A study to evaluate the effectiveness of guided imagery on reduction of anxiety among selected pre-operative patients admitted at SDM hospital Dharwad

 Corresponding author: Somashekhar. Ramappa. Kodliwad. Copyright © 2025 Author(s) retain the copyright of this article. This article is published under the terms of the Creative Commons Attribution Liscense 4.0. A study to evaluate the effectiveness of guided imagery on reduction of anxiety among selected pre-operative patients admitted at SDM hospital Dharwad Somashekhar. Ramappa. Kodliwad * Assistant Professor, Department of Adult Health Nursing, SDM Institute of Nursing Sciences Sattur, Dharwad. World Journal of Biology Pharmacy and Health Sciences, 2025, 21(01), 779-794 Publication history: Received on 19 December 2024; revised on 28 January 2025; accepted on 31 January 2025 Article DOI: https://doi.org/10.30574/wjbphs.2025.21.1.0110 Abstract “A study to evaluate the effectiveness of guided imagery on reduction of anxiety among selected preoperative patients admitted at SDM hospital Dharwad”. Background of the study: Guided imagery is a mind body intervention by which a trained practitioner or teacher helps a participant to evoke and generate mental images that stimulate or recreate the sensory perception of sights, sounds, tastes and images associated with touch. In the use of guided imagery, the therapist and client develop imagery scenes that produce feelings of calmness, tranquility, or pleasure for the client. It is critical that the therapist consult with the client as to the appropriateness of scenes, as a scene thought to be calming may not be relaxing to a particular individual. Purpose: To evaluate the effectiveness of guided imagery on reduction of anxiety among selected preoperative patients. Methodology: An evaluative approach was adopted for this study with pre-experimental one group pre and posttest design. By non-probability convenience sampling technique. 40 preoperative elective abdominal surgery patients were selected. Modified Hamilton Anxiety Scale was used to collect the data and collected data was analyzed by descriptive and inferential statistics. Results: The results of the study showed that pre-test level of anxiety of elective abdominal surgery patients was 12 (30%) of them had mild level of anxiety, 28 (70.00%) had severe level anxiety. In pretest the mean score was ±30.77 and SD was± 4.58 whereas the mean post-test score was ±12.82 and SD was ±4.04. The calculated ‘ t ’ value was ±21.88 which was higher than the table value i.e.2.02 which w a s s i g n i f i c a n t at p ≤0.05 level. Hence the research hypothesis was accepted. Conclusion: The study concludes that Guided Imagery Technique was effective in reduction of anxiety among preoperative elective abdominal surgery patients. Keywords: Anxiety; Perception; Imagery; Evaluate; Surgery; Significant 1. Introduction Anxiety is described as an unpleasant state of uneasiness or tension, which may be associated with abnormal hemodynamics as a consequence of sympathetic, parasympathetic and endocrine stimulation. Hospitalization is a critical negative life events that lead to the experience of considerable anxiety in patients may perceive on the day of surgery as the biggest and the most threatening day in their lives. The burden of emotional states such as anxiety, depression and stress in people undergoing surgery is in disputable. Preoperative anxiety is a common reaction World Journal of Biology Pharmacy and Health Sciences, 2025, 21(01), 779-794 780 experienced by patients who are admitted to the hospital for surgery. The unpleasantness is as a result of patients fear and doubts before surgery. Physically, preoperative anxiety can lead to many complications and risks related to surgery such as increased heart rate, blood pressure, palpitation, vasoconstriction, nausea, vomiting, and cardio pulmonary changes leading to need for more anesthesia during surgery and analgesics after surgery have been reported .In addition, patients also become so nervous and apprehensive that they are unable to understand or follow simple instructions, prolonged postoperative recovery and is linked to hospital stays. Those of negative effects may increase treatment costs and might become a burden to patient and their families. Moreover, preoperative anxiety leads to high risks of morbidity and mortality in patients. The patients who are hospitalized for surgery, experiences anxiety. Preoperative Anxiety also affects the patient’s perception of postoperative pain and has a negative impact on recovery from anesthesia. Management of preoperative anxiety is one of the challenges faced by the nurse and also responsibility to make an attempt to reduce it so as to enable patient to feel hospitalization and surgery a pleasant experience. The reduction of anxiety can be managed by nonpharmacological agent such as guided imagery. Guided imagery is a mind body intervention by which a trained practitioner or teacher helps a participant or patient to evoke and generate mental images that stimulate or recreate the sensory perception of sights, sounds, tastes, and images associated with touch. In the use of guided imagery, the therapist and client develop imagery scenes that produce feelings of calmness, tranquility, or pleasure for the client. It is critical that the therapist consult with the client as to the appropriateness of scenes, as a scene thought to be calming may not be relaxing to a particular individual. The scenes are embellished with as much sensory detail as possible, both to make the imagery seem more real and to completely involve or “absorb” the client in the experience. Note the sensory detail in these scene instructions: Close your eyes, sit back, take a few deep breaths, and relax. While your eyes remain closed, sitting in the chair and feeling relaxed, think about yourself on a tropical island. Make this image as real as possible, as if you really are there. As you look up, there are a few wispy clouds scattered across the brilliant blue sky. The turquoise ocean tumbles toward the shore in gentle, foam-capped waves. Gulls fly overhead; you hear their distant squawks. You feel the bright, warm rays of sun over your entire body and the light breeze blowing over your skin. You taste the salt from the air, as the wind blows in from the water. Walking along the beach, you encounter pleasing flowery scents from the nearby groves of tropical trees5. It has positive effect on heart rate, blood pressure, breathing and oxygen rates, brain waves, temperature and hormone balance. Guided imagery help, to relieve symptoms caused or made worse by stress, and anxiety. 2. Significance and need for study Nursing involves being a competent practioner in the physical social and psychological care of the patient in the preventive, promotive, curative and rehabilitative spheres. This also applies to preoperative nursing care which has more bearing on postoperative outcome of the patient. The need to promote psychological well-being of the patient and prevent psychological factors which may influence the patient adverse. Anxiety is an emotional state characterized by apprehension and fear resulting from the anticipation of a threatening event. The incidence of preoperative anxiety ranges from 11% to 80% in adult patients and also varies among different surgical groups. Preoperative anxiety may lead to various problems and a wide range of physiological and psychological responses, such as autonomic fluctuations, delayed jaw relaxation and coughing during induction of anesthesia, and increased an aesthetic requirement. In addition, it also has been correlated with increased pain, nausea, and vomiting in the postoperative period, prolonged recovery, and increased the risk of infection. A wide range of responses may be caused by anxiety such as physiological responses include tachycardia, hypertension, elevated temperature, sweating, nausea and psychological responses include changes in behavior such as increased tension, nervousness, and aggression. Many studies have revealed that a significant number of adult patients undergoing surgical procedures experienced high levels of preoperative anxiety. In a study of patients scheduled for neurosurgery, the frequency of preoperative anxiety is high that is 89% with around 60% to 90% of all surgical patients in the Western population compare to other surgeries. According to Indian study the incidences of preoperative anxiety have been reported up to 11 percent to 80 percent of adult patients. High preoperative anxiety levels may lead to increased postoperative analgesic requirement, prolonged World Journal of Biology Pharmacy and Health Sciences, 2025, 21(01), 779-794 781 hospital stay and significant contribution to adverse Perioperative outcome and poor patient satisfaction, so most surgeons postpone operations in cases with high anxiety. Therefore it’s necessary to prevent and reduce the anxiety among preoperative patients with certain non-pharmacological techniques like guided imagery. Another finding of study conducted in safdarjung hospital, New Delhi, India, showed that females were significantly more anxious than male on the day of surgery and their anxiety began sooner, during waiting for the surgery, significant symptoms of depression due to fear, worries, and uncertainties about surgery were experienced. A long time waiting for surgery with little information caused the preoperative anxiety2. The incidence of preoperative anxiety was also reported in Karnataka which is as high as 60 percent of surgical patients, according to survey 450 patients are involved in that study. Fear regarding anesthesia was reported in 34.4 percent in women and 17.7 percent in men whereas fear regarding surgery was stated as 24.2 percent in women and 21 percent in men. Various steps have been taken to reduce preoperative anxiety. Sedative, premedication are routinely administered to reduce preoperative anxiety. However, sedatives have their own side effects which can be minimized by the use of nonpharmacological intervention such as Guided imagery. Guided imagery is a natural treatment giving to reduce the anxiety, fear and insomnia that accompanies surgery. The benefits of guided imagery include anxiety reduction, decreased muscle tone, improved comfort during medical procedures, improvement in immune system, decreased recovery time following surgery, and reduction in sleeping problems. There are high degrees of preoperative anxiety in patients scheduled for surgery. Perioperative anxiety is often overlooked but it is associated with poor surgical outcome. Preoperative use of Guided imagery techniques with proper education regarding surgery will help in reducing anxiety and improving the quality of care. Nurses are able to understand the factors related to preoperative anxiety is the first step to improve the quality of preoperative nursing care. Nurses must concentrate not only on physical and physiological factors but also psychological and emotional factors. Through guided imagery technique nurse can reduce the anxiety of the patient. Hence, it is necessary to conduct this study in Hospital. Anticipating surgery can be stressful and many patients suffer from preoperative anxiety, which can cause serious health complications such as hypertension, rapid pulse and sugar metabolism changes. Israeli researchers from the University of Haifa have found that complementary medicine, combined with standard use of anti-anxiety drugs prior to entering the operating room can significantly reduce preoperative anxiety levels and improve outcomes. Objectives of the study • To assess the level of anxiety among selected preoperative patients. • To determine the effectiveness of guided imagery on anxiety among preoperative patients • To find an association between preintervention level of anxiety of preoperative patients and selected demographic variables 2.1. Hypotheses 2.1.1. Hypotheses of the study are tested at 0.05 level of significance. • H1 – There is a significant reduction in preoperative anxiety among patients undergoing surgery after implementation of the guided imagery. • H2 - There is a significant association between preintervention level of anxiety of preoperative patients and selected demographic variables 2.2. Assumptions 2.2.1. The assumptions of the study are • The physical and physiological care of patients undergoing surgery has been preferred but the psychological aspects of care have to greater or lesser extent been neglected. Hence invariably all the patients undergoing surgery experience anxiety. • Pre-operative patient’s anxiety may trigger complications during post-operative period. World Journal of Biology Pharmacy and Health Sciences, 2025, 21(01), 779-794 782 • Guided imagery technique may be an effective technique in reducing anxiety among preoperative patients, where nurses can practice it and does not produce any side effects on the patients practicing it. 2.3. Delimitations 2.3.1. The study is delimited to, • Patients admitted in SDM hospital, surgical wards for elective abdominal surgeries. • Selected preoperative patients who are having mild to moderate anxiety. 2.4. Conceptual frame work The conceptual framework selected for this study was based on Modified Rosemarie Rizzo Parse Human becoming School of thoughts nursing theory. The human becoming school of thought posits quality of life from each person’s own perspective as the goal of nursing practice states that the nurses who’s practical is “guided by the human becoming. Theory lives the process of the parse practice methodology by illuminating meaning, synchronizing rhythms, and mobilizing transcendence. Research guided by the human becoming theory explores the meaning of universal humanly lived experiences such as hope, taking life day-by-day, grieving, suffering and time passing. Here the nurse would guide individuals and/ or families to plan for the changing of lived health patterns. 3. Methodology 3.1. Research approach In the present study quantitative evaluative approach was used to find the effectiveness of guided imagery on reduction of anxiety among selected preoperative patients. 3.2. Research design The research design of a study throw lights on the basic strategies that researcher adopt to answer the questions and test the hypotheses. It studies the observable changes that take place in order to establish the cause-and-effect relationship. It directs the selection of a population for the study, procedures for sampling, and methods for measurements and plans for data collection and analysis. Pre experimental one group pre and post-test research design is used for this study. Group E (Patients undergoing elective abdominal surgeries in SDM Hospital) O1 X O2 Figure 1 Schematic representation of research design. 3.2.1. KEY • E = Experimental group • X = intervention (Guided imagery). • O1 = Observation before the guided imagery. • O2 = Observation after the guided imagery. 3.3. Variables under the study In quantitative studies, concepts are usually, referred to as variables which may be qualities, properties or characteristics of person, things or situation that can change or vary. A variable is any phenomenon or attitude under study. World Journal of Biology Pharmacy and Health Sciences, 2025, 21(01), 779-794 783 3.3.1. In this study variables are • Independent variable: Guided imagery. • Dependent variable: Anxiety of preoperative elective abdominal surgery patients. 3.3.2. Setting of the study The study was conducted in selected surgical wards of SDM Hospital, Dharwad. 3.3.3. Population In the present study the population consisted of preoperative elective abdominal surgery patients. 3.3.4. Target population In the present study target population consisted of preoperative patients undergoing elective abdominal surgery. 3.4. Sample In this study samples consisted of preoperative patient undergoing elective abdominal surgery admitted in surgical ward of S.D.M. Hospital Dharwad. 3.4.1. Sample size In the present study the sample consisted of 40 preoperative patients who were undergoing elective abdominal surgery admitted in the surgical wards of SDM Hospital Dharwad. 3.4.2. Sampling technique In this study non probability, convenience sampling technique was used to select 40 preoperative patients undergoing elective abdominal surgery. 3.4.3. Sampling criteria 3.5. The criteria for selection of sample in this study are 3.5.1. Inclusion criteria In the present study inclusion criteria are • Patients who are undergoing abdominal surgeries. • Patients who are willing to participate in guided imagery. • Those who are present and available at the time of data collection. • Patients who are admitted in surgical wards. 3.5.2. Exclusion criteria Sampling characteristics that can cause person or element to excluded from the target population are, • Patients who are critically ill. • Patients who are diagnosed with severe anxiety disorder. 3.6. Development and description of the tool The most important aspect of any investigation is collection of appropriate information which will provide necessary information provide an answer to the research question in the study. A data collection instrument or tool is a formal document used to collect and record information. An instrument used in research should be the best to obtain the data for drawing conclusions which are pertinent to the study and at the same time add the knowledge in the discipline. In this study a modified Hamilton Anxiety Scale was used to assess the level of anxiety regarding elective abdominal surgery among pr-operative patients. World Journal of Biology Pharmacy and Health Sciences, 2025, 21(01), 779-794 784 3.6.1. The tool was modified by the investigator based on • Research problem • Extensive review of related literature • Discussion and suggestion from the Guide and experts • Clinical experiences 3.6.2. Tool was developed based on the following points • Modified Hamilton anxiety scale to assess the pre and post intervention le v e l of anxiety among the preoperative patients. • Socio demographic proforma of participants • Systemic development of guided imagery audio recording developed by the investigator with the help of guided imagery training and known expert guidance and opinions. 3.6.3. Description, Scoring and Interpretation of tool: Hamilton anxiety scale was a standard tool developed by Hamilton which is four-point Scale, consists of 14items; this standard tool was modified as for the guidance of the research expert so as to achieve the intended objective of the study. The tool consisted of 14 questions related to the feelings experienced by the preoperative patients. There are four alternative response columns; for each question like Not present, mild, moderate and severe about the anxiety. Among 14items all 14 were positively worded hence scored as; 0, 1, 2, and 3 respectively. The total modified Hamilton anxiety score ranges from 042. 3.6.4. The Score was interpreted as follows: • Mild anxiety = 00-14 • Moderate anxiety = 15-28 • Severe anxiety = 2942 3.7. Testing of the tool 3.7.1. Content validity of the Tool Content validity examines the extent to which the measurement includes all the major elements relevant to the construct being measured. The developed tool with the objectives and entire content was given to seven experts from the M edical Surgical Nursing Department, C linical P sychologist and Statistician. The final tool was prepared as per the suggestions & advices given by the experts. Modifications were made based on the recommendations and suggestion of experts. After consulting guide and statistician, the final tool was refined and reframed. It was found to be valid and suitable for current study. 3.7.2. Pilot study The pilot study was conducted at SDMCMS & Hospital, Dharwad. Formal permission was obtained from the authorities and purpose of the study was explained to the subjects and confidentiality was assured. Written consent was obtained from subjects to participate in the study. Subjects are selected by nonprobability convenience sampling technique. On the first day, pre-test was done for the group by assessing Hamilton anxiety scale. On the same day, Guided Imagery interventions of preoperative patients were administered followed by the post test on 3rd day. The tool and study design were found to be feasible and practicable. Data analysis was done by using descriptive and inferential statistics. 3.7.3. Reliability of the tool The reliability of the tool was established by using test –retest method. (Karl Pearson coefficient of correlation method) which measure the co-efficient of internal consistency. The reliability coefficient “r” value of modified Hamilton anxiety scale regarding preoperative anxiety with the elective abdominal surgery interventions of guided imagery was 0.91, and developed tool found to be reliable World Journal of Biology Pharmacy and Health Sciences, 2025, 21(01), 779-794 785 3.7.4. Data collection method The study was conducted in SDMCMS & Hospital Dharwad. The data was collected, prior to data collection permission was obtained from the concerned authorities. The data collection procedure carried out by the researcher. 3.7.5. Steps followed in data collection process: • Subject are collected according to the selection criteria and assured the confidentiality of the sample • Written consent was obtained from subjects to participate in the study • Samples are selected by non-probability convenient sampling technique • On the first day, pre-test was done for the group with Modified Hamilton Anxiety Scale • On the same day guided imagery technique was administered to the group followed by the post test on 3rd day (just before the surgery). With the same scale. 3.7.6. Plan for data analysis Following steps were carried out while the collection of data was processed the expert advice and direction of statistician was sought. • Organized data in master sheet. • Computed frequency and percentage to be used for analysis of baseline data. • Mean and standard deviation for the obtained score were calculated. • Paired “t” test was used to evaluate the effective role of guided imagery on anxiety among preoperative patients. Yeates correction for chi-square (X2) test was used to find out the association between level of anxiety of preoperative patients score and selected demographic variables. 4. Results The data were collected from sample of 40 preoperative patients admitted in surgical wards by using modified Hamilton anxiety scale to evaluate the effectiveness of guided Imagery. The data, which are necessary for the study, were collected through Modified Hamilton anxiety scale and analysed by using relevant descriptive and inferential statistics. 4.1. The data were analysed on the basis of objectives of the study • To assess the level of anxiety among selected preoperative patients. • To determine the effectiveness of guided imagery on anxiety among preoperative patients • To find an association between preintervention level of anxiety of preoperative patients and selected demographic variables 4.2. Organization of the findings 4.2.1. The data is organized and presented under the following sections • Section 1: frequency and percentage distribution of subjects according to the demographic variables • Section 2: Pre-test level of anxiety score of preoperative patients undergoing elective abdominal surgery • Section 3: Post-test level of anxiety score of preoperative patients undergoing elective abdominal surgery • Section 4: Comparison of mean pre-test and post-test level of anxiety scores to evaluate the effectiveness of Guided Imagery technique. • Section 5: Association between pre-test level of anxiety of preoperative patient’s undergoing elective abdominal surgery and selected demographic variables. World Journal of Biology Pharmacy and Health Sciences, 2025, 21(01), 779-794 786 4.3. Section 1: frequency and percentage distribution of subjects according to the demographic variables Table 1 Frequency and percentage distribution of preoperative patients [n=40] Sr.No Demographic Variables Frequency Percentage 01 Age (In Years) a) 30-40 11 27.5 b) 41-50 09 22.5 c) 51-60 10 25 d) above 60 10 25 02 Gender a ) Male 26 65 b) Female 14 35 03 Religion a) Hindu 34 85 b) Christian 01 2.5 c) Muslim 05 12.5 d) Others 00 00 04 Marital Status a) Married 33 82.5 b) Unmarried 05 12.5 c) Widow 00 00 d) Widower 02 5 05 Educational Qualification a) Informal 06 15 b) Primary 17 42.5 c) Secondary 08 20 d) Degree 09 22.5 e) Post graduate 00 00 06 Type Of Family a) Nuclear 21 52.5 b) Joint 15 37.5 c) Extended 04 10 07 Occupation a) Skilled worker 15 37.5 b) Semi-Skilled worker 21 52.5 c) Un skilled worker 04 10 08 Monthly Family Income (In Rupees) a) Below 5000/- 09 22.5 b) 5001-10000/- 14 35 c) 10001 -15000/- 10 25 d) Above 15000/- 07 17.5 World Journal of Biology Pharmacy and Health Sciences, 2025, 21(01), 779-794 787 09 Dietary Pattern a) Vegetarian 06 15 b) Mixed 34 85 10 Previous History Of Surgery a) Yes 17 42.5 b) No 23 57.5 The data presented in the table -1 shows that maximum 11 (27.50%) of the patients were in the age group between 30 – 40 years each 10 (25%) of subjects were belongs to 51 – 60 year 10 (25%) and above 60 years of age respectively whereas 09 subjects (22.50%) were belongs to 41 – 50 years of age group. With regard to gender, data presented in the table 1 shows that, among 40 patients 26 (65%) are male and remaining 14 (35 %) were female. The data presented in the table 1 shows that, majority 34 (85%) of patients were belongs to Hindu religion, 01 (2.5%) were Christian and 05 (12.5%) are Muslim The data presented in the table 1 shows that, majority of the patients 33 (82.50%) are married, 05 (12.50%) patients are un married and 02 (5.00%) are widower and none of the patients are widow Pertaining to education, the data presented in the table 1 shows that, majority of the patients 17 (42.50%) were educated up to primary school, 06 (15%) were informal, 08 (20%), were educated up to high school, 09 (22.50%) were educated up to degree level and none of the subjects have completed post-graduation. The data presented in the table 1 shows that, majority of the patients 21 (52.50%) belongs to nuclear family, 15 (37.50%) patients were belongs to joint family and 04 (10%) patients were belongs to extended family. The data presented in the table 1 shows that, majority of sample 21 (52.50%) are semi-skilled worker, 15 (37.50%) were skilled worker and 04 (10%) of them were non-skilled worker. The data presented in the table 1 shows that, majority of the patients 14(35%) belonged to the Rs 5001-10000 income group, 09(22.50%) of the patients belonged to below Rs 5000 income group, 10(25%) of the patients belonged to Rs 10001-15000 income group and 07 (17.50%) patients belonged to above 15000 income group. The data presented in the table 1 shows that, majority of patients 34 (85%) were having mixed diet and other 06 (15%) were consuming vegetarian diet. The data presented in the table 1 shows that, majority of patients 23 (57.50%) were had the previous history of surgery and other 17 (42.50%) of the patients are don’t have the history of previous surgery. 4.4. Section 2: Pre-test level of anxiety score of preoperative patients undergoing elective abdominal surgery. Table 2 Frequency and percentage Distribution of subjects by pre-test levels of preoperative anxiety. [n=40] Level of Anxiety Frequency Percentage Mild anxiety 00 00.00 Moderate anxiety 12 30.00 Severe Anxiety 28 70.00 Total 40 100.00 Table: 2 and Fig: 02 shows the classification of preoperative patients on pre-test level of anxiety undergoing abdominal surgery. Among 40 preoperative patients no one patients are belongs to mild anxiety 30% (12) of them had moderate anxiety level, 70.00% (28) had severe level of anxiety [n=40] World Journal of Biology Pharmacy and Health Sciences, 2025, 21(01), 779-794 794 [22] Marisa. Manuela. Batista. Dos.Santos. Jose. Carlos. Amado. 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