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RAJIV GANDHI UNIVERSITY OF HEALTH AND SCIENCES BANGALORE – KARNATAKA PERFORMA SYNOPSIS FOR REGISTRATION OF SUBJECT FOR DISSERTATION SUBMITTED BY: Mr.SUBIN KOCHUPARAMBIL 1ST YEAR.MSC. NURSING PSYCHIATRIC NURSING SNEHA COLLEGE OF NURSING 1 RAJIV GANDHI UNIVERSITY OF HEALTH AND SCIENCES BANGALORE – KARNATAKA PERFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION NAME OF THE CANDIDATE 1 AND ADDRESS 2 NAME OF THE INSTITUTION COURSE OF STUDY AND SUBJECT. DATE OF ADMISSION TO THE COURSE 3 4 Mr. SUBIN KOCHUPARAMBIL 1st YEAR MSC NURSING, SNEHA COLLEGE OF NURSING, BANGLORE. SNEHA COLLEGE OF NURSING 1ST YEAR M.Sc. NURSING PSYCHIATRIC NURSING 01/07/2011 “A STUDY TO ASSESS THE EFFECTIVENESS OF GUIDED IMAGERY IN THE REDUCTION OF STRESS AND PAIN AMONG ONCOLOGY PATIENTS FROM SELECTED HOSPITALS IN BANGLORE.” 5 TITLE OF THE TOPIC 6 Brief resume on intended work 6.1: Need for the study 6.2: Review of Literature 6.3: Objectives of the study 6.4: Hypothesis 7 Materials and Methods: 7.1: Sources of Data: Data will be collected from the HIV/AIDS patients admitted in selected rehabilitation center in Bangalore. 7.2: Method of Data Collection: Self administered questionnaire method 7.3: Does the study require any investigation or intervention to be carried out on the patients or human or animals? NO 7.4: Has ethical clearance been obtained? YES ENCLOSED ENCLOSED ENCLOSED ENCLOSED 2 6: BRIEF RESUME OF THE INTENTED WORK INTRODUCTION, “To look behind or to look up front is not as important as to look inside”- Randolf waldo The ability and power of the mind to help influence the body in healing is quite extraordinary, and at times, it seems unbelievable what can transpire with this powerful influence. The connection between the mind and physical health has been well documented and extensively studied. One among the application of those studies is mentioned as the therapeutic Guided Imagery, which will help us to tap into its powerful influence for cancer treatment and recovery.1 Imagery is said to be a relaxation technique, similar to meditation and self-hypnosis, that has physical and psychological effects. Promoters claim it can relax the mind and body by decreasing heart rate, lowering blood pressure, and altering brain waves. Some supporters also say that imagery can relieve pain and emotional anxiety, make drugs more effective, and provide emotional insights. Practitioners use imagery to treat people with phobias and depression, reduce stress and pain, increase motivation, promote relaxation, increase control over one’s life, improve communication, and even to help people stop smoking. Imagery is also used in biofeedback, hypnosis, and neuro-linguistic programming. For oncology patients, some supporters of imagery report that it can relieve nausea and vomiting from chemotherapy, relieve stress associated with having cancer, enhance the immune system, help with weight gain, combat depression, and lessen pain.2 Guided imagery is believed to have been used as a medical therapy for centuries. There is recorded evidence that Tibetan monks in the 13th and 14th centuries began meditating and 3 imagining that Buddha would cure diseases. Some say the techniques even go back to the ancient Babylonians, Greeks, and Romans. The Simonton’s popularized imagery therapies in a bestselling 1978 book titled Getting Well Again. The book described their experiences in treating oncology patients with imagery and other therapies.3 Guided imagery is also known as mind-body medicine, essentially because we are using our mind to affect the status of our body, this form of alternative therapy has two main objectives: Emotional conflicts due to negative life experiences can be shed from the conscious mind by teaching the individual to re-train their thoughts and feelings to a peaceful co-existence with the former bad experiences.4 Some commonly used types of guided imagery include; Relaxation imagery, which involves conjuring up pleasant, relaxing images that rest the mind and body. These may be experiences that have already happened, or new situations. In healing imagery, patients coping with diseases and injuries can imagine cancer cells dying, wound healing, and the body mending itself. Or, patients may picture themselves healthy, happy, and symptom-free. In Pain imagery, individuals can control pain through several imagery techniques.4 The simplest explanation of guided imagery as one of the types of alternative medicine is the principle of using your own positive reinforcement from the mind to improve your health and well-being. Guided Imagery has been called the language of the mind. It is a language that the mind can use to talk to the body, a language the body can understand immediately without question. It has also been described as the interface, or connection between the body and the mind because of the positive chemical and biological changes it can produce in the body. These changes are extremely useful in the successful treatment of and recovery from cancer.5 4 6.1:NEED FOR THE STUDY Over half of the patients diagnosed with cancer suffer from stress and pain. Often, analgesic medications do not completely relieve the pain and alternative measures are sought out for relief. Mind—body techniques such as guided imagery have been thought to be helpful and used as an adjuvant to pain relief. The studies performed from 2001 to 2008, which investigated the use of guided imagery for relief of cancer pain. Electronic databases were searched with the keywords cancer pain, visualization, and guided imagery, for any studies utilizing guided imagery with an outcome measure of pain. Five studies included pain as either a primary or a secondary outcome measure. In three of those, pain intensity and pain-related distress decreased in the guided imagery intervention versus control.6 While guided imagery cannot fight cancer itself, the technique may help to treat certain cancer-related complications. Although there are many different approaches to guided imagery, the technique often involves visualizing in a peaceful place. When used as an adjunct treatment for oncology patients (and other health conditions), guided imagery may also involve visualizing specific images associated with healing. Guided imagery appears to increase comfort and support psychological well-being in oncology patients, according to a research review of six clinical trials.7 Other studies on guided imagery and oncology patient care are:1) Guided Imagery and Cancer Pain 2)Guided Imagery and Mood and 3) Guided Imagery and Immune Response. 1) Guided Imagery and Cancer Pain In a pilot study of 62 hospitalized oncology patients currently experiencing pain, researchers found that using guided imagery audiotapes helped to reduce pain intensity. Study 5 results suggest that patients with greater visualization abilities may be more likely to experience pain reduction when using guided imagery.8 A study conducted in the University of Sydney in Australia observed that progressive muscle relaxation combined with guided imagery has the potential to promote relief of cancer pain. The techniques appear to produce a relaxation response that may break the pain-muscletension-stress and anxiety cycle and facilitate pain relief through a calming effect. This technique seems to provide a self-care strategy that, to a limited extent, shifts the locus of control from clinician to patient.9 2) Guided Imagery and Mood Guided imagery may help to boost mood and improve quality of life for oncology people , according to a study of eight people with a history of cancer. For 10 weeks, half the participants took part in weekly sessions that combined guided imagery and music. Compared to study subjects assigned to a waitlist, the treatment group experienced greater improvements in mood and quality of life.10 A study conducted to measure the effectiveness of customized guided imagery for increasing comfort in early stage cancer. They found that listening to a guided imagery audiotape once a day for the duration of the study indicated a significant overall increase in comfort over time, and was especially salient in the first three weeks of therapy.10 3) Guided Imagery and Immune Response Preliminary research indicates that guided imagery may improve immune response in oncology people. In a pilot study of 28 breast cancer patients, for instance, those who took part in a guided imagery and relaxation program prior to undergoing surgery experienced increased activity in natural killer cells which means it is known to play a key role in immune defense.11 6 Although there's no evidence that guided imagery can directly combat cancer, using guided imagery may be of some benefit to cancer patients, especially in terms of emotional health. This alternative therapy may also help to cope with cancer-related complications as well as the adverse effects of oncology treatments like radiation and chemotherapy.12 The researcher felt from his clinical experience that most of the cancer patients are vulnerable to severe stress and pain, which cannot be relieved by analgesics or other sedative drugs. Hence based upon the above information, the researcher felt that there is a need to create awareness among oncology patients about various aspects of imagery treatment in the reduction of stress and pain and to find out, up to what extend it is successive is reducing stress and pain among those patients, by conducting an experimental study among selected oncology institutes in Banglore. 6.2:REVIEW OF LITERATURE. Review of literature refers to the activities involved in identifying and searching for the information on a topic and developing and understanding it. It is a written summary to the state of an art on a research problem. Review of literature is an important step in research process. The review of literature on a topic of interest often prepared to put a research problem in context or as the basic for the implementation project. It helps to relate the findings from one study with a view to establish a comprehensive body of scientific knowledge in a professional discipline, from which valid and pertinent theories may be developed. A study conducted in a Cancer Hospital and Research Institute at Ohio State University in Columbus found that those patients using a chemotherapy-specific guided-imagery audiotape expressed a significantly more positive experience with chemotherapy, finding guided imagery 7 to be an effective intervention to promote patient involvement in self-care practices and to increase patient coping abilities during symptom occurrence.11 A study conducted in Walther Cancer Institute found that individuals who participated in guided imagery sessions scored better on both mood scores and quality of life scores than those who did not. Interestingly, these scores continued to improve in the experimental group, even after sessions were complete, indicating that guided imagery is effective in improving mood and quality of life in oncology patients.12 A study conducted in Ohio State University tried a self-hypnotic, cue-controlled relaxation, and guided imagery intervention that showed a marked and clinically significant reduction in nausea and vomiting as well as a concurrent increase in sleep duration in oncology patients.13 A study conducted by researchers at Ohio State University in Columbus, Ohio found that oncology patients who used imagery while receiving chemotherapy felt more relaxed, better prepared for their treatment and more positive about care than those who didn't use the technique. They also found it can help chemotherapy patients cope with one of the most severe side effects of their treatment.14 A study conducted in University School of Nursing in Baltimore, Maryland showed significant benefits from the use of information, cognitive restructuring, and relaxation with guided imagery in those patients with breast cancer who underwent autologous bone marrow/peripheral blood stem cell transplantation. This strategy was found to be effective in significantly reducing anxiety, nausea, and nausea combined with fatigue 7 days after surgery when the side effects of treatment are usually the most severe.15 8 A study conducted in the Center for Stress Management examined the effects of mental imagery on the immune system response, and specifically, on depressed white blood cell (WBC) counts. Results indicated significant increases in WBC count for all patients over a 90-day period, even when possessing disease and illnesses that would have predicted a decrease in WBC count.16 A study conducted by Danish researchers found increased natural killer cell activity among ten college students who imagined that their immune systems were becoming very effective. Natural killer cells are an important part of the immune system because they can recognize and destroy virus-infected cells, tumor cells and other invaders. A group of metastatic oncology patients using daily imagery for a year achieved significant improvements in natural killer cell activity and several other measures of immune functioning.17 A study conducted in the University of Miami found that 13 weeks of guided imagery and music showed significant decreases in cortisol level, the stress hormone which strongly correlated with mood disturbances, as well as demonstrating a significant reduction in depression, fatigue, and total mood disturbance.17 A study conducted in the Anderson cancer Center in Houston, TX observed a desire for and a benefit from patients being able to attach meaning to the disease and its treatment. They felt that this is why many are drawn to guided imagery as a tool in the management of oncologyrelated stress and pain by using it to reconnect to the self, to make sense of their experiences with breast cancer, and for managing oncology pain in a manner that increases ones sense of control, thereby alleviating the suffering of the survivor.18 Relaxation and guided imagery are useful strategies for cancer pain; however, their effects vary from patient to patient. Patients' perceptions of these treatments and factors that 9 contribute to their effectiveness have not previously been described. Data from interviews conducted after a trial of guided imagery and progressive muscle relaxation (PMR) interventions were analyzed to compare patients' perceptions of treatment effects with observed changes in pain scores, and to explore patients' ideas about factors that contributed to the effectiveness of each intervention. Post-study interviews were conducted with 26 hospitalized patients with cancer pain who had completed trials of guided imagery and progressive muscle relaxation. In most cases, participants' perceptions of treatment effects shown observed changes in pain scores. Participants described treatment and patient characteristics that influenced effectiveness of the interventions such as active involvement in the intervention, guided instructions, providing a source of distraction, stimulating relaxation, individual abilities and preferences, and pain qualities.19 STATEMENT OF THE PROBLEM “A STUDY TO ASSESS THE EFFECTIVENESS OF GUIDED IMAGERY IN THE REDUCTION OF STRESS AND PAIN AMONG ONCOLOGY PATIENTS IN SELECTED HOSPITALS IN BANGALORE.” 6.3:OBJECTIVES To identify the severity of stress and pain in oncology patients before and after the application of guided imagery To evaluate the effectiveness of guided imagery in the of patients by comparing the pre application and post application results. To identify the association between selected demographic variable and stress and pain. 10 6.4:HYPOTHESIS H0. - There will not be a significant association between selected socio demographic variables , stress and pain level among oncology patients. H1. There will be a significant association between selected socio demographic variables and level of stress and pain level among oncology patients. H2. There will be a significant difference between pre and post application of guided imagery in the reduction of stress and pain among oncology patients. 6.5:OPERATIONAL DEFINITION. Assess:- In this study it refers to an activity to measure the outcome by using structured interview schedule. Effectiveness:- In this study it refers to the outcome of imagery therapy upon stress and pain among selected oncology patients. Guided imagery:- Here it refers to the use of relaxation and mental visualization to improve mood and physical wellbeing. Oncology Patients:- In this study it refers to all the patients who are admitted for the treatment of cancer, in selected oncology institutes in Banglore. 6.6:ASSUMPTION The study is based on following assumptions : 1. Most of the oncology patients will have stress and pain. 2. After the application of guided imagery some changes may occur in their stress and pain level. 11 6.7:DELIMITATIONS OF THE STUDY. Data collection period will be limited to 4-6 weeks. Sample size will be limited to 50 patients. The study is limited to only selected hospitals in Bangalore. 7: MATERIALS AND METHODS OF STUDY. 7.1: SOURCE OF DATA COLLECTION:Oncology patients from selected hospitals in Banglore, Karnataka. 7.2: METHOD OF DATA COLLECTION Research design - Pre experimental, one group pre test post test study is planned for research study. Sample technique - Non probability convenient sampling. Population - Oncology patients from selected hospitals in Bangalore. Sample - Oncology patients from selected hospitals in Bangalore who have fulfilled the inclusion criteria. Sample size - 50 oncology patients from selected hospitals in Bangalore. Setting of the study - The study is planning to conduct in selected Oncology institutes in Bangalore. 12 Research variable Dependent variable - In this study the dependent variable is Stress and pain among oncology patients. Independent Variable - In this study independent variable is guided imagery in reduction of stress and pain among oncology patients. PROJECTED OUTCOME. This study will help the oncology patients to decrease their sufferings and cope up with the disease condition by the use of guided imagery. 7.2.1:CRITERIA FOR SELECTION OF SAMPLE. 1. Inclusive criteria:a) Male and female oncology patients from selected hospitals in Banglore. b) Oncology patients who are willing to participate. c) Oncology patients who understands either kannada or english. 2. Exclusive criteria:a) Male and female oncology patients those who are not willing to participate. b) Patients those who are not available at the time of study. 7.2.2: TOOLS OF RESEARCH Type of tool selected Section A:1. Socio demographic data sheet Section B:1. Cohen’s perceived stress scale 13 2. Numerical pain rating scale. 7.2.3: DATA COLLECTION Collection of data will be done by using a self administered questionnaire/structured interview schedule. 7.2.4: METHOD OF DATA ANALYSIS AND PRESENTATION Descriptive statistics - It includes percentage, frequency, mean and standard deviation. Inferential statistics - It include paired‘t’ test and chi-square test. 7.3: ETHICAL CONSIDERATION Does the Study Require Any Investigation OR Intervention to be Carried Out on Patients OR Other Humans OR Animals? No Has the ethical clearance being obtained from the institution? Yes 14 8 REFERENCES 1. Elizabeth scott.Use guided imagery for relaxation 2006:153-157. 2. Relaxation techniques: Learn ways to calm your stress May 2007:267-274.Available from www.mayoclinic. 3. Burt goldman. A short history of guided imagery 2007: 37-44. 4. Weil A, Martin Rossman.Self-Healing with Guided Imagery 2006;36:163-171. 5. Kwekkeboom KL, Wanta B, Bumpus M. Individual difference variables and the effects of progressive muscle relaxation and analgesic imagery interventions on cancer pain. J Pain Symptom Manage 2007: 386-391. 6. Rof Spencer JW, Jacobs JJ. Complementary/Alternative Medicine: An Evidence-Based Approach. 2005;22:368-381. 7. www.guidedimageryinc.com 8. Kwekkeboom KL, Kneip J, Pearson L. "A pilot study to predict success with guided imagery for cancer pain." Pain Manag Nurs. 2006:26-31. 9. Carulla Torrent J, et al. Oncologists’ perceptions of cancer pain management : the real and the idea. Eur J Pain. 2007;11:352–359. 10. Newell SA, Sanson-Fisher RW, Savolainen NJ. Systematic review of psychological therapies for oncology patients: overview and recommendations for future research.2009: 631-647. 11. University of South Florida College of Nursing, Tampa, FL 33612-4766, USA. [email protected]: Biol Res Nurs.Jan 2008;9(3):205-14 12. Rossman M .Imagery and cancer recovery 2008:47-52. 13. www.quantumjumping.com 15 14. Goudas LC, Bloch R, Gialeli-Goudas M, Lau J, Carr DB. The epidemiology of cancer pain. Cancer Invest. 2005:463-477. 15. Sarkar TK, Segar A, Walker LG. "Immuno-modulatory effects of relaxation training and guided imagery in women with locally advanced breast cancer undergoing multimodality therapy: a randomised controlled trial." Breast. 2009;5:87-91 16. Olness, K Imagery as adjunct therapy cancer:journal of Pediatric Hematology/Cancer;2007: 364-372 17. Walker LG, et al. Psychological, clinical and pathological effects of relaxation training and guided imagery. Br J Cancer.2005:876-883 18. Vainio A, Auvinen A. Prevalence of symptoms among patients with advanced cancer: An international collaborative study: Symptom prevalence group. J Manage. 2008;127:276–286. 19. Kwekkeboom KL Complement Ther Clin Pract.2008Aug;14(3):185-94 16 Pain Symptom