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“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.