“A STUDY TO DETERMINE THE EFFECTIVENESS OF GUIDED IMAGERY ON ANXIETY LEVEL AMONG

CLIENTS UNDERGOING MRI IN SELECTED HOSPITAL

OF RAICHUR”

PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION

REMYA MATHEWS

NAVODAYA COLLEGE OF NURSING RAICHUR

DECEMBER -2009

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES BANGALORE, KARNATAKA

PROFORMA FOR REGISTRATION OF SUBJECTS FOR DESSERTATION

1. Name of the candidate : Miss.REMYA MATHEWSand address M.Sc Nursing Ist Year,

Navodaya College of Nursing Mantralayam Road, Raichur – 584103.

2. Name of the Institution : Navodaya College of Nursing

3. Course of study : M.Sc Nursing Ist Yearand subject Medical – Surgical Nursing

4. Date of admission in to : 11/06/2009the course

5. Title of the Topic :

“A STUDY TO DETERMINE THE EFFECTIVENESS OF GUIDED IMAGERY ON ANXIETY LEVEL AMONG

CLIENTS UNDERGOING MRI IN SELECTED HOSPITAL

OF RAICHUR”

6. BRIEF RESUME OF THE INTENDED WORK:

6.1 NEED FOR THE STUDY:

“Worry is a thin stream of fear trickling through the mind. If encouraged, it cuts a channel into which all other thoughts

are drained”

Anxiety is a pervasive feeling of dread, apprehension and

impending disaster. Generalized anxiety disorder (GAD) is characterized

by excessive, exaggerated anxiety and worry about life events with no

obvious reasons for worry.1

The exact cause of anxiety is not fully known, but a number of

factors including genetics, brain chemistry and environmental stress

appear to contribute its development. Genetic theory states that anxiety

occur in about 2 (%) of the general population, about 15(%) to 25(%) of

the relatives of patients with anxiety.2

Magnetic Resonance Imaging (MRI) or Nuclear Magnetic

Resonance Imaging (NMRI) is a medical imaging technique most

commonly used in radiology to visualize the internal structure and

function of the body. MRI provides much greater contrast between the

different soft tissues of the body than Computed Tomography (CT). The

first MRI image was published in 1973, and the first cross sectional

image of a living mouse was published in January 1974. The first studies

performed on humans were published in 1977. MRI was developed from

knowledge gained in the study of nuclear magnetic resonance. MRI is

useful in neurological (brain), musculoskeletal, cardio vascular and

oncological imaging.1

Because clients must remain still in the tight space of the MRI

scanner for upto 2 hours or more, MRI’s frequently create anxiety and

panic. This can cause significant harm to clients and greatly increasing

costs. Clients undergoing MRI experience severe claustrophobia or panic

attacks and report milder distress.1

The anxiety related symptoms of clients undergoing MRI are

vertigo, whiplash, irritable bowel syndrome, indigestion, migraine,

tourette syndrome, huntington’s disease, cushing syndrome, tinnitus and

depression.3

A study was conducted by the department of psychology to

investigate MRI related phobia and identify risk factors for

claustrophobia development. A sample of 108 subjects who had never

had a scan, 57 males and 51 females ranging in age from 19 to 72 years,

mean age of 43 years evaluated before and after the scan and contacted

for one month follow up. The results reported that pre scan report of pain

was significantly correlated with stopping the scan, the pre scan Fear

Survey Schedule scores correlated significantly with reported

claustrophobic feelings after scan and stopping the scan correlated

significantly with follow up report of an increase in claustrophobic

feelings. The study concluded that pre scan pain and fear assessment

may help predict and allow intervention in phobic response during and

after the MRI scan.4

The statistical analysis reveals that anxiety related reactions occur

in approximately 4(%) to 30(%) of clients undergoing MRI, ranging from

apprehension to severe reactions that interfere with the performance of

the test.5

Guided imagery is a programme of directed thoughts and

suggestions that guide imagination towards a relaxed, focused state. The

guided image has been found to provide significant stress reduction

benefits, including physically relaxing the body quickly and efficiently

and even helping participants get in touch with deeper levels of wisdom

(held on a sub conscious level) that would help them better manage their

lives in ways that would reduce stress. With the help of an imagery tape,

a professional helper , or just one’s imagination, those who practice

guided imagery get into a deeply relaxed state and envision with great

detail relating to all of the senses provides a relaxing scene. The studies

demonstrate that the health benefits of imagery are so numerous that

many hospitals are incorporating imagery as an option for treatment.6

Many studies have shown that relaxation with guided imagery or

hypnosis can reduce client anxiety and movement even in children,

increase client tolerance and satisfaction with the procedure and reduce

the need for sedation in MRI. There are different types of guided

imagery such as relaxation imagery, healing imagery, pain control

imagery and mental rehearsal.6

A randomized experimental study was conducted to examine the

effects of guided imagery on anxiety levels and movement of clients

undergoing non emergency MRI in USA. A sample of 41 subjects were

randomly assigned into two groups (experimental and control). The

results reported that the subjects who listened to a guided imagery or

relaxation tape (n=20) before their MRI scan and used guided imagery

during their scan had lower levels of anxiety than the control group.

(n=21). The results of this investigation support the use of guided

imagery as a therapeutic intervention.7

Guided imagery can reduce anxiety and movement during MRI and

improves quality of images. The use of guided imagery can save money

by reducing need for sedation and or cancellation of procedures and

increase client satisfaction with the procedure.

Hence the researcher felt the need to determine the effectiveness of

guided imagery on anxiety among clients undergoing MRI in selected

hospital of Raichur.

6.2 REVIEW OF LITERATURE:

A literature review is an examination of the research that has been

conducted in a particular field of study. It is to find out the methods of

study It helps us to determine what has been done in the past and will

give us pointers on how to develop or make some progress on its status.

It provides basis to locate pertinent data and new ideas that need to be

included in the present study. It helps the investigator to find the

comparative study that could be used for supporting present findings and

drawing conclusions.8

The review has been grouped in two parts,

(I) Studies related to the effectiveness of guided imagery on

anxiety among clients undergoing MRI

(II) Studies related to the effect of guided imagery on other health

related problems.

Studies related to the effectiveness of guided imagery on anxiety among

clients undergoing MRI

An experimental study was conducted to examine the effect of

guided imagery on anxiety among patients undergoing magnetic

resonance imaging in USA. All subjects were randomly assigned (20 in

the experimental group and 21 in the control group) . The participants

were encouraged to use guided imagery during the MRI and also

encouraged to imagine the colours, sounds, smells and feelings. Data

were collected by using state anxiety and a brief questionnaire directed at

describing their MRI experience as well as any relaxation techniques used

during the scan. The results reported that the mean trait anxiety scores

for the experimental and control group were similar. ( t = 0.63, df = 39,

p= 0.53) and after listing to the relaxation or guided imagery tape,

experimental group had an 11.2 drop in their mean anxiety score, where

as the control group had a drop of only 1.3. The study concluded that the

guided imagery have a significant effect in reducing anxiety of clients

during MRI.9

A study was conducted to assess the anxiety and its determinants in

patients undergoing MRI by Department of Psychology in Stockton.

Ninety five per cent of the clients completed the procedure although

37(%) reported moderate to severe anxiety. It is concluded that anxiety in

clients undergoing MRI is a multifaceted phenomenon involving fear of

closed spaces( claustrophobia), pain, the unknown, as well as

apprehensions about what the test might reveal. It is also stated that the

best way to avoid traumatizing the client is to assess these variables in

advance.10

Studies related to the effect of guided imagery on other health related

problems.

An experimental study was conducted to measure the effectiveness

of customized guided imagery for increasing comfort in women at an

early stage of breast cancer by a College of Nursing in USA. Fifty three

women ( 26 in the experimental group, 27 on the control group) aged 37

to 81 years were randomly assigned. The experimental group was to

listen to a guided imagery audio tape once a day for the duration of the

study and the radiation therapy comfort questionnaire was self

administered at three time points prior to the introduction of intervention

and the beginning of radiation therapy ( Time 1), three weeks later ( Time

2) and three weeks after completing radiation therapy (Time 3). The

results of the study showed that there was significant differences between

the control and experimental group and also stated that guided imagery is

an effective intervention for enhancing comfort of women undergoing

radiation therapy for early stage breast cancer.11

A quasi experimental study was conducted to assess the

effectiveness of guided imagery on blood pressure among PIH mothers in

Madurai, India. A sample of 30 PIH mothers were selected by using

purposive sampling method. The results reported that there was a

significant reduction in both systolic and diastolic pressure after guided

imagery among PIH mothers and is (P < 0.05). The study concluded that

guided imagery was independently effective among PIH mothers in

reducing blood pressure.12

A quasi experimental was conducted by Department of Nursing in

Taiwan to assess the long term effect of an audio visual relaxation

training treatment involving deep breathing, exercise, muscle relaxation,

guided imagery and meditation and compared with routine nursing care

for reducing anxiety, improving sleep and promoting relaxation among

Chinese adults with cardiac disease. A convenience sample of 100

cardiology patients (41 treatment, 59 control ) admitted to Medical Center

Hospital in the Republic Of China was studied for one year. The results

reported that the hypothesized relationship and relaxation training ( P

< .05) improved anxiety, sleep and relaxation in the treatment group as

compared to the control group. The study concluded that audio-visual

relaxation training might be a beneficial adjunctive therapy for adult

cardiac patients.13

A longitudinal, prospective randomized controlled clinical trial was

conducted to investigate the effects of a 6 week intervention of guided

imagery on pain level, functional status, and self efficacy in persons with

fibromyalgia and to explore the dose response effect of imagery use on

outcomes. The samples include 48 persons with fibromyalgia recruited

from physicians offices and clinics in the Mid. Atlantic region. Data were

collected by using short form McGill pain questionnaire, arthritis Self

efficacy scale (ASES) and fibromyalgia impact questionnaire (FIQ) at

baseline, 6, 10 weeks. Results reported that the FIQ scores decreased time

in the guided imagery group compared usual core group (p=0.03) and

ratings of self efficacy for managing pain (p=0.03) and other symptoms

of fibromyalgia also increased significantly over time (p=< 0.01) in the

guided imagery group compared to the usual care group. The study

concluded that guided imagery is effective in improving functional status

and sense of self-efficacy for managing pain and other symptoms of

fibromyalgia.14

An experimental study was conducted to examine the effect of

imagery on children’s pain and anxiety during catheterization by

University of Minnesota School of Nursing, USA. Twenty four children,

aged 9 to 17 years were randomly assigned to a control or imagery

condition. Physiological, psychological and behavioral data were used to

rate children’s pain and anxiety during catheterization. The study

concluded that children in the imagery condition displayed fewer distress

behaviors during cardiac catheterization and reported lowest levels of

pain.15

A experimental test control group study with 60 participants was

conducted to examine the subjective feelings of timelessness, motion

boundary lessness, transcendence, and increased imagination experienced

during pleasant guided imagery within Martha Roger’s Science of

Unitary Human Beings and to prove the Roger’s Principle of reasoning.

The findings suggest that Roger’s principle of reasoning may provide an

explanation of the subjective feelings experience during pleasant guided

imagery. 16

A community based nursing study was conducted in Sydney,

Australia to compare the effects of progressive muscle relaxation and

guided imagery on anxiety, depression and quality of life in people with

advanced cancer. A sample of 56 people with advanced cancer who were

experiencing anxiety and depression were randomly assigned to 1 of 4

treatment conditions like progressive muscle relaxation training, guided

imagery techniques for anxiety, depression, and the quality of life using

the Hospital Anxiety and Depression Scale and the Functional Living

Index Cancer Scale. The study concluded that positive changes occurred

for depression and anxiety.17

A pre experimental study was conducted by the Medical College

of Georgia to test the Donovan Relaxation with Guided Imagery (RGI)

and to investigate its effect on reducing state anxiety, as measured by the

Spielberger State-Trait Anxiety Inventory (STAI). A sample of 33

graduate nursing students were assigned the RGI script was administered

three times, at two weeks intervals between sessions. The findings

revealed that state anxiety levels were reduced in each of the three to

previous levels into two weeks; and that trait anxiety levels were

unchanged. 18

6.3 STATEMENT OF THE PROBLEM:

A study to determine the effectiveness of guided imagery on anxiety

level among clients undergoing MRI in selected Hospital of Raichur.

6.4 OBJECTIVES OF THE STUDY:

1. To assess the level of anxiety of clients undergoing MRI.

2. To evaluate the effectiveness of guided imagery on anxiety

level among clients undergoing MRI.

6.5 HYPOTHESIS:

H1 ; There will be a significant difference in the anxiety level before

and after the guided imagery among clients undergoing MRI.

H2 ; There will be a significant association between anxiety level and

selected demographic variables ( age, sex, race and site of the scan).

6.6 OPERATIONAL DEFINITIONS:

Anxiety

Anxiety is a feeling of apprehension experienced by the clients

undergoing MRI. For the present study, anxiety will be measured by

using anxiety scale.

Effectiveness

Effectiveness is the extent to which the guided imagery has reduced the

anxiety levels among clients undergoing MRI.

Guided imagery

Guided imagery is a convenient and simple relaxation technique in order

to manage stress and reduce tension.

MRI

MRI ( Magnetic Resonance Imaging) is a medical imaging technique use

in radiology to visualize the internal structure and function of the body.

Clients

People who have problems need to be diagnosed and who undergo MRI

in selected hospital of Raichur.

7. MATERIALS AND METHODS:

7.1 SOURCE OF DATA:

Design:

The design of the study is experimental.

O 1 x O2

O1 O2

O1 – Pretest

X – Intervention (Guided Imagery)

O2 – Posttest

Setting of the study:

Raichur is one of the backward district. It has an area of 6,839

sq.mt and located in Northern Karnataka. In Raichur, 4 hospitals are

functioning. Among them Navodaya Medical College Hospital and

Research Centre is selected for the study. This hospital was established in

the year 2001 and in December 2008 MRI has started in Navodaya

Medical College Hospital and Research Centre. Nearly 100 patients will

be coming to take MRI per month and among them spine and cervical

cases are reported more.

Population:

The population for the study includes the clients undergoing MRI

in Navodaya Medical College Hospital and Research Centre.

Sample :

A sample of 60 clients ( 30 experimental group, 30 control group)

undergoing MRI in Navodaya Medical College Hospital and Research

Centre will be selected for the study purpose.

Sampling technique:

Purposive sampling technique will be used to select samples. A

sample of 60clients will be taken and will be allotted to experimental and

control groups on the basis of the days which they undergo MRI.

SELECTED VARIABLES:

The variables included in the study are :

Dependent variables:

Anxiety level of the clients undergoing MRI.

Independent variables:

Guided imagery for clients undergoing MRI.

Extraneous variables:

The extraneous variables are age, gender, religion, education,

previous experience of MRI.

1. Age: It is categorized as

a) 30-40 years

b) 41-50 years

c) 51-60 years

d) Above 60 years

2. Gender:

Gender of the sample is categorized as

a) Male

b) Female

3. Religion:

Religion of the sample is categorized as

a) Hindu

b) Muslim

c) Christian

d) Others

4. Basic Educational Qualification:

a) Illiterate

b) Primary school

c) High school

d) P.U.C

e) Diploma

f) Degree

g) Others

5. Occupation:

It is categorized as

a) House wife

b) Coolie

c) Business

d) Private employee

e) Government employee

f) Others

6. Monthly Family Income:

a) Rs.1000/- -- Rs. 3000/-

b) Rs.3001/- -- Rs. 5000/-

c) Rs.5001/- and above

7. Type of Family:

It is categorized as

a) Nuclear family

b) Joint family

8. Sources of Information:

a) Mass media

b) Magazines

c) Health professionals

d) Relatives

e) Friends

9. History of previous MRI?

a) Yes

b) No

If yes, specify….

10.Personnel history of anxiety disorder

a) Yes

b) No

If yes, specify….11.Family history of anxiety disorder

a) Yes

b) No

If yes, specify….

Inclusion Criteria:

The study includes the client who are

1) Undergoing MRI in Navodaya Hospital and Research Centre

2) Willing to participate in the study

3) Understands Hindi, English, Kannada

4) Above 30 years of age

Exclusion Criteria:

The study excludes the client who are not

1) Undergoing MRI in Navodaya Hospital and Research Centre

2) Willing to participate in the study

3) Understands Hindi, English, Kannada

4) Below 30 years of age

7.2 METHODS OF COLLECTING DATA:

Data Collection Instrument:

Data collection instrument consists of 2 parts, Part I and Part II.

Part I deals with socio demographic data and Part II consists of anxiety

scale to measure the level of anxiety among client undergoing MRI in

Navodaya Medical College Hospital and Research Centre.

Data Collection Method:

After obtaining permission from the significant authorities and

consent from the subjects, the Investigator will evaluate the effectiveness

of guided imagery on anxiety level by administering the anxiety scale.

Sixty clients undergoing MRI will be selected by using purposive

sampling technique, out of which 30 clients will be assigned to

experimental group and 30 clients will be assigned to control group

according to the days which they undergo MRI. The anxiety level of

clients (both groups) will be assessed by using anxiety scale before MRI

and guided imagery will be given to experimental group by the

Investigator and control group will not receive any intervention.

Immediately following MRI, both groups will be asked to again report

their level of anxiety during their scan and will be assessed by using

structured anxiety scale.

Plan For Data Analysis:

Data from the sample will be analyzed by using descriptive and

inferential statistics. Sample characteristics will be organized and

summarized with the help of descriptive statistics i.e percentage,

frequency, mean and standard deviation. Effectiveness of guided imagery

will be tested by using ‘t’ test. Testing the level of significance of

hypothesis will be done with the help of inferential statistics like chi-

square test.

Projected Outcome:

The result of the study gives an insight for the future researchers to

have indepth studies regarding the effect of guided imagery in reducing

the anxiety.

7.3 DOES THE STUDY REQUIRE INTERVENTION?

Since it s an experimental study, it requires intervention.

7.4 HAS ETHICAL CONSIDERATION BEEN OBTAINED FROM

YOUR INSTITUTE IN CASE OF 7.3?

1. Permission will be obtained from Institutional Ethical

Committee, Navodaya College of Nursing, Raichur .

2. Permission will be obtained from Navodaya Medical

College Hospital and Research Centre.

3. Consent will be obtained from the samples.

8. LIST OF REFERENCE:

1) Wikipedia; THE FREE ENCYCLOPEDIA

2) Bhatia ; TEXT BOOK OF PSYCHIATRY; 5th edition; pg no.

13.2-13.3.

3) Medicine Net .com

4) L.Christine; JOURNAL OF BEHAVIOURAL MEDICINE;

1990.

5) Carlos Melendez; “Anxiety related reactions associated with

magnetic resonance imaging examinations” THE JOURNAL

OF THE AMERICAN MEDICAL ASSOCIATION ; Vol

270(6); pg no. 745-747.

6) Martin L.Rossman; JOURNAL OF GUIDED IMAGERY

FOR SELF HEALING; 2000.

7) M.B Thompson; “ The effects of guided imagery on anxiety

levels and movements of clients undergoing magnetic resonance

imaging “ JOURNAL OF HOLIST NURS PRACT; Vol 8(2);

pg no. 59-69.

8) Denise F.Polit, Benedeth P.Hungler; NURSING RESEARCH

PRINCIPLES AND METHODS; Philadelphia Lippincott

Company; 6th edition; pg no. 105-106; 1999.

9) Cathie. E.Guzetta;ESSENTIAL READINGS IN HOLISTIC

NURSING; American Nurses’s Association; 1999; pg no. 273-

276.

10) Katz RC;” Anxiety and its determinants in patients

undergoing magnetic resonance imaging ” JOURNAL

BEHAV THER EXP PSYCHIATRY; Vol 25(2); pg no.131-

134.

11) Kolcaba K ;”The effects of guided imagery on comfort of

women with early stage breast cancer undergoing radiation

therapy” JOURNAL OF ONCOL NURSE FORUM ; Vol

26(1) ; pg no. 67-72; 1999.

12) Kavitha.K; “Effectiveness of guided imagery on blood

pressure among PIH mothers”; JOURNAL THE NURSE

vol:1(2) pg.no.15-17,2009.

13) Tsai SL; “Audio-visual relaxation training for anxiety, sleep,

and relaxation among Chinese adults with cardiac disease ”

JOURNAL OF RES NURSE HEALTH ; Vol 27(6); pg no.

458-468; 2004.

14) Taylor AG; “Effects of guided imagery on outcomes of

pain, functional status, and self-efficacy in persons diagnosed

with fibromyalgia” JOURNAL OF ALTERN

COMPLEMENT MED: Vol 12(1); pg. no. 23-30;2006.

15) Pederson C; “Effect of imagery on children’s pain and

anxiety during cardiac catheterization ”JOURNAL OF

PEDIATR NURS; Vol 10(6); pg no. 365-374.

16) Nora I.P; GUIDED IMAGERY WITHIN ROGER’S

SCIENCE OF UNITARY HUMAN BEINGS.

17) Sloman ; “Relaxation and imagery for anxiety and

depression control in community patients with advanced cancer

“ JOURNAL OF CANCER NURSING; Vol 25(6); pg no.

432-435.

18) Jane Valerie King; “A holistic technique to lower anxiety:

Relaxation with guided imagery” JOURNAL OF HOLISTIC

NURSING; Vol. 6(1); pg no. 16-20.