What is the impact of guided imagery as a nursing intervention in the management of acute and chronic pain?

Guided Imagery

By: Margaret Gerulski, Diane Kumar, & Brea YangFerris State UniversityFall 2011

(google.com, n.d.)NURS 317 Spirituality in Nursing Group 5 Group PresentationGuided ImageryBy: Margaret Gerulski, Diane Kumar & Brea Yang1IntroductionWhat is the impact of guided imagery as a nursing intervention in the management of acute and chronic pain?

(google.com, n.d.)

WELCOME to our presentation on guided imagery. We hope you enjoy the path through our evaluation of the literature and the impact of its use as a nursing intervention in the management acute and chronic pain. What is the impact of guided imagery as a nursing intervention in the management of acute and chronic pain? Pain management is one of the most important aspects of nursing care. Working at the bedside, as we do, places us in a position to teach our patients alternative ways of coping with pain. Margaret and Diane are both labor and delivery nurses, and learning about guided imagery as an alternative to pain medication may be a beneficial alternative to teach patients as they are progressing through labor and have chosen not to use pain meds. By aiding them with alternative methods, such a guided imagery, we would be helping to support the patient achieving their goal of a non medicated childbirth. Brea works on a medical/surgical floor and her interest in this topic stems from the amount of IV pain medications they give to their patients. As nurses, we all think it is important to educate our patients about alternative therapies that can be used along with drugs to manage pain.

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DefinitionGuided imagery is a technique that utilizes stories or narratives to influence the images and patterns that the mind creates (Hart, 2008, p. 295).

Thought process that invokes and uses the senses of vision, hearing, smell, taste, movement, position, and touch (Young & Koopsen, 2011, p. 76).

(google.com, n.d.)Guided imagery refers to a wide variety of techniques including simple visualization and direct suggestion using imagery, metaphor and story-telling, fantasy exploration and game playing, dream interpretation, drawing, and active imagination where elements of the unconscious are invited to appear as images that can communicate with the conscious mind (academyforguidedimagery.com, n.d.). It was once considered an alternative therapy, but is now more widely accepted in the scientific, as well as the public arena. Guided imagery works by allowing the patient to enter a relaxed state of mind, and then focus their attention on images associated with the issues they are confrontingpatients coping with chronic pain can be invited to visit and experience and Inner Sanctuary where there is no pain (academyforguidedimagery.com, n.d.). Guided imagery has been shown that it can affects on all major physiological systems of the body-respirations, blood pressure, heart rate, gastrointestinal mobility, cortisol levels, as well as immune responsiveness (academyforguidedimagery.com, n.d.). Guided imagery represents an important alternative to using medications, is much safer, has fewer complications, as well as contra-indications, and produces specific physiologic changes that can aid in healing (academyforguidedimagery.com, n.d.).The need to study ways to facilitate awareness of choice and the freedom to act on choice is nowhere more relevant than with persons experiencing chronic pain. Chronic pain is one of the clearest examples of the complex relationship between the mind, body, spirit, and environment (Lewandowski, 2004).Academy for Guided Imagery. Retrieved on 11/25/11 at http://www.academyfor guidedimagery.com/whatisguidedimagery/index.html.

Tropical beach photo. Retrieved November 20, 2011 from www.google.com (guided_imagery.jpg).

3BackgroundUsed in ancient timesCultural and religious usesVariety of usesMind / Body connection

Pain is inevitable; suffering is optional--Hindu Spiritual-- (Bresler, 2010)

(google.com, n.d.)

According to the National Pain Foundation (NPF), our mind processes everything we do through images, it is the most fundamental language we have (n.d.). The mind uses this language to communicate with the body (NPF, n.d.). Ancient civilizations, including Navajo Indians, Egyptians, and Greeks, have considered imagery a healing tool in many world cultures and religions (NPT, n.d.). During the birth of the Western culture the healing rituals which included prayer and guided imagery continued to be viewed as an essential part of medicine and healing (empoweredwithin.com, n.d.)

In the 1960s psychologists began to see the effects of the connection between the mind and body (empoweredwithin.com, n.d.). Over the past 15 years guided imagery has been documented to provide positive outcomes in both the medical field and health in general (Naparstek, 2007). Some of the documented results reported for guided imagery use include: reducing pain from arthritis, fibromyalgia, cancer and decreasing discomfort during medical procedures (Naparstek, 2007). A recent meta-analysis showed that hypnosis and imagery reduced pain and the need for pain medication in laboring women (Naparstek, 2007). Guided imagery and visualization has also been used to increase performance in athletes, to aid in leadership training, and business success (NPF, n.d.).

4 Effects of Guided Imagery on Outcomes of Pain, Functional Status, and Self-efficacy in Persons Diagnosed with Fibromyalgia (Menzies, Taylor, and Bourguignon, 2006)Objective: Effects of on pain levels, functional status, and self-efficacy in persons with fibromyalgia (FM) with Guided Imagery.Method: Randomized Control Clinical Trial Participants: 48 people were recruited from physicians offices &clinics in the University of Virginia Health System.Intervention: 3 guided imagery audiotapes with average of 20 minute per audiotape for 2 weeks eachMeasures: Pain, functional status, and self-efficacyOutcomes: Improvement on functional status and self-efficacy, but not change in pain levels

The first article reviewed the Effects of Guided Imagery on Outcomes of Pain, Functional Status, and Self-efficacy in Persons Diagnosed with Fibromyalgia. This study investigated the effects of a 6-week intervention of guided imagery and explored dose-response effect of imagery use on outcomes.This study included a 2 group randomized controlled clinical trial examining the effectiveness of guided imagery, as adjunctive modality.The participants were recruited from physicians offices & clinics in the University of Virginia Health System. The sample size originally included 50 participants of which 2 were excluded due to low scores on the Fibromyalgia Impact Questionnaire (FIQ). The participants were volunteers who signed a consent and met the requirements and passed the FIQ. The interventions for this study included 3 guided imagery audiotapes lasting an average of 20 minutes each, they were used at 2 week intervals over a 6 week period. The use of the Short-Form McGill Pain Questionnaire, Arthritis Self Efficacy Scale, and Fibromyalgia Impact Questionnaire evaluated both sensory and affective pain. These tests were done as a baseline, 6 and 10 week follow up intervals. The participants also kept track of the frequency of tape use and mailed it to the facilitator each week.The functional status of individuals improved in the guided imagery group at 6 weeks and the improvement was maintained at 10 weeks compared to the usual care group who did not exhibit any changes. Self efficacy for managing both pain and other symptoms improved in the guide imagery group compared to the usual care group. However, the guided imagery intervention was not effective on the measured pain. How does it affect nursing? Fibromyalgia is a chronic pain with no cure that cannot be managed by drugs alone but in adjunctive therapy such as guided imagery. Nurses need to understand guided imagery is more than positive pure thinking. The images that people come up with in their minds have long term effects on their body and mind. Nurses need to understand recommendations to use guided imagery as adjunctive therapy to manage and treat the patients condition. People need to be empowered to manage their symptoms because empowerment has the potential to positively affect psychological and physiological state of these persons ( Menzies & et al, 2008).

5Changes in the Meaning of Pain with the use of Guided Imagery (Lewandowski, Good, & Draucker, 2005)Purpose: determine how verbal descriptions pain changed after guided imageryMethod: Mixed method, concurrent nested design, and use of verbal pain descriptorsParticipants: Computer randomized selection Interventions: Use of a guided imagery tape was used over a 4 day periodMeasures: 102 pain descriptorsOutcomes: Improved pain verbal pain descriptions in the treatment group.

The second article reviewed Changes in the Meaning of Pain with the use of Guided Imagery includes a study that was intended to determine if participants with chronic pain describe their pain differently after using a guided imagery tape and if these perceptions change over time. This method included both quantitative and qualitative data that used a pain scale and pain descriptors. The participants were randomly chosen to be in the control or treatment group. There were 44 original participants in the study. Originally the study began in a large home health care facility, but due to the limited sample size was extended to neighboring senior citizen housing complexes. 2 of the originally consenting participants withdrew from the study and a computerized randomization was used for the remaining participants. After instruction the treatment group used a 7 minute guided imagery tape a minimum of 3 times a day over a 4 day period and the control group received the usual treatment. The treatment group also kept a journal listing when they had used the tape and take their pain medications. All members in the study had chronic pain and were not starting any other new treatment plans prior to or during the study. The control group was told they would also receive the guided imagery tape at the conclusion of the study.The participants were interviewed prior to randomization and daily at set times throughout the study.The meaning of pain as never-ending was a prominent theme for participants before randomization to treatment and controlgroups. It remained a strong theme for participants in the control group throughout the 4-day study period; however, pain as never-ending did not resurface for participants in the treatment group (Lewandowski, et al., 2005).

6Guided Imagery as a Therapeutic Recreation Modality to Reduce Pain (Bonadies, V., 2010) Purpose: Impact of guided imagery on chronic painMethod: Use of visual analog scaleParticipants: 1 participant at a 206 bed residential health care facilityInterventions: Guided imagery using a pain intensity scaleMeasures: Verbalization of client of pain levelsOutcomes: Improved level of pain

The third article that was reviewed Guided Imagery as a Therapeutic Recreation Modality to Reduce Pain evaluates the effectiveness of guided imagery on chronic pain. This trial takes place in a 206 bed residential health care facility for people with AIDS, located in New York City. This facility incorporates traditional medicine as well as incorporating complementary and alternative therapies including yoga, acupuncture, Reiki, meditation, guided imagery, breathing techniques, music therapy, and art therapy to help cope with pain and anxiety. The purpose of this study was to determine if patients suffering from chronic pain associated with complications of AIDS were aided with the use of guided imagery. There was only one patient at this facility that was willing to participate in the guided imagery trial. The use of the Visual Analog Scale was used to measure the patient pain level prior to therapy and then using the Pain Intensity Scale guided imagery was used to use the image the intensity scale 0-10 and view it in one of several ways (example dial on a radio or an electric blanket) and imagine turning the dial down on his pain to a tolerable level and then locking it there. This study was measured using the patients perception in the pain level at the end of the session. The patient reported a lower level of pain which supported Bonadies goal to determine the effects of guided imagery on chronic pain. This is a low cost, easy to learn, non-invasive, self managed and controlled therapy with can be used in conjunction with other pain medications.7 What is the impact of guided imagery as a nursing intervention in the management of pain and chronic pain?Nursing Responsibility

Use in Chronic and Acute Pain

Use in Childbirth

Part of Holistic Nursing

Evidence-Based Nursing intervention

(google.com, n.d.)Pain management is the primary responsibility of the nurse. Finding non pharmaceutical method of treating pain is essential in balancing the mind, body and spirit. Through most of the articles read for this assignment, it was evident that guided imagery appears to have potential as a useful nursing modality for chronic pain sufferers (Lewandowski, 2004, p. 233). The articles have provided evidence that both chronic and acute pain can be influenced by guided imagery. The use of guided imagery and alternative therapies have been long used in decreasing the pain and discomfort of childbirth (Koehn, 2000). Koehn, 2000, also discusses a review of literature that verified guided imagery aided in decreasing pain, anxiety, blood pressure, and heart rate, making it an applicable nursing intervention in holistic comfort (p. 75). Guided imagery is a part of holistic nursing, which allows the nurse more independence in learning how to provide care that has an impact on the whole person, not just the physical aspect (Koehn, 2000). Guided imagery is considered a successful evidence-based nursing intervention in assisting patients with the pain experience (Lewandowski, Good, & Draucker, 2005).

8Limitations in Research Practicing imagery 15-20 minute daily will increase the success, therefore can be seen as a time consuming activity.Limited time frames to evaluate effectiveness.Research studies on alternative therapies is limited.More studies on chronic pain than acute pain.Limitations of these studies were small sample size, lack of randomization, non-equality of treatment and control groups, and lack of control for opioid intake and imagery ability (Lewandowski, et al., 2005)Pain is subjective

All the articles reviewed have shown that practicing imagery increases its success. Because it can be a time consuming activity, this may limit its use in research. Due to the limited amount of research, the findings on the use of guided imagery for pain management is encouraging, but not yet found to be convincing. It is not viewed as a useful tool at this time by the medical profession. There appears to be more research studies on its impact on chronic pain as compared to acute pain, although an increase in recent studies has investigated its use in postoperative pain, laceration repair, burn therapy, and injection administration in children. The other limitations in these studies were small sample size, lack of randomization, non-equality of treatment and control groups, and lack of control for opioid intake and imagery abilities. Since pain is considered a subjective vital sign, it is difficult to compare one persons perception to another and the benefits they receive. 9Limitations for use of Guided Imagery in PracticeShort hospital staysLimited nursing timeLack of education of nursing staffFor optimal effectiveness Clients and families need to have knowledgeWillingness to participateContinual practice

After performing our literature reviews several limitations were identified for use of guided imagery as a nursing intervention in actual practice. Due to the short length of hospital stays it would difficult to teach this method and to evaluate its effectiveness. This is a intervention that requires ongoing support and evaluation. Due to the lack of education of most nursing staff in this practice, unless it was a required practice many would not take the time to learn this intervention. Also with the lack of nursing time not only because of patient to nurse ratios, but also because of the limited amount of interaction most nurses have with their patients. For optimal effectiveness this intervention would need to be well received by the patient and his/her family, they would need instruction and have a willingness to participate with this treatment. It has been shown that it takes continual practice to effectively learn guided imagery and increase its benefit in pain management.10Conclusion

(Bresler, 2010)

In conclusion to determine whether guided imagery modality continues to be effective in reducing pain there needs to be follow-up in future study designs (Lewandowski, 2004 p. 240).Helping chronic pain sufferers to knowingly participate in change as they evolve with the pain experience is an integral aspect of the art and practice of nursing (Lewandowski, 2004 p. 241). Patients can derive not only symptomatic relief but actual physiologic healing in response to treatments that primarily work through beliefs and attitudes about an imagined reality. (Bresler, 2010)11ReferencesAcademy for Guided Imagery. Retrieved on 11/25/11 at http://www.academyfor guidedimagery.com/whatisguidedimagery/index.html

Bonadies, V. (2010). Guided imagery as a therapeutic recreation modality to reduce pain. Annual in Therapeutic Recreation, 18, p. p. 164-174.

Bresler, D. (2010). Raising pain tolerance using guided imagery. Practical Pain Management, July/August, 10(6), 25-31.

Empowered Within. (n.d.) Retrieved November 20, 2011 from: http://www.empoweredwithin.com/main%20info/Historyof guidedimagery.html

Google.com. (n.d.). All images retrieved November 20, 2011 from: www.google.com (guided_imagery.jpg).

Hart, J. (2008). Guided imagery. Alternative and Complementary Therapies, 14 (6), pp. 295-299. doi: 10.1089/act.2008.14606.

Koehn, M. L. (2000). Alternative and complementary therapies for labor and birth: An application of Kokcabas Theory of Holistic Comfort. Holistic Nursing Practice, 15(1), p.p. 66-77. Retrieved November 15, 2011 from: http://0-ovidsp.ovid.com.libcat.ferris.edu/ovidweb.cgi?T+JS20000100000-000009&LSLINK=80&D+ovft.

12ReferencesKoehn, M. L. (2000). Alternative and complementary therapies for labor and birth: An application of Kokcabas Theory of Holistic Comfort. Holistic Nursing Practice, 15(1), p.p. 66-77. Retrieved November 15, 2011 from: http://0-ovidsp.ovid.com.libcat.ferris.edu/ovidweb.cgi?T+JS20000100000-000009&LSLINK=80&D+ovft.

Lewandowski, W. A. (2004). Patterning of pain and power with guided imagery. Nursing Science Quarterly, 17(3), p.p. 233-241. doi: 10.1177/0894318404266322.

Lewandowski, W., Good, M., & Draucker, C. B. (2005). Changes in the meaning of pain with the use of guided imagery. Pain Management Nursing, 6(2), p.p. 58-67.

Menzies, V., Taylor, A. G., Bourguignon, C. (2006). Effects of guided imagery on outcomes of pain, functional status, and self-efficacy in person diagnosed with fibromyalgia. The Journal of Alternative and Complementary Medicine, 12 (1), pp. 23-30

Naparstek, B. (2007). Guided imagery: A best practice for pregnancy and childbirth. International Journal of Childbirth Education, 22(3), p. 4-8.

National Pain Foundation. (n.d.). Retrieved November 15, 2011 from: http://www.nationalpainfoundation.org/articles/93/guided-imagery-and-pain-relief13Thank You for Your TimeTHE END

Introduction: Description and analysis of the practice issue concerning spirituality and health outcomesPoints PossiblePoints AwardedCommentsClear Introductory Description of Practice Concern/Interest: Describes reason for interest or concern 55What a great way to start with the guided imageryPractice Environment: Provides clear description of the topic related to patients spirituality and health outcomes. Provides background information and an overview. Provides clarification of terminology if needed.1010Good overviewResearch Question: Provides a clear research question to investigate.55Literature ReviewResearch Findings: Shares the findings of a minimum of 3 research studies from professional journals. Briefly describes the research approaches and findings or the main thesis of each study/article. 1515Very good articles to use to support your topic and questionCritique of the Research: Attempts to point out any research limitations/credibility of the studies.55ConclusionImplications For Practice: Identifies potential practice implications of research. This goes beyond implications included in the study itself, to include perceptions of implications for personal practice.2020A very strong aspect of this presentationStandards and APA CriteriaAPA: Adheres to APA manual guidelines. Narration included.55Annotated Bibliography Three annotated bibliographies focused on summarizing the article, assessing the article, and reflecting your opinion. APA format followed15(11)Graded separatelyClass Discussion: Presents research question and related finding to class and responds to peers in a knowledgeable manner reflecting a solid understanding of the topic in all postings. A strong focus on application to practice is expected. 1010Excellent.TOTAL POINTS 10085 + 11 = 96Group 5: Research Topic and Presentation:Grading Criteria and CommentsGroup 5: A wonderful presentation. The class discussion reflected the interest and your knowledge of the topic. Great teamwork to pull off such a solid presentation. Combined score of 96 is annotated bibs plus the presentation.