Integrative Imagery and Surgery Preparation
Integrative Imagery and Surgery Preparation
By Terry Miller Reed, RN, MS, HNC
It is often thought that medicine is the curative process. It is no such thing; medicine is the surgery of functions, as surgery proper is that of limbs and organs. Neither can do anything but remove obstructions; neither can cure; nature alone cures. Surgery removes the bullet out of the limb, which is an obstruction to cure, but nature heals the wound. . . . Medicine, so far as we know, assists nature to remove the obstruction, but does nothing more. And what nursing has to do in either case, is to put the patient in the best condition for nature to act upon him.
Florence Nightingale, 1860
Imagery is a perfect example of the mind-body connection. Imagine biting down on a wedge of lemon. Feel the juice squirt inside your mouth. Now swallow the lemon juice. Did you get a sour taste in your mouth, or did you start to salivate? Many people do. This example demonstrates how imagery works. The body doesn’t distinguish between biting into the lemon and imagining biting into the lemon—the same physiological response occurs. So it follows that a person choosing to direct her mind toward some beneficial result, as opposed to worrying, can activate the healing response.
Imagery is not new. It is a natural, everyday process, a flow of thoughts that can be experienced with all of the senses, not only with the visual sense. When worrying or fantasizing, the mind uses imagery. In the words of Dr. Martin Rossman, "Imagery is a window on your inner world, a way of viewing your own ideas, feelings, and interpretations."1
Both guided imagery and integrative imagery are therapeutic and beneficial, but differ in approach and depth of mind-body interaction. Whereas guided imagery is prescripted, integrative imagery takes the process to an even deeper level by eliciting and working with a patient’s own images, both positive and negative. This process is most often facilitated by a health care practitioner specifically trained in imagery techniques. For example, prior to surgery a nurse can help prepare an anxious patient by asking the patient to bring to mind a healing image and then assisting the patient to interact with the image, often in dialogue. In one case, a patient was able to see his white blood cells as cats stalking their prey and to request that they be vigilant throughout the surgery. Individualizing the imagery process in this way allows patients to participate in their own healing.
Clinical Research
In addition to the stress the body experiences during surgical intervention, the procedure itself can be emotionally stressful. Studies have shown that when psychological or physical stress is marked or overly prolonged, hypersecretion of cortisol by the autonomic nervous system precipitates a state of protein depletion and negative nitrogen balance.2 These catabolic influences can adversely affect surgical wound healing rate and quality.3 The following imagery studies show improved outcomes on wound healing, length of hospital stay, pain, anxiety, and medication use.
In a prospective, randomized trial at Columbia Presbyterian Medical Center, researchers studied 32 patients admitted for first-time elective coronary artery bypass surgery between September 1994 and March 1995.4,5 Members of the experimental group were taught imagery and relaxation techniques; the control group received standard care. The patients in the experimental group were significantly more relaxed postoperatively compared to the control group. Patients who practiced their imagery and relaxation exercises used significantly less pain medication than those who were noncompliant. There were no significant differences between the groups on intra-operative parameters, length of stay, morbidity, or mortality.
In a study of patients undergoing elective colorectal surgery at the Cleveland Clinic, an experimental group used audiotapes of a "Special Place" imagery technique for the three days prior to and the six days following surgery.6 As compared to the control group (n = 65), the experimental group (n = 65) showed a 50% reduction in postoperative narcotic use, 50% reduction in time to return of bowel function, and a 1.5-day (from 7.9 to 6.4 days) reduction in average length of stay.
Finally, in a study of 51 patients undergoing colorectal or anal surgery, Manyande et al randomly assigned patients to audio imagery tapes or an audiotape of general hospital information.7 Results demonstrated lower cortisol levels in the imagery group than in the control group both pre- and postoperatively. Heart rate reached a lower maximum in the imagery group than in the control group during surgery (68.1 vs. 82.3; P = 0.01). The imagery group experienced less postoperative pain, were less distressed, felt they coped better, and requested less pain medication than the control group.
Adverse Effects
When applied appropriately, imagery techniques are safe and offer great benefit. However, the use of imagery does engage the patient’s imagination and can affect the psyche in complex ways. Not all patients are ideally suited for this type of intervention. It has been reported that imagery use has had a significant destabilizing psychological effect or "abreaction" in some situations.8
Value of Imagery
The use of imagery and relaxation in preparation for surgery should include the entire perioperative continuum. First and foremost, imagery reduces patient anxiety and pain. By using integrative imagery preoperatively, a patient experiences how imagery works and which specific images and interactions are needed to catalyze his full healing potential. In addition, preoperative use of imagery strengthens a patient’s belief in this self-care tool and offers a means of controlling surgical outcomes. The establishment of an "inner healer" also strengthens a patient’s ability to access his own healing power for present and future self-care. Other benefits include the minimal side effects of imagery use, enhanced quality of life, accelerated healing, and consequently, earlier return to normal activities.
There also are benefits for providers, third-party payors, hospitals, and free-standing surgery facilities. Fewer complications, decreased length of stay, and patient satisfaction represent documented outcomes of imagery use.
Finally, many nurses who use imagery report a decrease in personal burnout as they apply this tool to potentiate healing in their patients and themselves.
Fiscal Considerations
The capital investment necessary to establish an integrative imagery program is minimal, but would include the purchase of several audiotape players. Grants such as those available through the National Center for Complementary and Alternative Medicine are available to offset this expense.9
Once an integrative imagery program is implemented, there is very little need for additional resources since the patient uses audiotapes throughout the perioperative period. (For more information, see "An Integrative Imagery Template for Perioperative Nursing" below.) Use of a clinical pathway prompts hospital staff to reinforce the patient’s plan thus reducing the need to train in-house staff. The primary budgetary impact is the cost of two preoperative sessions with a nurse trained in integrative imagery. Holistic modalities using energy, acupressure, music, or acupuncture also can be incorporated. Complimentary imagery sessions can be offered as an incentive for patients to develop self-care tools.
Conclusion
Health care is changing in dramatic ways and so is the role of nursing. A critical question to consider was asked by Florence Nightingale: ". . . Are we walking to the future, or to the past?"10 The use of imagery as described in this article is presently on the cutting edge for nursing. It is safe when used appropriately, it is time- and cost-effective, it focuses on patient satisfaction, and it is often fun. Perhaps, most importantly, imagery offers nurses and patients a path to self-empowerment. In the words of Jane Giedt, RN, PhD, "Guided imagery is especially applicable to holistic nursing practice because it acknowledges the wholeness of the person both in practicing the strategy and in evaluating the effects. Guided imagery is an independent nursing intervention that can be provided for any person able to perform the techniques."11
Ms. Miller Reed is the co-founder and co-director of the Nurses Certificate Program in Imagery, sponsored by the American Holistic Nurses’ Association, and has an imagery and stress management practice in Foster City, CA.
References
1. Rossman M. Healing Yourself: Step-by-Step Program for Better Health Through Imagery. New York: Awareness Press; 1987.
2. Guyton AC. Human Physiology and Mechanisms of Disease. 34th ed. Philadelphia, PA: WB Sanders Co.; 1982.
3. Schilling J. Wound healing. Surgical Rounds 1983;7:46-62.
4. Ashton C Jr., et al. Self-hypnosis reduces anxiety following coronary artery bypass surgery. A prospective, randomized trial. J Cardiovasc Surg 1997;38:69-75.
5. Oz M. Healing from the Heart. New York: EP Dutton; 1998.
6. Tusek D. Guided imagery as a coping strategy for perioperative patients. AORN 1997;66:644-649.
7. Manyande A, et al. Preoperative rehearsal of active coping imagery influences subjective and hormonal responses to abdominal surgery. Psychosom Med 1995;57:177-182.
8. Hammond DC. Handbook of Hypnotic Suggestions and Metaphors. New York: WW Norton & Co.; 1990.
9. National Center for Complementary and Alternative Medicine. Available at: http://nccam.nih.gov. Accessed April 3, 2000.
10. Halo Shames K. The Nightingale Conspiracy: Nursing Comes to Power in the 21st Century. New York: Enlightenment Press; 1993.
11. Giedt J. A psychoneuroimmunological intervention in holistic nursing practice. J Holist Nurs 1997;15:112-127.
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