The mothers who received peppermint spirits
aromatherapy in this study were exposed to the alcohol in 1 mL of peppermint spirits by inhalation, not
ingestion. Since the effects of alcohol on the baby
are directly related to the amount of alcohol the
mother consumes (La Leche League International,
2010), the researchers, pharmacy department, and
the institutional review board considered the administration of peppermint spirits aromatherapy intervention used in this study to be safe for mothers and
their babies.
The telephone recruitment nurse followed a
script that explained the purpose of the study. No

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96Journal of Holistic Nursing / Vol. 30, No. 2, June 2012

deception was usedpotential participants were

informed about the three intervention groups and
agreed to be randomly assigned to one of them as
part of the informed consent process. Using a placebo
intervention adds an element of control to experimental studies (Burns & Groves, 2009). Informing
the participants beforehand regarding the potential
use of a placebo in the study avoided ethical concerns regarding deception. No monetary or other
compensation was given to participants. It should
also be noted that a participant could opt out of the
study at any time during the intervention as indicated
in the study consent signed by the participants. Also,
if a participant requested a traditional antiemetic, it
would immediately be prepared regardless of the
participants assigned treatment group.

Study Processes and Procedures

Recruitment flyers were sent to obstetricians offices
and posted in classrooms used for child birthing
classes. The project recruiter telephoned women
who were scheduled for a C-section and followed a
recruitment script to invite them to participate in
the study. The recruitment goal was set at 84 participants, 28 per intervention group with complete
data collected. Participants were told they would be
assigned to one of three intervention groups. An
enrollment package was then sent to the women.
The enrollment package contained a study description sheet, consent form, and background form.
Women brought the signed consents and background
forms to the hospital admissions department (AD)
when they came on the day of their admission to the
hospital.
The coordination of three departments was used
to enhance the validity of the study while assuring
inclusion of the participants in the study. The AD
staff performed random assignment, nursing staff in
the L&D unit verified participation, and nurses on
the mother/baby (M/B) unit conducted the assessments and implemented the interventions. Staff in
the AD assigned participants to intervention groups
per protocol using a blocked systematic random
assignment method. Participants were assigned to
intervention groups in blocks of three, one to each
group, to foster equal sample sizes in the three
groups. At this time a color-coded round label designating participants intervention group assignment
was placed on the front of each participants chart.

Staff in the L&D unit asked each participant if

she was participating in the peppermint study. If the
participant said yes, the L&D staff verified that the
participant understood the purpose of the study and
that the consent form was signed and on the chart.
They also verified the placement of the color sticker
on the chart.
When each of the post C-section patients was
transferred to the M/B unit the assigned nurse
checked to see if the patient was participating in the
study and noted the label color on the chart, indicating the participants intervention group assignment. Whenever a participant first became nauseated, the nurse assessed her nausea level using the
nausea scale (baseline), administered the assigned
intervention, and reassessed her nausea level at 2
and 5 minutes after the initial intervention. Each
participant in both aromatherapy groups received a
second and third aromatherapy intervention immediately after the second and third nausea assessments. Nurses assessed each participants nausea
by asking her to rate it using a 6-point ordinal nausea scale. If the participant was still nauseated after
the 5-minute assessment, she was offered a standard
nausea medicine. Also, each participant had the right
to request standard treatment at any time during the
study. If the participant wanted the standard nausea
medication the nurse prepared it immediately.

Administration of Aromatherapies
and Standard Antiemetic Therapy
When a participant in either the peppermint spirits
aromatherapy or placebo aromatherapy group
became nauseated, the staff nurse went to the medication room and obtained an administration packet.
Each packet consisted of a cotton ball inside of a
mini ziplock bag and a syringe containing either the
peppermint spirits (1 mL) or sterile water with green
food coloring (1 mL). In the medication room the
nurse inserted the contents of the syringe into the
cotton ball and closed the ziplock bag. The ziplock
bag was taken to the participants room where the
nurse used the nurse script to instruct the participant to hold the open ziplock bag 2 inches under her
nose and to take three slow, deep breaths in through
the nose and out through the mouth. In accordance
with the script, the nurse supervised the participant
for 5 minutes, reassessing the participants nausea
level after 2 minutes and then administering the

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Peppermint Aromatherapy / Lane et al.97

aromatherapy intervention for the second time.

The nurse assessed the participants nausea level
for the third and final time 5 minutes after administering the initial intervention and then administered
the third aromatherapy intervention to the participant. The mother did not hold her baby during the
inhalations.
When a participant in the standard antiemetic
therapy group stated that she was nauseated, the
staff nurse administered the nausea scale and asked
the participant if she wanted to receive the antiemetic prescribed by her physician. The staff nurse
administered the prescribed antiemetic, usually
intravenous ondansetron or promethazine suppository, and then reassessed the participants nausea
level 2 minutes and 5 minutes after administering
the medication.

Instruments/Measurements
An ordinal nausea scale adapted from one used by
Tate (1997) was used to measure the participants
subjective perceptions of nausea and vomiting. The
6-point descriptive ordinal rating scale ranged from 0
to 6 with the following descriptors next to each number, respectively: I am not experiencing any nausea,
I feel slightly nauseated, I feel moderately nauseated, I feel extremely nauseated, I feel so nauseated I feel I am about to vomit, and I vomited. It
took participants less than 5 seconds to identify their
nausea levels. A background form developed by the
researchers was used to collect demographic, alternative therapy use, and pregnancy-related information.
Participants were asked to fill out the background
form and bring it to the hospital on admission.

Data Analysis
The data were analyzed using descriptive and inferential statistics. Descriptive statistics, including means,
standard deviations, and/or frequencies, were used to
analyze data from the background form and nausea
scale. Inferential statistics, specifically Fishers exact
probability tests, were conducted to test the hypotheses due to the ordinal nature of the nausea scale and
low cell frequencies (less than 5). This required comparing two groups at a time and recoding the nausea
scale as a dichotomous variable. Nausea scores were
recoded from 6 levels to 2 levels: scores of 0 to 1
were recoded as none-low and scores of 3 to 5 were
recoded as high. Since it was deemed neither low

nor high, the score of 2 was not recoded. Difference

from baseline nausea level was computed by categorizing participants postintervention nausea level as
decreased (changed from high to none-low) or
remained high (high baseline level did not decrease).
The overall significance level for this study was
set at p = .05. Since only two groups could be tested
at one time and multiple hypotheses (5) were being
tested for each of the two group comparisons (peppermint spirits aromatherapyplacebo aromatherapy
and peppermint spirits aromatherapystandard antiemetic therapy), the Bonferroni correction was used,
and the significance level for each of the 10 hypothesis tests was set at .005 (.05/10).

Results
Thirty-five of the eligible participants became nauseated during the study, 22 (63%) in the peppermint
spirits aromatherapy group, 8 (22%) in the placebo
aromatherapy group, and 5 (14%) in the standard
antiemetic therapy group. Many participants (n = 24)
did not become nauseated while they were on the
M/B unit and thus did not meet the inclusion criteria. Many other participants were excluded for a
variety of other reasons. Some participants were
missed by the AD and were not assigned to an intervention group; others were not confirmed by L&D
personnel. A small number of participants refused to
participate when they could not be in the peppermint
group. Attrition numbers were also affected by participants who delivered early or had an emergency
C-section or related complications. Also, not all
nurses on the nursing unit implemented the research
protocol. Some nurses did not implement the
research protocol at all; others did not implement the
research protocol for participants in the placebo
aromatherapy group. No participants were excluded
due to untoward effects of the aromatherapy
interventionsthere were no reports of sedation or
other problems in the mothers or babies receiving
either of the two aromatherapy interventions. Another
problem was that data were incomplete and could not
be used if the nausea scale had not been completed at
all three nausea assessment points. The data for
many participants were destroyed because their study
forms were not removed from the chart before the
participants discharge and were subsequently discarded and shredded by medical records personnel
per hospital policy. Although data collection for this

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98Journal of Holistic Nursing / Vol. 30, No. 2, June 2012

Table 1 Frequency of Nausea Levels by Group and Time of Assessment

Group & Time

No

Slightly

of Assessment

Nausea

Nauseated
Nauseated
Nauseated
Peppermint Aromatherapy (n=22)

Moderately

Extremely

About to
Vomit

Vomited

Baseline

12

2-Minutes

5-Minutes

12

Post Initial
Intervention:

Placebo Aromatherapy (n=8)

Baseline

2-Minutes

5-Minutes

Post Initial
Intervention:

Standard Antiemetics (n=5)

Baseline

2-Minutes

5-Minutes

Post Initial
Intervention:

study was extended from originally established

12 months to 18 months as researchers worked to
increase the sample size, the recruitment goal of
84 participants who became nauseated was not met.
Time commitment from the involved departments
was not available beyond this extended 18-month
time frame. As a result of all these challenges, the
resulting sample sizes in each group are smaller than
planned (less than 28 participants in each group).
The mean age for the participants was 31.3 years
and ranged from 22 to 43 years (n = 34). Of the
25 participants who reported their race and marital
status, 60% were Black, 12% were Hispanic, and
28% were Caucasian, and the majority of these participants were married (72%). The usual method of
anesthesia used for the C-section was spinal (93%, n
= 27). Forty-eight percent (n = 12) reported they
were often or always nauseated during their pregnancy. Most of the participants were between 38 to
39 weeks gestation (74%, n = 20). Slightly more than
half delivered male babies (54%, n = 13). Fourteen
male babies (82% of the 17 reported) were also

delivered by participants who never became nauseated and were therefore excluded. The majority of
participants reported that they had used some form
of alternative therapy for nausea (68%, n = 17).

Within-Groups Comparisons of Nausea

Levels (Research Questions 1 to 3)
Peppermint spirits aromatherapy group (experimental). As shown in Table 1, at baseline participants in
the peppermint spirits aromatherapy group experienced nausea levels ranging from slight to about to
vomit. Almost all these participants, 19, felt that
they were either extremely nauseated or about to
vomit at this time point. At 2 minutes after the initial intervention more than half of these participants, 14, experienced none-slight levels of nausea.
Another 6 were experiencing moderate levels of
nausea at this time point, yielding 20 of 22 participants experiencing none to moderate nausea at this
time point. At 5 minutes after the initial intervention
more than half of these participants, 12, experienced

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Peppermint Aromatherapy / Lane et al.99

Table 2 Hypothesis Testing: Cell Frequencies and Fisher Exact Probability Test Results
Hypothesis Test
Number

1a
2a
4a
3a
5a
Hypothesis
Test Number

1b
2b
4b

3b
5b

Time

Group
PSA

Baseline
Post-Treatment:
2-Minutes
5-Minutes
Difference from Baseline
at: Decreased
2-Minutes
5-Minutes

None-Low
1

High
19

14
17

2
3

12
15

2
3

Time

Nausea Level
None-Low
0

PA

p-value

High
5

1.000

0
0
Remained High
0
0

7
7

.000
.000

5
5

.002
.002

Group
PSA

Baseline
Post-Treatment:
2-Minutes
5-Minutes
Difference from Baseline
at: Decreased
2-Minutes
5-Minutes

None-Low
1

High
19

14
17

2
3

12
15

2
3

Nausea Level
None-Low
0

SAT

p-value

High
5

1.000

0
0
Remained High
0
0

5
4

.001
.003

5
4

.002
.005

Note: PSA=peppermint spirits aromatherapy, PA=placebo aromatherapy, SAT=standard antiemetic therapy

no nausea, and another 5 experienced slight nausea.

This yields 17 of 22 participants experiencing noneslight levels of nausea 5 minutes after the intervention. Therefore, the answer to the first research
question, will participants in the peppermint spirits
aromatherapy group report a decrease in nausea, is
yes.
Placebo aromatherapy group (control). At baseline 4 of
the 8 participants in the placebo aromatherapy group
felt that they were either extremely nauseated or
about to vomit, and 3 reported feeling moderately
nauseated (see Table 1). At 2 minutes after the initial
intervention, 6 of these participants felt that they
were either extremely nauseated or about to vomit
and 1 woman vomited. At 5 minutes after the initial
intervention, 7 of these 8 participants continued to
experience either extreme nausea or thought that
they were about to vomit. None of the participants in
the peppermint aromatherapy group had their nausea
reduced to none or slight levels at either 2 or 5 minutes after the initial intervention. The nausea levels
of 6 of these participants remained the same at all
three time points. Thus, the answer to the second
research question, will participants in the placebo

aromatherapy group report a decrease in nausea, is

no.
Standard antiemetic therapy group (control). At baseline
all 5 participants in the control group felt that they
were either extremely nauseated or about to vomit
(see Table 1). Their nausea was unchanged at 2 minutes. At 5 minutes, the nausea level of 1 of these 5
participants had decreased from about to vomit to
moderately nauseated. Similar to participants in
the placebo aromatherapy control group, none of
these participants had their nausea reduced to none
or slight levels at either 2 or 5 minutes after the initial intervention, and 4 of the 5 participants in this
group experienced no change in their nausea levels
from one assessment time to another. Therefore, the
answer to the third research question, will participants in the standard antiemetic therapy control
group report a decrease in nausea, is no.

Between-Groups Comparisons
of Nausea Levels (Hypotheses 1 to 5)
Nausea levels at baseline. Participants in all three
intervention groups had similar levels of nausea at

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100Journal of Holistic Nursing / Vol. 30, No. 2, June 2012

baseline. Almost all the participants, 29 of 35, felt

that they were either extremely nauseated or about
to vomit. In other words, no significant differences
between the participants in the peppermint spirits
aromatherapy group and those in the other two
groups were found at this time (see Table 2, 1a
and 1b). Thus, the hypotheses that there were no
differences in the nausea levels of the peppermint
spirits and the placebo aromatherapy (1a) and standard antiemetic therapy (1b) groups were supported.
Nausea levels at 2 minutes after the intervention. There
were significant differences in nausea levels 2 minutes
after the initial intervention (see Table 2, 2a and 2b).
The two hypotheses, participants who receive peppermint spirits aromatherapy will experience less nausea
at 2 minutes after the initial intervention than do
participants who receive either placebo aromatherapy
(2a) or standard antiemetic therapy (2b), were supported.
Nausea levels at 5 minutes after the intervention. There
were significant differences in nausea levels 5 minutes after the initial intervention (see Table 2, 3a
and 3b). Thus, the two hypotheses, participants
who receive peppermint spirits aromatherapy will
experience less nausea at 5 minutes after the initial
intervention than do participants who receive either
placebo aromatherapy (3a) or standard antiemetic
therapy (3b), were supported.
Decrease in nausea levels at 2 minutes after the intervention. There were significant differences in the
decrease in nausea levels from baseline to 2 minutes (see Table 2, 4a and 4b). Thus, the two hypotheses, participants who receive peppermint spirits
aromatherapy will experience a greater decrease in
nausea at 2 minutes after the initial intervention
compared with baseline than to participants who
receive either placebo aromatherapy (4a) or standard antiemetic therapy (4b), were supported.
Decrease in nausea levels at 5 minutes after the intervention. There were significant differences in the
decrease in nausea levels from baseline to 5 minutes
in participants who received peppermint spirits aromatherapy compared with those who received placebo aromatherapy but not when compared with
those who received standard antiemetic therapy (see
Table 2, 5a and 5b). Thus, only one of the two
hypotheses, participants who receive peppermint

spirits aromatherapy will experience a greater

decrease in nausea at 5 minutes after the initial
intervention compared with baseline than do participants who receive either placebo aromatherapy
(5a) or standard antiemetic therapy (5b), were supported only for the placebo aromatherapy group.
Overall results. Participants in all three intervention
groups had similar levels of nausea at baseline (see
Table 1). When their levels of nausea were measured again, 2 and 5 minutes after the initial intervention, their levels of nausea were significantly
different. The nausea levels of participants in both
the placebo aromatherapy and standard antiemetic
therapy control groups did not decrease much (see
Table 2). For example, 0 of 8 participants in the placebo aromatherapy group and 0 of 5 participants in
the control group experienced either no or slight
levels of nausea at 2 and 5 minutes after the initial
intervention, respectively. This is very different from
the 14 and 17 participants in the peppermint spirits
aromatherapy group (n = 22) who experienced either
no or slight levels of nausea at 2 minutes and 5 minutes after the initial intervention, respectively. Since
staff nurses gave the same instructions regarding
breathing using the assigned aromatherapy to participants in both the peppermint spirits aromatherapy and placebo aromatherapy groups and the standard antiemetic therapy group used no breathing
technique, the data do not support the breathing
technique used to inhale the aromatherapy as an
effective method to reduce nausea. In addition to
supporting the within group comparisons, the data
supported the research hypotheses9 of the 10
hypothesis tests were significant. Thus, the peppermint spirits aromatherapy was effective in reducing
postoperative nausea, whether comparing participants in this group to themselves or to participants
in either of the two control groups.

Discussion
The findings of this study supported the effectiveness of peppermint spirits aromatherapy in participants who became nauseated post C-section whether
comparing participants in this group to themselves
or to either of the two control groups. Our findings
support those of Tate of (1997), who found peppermint oil aromatherapy effective and peppermint
essence ineffective in 18 postoperative gynecological

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Peppermint Aromatherapy / Lane et al.101

surgery patients, and Burns et al. (2000), who found

peppermint oil aromatherapy effective in reducing
nausea during childbirth. These findings are different from those of Anderson and Gross (2004), who
found reduced nausea scores but no differences
between peppermint oil, isopropyl alcohol, and
saline aromatherapy groups of ambulatory surgery
patients. The findings of our study, like those of
Langevin and Brown (1997), did not support the use
of placebo aromatherapy.
In this study, participants in both the peppermint
spirits aromatherapy and the placebo aromatherapy
groups received the same staff nurse-provided
instructions and supervision regarding breathing to
inhale the assigned aromatherapy, and yet the results
were different between these two groups. Although
using aromas that have been shown, through their
historical use and/or study, to reduce nausea, can
take advantage of the placebo effect, using the positive expectations of both the participants and nurses
to potentiate the effects of the aromatherapy, this did
not occur in our study. It should be noted that the
placebo effect may not have occurred in the placebo
aromatherapy group if participants in this group,
knowing that there was a placebo group in this study,
may have deduced that they were members of that
group because they could not smell a peppermint
aroma when they inhaled the treatment. This knowledge may have prevented the placebo aromatherapy
from eliciting the placebo effect in these participants. The placebo effect, a manifestation of the
close relationship between the mind and body, occurs
when the expectation of an effect by itself causes the
effect to occur (Freeman, 2009b; Guzzetta, 2005;
Rodgers & Micozzi, 2011).
There were several differences between our
study and the previous three studies. Although participants in two of these three studies were postoperative patients, the types of surgery varied: ambulatory surgery patients in the study by Anderson and
Gross (2004), gynecological surgery patients in the
study by Tate (1997), and C-section patients in our
study. Participants in the Burns et al. (2000) study,
women in labor, and included women who had
C-section and vaginal as well as spontaneous and
induced deliveries. Different treatments were given
to patients on different units in the study by Tate. In
the study by Anderson and Gross, participants were
randomly assigned to treatment groups after they
spontaneously reported nausea, and in our study,
participants were randomly assigned to intervention

groups when the hospital AD personnel admitted

them to the hospital and the study, before their surgery and experience of postoperative nausea. The
study by Burns et al. was an observational one that
used routinely collected and audited data.
Tate (1997), Burns et al. (2000), and Anderson
and Gross (2004) studied peppermint oil aromatherapy. Tate also used peppermint essence (undefined composition) as a placebo control, whereas we
used peppermint spirits, which contains both peppermint oil and ethyl alcohol. The peppermint spirits used in our study may have had a synergistic and
more soothing treatment effect than the peppermint
treatments used in the other two studies. The participants in the standard antiemetic therapy group in
our study did not receive any instructions regarding
their breathing, whereas all groups in the study by
Anderson and Gross received aromatherapy using
the prescribed breathing technique.
Although these studies focused on patientreported nausea on a nausea rating scale, different
rating scales were used. A 100-mm visual analogue
scale was used in the study by Anderson and Gross
(2004), and nausea was measured at baseline and 2
and 5 minutes posttreatment. A 5-point descriptive
ordinal rating scale was used to measure nausea
every 4 hours, and the average per-person nausea
scores per day were analyzed in the study by Tate
(1997). A 3-point descriptive ordinal rating scale
was used to measure the overall effectiveness of
peppermint oil aromatherapy on nausea in the study
by Burns et al. (2000).
The total sample size, 33, in the Anderson and
Gross (2004) study was similar to the final sample
size in our study, 35; these two sample sizes were
almost double the sample size of 18 in Tates (1997)
study. The sample size in our study was also more
than that of two studies described by Buckle
(2009)more than triple that of the study by
Figuenick (n = 10) and double that of the study by
Piotrowski (n = 17). Although Tate did not report
the samples sizes for each treatment group, the
group sample sizes reported by Anderson and Gross
were approximately equal, unlike those of our study.
It seems likely that the number of participants who
received the placebo aromatherapy or standard antiemetic therapy in our study was similar to those who
received the placebo aromatherapy or no treatment
in the study by Tate. In contrast, the number of participants who received peppermint spirits aromatherapy in our study was more than the entire sample

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102Journal of Holistic Nursing / Vol. 30, No. 2, June 2012

size in the study by Tate and twice that of the peppermint oil aromatherapy group in the study by
Anderson and Gross. One or more of these differences may explain the differences in the results of
these three studies.

Lessons Learned
Our study was affected by some of the typical
challenges experienced by nurse researchers when
attempting to study alternative therapies using the
traditional medical model. The major methodological limitations were the small and unequal sample
sizes that resulted from problems with selection and
attrition of participants. This was also a problem in
the two experimental studies of peppermint oil aromatherapy to treat postoperative nausea discussed
in the literature review (Anderson & Gross, 2004;
Tate, 1997).
Many of the challenges encountered in our study
occurred because this was an unfunded research
study conducted in the real world of hospital and
clinical nursing practice instead of a laboratory setting. As a result, much less control could be exerted
over the study, and unanticipated events hindered
the implementation of the study as designed. There
were no dedicated study personnel to implement the
protocol, administer the interventions, and collect
the data, or even to monitor the study to ensure
appropriate tracking and enable the early identification of problems; instead, multiple people in multiple departments implemented assigned parts of the
study, including regular unit staff nurses who added
study interventions and data collection to their
already heavy workloads. If we were to replicate our
study, rather than forcing it into the medical model
with control groups and placebos, we would use
peppermint spirits aromatherapy as a complementary therapy rather than an alternative therapy to the
traditional therapies that are currently being used in
our hospital. This may increase the buy in of nursing
staff and patients involved in the study.

Conclusion
The study results provide additional support for the
use of peppermint spirits aromatherapy as a useful
adjunct intervention for postoperative nausea following a C-section. Our study was unique because it
used a combination product of both peppermint and
ethyl alcohol, instead of the previous studies that
examined peppermint oil and/or isopropyl alcohol as

separate aromatherapy agents. Limitations of the study

were related to the small sample size and methodological issues. Our study should be replicated with
larger sample sizes at other facilities with male and
female patients undergoing a variety of surgical procedures. Using the aromatherapy with different
aromas, such as ginger, spearmint, and/or isopropyl
alcohol, and as a complementary therapy in conjunction with standard therapies may help improve
implementation of the protocol. The findings of the
study are useful for nursing because peppermint
spirits aromatherapy improved nausea symptoms
without causing sedation, which can interfere with
breast-feeding and bonding time with the baby. The
lessons learned from the study involve the importance of staff buy in and involvement with a project.
Many staff members did not want to administer a
placebo. Patients also in general wanted to be in the
intervention group that received peppermint aromatherapy. Involving fewer people and departments in
the project and minimizing the number of data collection forms may have been useful in preventing
lost information. The findings of our study add to
the body of evidence from previous studies on the
effectiveness of peppermint aromatherapy in reducing postoperative nausea and could be used as part
of a proposal to request funding for a larger study.

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alcohol and intravenous ondansetron for treatment of postoperative nausea. AANA Journal, 71, 127-132.

Bios
Betty Lane, RN, MSN, PhD, associate professor/clinical
nurse researcher at Clayton State University, Morrow, Georgia.
Kathi Cannella, RN, MSN, PhD, associate professor at Clayton State University, Morrow, Georgia.

Cathy Bowen, RN, AD, staff nurse at Southern Regional

Medical Center.
David Coplan, Pharm.D., MPA, FASHP, pharmacy clinical
manager at Southern Regional Medical Center, Riverdale
Georgia.
Grace Nteff, RN, MSN, NP, assistant professor of nursing at
Clayton State University, Morrow, Georgia.
Katrina Barnes, RN, MSN, assistant professor of nursing at
Clayton State University, Morrow, Georgia.
Melanie Poudevigne, PhD, associate professor and director of
Health and Fitness Management at Clayton State University.
Jacqueline Lawson, RN, MBA, director of Women's Center,
Southern Regional Medical Center, Riverdale Georgia.

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