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Nurse Led Guided Imagery Education and Improving the Adult Client Experience: A Pre and Post Test StudyKatrina JamesPennsylvania State UniversityAbstractThe purpose of this project was to implement an education program concerning the use of nurse led guided imagery on hospitalized adult clients. The target group was the night shift nurses of 4 Main at Wellspan York Hospital. The efficacy of the education was measured using a pre and post-test survey. An informational handout was given in addition to a verbal teaching session on the benefits, ease of implementation, and overall knowledge concerning the intervention. A literature review of 13 studies was done to provide current data on the subject. The review focused on the use of guided imagery as a cost effective intervention for anxiety, stress, and pain perception in the adult client with various disease processes. Several databases were searched to include ProQuest Nursing and Allied Health Journals, PubMed (Medline), and CINAHL (Cumulative Index for Nursing and Allied Health). There is currently a lack of scientific evidence to completely prove or disprove the efficacy of guided imagery. There is however, significant statistical data to support that it is effective in reducing anxiety, stress, and pain in adult clients. Further systematic research to include a larger study population is needed to persuade more to adopt guided imagery into practice.Keywords: guided imagery, distraction, anxiety, pain, non-pharmacological, stress, adultIntroductionNursing as a whole is both part art and part science in nature. In order to provide the best quality of holistic care, the nurse must address both physical and psychological needs of the client (Selimen & Andsoy, 2011). Guided imagery is a technique that can link the psychological mind to the physical body and alter its response to stressors when performed correctly. Guided imagery is defined as a form of deliberate, directed daydreaming, usually consisting of words and phrases which invoke a detailed depiction of peaceful or serene scenery, a place of fond memories, or a fantasy location. When effective these images can have several sensory qualities such as visual, auditory, olfactory, and tactile (Bonadies, 2009). The purpose of imagery is to elicit a relaxed state and allow for an increased sense of control over the stressing symptoms the client may be experiencing (Geidt, 2015). The use of guided imagery and distraction techniques can decrease anxiety, pain perception, and stress in the adult client. This therapeutic mind-body technique can also improve overall feelings of well-being before, during, and/or after invasive or stress inducing procedures such as wound care, cancer treatment, venipuncture, surgery, and dressing changes. There is evidence to support that it can also have an effect on those dealing with chronic conditions to include fibromyalgia, osteoarthritis, asthma, and musculoskeletal pain. Guided imagery is a cost effective, non-pharmacological intervention that can be utilized by nurses in and out of the hospital setting. This project discusses the following question; for nurses caring for both acute and chronic Medical-Surgical adult clients in the hospital setting, will an education program targeting nurse led guided imagery result in an improved understanding and potential implementation in practice?BackgroundAnxiety and stress are two commonalities that present when an individual is ill or experiencing pain. This especially holds true for those individuals who are experiencing an acute illness or health related event such as being scheduled for an unexpected surgery or losing a limb in an accident. Also affected, are those being treated for chronic illnesses such as receiving chemotherapy treatment for cancer, or being hospitalized for an asthma exacerbation or worsening of fibromyalgia or osteoarthritis symptoms. In addition to the stress related to the disease process itself, the client is usually in an unfamiliar setting and is experiencing feelings of hopelessness, worry, powerlessness, and role conflict (Lewandowski & Jacobson, 2013). It is the body’s natural response to such stressors to activate the sympathetic nervous system via the release of adrenal-medullary hormones such as adrenaline and noradrenaline, which can in turn cause vasoconstriction increasing the respiratory rate, heart rate, blood pressure and body temperature (Lin, Hsieh, Hsu, Fetzer, & Hsu, 2011). The anxiety response can decrease immunity and delay wound healing and can alter the client’s thoughts and behaviors (Selimen & Andsoy, 2011). Guided imagery as a complementary and alternative medicine (CAM) therapy can improve the patient’s emotional state and in turn lessen the effects of the stress response when used consistently. Due to the benefits that have been associated with guided imagery, a review of literature will be completed to answer the following question; can nurse led guided imagery and distraction techniques during invasive procedures lessen the perception of pain, anxiety, and discomfort of the adult patient?Review of LiteratureMethodThe following databases were accessed through the Penn State Library Nursing Research Center; PubMed (Medline), CINAHL (Cumulative Index for Nursing and Allied Health), the Cochrane Library, and ProQuest Nursing and Allied Health Journals. The publication dates of these studies ranged from the years 1997 to 2015. The article published in 1997 was chosen to be included in this study due to its relevance and background information on the topic. The other 12 articles were published within the past 10 years. All articles were available in English but some studies were performed outside of the United States to include Turkey, Greece, Spain, United Kingdom, and China. Articles chosen for this review were found using various combinations of the following search terms; guided imagery, distraction, adults, nursing, non-pharmacological, CAM therapies, pain, anxiety, depression, stress, and intervention. A total of 25 studies was originally found and then narrowed down to 13 using specific inclusion and exclusion criteria.Inclusion CriteriaThe inclusion criteria consisted of adults, both male and female aged 18 and older. To be included in the review the study participants had to have been experiencing anxiety, stress, or pain (both chronic and acute) in relation to either a disease process such as cancer, osteoarthritis, fibromyalgia, or asthma. Burn patients, cardiac surgery patients, and arthroplasty patients were also included in the collection of research. Combination of guided imagery and other CAM therapies were included due to the close relationship of the type of intervention. Exclusion Criteria All studies that included children or infants were excluded. Also, outpatient or strictly home based interventions without close monitoring were excluded from this pool of data. Studies not provided in an English translation were also excluded.Guided Imagery Methodology and Holistic Care of ClientsGuided imagery as a nursing intervention uses the principle of psychoneuroimmunology (PNI) in order to relieve the client of the stressing symptoms they are experiencing (Giedt, 1997). The theory behind this technique is based upon the connection between mind and body and how a person’s perceptions influence their interactions between both the external and internal environments. As stated by Bonadies (2009), care planning and practice by both the nurse and client are integral in the efficacy of the guided imagery intervention. Guided imagery involves more than just the visual sense and nearly anyone can use it as an intervention as adjunct to various types of pain and anxiety responses. The psychological changes that one experiences in the stress response such as fear of an upcoming procedure need to be treated according to that client’s specific personality, which encompasses the need for holistic care (Selimen & Andsoy, 2011). In the peri-operative setting, nurses are entrusted with creating a therapeutically calm environment in order to assist in decreasing the client’s fear, tension, and overall stressors. Studies have shown that by providing an additional intervention as simple as recalling a happy event from the past can assist in decreasing the stress response and physical symptoms that come along with it (Selimen & Andsoy, 2009). Guided Imagery and Acute Illness or Stressors In the systematic review done by Posadzki and Ernst (2011), clinical trials were reviewed involving both musculoskeletal pain and guided imagery intervention. They included a total of 9 studies involving 201 patients from various countries. The population ranged in the middle age category and included fibromyalgia syndrome (FMS), elderly osteoarthritis (OA), postoperative patients, and those suffering from chronic pain. The control groups received standard care, sham guided imagery, placebo and standard care, or no intervention. The total number of patients that benefitted from the guided imagery technique was 115 (Posadzki & Ernst, 2011). In the instance of burn clients, the stress response can be detrimental in that it places them in a hypermetabolic response state, further increasing their need for nutritional support. Enteral or parenteral feedings are usually required due to the difficulty most post burn clients have consuming the needed 20-100% increase in caloric consumption (Hoffman & Klein, 2010). In order to see what the effect guided imagery would have on the hypermetabolic state of these clients a pilot study was performed to include 10 subjects. Six subjects were in the control group and received usual care and 4 subjects were in the treatment group and to receive the guided imagery intervention. To gather the baseline data the subjects were monitored using a computerized system which measured heart rate, blood pressure, and respirations. The resting energy expenditure was also measured as a method to record the caloric expenditure. Patients in the intervention group received intervention daily and were asked to imagine a place where they felt safe and comfortable (Hoffman & Klein, 2010). Subjects were encouraged to use the intervention throughout the day, especially during times of dressing changes and any type of active therapy sessions. In the study done by Thomas and Sethares (2010), they included 121 patients scheduled for elective total joint arthroplasty. A 2-group quasi-experimental design was used. The interventional group of 69 clients listened to a guided imagery CD that promoted harmony and peacefulness, while the control group of 52 clients received usual care. The theoretical framework used in this study was the gate control theory developed by Melzack and Wall in 1965. The focused concentration related to the use of guided imagery may possibly interrupt the negative sensory stimulus, causing the perception of pain and therefor help to alleviate the client’s symptoms and provide relief.In regards to the efficacy of guided imagery on clients undergoing cardiac surgery, a study was done by Casida and Lemanski (2010), which analyzed how pre and post-operative pain could be reduced by using this as an intervention. There was a total of 7 articles included in their study and both the control groups received usual care and the intervention group received guided imagery. The topics of interest were length of stay, anxiety/tension, and pain reduction. Numeric, open-ended, and visual scales were used to measure anxiety and pain while length of stay was gathered from hospital data. Guided Imagery and Chronic ConditionsFibromyalgia pain is a chronic condition that can in turn affect the quality of life of those suffering from it. A study was done to evaluate the effects that guided imagery can have on pain perception of clients diagnosed with the condition. The use of Marth Rogers’ science of unitary beings was used in this study in order to correlate the holism involved in the health dynamic connecting both mind and body (Onieva-Zafra, Garcia, & del Valle, 2015). One of the many benefits of guided imagery is that it is a self-management technique and once taught the client can continue to utilize it to improve their symptoms. This study consisted of 55 participants aged 18-70 years old. A 2 group experimental design was used. There were 28 clients in the intervention group who listened to 15-minutes of a relaxation CD daily and the remaining 27 received usual care as the control group. There were significant changes in the depression ratings reported by participating subjects indicating that the guided imagery was effective. A study done by Lahmann et. al (2009) indicated that a strong relationship existed between the use of functional relaxation and guided imagery and a reduction of seriousness of asthma related illness. In this study a total of 64 participants, 16 of which received functional relaxation as an intervention, 14 who received solely guided imagery, 15 who received both interventions, and a control group who received a placebo relaxation technique. The findings from this study indicated that the process of functional relaxation was more effective than the guided imagery intervention in having a positive effect on respiratory parameters. Another study by Charalambous, Giannakopoulou, Bozas, and Paikousis (2015), studied the effects of progressive muscle relaxation and guided imagery have on cancer patients suffering from prostate or breast cancers. There was a primary emphasis on the anxiety and depression suffered by those who are receiving treatment for these disease processes. The study itself was well done in that it was randomized, the accessors were blinded, and a scientific methodology was followed. The Zung Self rating anxiety (SAS) was used to measure anxiety while the Beck depression interview (BDI) was used to measure depression. Measurements were acquired both at baseline and throughout the length of the study. The results of this study provided strong evidence of the correlation between the decreased anxiety and depression in the intervention group. This is yet another positive outcome of the use of guided imagery as an effective intervention. In a systematic review in relation to orthopedic pain and the use of non-pharmacological interventions, Büyüky?lmaz (2015) found that there was a decrease in perception of pain while using a combination of both pharmacological pain medicines and CAM therapies. It was agreed there was no reason to not implement the intervention in more settings to help reduce the need for increased analgesics and to improve the clients’ quality of life. Discussion The findings from the Casida and Lemanski (2010) study were significant in that not only did 3 of the studies show a decreased length of stay, but fatigue was reduced, sleep was improved, pain required less analgesic, and anxiety was reduced. One of the many benefits of guided imagery is that it is a self-management technique and once taught the client can continue to utilize it to improve their symptoms. Each person is unique in that the imagery modality may work for a 39 year old woman with cancer related pain but not for another with the same age and disease process. We must keep this in mind in that the study of CAM therapies such as guided imagery will never be a clear cut study. Statistical analysis of variability can decrease this level of human error. Overall, the practice of nurse guided imagery has a hopeful future in the care facilities of tomorrow. Implications for PracticeAlthough there is not a significantly large group of data that has been collected to strongly support the claims that guided imagery is in fact effective, in decreasing clients’ perceptions of pain, anxiety, and stress the research is promising that there will soon be an implementation of this intervention in the near future. With no evidence of client harm the research will continue. As the trends continue in that clients are more interested in holistic and non-pharmacological interventions I see a push for the implementation of guided imagery protocols in the research led institutions within the next decade. In order to better the practice of today, simple implementation should be applied in the inpatient setting with all mentally capable patients. The first step in this implementation is to create a basic script that contained several different approaches. An educational meeting would be scheduled where all staff go over basics and practice the script with one another. After the rehearsal and education process, the nurse would choose the script containing the topic that best fits the patient. The next step would be to lead the patient in creating the mental image or topic of their choosing. If the evidence based practice committee would want to do a pilot study to measure effectiveness and acceptance by both patients and staff, a study would be planned and implemented. If the pilot study were a success then a protocol would be suggested and created. Limitations There was a lack of large group randomized controlled trial studies that specifically look at guided imagery and distraction techniques for adult clients in both acute and chronic health situations. A majority of the adult focused research on the topic is now outdated and needs to be recreated using more reliable scientific methods. There is a significant amount of research on distraction and guided imagery focusing on children, but there is a research gap when applying it to an adult population. Also there are few concrete studies done on the implementation of nursing based interventions in these settings using a blinded and randomized methodology. There is much to be done to further support the use of guided imagery into evidence based practice.ConclusionThe use of guided imagery and distraction techniques in both the acute and chronic treatment of stress, anxiety, and pain is a cost effective adjunctive therapy with promising results. Although there is a need for further research most studies have found statistically significant differences in the intervention versus control groups in that there was a decrease in one of the aforementioned symptoms. With the support that there is no negative impact to implementing distraction techniques or guided imagery interventions with clients of any of the mentioned conditions, there is no harm in completing more studies to better support this alternative therapy. Project Plan: Part 1 The guided imagery educational project plan was completed and was initiated from October 2015 to November 2015. The focus of this project was to educate nurses on the basics of guided imagery, with a focus on patient benefits, and ease of implementation. The unit involved was the 4 Main medical-surgical telemetry unit at Wellspan York Hospital. Deneen Harbold, RN was the project coordinator. Sheila Perry, RN also assisted in the educational process of this project. Current research from well-known databases such as PubMed, and ProQuest Nursing and Allied Health Journals, present guided imagery as an effective non-pharmacological intervention to decrease anxiety, stress, and patient pain perception. Due to its ease of nurse led implementation as well as it being cost effective, there was an opportunity to test the current staff’s knowledge on the topic, acceptance of the intervention, and confidence level of implementation. Purpose of ProjectThere is substantial evidence describing the use of guided imagery to improve patients’ overall hospital experience, to include prolonged health benefits through use of this learned technique in the outpatient setting. From the aforementioned research and areas of interest, the following PICO question was formed to guide this project; for nurses caring for both acute and chronic Medical-Surgical adult clients in the hospital setting, will an education program targeting nurse led guided imagery result in an improved understanding and potential implementation in practice? The purpose of this initiative was to provide an overview of guided imagery to the nursing staff on 4 Main to increase awareness of the technique and to encourage use and possible implementation of a guided imagery protocol. The scope of this initiative is vast in that it could transfer to a variety of hospital and outpatient settings to include numerous acute or chronic conditions. Any area of practice in which there are clients who are able to comprehend verbal direction, execute simple commands, and are in a sound state of mind. Logistics and MethodologyThe key leader of the project, Katrina James, SN was assisted by both Deneen Harbold, RN and Sheila Perry, RN two night shift nurses on 4 Main, Wellspan York Hospital. The research, educational material, and pre and post-test surveys was completed by Katrina James, SN. All surveys collected were anonymous. Ten night shift nurses were given a pre-test survey to assess their baseline knowledge on the topic of guided imagery. The staff was then given verbal instruction about the use and research regarding the topic as well as given an informative handout. The final post-test survey was given to assess the efficacy of the teaching and to gauge the acceptance and confidence level of the nurses on guided imagery as a nursing intervention. The survey and handout material was dispersed by all three team members while the teaching was completed by Katrina James, SN only.Results The pre and post-test surveys can be found in Appendix A and B. The informational handout can be located in Appendix C. The pre-test survey results showed significant variation. Guided imagery was only defined correctly by 3 out of 10 of the survey participants, leaving the other 4 to provide only a partially correct answer and 3 to either state knowledge deficit or an unrelated topic. Answers on implementation in the pre-test survey were also rather dispersed. Only 3 participants were able to correctly identify how a nurse might implement the intervention whereas 4 had a partially correct response, leaving the remaining 3 to have no knowledge on the subject. The majority of nurses responded to confidence in using guided imagery as a therapeutic intervention with a “not at all confident” or “slightly confident” during the pre-test. All of this data supports the need for education on guided imagery as a simple intervention technique, that when practiced can help clients with a plethora of symptomology to better their own experience. The post-test survey results differed greatly from the pre-test. The occurrence of incorrect answers to knowledge based questions was less than 20 percent. The confidence level in applying the intervention also increased from “not at all”, or “slightly” to the majority either “moderately” or “very” confident. This finding indicates that the education was able to provide simple examples that nurses felt they could implement without issue. Overall efficacy scores improved as well with an average of 4 out of 5 score. The increased scores could indicate that there was enough supporting evidence in the research that was presented, to show more benefit than risk to clients. Project Plan: Part 2The changes that took place as a result of the education initiative, were in the minds of and attitudes of the nursing staff. Their overall knowledge on the topic increased and they were also more encouraged to try guided imagery as a nursing intervention. The process measure were pre and post-test surveys which were comprised of multiple choice, open ended, and Likert Scale questions. The frequency of measures were weekly. The data collection process lasted three weeks after October 30 and was ongoing. The overall outcome measures were centered on staff surveys. The pilot area barriers included staff non-compliance, feelings of increased workload and inability to find time for survey, and lack of interest. The facilitators included Deneen Harbold, RN (preceptor), Sheila Perry, RN (staff nurse) and Katrina James, SN (project leader). ImplementationThe communication for this project consisted of peer coach meetings. The education was targeted for the 4 Main night shift nurses at Wellspan York Hospital from October 2015-November 2015. Teaching was reinforced through peer coaching and handouts. Peer feedback was collected and overall acceptance levels were high.Modifications/ LimitationsIn order to provide more sound results a larger sample would have been preferred. Also, if this project were to not have any limitations, it would have been preferred that it was done on a variety of different floors with various client bases. A larger poster board that could have been hung in several nursing lounges would have provided more education than a simple handout alone. If management or educational committees were to get involved and express interest then a possible pilot study to include an actual implementation of guided imagery on the floor plus an added client survey on their perception of the intervention would have provided excellent data. Overall for a starter project the results were few but gave a good insight into the knowledge and acceptance of nurses at this health care facility. DiscussionThe PICO question, “for nurses caring for both acute and chronic Medical-Surgical adult clients in the hospital setting, will an education program targeting nurse led guided imagery result in an improved understanding and potential implementation in practice?” was answered to a degree. The educational material that was presented did improve post-test survey scores while also showing an increase in the confidence levels of nurses in the efficacy of guided imagery as an intervention for anxiety, pain, and stress. This is hopeful and sheds light on the possibility of a future protocol and wide based acceptance of this simple technique to improve the inpatient experience. Overall, the project was a success. ReferencesBonadies, V. (2009). Guided imagery as a therapeutic recreation modality to reduce pain and anxiety. Therapeutic Recreation Journal, 43(2), 43-55. Büyüky?lmaz, F. (2014). Non- pharmacological intervention in orthopedic pain: A systematic review. International Journal of Caring Sciences, 7(3), 718-726.Casida, J., & Lemanski, S. A. (2010). An evidence-based review on guided imagery utilization in adult cardiac surgery. Clinical Scholars Review, 3(1), 22-30. doi:10.1891/1939-2095.3.1.22Charalambous, A., Giannakopoulou, M., Bozas, E., & Paikousis, L. (2015). A randomized controlled trial for the effectiveness of progressive muscle relaxation and guided imagery as anxiety reducing interventions in breast and prostate cancer clients undergoing chemotherapy. Evidence-Based Complementary and Alternative Medicine, 1-10. , J. F. (1997). Guided imagery: A psychoneuroimmunological intervention in holistic nursing practice. Journal of Holistic Nursing, 15(2), 112-127. doi:10.1177/089801019701500204Hoffman, C. A., & Klein, J. M. A. (2010). Relaxation and visual imagery techniques: Do they work? Can they really help burn clients? MedSurg Nursing, 19(3), 169-174. Lahmann, C., Nickel, M., Schuster, T., Sauer, N., Ronel, J., Noll-Hussong, M., Loew, T. (2009). Functional relaxation and guided imagery as complementary therapy in asthma: A randomized controlled clinical trial. Psychotherapy and Psychosomatics, 78(4), 233. doi:10.1159/000214445Lewandowski, W., & Jacobson, A. (2013). Bridging the gap between mind and body: A biobehavioral model of the effects of guided imagery on pain, pain disability, and depression. Pain Management Nursing: Official Journal of the American Society of Pain Management Nurses, 14(4), 368. doi:10.1016/j.pmn.2011.08.001 Lin, M., Hsieh, Y., Hsu, Y., Fetzer, S., & Hsu, M. (2011). A randomised controlled trial of the effect of music therapy and verbal relaxation on chemotherapy‐induced anxiety. Journal of Clinical Nursing, 20(7‐8), 988-999. doi:10.1111/j.1365-2702.2010.03525.x Onieva-Zafra, M. D., García, L. H., & del Valle, M. G. (2015). Effectiveness of guided imagery relaxation on levels of pain and depression in clients diagnosed with fibromyalgia. Holistic Nursing Practice, 29(1), 13-21. doi:10.1097/HNP.0000000000000062Posadzki, P., & Ernst, E. (2011). Guided imagery for musculoskeletal pain: A systematic review. The Clinical Journal of Pain, 27(7), 648-653. doi:10.1097/AJP.0b013e31821124a5Selimen, D., & Andsoy, I. I. (2011). The importance of a holistic approach during the perioperative period. AORN Journal, 93(4), 482-490. doi:10.1016/j.aorn.2010.09.029.Thomas, K. M., & Sethares, K. A. (2010). Is guided imagery effective in reducing pain and anxiety in the postoperative total joint arthroplasty client? Orthopaedic Nursing, 29(6), 393-399. Appendix A: Capstone Pre-test SurveyClinical Capstone Project: Pre-test SurveyKatrina James, SNThe Pennsylvania State UniversityFall 2015What is guided imagery? Guided imagery is a type of ____ (circle one)ExaminationDeep sleep MeditationYogaWhat are some patient benefits of nurse led guided imagery?How might a nurse implement the use of guided imagery?As a nurse, how confident do you feel using guided imagery to decrease anxiety and discomfort in your patients during invasive procedures or stress inducing care tasks? Using a scale of 0= Not at all confident to 5= Very effective, please circle your answerNot at all confident (0)Mildly confident (1)Moderately confident (2)Very confident (3) How well do you think that guided imagery as a nursing intervention would be as an effective means of decreasing overall patient anxiety, pain, and/or stress? *Using a scale of 0=Not at all effective to 5=Extremely effective, please circle your answer.012345Appendix B: Capstone Post-test SurveyClinical Capstone Project: Post-test SurveyKatrina James, SNThe Pennsylvania State UniversityFall 2015What is guided imagery? (circle one)An ultrasound or visually-assisted/guided procedureHelping a recently blind individual to imagine or visualize imagesA relaxation technique using words to evoke positive mental images, feelings, and thoughts with the purpose of reducing stress, anxiety, and pain perceptionUsing a magnifying device to examine a patientGuided imagery is a type of ____ (circle one)Examination techniqueDreamingGuided relaxationYogaAn example of using guided imagery would be____? (circle one or more)Talking with a patient to describe a setting in which the patient feels is relaxingTelling a client to think of their favorite food while NPOHaving a client describe a favorite vacation spot while performing wound careDiscussing with the patient whether to keep the TV on during assessment As a nurse, how confident do you feel using guided imagery to decrease anxiety and discomfort in your patients during invasive procedures or stress inducing care tasks? Using a scale of 0= Not at all confident to 5= Very effective, please circle your answerNot at all confident (0)Mildly confident (1)Moderately confident (2)Very confident (3)Which of the following are benefits of using guided imagery? (circle one or more)Decreased stress for the patientImproved patient experienceDecreased use of analgesicsReduced self-rated anxietyDecreased length of stay in the hospital How well do you think that guided imagery as a nursing intervention would be as an effective means of decreasing overall patient anxiety, pain, and/or stress? *Using a scale of 0= Not at all effective to 5= Extremely effective, please circle your answer. 012345Appendix C: Education Summary Handout ................
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