NRS 3012 Nursing Use of Guided Imagery Therapy for Patients with Chronic Pain

Chronic pain is the primary reason that patients with chronic diseases become sedentary, and the management of pain should be the primary concern of nurses caring for patients with chronic pain (CP) (Onieva-Zafra et al., 2015). Inadequately managed CP can result in difficulty with personal and recreational life activities and decreased quality of life (Baird et al., 2010), and is thus an issue of great importance to nursing. Although pharmacological interventions, such as analgesics, are commonly prescribed for CP reduction, many patients report adverse effects and financial burden with long term use (Baird et al., 2010).

NRS 3012 Nursing Use of Guided Imagery Therapy for Patients with Chronic Pain

Therefore, the implementation of non-pharmacological complementary and/or alternative interventions have been favored by nurses and patients, alike, for managing CP (Coelho et al., 2018), and one such intervention is guided imagery (GI) (Onieva-Zafra et al., 2015). GI is used as an adjunct to standard nursing care, and various nursing studies have supported it as a non-invasive therapeutic intervention which can effectively diminish pain intensity (Kwekkeboom et al., 2010). GI, defined as the intentional use of mental images and sensory attributes that are the result of imagination or memory to achieve a desired therapeutic goal, is now increasingly implemented in clinical nursing settings for CP management (Coelho et al., 2018).

The use of GI as a non-pharmacological nursing intervention is relevant to professional nursing practice because it is an effective independent nursing intervention that can improve patient outcomes at an affordable cost and it requires little effort for the patient (Coelho et al., 2018 NRS 3012 Nursing Use of Guided Imagery Therapy for Patients with Chronic Pain). The purpose of this paper is to write an empirically-based literature review related to the use of GI as a non-pharmacological nursing intervention and assess its effect on CP reduction among adult patients with chronic diseases.

Review of the Literature

In a study by Onieva-Zafra et al. (2015), the purpose was to evaluate the effects of a GI intervention on pain management and depression among patients diagnosed with fibromyalgia (FM). The sample consisted of 55 patients between the ages of 18 and 70 years, who were recruited from three FM associations established in the Southern Spanish cities of Cordoba, Granada, and Almeria.

The study design was a two-group quasi-experimental study with an experimental group (n=28) and a control group (n=27). Participants in the experimental group received an eight-week GI intervention led by the researchers in addition to standard nursing care. The control group received standard nursing care without GI. The method used consisted of using two CDs developed by the researchers, both lasted 15 minutes and were recorded using the same voice.

Patients were instructed to use the CD at home for at least four days during the first week and every day during subsequent weeks. They also received a notebook with the Visual Analogical Scale (VAS) to document their pain daily at bedtime. The data collected were pain and depression, both collected at the baseline, post intervention (4th week), and at the end of the study (8th week). Pain was assessed with the VAS on a 0-10 point numeric rating scale, and the McGill Pain Questionnaire Long Form (MPQ-LF) which was used to specify patients’ subjective pain experiences.

Depression was assessed using VAS, and the Beck Depression Inventory (BDI) which consists of 21 multiple-choice questions. For all scales, higher scores represented worse results. Demographic data, such as age, education, marital status, and gender were also collected. The results revealed that at the baseline there were no significant differences (p > .05) in the total pain or depression scores reported by either group. The mean pain scores measured by VAS pain (baseline/week4/week8) were 7.66/5.89/8.05 in the GI group and 7.71/7.97/8.75 in the control group, but they were not statistically significant (p = .134). However, 28 participants reported a significant reduction in pain (p = .046) at week four compared with baseline scores.

The mean pain scores measured by MPQ-LF sensory subscale (baseline/week4/week8) were 17.4/16.8/16.3 in the GI group and 16.8/19.2/20.6 in the control group, indicating significant pain reductions in the GI group (p = .048) by the eighth week. The mean depression scores measured by BDI (baseline/week4/week8) were 3.62/3.24/3.20 in the GI group and 3.62/3.66/3.66 in the control group, indicating depression improved significantly in the GI group at week four compared to baseline (p = .010) and at week eight versus week four (p =. 001).

However, when measured by VAS depression, the mean scores (baseline/week4/week8) were 6.48/4.34/4.37 in the GI group and 5/5.55/5.44 in the control group, indicating no significant improvements. The control group showed no significant changes from the baseline to week four. No significant between-group differences were noted for any demographic data. Onieva-Zafra et al. (2015) concluded that use of a complementary GI intervention was effective in relieving pain and depression compared to using standard care alone among patients diagnosed with FM.

In a study by Coelho et al. (2018), the purpose was to evaluate the effects of GI on pain, comfort, heart rate, and respiratory rate among patients receiving care in palliative care units (PCUs). The sample consisted of 26 patients, ages 45-93 years old, who were hospitalized in PCUs located in Portugal. The study design was a one-group, pretest-posttest, pre-experimental design. The method used consisted of a two-session GI program. Each session was personalized, lasting 17 minutes on average, and conducted within an interval of one or two days. Prior to the first session, all participants (n=26) chose an environment that they found most comforting to do the GI. The patient was invited to elaborate on a sequential set of mental images, focusing particularly on the sensory content of these scenarios through vision, hearing, smell and touch.

Then it was suggested to the patient by the researchers to imagine taking a walk, and meeting with someone special. After that, the patient was invited to leave the place and to bring with him/her what felt good, leaving the state of relaxation. Finally, it was suggested that the patient look at the PCU as a space where there are healthcare professionals who can help them feel comfortable. Same day pre- and post- procedural data were collected for both sessions. The data collected were comfort, pain, heart rate, and respiratory rate. Data were collected using the Holistic Comfort Questionnaire-Portuguese-Doentes Cronicos (chronic patients) (HCQ-PT-DC), an instrument designed to measure holistic comfort among patients at the end of life.

The scale is composed of 26 affirmations (19 items for this study due to the fragility of the participants) with responses on a Likert-type scale from 1 (“I strongly agree”) to 5 (“I strongly disagree”), higher scale scores correspond to a higher level of comfort. The visual analog comfort scale (VAS) and the visual analog pain scale (VAS) were used to quantify the participants’ comfort and pain intensity. Both VAS scales are a straight line, 10 cm in length, and each participant was asked to indicate on the line the point that best described his/her level of comfort/pain. The evaluation of heart rate was conducted through the radial pulse palpation, and respiratory rate was conducted by observing the movements of the thoracic wall.

Demographic data such as gender, education, marital status, age, diagnosis and days of hospitalization were also collected. The results indicated that the GI intervention significantly increased the participants’ (n=26) comfort with a large effect size (r) in comparison to baseline scores as measured by HCQ-PT-DC (z = -4.46,
p < .001, r = 0.62) and measured by the VAS comfort (z = -4.49, p < .001, r = 0.62). All participants reported a significant decrease in pain with a large effect size (z = -4.48, p < .001,
r = 0.62). This same pattern was observed with heart rate (z= -4.46, p  < .001, r = 0.62). Moreover, 96.15% of the participants showed a significant decrease in respiratory rate with a large effect size (z= -4.40, p < .001, r = 0.61). No significant between-group differences were noted in any demographic data. Coelho et al. (2018) concluded that the use of GI significantly improves the comfort of patients in PCUs and decreases pain, heart rate, and respiratory rate.


In summary, the literature reviewed indicated that using GI as a nursing intervention led to decreased pain and depression among adult patients with FM (Onieva-Zafra et al., 2015). The literature also showed a statistically significant increase in comfort, decrease in pain, heart rate and respiratory rate when GI were individualized among PCU patients receiving the interventions (Coelho et al., 2018). Both studies had congruent findings that supported the incorporation of GI as a nursing intervention that resulted in positive patient outcomes.

Nursing Implications

The nursing implications related to the use of GI as a nursing intervention for alleviation of pain among adults with CP are numerous. Nurses need to assess patients with chronic illnesses for pain throughout their care, because CP affects their general state, physiological and psychologically (Onieva-Zafra et al., 2015). Nurses must develop an appropriate nursing diagnosis, such as CP, based on each patient’s assessment data in order to facilitate management of their physical and psychological symptoms (Kwekkeboom et al., 2010). Following the establishment of an appropriate nursing diagnosis, nurses should develop a care plan that includes GI as a complementary intervention to manage CP, as it is economically-affordable, easy to implement and can be used without great investment or training (Onieva-Zafra et al., 2015).

Nurses have a responsibility to provide high quality care to patients, which includes the management and alleviation of CP (Onieva-Zafra et al., 2015). GI as a non-pharmacological intervention used as an adjunct to standard nursing care has been shown to be effective in alleviating CP and depression in adult patients with chronic diseases (Onieva-Zafra et al., 2015). GI has been found not only to decrease pain levels in patients suffering from chronic diseases, but also to increase comfort levels (Coelho et al., 2018).

Physiological responses have also been noted among participants, including decreased heart rate and respiratory rate (Coelho et al., 2018). Therefore, in order to reduce and manage CP, nurses should implement GI as an evidence-based intervention when the assessment data indicates patients are experiencing CP and it is appropriate to the patient’s individualized care plan.

Furthermore, it is important for the nurse to evaluate the effectiveness of GI interventions in reducing pain and if needed the nurse should incorporate additional patient-centered pain relief interventions. Future nursing research is needed to minimize other factors that could have influenced the outcomes of the GI studies, such as home environment, family supports and social status. Both studies used a quasi-experimental design, however, because of the small sample sizes, future research would benefit from larger samples and other patient populations to create more conclusive evidence regarding the benefits of GI as a nursing intervention for CP management.


In conclusion, pain management for patients with chronic diseases is one of the most important aspects of the care provided by a nurse (Onieva-Zafra et al., 2015). Nurses have a responsibility to provide high quality patient care, and the goals of CP management are to improve patient comfort and their quality of life (Onieva-Zafra et al., 2015).

GI is a non-invasive and inexpensive therapeutic intervention. Nurses can use GI as a non-pharmacological nursing intervention in adjunct to standard care for the management of CP (Onieva-Zafra et al., 2015 NRS 3012 Nursing Use of Guided Imagery Therapy for Patients with Chronic Pain). By implementing evidence-based GI interventions to alleviate CP for patients with chronic disease, nurses can significantly improve patients’ physiological and psychological outcomes.

NRS 3012 Nursing Use of Guided Imagery Therapy for Patients with Chronic Pain References

  • Baird, C. L., Murawski, M. M., & Wu, J. (2010). Efficacy of guided imagery with relaxation for osteoarthritis symptoms and medication intake. Pain Management Nursing, 11(1), 56–65.
  • Coelho, A., Parola, V., Sandgren, A., Fernandes, O., Kolcaba, K., & Apóstolo, J. (2018). The effects of guided imagery on comfort in palliative care.
  • Kwekkeboom, K. L., Abbott-Anderson, K., & Wanta, B. (2010). Feasibility of a patient-controlled cognitive-behavioral intervention for pain, fatigue, and sleep disturbance in cancer. Oncology Nursing Forum, 37(3), E151-E159.
  • Onieva-Zafra, M. D., García, L. H., & Del Valle, M. G. (2015). Effectiveness of guided imagery relaxation on levels of pain and depression in patients diagnosed with fibromyalgia. Holistic Nursing Practice, 29(1), 13–21.

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