Transcript Guided Imagery for Chronic Pain in GONDA

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, BSN
Evidence-Based Practice Fellow
GONDA Observation UNIT (GOU)
Ronald Reagan UCLA Medical Center
Clinical Issue
 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
Definition of Terms
 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)
Current Practice
 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
Significance of Problem
 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
Purpose
 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
Evidence-Based Practice Question
In patients admitted to GONDA Observation
Unit who suffer from chronic pain does
implementing the addition of an evidencebased Guided Imagery (GI) intervention as
compared to usual care (current pain
management regimen) improve pain
management?
What Does the Evidence Tell Us
 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 About Both
the Physical & Psychological Effects of
Guided Imagery?
 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
Mayo Clinic – Mayo Clinic Guide to
Alternative Medicine 2011
 “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!
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
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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
Criteria for Project
 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:
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
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
Non-verbal patients
Confused or disoriented patients
Deaf patients
Non-English speaking patients
Does Patient
Have Chronic
Pain?
Continuation of
Plan of Care
Does Patient
Meet Inclusion
Diagnosis and
Criteria?
Length of Time
Used by Patient
Pain Score
Pain Score
Standard of Care
Implement
Guided Imagery
Intervention
Educate & Offer
Guided Imagery
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 postintervention
Results of RN Survey: Knowledge and
Self-Reported Practices
N = 26
Demographic Characteristics of the Sample
Pre and Post Survey
Variable
Age
20-29
30-39
40-49
50 or more yrs
Gender
Female
Male
Highest Degree
ADN
BSN
Master’s
N
%
3
4
10
9
11%
15%
39%
35%
22
4
85%
15%
5
18
3
19%
69%
12%
Demographic Characteristics of the Sample
Pre and Post Survey
Variable
N
%
CNI
1
4%
CNII
13
50%
CNIII
6
23%
ANI/II
5
19%
Other
1
4%
Days
14
54%
Nights
11
42%
Rotate
1
4%
Job Class
Usual Shift
Demographic Characteristics of the Sample
Pre and Post Survey
Variable
N
%
< 1 year
1
4%
2-5 years
3
11%
6-10 years
4
15%
11-20 years
7
27%
> 20 years
11
42%
Yrs RN Experience
Results: Percent Correct Score on Pre and Post
Knowledge Survey Among Nurses
100
% Correct
80
69
71
60
Pre
Post
40
NS
20
0
Knowledge Score
Educating Nurses
100
96
100
96**
% Correct
80
85*
60
65
65
Pre
40
Post
20
*p = .09
** p = .01
0
Def of Chronic Pain
Do Sickle Cell
Patients Have
Chronic Pain?
What is GI?
Mean Confidence/Attitude Score of
Composite Score
Mean Score
4
3.21 *
3
2.97
Pre
Post
2
1
P= 0.001
(1=Strongly Disagree to 4=Strongly Agree)
% of responses of
“Agree” and “Strongly Agree”
Results: Nurses’ Perspective on NonPharmacological Methods of Pain Control
100
73
60
40
92*
88*
80
54
Pre
Post
20
P < .002
0
Communicating With
Patients/Non
pharmacologic
Alternatives
Knowledge of Alt
Available Resources at
UCLA for Chronic Pain
Results: Perception of Treating Chronic Pain
100
96*
96
% of Respondents
95
90
85
85
Pre
Post
82
*p = .005
80
75
GOU Has an Effective
Plan for CP
I Have Adequate
Skills to Treat CP
Results: Perspective on Use of GI
100
100
97
% of Respondents
96
95
92
90
Pre
85
Post
80
75
Benefit RN/Patient
Relationship
GI is Effective for CP
Results: Nurses’ Knowledge and Skill in Using
Guided Imagery
80
70
% of Respondents
60
50
40
30
Pre-Education
20
Post-Education
10
0
Level of Skill/Knowledge
Results: Other Comments by Nurses
Results: Strategies to Consider in Managing
Patients Chronic Pain in the GOU
 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
Practice Outcomes
N=2
Patients Perception of GI
Intervention
 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
Barriers/Limitations to Continuing
Guided Imagery
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
RN Post Intervention Survey
 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
Conclusions
 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
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
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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