evidence based guideline for use of audio pain-centered guided imagery as an adjunct for the...
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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