Evidence Based Guideline for Use of Audio Pain-Centered Guided Imagery as an

Adjunct for the Management of Chronic Pain in GONDA Observation Unit (GOU)

Jeremy J Bennett, RN, BSNEvidence-Based Practice Fellow

GONDA Observation UNIT (GOU)Ronald Reagan UCLA Medical

Center

The practice issue we addressed was the control of chronic pain in patients staying in GONDA Observation Unit adjunctively with the current use of their established pain regimen

Many of our patients have a history of chronic pain

Many times prescription medication is not enough and we as nurses could use alternative nursing interventions to help better control chronic pain

Clinical Issue

Chronic pain – > 30 days beyond the usual course of an acute disease

/injury Chronic pathological process that causes continuous pain

(Persson, et al 2008)

Guided Imagery – An immersive, hypnotic, self-administered audio intervention Delivers soothing words and music Drives attention inward and structures a healing experience

that targets specific goals (Naparstek 2011)

Increases patient’s control over their pain (Lewandowski, et al 2005)

Definition of Terms

Prescription medications – current home pain regimen plus in-house prn medications

Comfort measures – heating/cooling packs, elevation, distraction, etc.

Guided imagery not readily available or accessible to staff RNs

Current Practice

Chronic pain is a widespread problem for many patients admitted to GOU

The majority of patients admitted to GOU suffer from chronic pain

Pain management is complex and may not be enough

Patients suffering from chronic pain many times feel that they have no control over their pain

Significance of Problem

Provide an evidence-based guideline for the use of an audio pain-centered Guided Imagery intervention as an adjunct for the management of chronic pain for patients in GOU

Increase Staff RN knowledge of guided imagery intervention

Decrease pain for our chronic pain patients

Purpose

In patients admitted to GONDA Observation Unit who suffer from

chronic pain does implementing the addition of an evidence-based Guided

Imagery (GI) intervention as compared to usual care (current pain management regimen) improve pain

management?

Evidence-Based Practice Question

Many GOU patients experience chronic pain diagnoses such as: Arthritis/Osteoarthritis/Neck and spine pain Fibromyalgia/Neuropathy Sickle Cell Disease

Pharmacological therapy alone may not be sufficient to control the pain

Guided imagery is an adjunctive therapy that has been shown to decrease the need for and reliance on pain medications (Hollins et al. 2012)

Patient's perception of pain may be altered and their ability to control their pain may become enhanced (Hart 2008; Ozu 2010; Lewandowski, et al 2005)

What Does the Evidence Tell Us

Physical Effects (United States Department of Health & Human Services 2012): Decreases blood pressure, heart rate, O2 consumption, and

levels of stress hormones Slows breathing Encourages a sense of well-being

Psychological Effects (Lewandowski, et al 2005; Ozu 2010): Focuses on interaction between the brain, mind, body, and

behavior Explores the powerful ways emotional, mental, spiritual, social,

and behavioral factors can directly affect health Changing the patient’s pain experience (Ozu 2010):

Their pain is under their control They have the power themselves to decrease and control their

pain Their perception of pain and daily life begin to change

What Does the Evidence Tell Us About Both the Physical &

Psychological Effects of Guided Imagery?

“Green Light” – In treating a variety of health problems it provides multiple benefits and poses virtually no risks

PET scanning found that the same parts of the brain are activated when people are imagining something as when they’re actually experiencing it!

Mayo Clinic – Mayo Clinic Guide to Alternative Medicine 2011

Baur, Brent MD. (2010). Mayo clinic guide to alternative medicine 2011: Top 10 alternative therapies, control your stress and more (Revised and Updated ed.). Time Home Entertainment.

Partial List of Evidence

Hollins M, Stonerock G, Kisaalita N, Jones S, Orringer E & Gil K. Detecting the Emergence of Chronic Pain in Sickle Cell Disease. Journal of Pain and Symptom Management. June 2012, 43 (6): 1082-1093.

Lewandowski W, Good M, Draucker CB. Changes in the meaning of pain with the use of guided imagery. Pain Manag Nurs. 2005 Jun, 6(2): 58-67.  

Persson A L, Veenhuizen H, Zachrison L, Gard G.  Relaxation as treatment for chronic musculoskeletal pain: a systematic review of randomised controlled studies. Physical Therapy Reviews 2008; 13(5): 355-365.

Hart J. Guided Imagery. Alternative and Complementary Therapies. December 2008, 14(6): 295-299.

Özü, Ö. (2010). Guided imagery as a psychotherapeutic mind-body intervention in health psychology: A brief review of efficacy research. Europe’s Journal of Psychology, 6(4), 227-237.

Naparstek B. Guided Imagery: A Portable, Self-Administered, Low-Cost, Effective, User Friendly Tool for Posttraumatic Stress. Health Journey’s: PowerPoint slides retrieved from George Mason University College of Health and Human Services. 2011.

United States Department of Health and Human Services, National Institutes of Health, & the National Center for Complementary and Alternative Medicine. (2012). Relaxation techniques for health: an introduction (NCCAM Publication No. D461). Maryland: National Center for Complementary and Alternative Medicine. Retrieved from http://nccam.nih.gov/sites/nccam.nih.gov/files/D461.pdf

Inclusion: History of chronic musculoskeletal pain,

neuropathy/fibromyalgia, and sickle cell disease Patients whose primary admission diagnosis

includes acute pain in addition to the history of chronic pain

Both inpatient and observation patients Exclusion:

Non-verbal patients Confused or disoriented patients Deaf patients Non-English speaking patients

Criteria for Project

Does Patient Have Chronic

Pain?

Does Patient Meet Inclusion Diagnosis and

Criteria?

Pain Score

Standard of Care

Educate & Offer Guided Imagery

Implement Guided Imagery

Intervention

Pain Score

Length of Time Used by Patient

Continuation of Plan of Care

Interventions

Interventions

Developed and implemented an evidence-based guideline

Assessed nurses' baseline knowledge of key aspects of the Evidence-Based Guideline

Educated nurses on new practices and guideline Reassessed nurses' knowledge post education session Provided coaching and mentoring at the bedside to

facilitate understanding and adherence to new practice Evaluated effect of adjunctive therapy on patient’s

pain scores

Outcomes

Outcomes Measured

Two sets of outcomes were measured: Knowledge Outcomes: RN knowledge

survey (pre and post intervention) Practice Outcomes (post-intervention)

Appropriate documentation of pain scores both pre & immediately post intervention on the Verbal Numeric Rating System

Effect on patient’s pain score immediately post-intervention

Results of RN Survey: Knowledge and Self-Reported Practices

N = 26

Demographic Characteristics of the Sample Pre and Post Survey

Variable N %Age 20-29 3 11%

30-39 4 15%40-49 10 39%50 or more yrs 9 35%

GenderFemale 22 85%Male 4 15%

Highest Degree

ADN 5 19%BSN 18 69%Master’s 3 12%

Demographic Characteristics of the Sample Pre and Post Survey

Variable N %

Job Class

CNI 1 4%

CNII 13 50%

CNIII 6 23%

ANI/II 5 19%

Other 1 4%

Usual Shift

Days 14 54%

Nights 11 42%

Rotate 1 4%

Demographic Characteristics of the Sample Pre and Post Survey

Variable N %

Yrs RN Experience

< 1 year 1 4%

2-5 years 3 11%

6-10 years 4 15%

11-20 years 7 27%

> 20 years 11 42%

Results: Percent Correct Score on Pre and Post Knowledge Survey Among

Nurses

0

20

40

60

80

100

69 71

PrePost

Knowledge Score

% C

orr

ect

NS

Educating Nurses

020406080

10096

65 65

10085*

96**

PrePost

% C

orr

ect

*p = .09

** p = .01

Mean Confidence/Attitude Score of Composite Score

1

2

3

4

2.973.21 *

PrePost

(1=Strongly Disagree to 4=Strongly Agree)

Mean

S

core

P= 0.001

Results: Nurses’ Perspective on Non-Pharmacological Methods of Pain

Control

020406080

100

5473

88* 92*

PrePost

% o

f r

esp

on

ses o

f

“A

gree” a

nd

“S

tron

gly

Ag

ree”

P < .002

Results: Perception of Treating Chronic Pain

GOU Has an Effec-tive

Plan for CP

I Have Adequate Skills to Treat CP

75

80

85

90

95

100

82

85

96* 96

PrePost

% o

f R

esp

on

den

ts

*p = .005

Results: Perspective on Use of GI

Benefit RN/Patient Relationship

GI is Effective for CP75

80

85

90

95

100

96

92

100

97

PrePost

% o

f R

esp

on

den

ts

Results: Nurses’ Knowledge and Skill in Using Guided Imagery

0

10

20

30

40

50

60

70

80

Pre-EducationPost-Education

Level of Skill/Knowledge

% o

f R

esp

on

den

ts

Results: Other Comments by Nurses

Environmental Modification Integrating Alternative Therapies With Medication

Regimes Could also be useful for other patients than only those

with Chronic Pain (i.e., anxiety, emotional disorders, depression, etc.)

Integrating MD and NP knowledge and support of intervention

There are many alternatives out there other than prescription medication to control chronic pain

Results: Strategies to Consider in Managing Patients Chronic Pain in

the GOU

Practice Outcomes

N = 2

Both utilized GI for 15 minutes Only one had only tried some relaxation

techniques in the past The patient who concurrently used

prescription meds stated she felt the GI intervention further helped treat her pain and that she was pleased with the therapy and wanted to continue utilizing it in conjunction with her pain meds

Patients Perception of GI Intervention

Eleven nurses were surveyed post intervention

Patients’ willingness and openness to try Many patients on long term prescriptions may

be hesitant Time – sitting down and talking to the patient Interruptions to patient/Noises Short stay observation patients

Barriers/Limitations to Continuing Guided Imagery

100% would be willing to try for themselves

100% thought it was a valuable tool that should be kept

10 of the 11 felt comfortable talking to their patients

9 of the 11 felt patients with other diagnoses in GOU would benefit

RN Post Intervention Survey

Many chronic pain patients are admitted to GOU, including almost all of UCLA RR Sickle Cell patients

Alternative therapies to use adjunctively with medication are not always readily available in GOU

Staff nurses in GOU were educated and trained to utilize a pain-centered GI Intervention

In the 2 patients who utilized the intervention, both reported a decrease in pain and increase in relaxation

GOU will continue our trial of GI with chronic pain patients

Conclusions

Future Plans

Continue utilization of guided imagery intervention

Work with unit leaders and colleagues to integrate guideline into unit routines through performance improvement processes and include in orientation program and annual skills day

Consider use for diseases other than chronic pain alone

Disseminate to other units, and throughout the nursing department in a variety of forums

Consider dissemination nationally via abstract submission and publication

Acknowledgements to Team

GONDA Observation Unit Nursing Staff GONDA Chronic Pain Patients Mark Flitcraft RN, MSN, Unit Director Miriam Gonzalez, RN, MS, EBP Clinical Mentor

Key Stakeholders/Change Champions Sofie Rosa Diana Patricia Krishna Amelia Tina Geraldine

Questions and Comments