INDIVIDU : D3KEPMA2A_REZA FANI BACHTIAR_P17210181018

PAIR : D3KEPMA2A_REZA FANI BACHTIAR_P17210181018 and D3KEPMA2A_NOVA

PURNAMA SARI_P17210183050

PENUGASAN 1

A. JOURNAL

Complementary Therapies in Clinical Practice 38 (2020) 101077

Contents lists available at ScienceDirect

Complementary Therapies in Clinical Practice

journal homepage: http://www.elsevier.com/locate/ctcp

The effects of preoperative guided imagery interventions on preoperative

anxiety and postoperative pain: A meta-analysis
a, * b
Cristina Alvarez�-García , Züleyha S¸ims¸ek Yaban
a Department of Nursing, University of Ja�en, Campus Las Lagunillas, 23071, Building B3, Office 221, Ja�en, Spain
b Department of Nursing, Faculty of Health Sciences, Kocaeli University, Kocaeli, Turkey

ARTICLE INFO ABSTRACT

Keywords: Introduction: Preoperative anxiety and postoperative pain are common problems in patients undergoing surgery.
Adults The aim of this study is to analyse the effect of using guided imagery prior to surgery in adults and children to
Anxiety
reduce preoperative anxiety and acute postoperative pain, compared with conventional preoperative nursing care.
Children
Guided imagery
Methods: A systematic review and meta-analysis were conducted. We searched randomised clinical trials in
Postoperative pain
Preoperative care
databases and search engines.
Results: A total of 1101 records were identified, of which 21 were included in the qualitative synthesis. Two random
model meta-analysis were performed with eight trials. Guided imagery preoperatively was shown to be effective in
relieving preoperative state anxiety in children (d ¼ 3.71), preoperative trait anxiety in adults (d ¼ 0.64) and
postoperative pain in adults (d ¼ 0.24). Postoperative pain in children and preoperative state
anxiety in adults was reduced but without significant difference.
Conclusion: Guided imagery preoperatively is an effective, easy and low-cost intervention.

score by 0.74 [6]. A systematic review [7] showed that the incidence of
acute postoperative pain (pain of more than 45 in Verbal Rating Scale and
1. Introduction Numerical Pain Scale [0–100]) is around 26%–29% in adults. In children, it
is around 20%–26% [8]. Nurses play an important role in
The preoperative period is well known to provoke anxiety in most
patients scheduled for surgery. The incidence of preoperative anxiety is * Corresponding author.
around 11%–80%, depending on the type of surgery, patient gender, and
E-mail address: cagarcia@ujaen.es (C. Alvarez�-García).
whether the patients are experiencing surgery for the first time [1,2]. In
children, the incidence of preoperative anxiety is affected by age and
parental anxiety, as well as the same factors that affect adults; incidence is
around 16%–81% in the paediatric population [3]. Spielberger [4] divides
anxiety into state and trait. It is assumed that state anxiety varies in
intensity and fluctuates over time as a function of the stresses that impinge
upon the individual. State anxiety is distinguished from trait anxiety, which
is defined in terms of individual differences in the fre-quency that anxiety
states are manifested over time.
Anxiety is the most common predictor for acute postoperative pain [5].
An increase of 10 on the preoperative state or trait anxiety score as
assessed by State-Trait Anxiety Inventory increases the pain intensity
 increase endorphins, and decrease anxiety, pain, blood loss, and the use
of pain medications. It affects the autonomic balance of the body by
providing pain relief, since inadequate acute postoperative pain man- refocusing the mind, resulting in physiologic relaxation by lowering
agement leads to poor recovery, diminished quality of life, increased sympathetic and increasing parasympathetic nervous system response
healthcare costs and utilisation, and it is a predictor of chronic pain in adults through neurochemical and peptide changes [14]. Guided imagery
[7] and children [9]. Nurses used to provide analgesics as the only way to describes any of various mind-focused techniques, ranging from
relieve acute postoperative pain, but the integration of comple-mentary visualisation and direct imagery-based suggestion through metaphor and
therapies (CT) in the preoperative period can ameliorate the anxiety and storytelling; it is a journey in the mind and experienced using all the senses
pain experienced by surgical patients [10,11]. [15]. In a guided imagery session, a nurse or other individual
Seven types of CT have already been included in the Nursing In-
terventions Classification: biofeedback, hypnosis, meditation facilita-tion,
music therapy, relaxation therapy, therapeutic touch, and guided imagery
[12]. The review by Skeens [13] showed that guided imagery can be used
in children and adults to create feelings of empowerment and relaxation,
https://doi.org/10.1016/j.ctcp.2019.101077
Received 31 July 2019; Received in revised form 30 November 2019; Accepted 3 December 2019
Available online 4 December 2019
1744-3881/© 2019 Elsevier Ltd. All rights reserved.
C. Alvarez�-García and Z.S¸. Yaban (PhD dissertations and conference abstracts), and by inverse search in the
references of the articles found.
leads the patient through an imagery technique or script. This can take The search strategy included PICO (Population, Intervention, Com-
place in a group or in one-to-one sessions. Recordings of spoken
parison and Outcomes) terms and keywords derived from the scoping
scripts on audiotapes are also commonly used, allowing patients to
search and expertise in the subject field. The search was carried out in
practice in a location of their choosing. Patients may also use imagery
without the guidance of a script. Gentle background music often English, Spanish and Turkish. The search strategies used in each
accompanies im-agery sessions to help maintain a relaxed state and data-base are shown in Table 1.
to free the mind from other thoughts [14,16]. The state of relaxation 2.2. Eligibility criteria
produced by guided imagery leads to a decrease in anxiety, and this is
associated with a decrease in acute postoperative pain [15]. Inclusion criteria for considering studies for this review were: (a)
Nowadays, the use of CT techniques to reduce preoperative participants were adults and children according to the decision of the
anxiety and acute postoperative pain is being developed and we can authors of the trials; (b) the intervention was individualised guided imagery,
find various systematic reviews of CT used in children, such as or with the use of a Compact Disk (CD), prior to the surgery; (c) there was a
hypnosis [17] and music [18], and in adults, such as music [19], comparison with conventional preoperative nursing care;
acupuncture [20] and massage [21]. (d) the outcomes looked at preoperative anxiety and acute postoperative
One systematic review studied the effectiveness of non-
pharmacological intervention, such as guided imagery, before surgery to
relieve postoperative pain in children [22], and another review studied this
same topic in adults [23]. Both reviews found that guided imagery was
beneficial to relieving postoperative pain, but the level of evidence of these
reviews, following the Joanna Briggs Institute rec-ommendations [24], was
medium since no statistical methods were used to compare the results of
the different studies, and they have not addressed the heterogeneity of
clinical trials or possible publication biases, among other important issues.
Besides this, we were not able to find any systematic review which
analyses the effect of guided imagery in relieving preoperative anxiety. In
the absence of a high level of evi-dence in the systematic reviews, our
objective was to analyse the effect of guided imagery prior to surgery in
adults and children to reduce preoperative anxiety and acute postoperative
pain, compared with conventional preoperative nursing care. Individual
control trials have studied this phenomenon but the results of them are
diverse.

2. Materials and methods

This study follows the method guidelines in the Cochrane

Handbook [25] which informs the conduct of a systematic review with
meta-analysis, reported in line with the PRISMA statement [26].
2.1. Literature search

The search employed topic-based strategies designed for each data-

base, from inception to April 7, 2019. We searched in databases (PubMed,
CINAHL, WOS, Scopus, Cochrane, Lilacs, CUIDEN Plus, and the Council
of Higher Education Database), selected internet sites and indices (Turning
Research into Practice and Google Scholar), key jour-nals (Alternative
Medicine Alert, BMC Complementary and Alternative Medicine,
Complementary Therapies in Clinical Practice, Complemen-tary Therapies
in Medicine, Journal of Alternative and Complementary Medicine, and
Journal of Evidence-Based Complementary and Alterna-tive Medicine),
Clinical-Trials.gov (http://www.clinicaltrials.gov/), unpublished research
 �
Complementary Therapies in Clinical Practice 38 (2020) 101077 postoperatorio* OR posoperatorio* OR postquirúrgico*)
AND (imagenes OR imag*)
�
Council of Higher
Table 1 (Güdümlenmis¸ hayal OR yonlendirilmis¸ hayal) AND
€
Education Database (ameliyat oncesi anksiyete OR ameliyat sonrası agrı OR

Search strategy in the different databases. € �

preoperatif anksiyete OR postoperatif agrı)�
Database Search Strategy
PubMed (anxiety [mh:noexp] OR anxiety [tiab] OR anxiou*
[tiab] OR nervousness [tiab] OR pain [mj] OR pain pain just after surgery; (e) the study design was a randomised clinical
[tiab]) AND (general surgery [mh] OR surgery [tiab] OR trial (RCT), and (f) the languages were English, Spanish and Turkish.
operative surgical procedures [mh] OR operative
surgical procedure* [tiab] OR preoperative period [mh] Exclusion criteria included studies that offered guided imagery in
OR preoperative period* [tiab] OR preoperative care combination with other therapies, studies that assessed postoperative
[mh] OR preoperative care [tiab] OR preoperative
pain later than one day after the surgery and studies that offered
procedure* [tiab] OR preoperat* [tiab] OR
postoperative period [mh] OR postoperative period* guided imagery only after surgery.
[tiab] or postoperative pain [mh] OR postoperative
pain* [tiab] OR postoperat* [tiab]) AND (imagery [mh] 2.3. Selection process and data extraction
OR imager* [tiab] OR guided imager* [tiab])
CINAHL (MM anxiety OR AB anxiety OR AB anxiou* OR AB Two reviewers searched information sources independently and
nervousness OR MM pain OR AB pain) AND (MH assessed identified studies for inclusion. Records were managed
operative surgery OR AB operative surgery OR AB
through End Note. The full text of a study was reviewed when it could
surgery OR MH preoperative period OR AB preoperative
period* OR MH preoperative care OR AB preoperative not be clearly excluded on the basis of its title and abstract, following
care OR AB preoperative procedure* OR AB preoperat* discus-sion between the two reviewers. A study was included when
OR MH postoperative period OR AB postoperative both re-viewers independently assessed it as satisfying the inclusion
period* or MH postoperative pain OR AB postoperative
criteria from the full text. In case of disagreement, both reviewers
pain* OR AB postoperat*) AND (MH guided imagery OR
AB imager* OR AB guided imager*) examined the documents together following the decision rule identified
WOS (anxiety OR anxiou* OR nervousness OR pain) AND in the data extraction protocol until a consensus was reached.
(surgery OR preoperat* OR postoperat*) AND (imager* Data was extracted by the two researchers independently. Data
OR “guided imagery”)
extracted included the following summary data: method, setting, par-
Scopus (anxiety OR anxiou* OR nervousness OR pain) AND
(surgery OR preoperat* OR postoperat*) AND (imager* ticipants, surgery, interventions, outcomes measures, tools, and
OR “guided imagery”) results. In the outcomes, the anxiety was divided into state anxiety and
Cochrane (anxiety OR anxiou* OR nervousness OR pain) AND
trait anxiety following Spielberger [4]. Data was presented in tabulated
(surgery OR preoperat* OR postoperat*) AND (imager*
OR “guided imagery”) form to allow for qualitative comparison.
Lilacs (anxiety OR anxiou* OR nervousness OR pain) AND
(surgery OR preoperat* OR postoperat*) AND (imager*
OR “guided imagery”)
CUIDEN Plus (ansiedad OR dolor) AND (cirugía OR quirúrgico* OR
operacion OR operaciones OR preoperatorio* OR

2
C. Alvarez�-García and Z.S¸. Yaban Identification Records identified through
database searching
2.4. Quality assessment (n = 1,094)

Risk of bias for each included trial was independently assessed by

the same initial reviewers and summarised in a table. We used the
Cochrane Collaboration tool for assessing risk of bias in randomised
trials to assess the risk of the included studies [27]. Disagreements
were resolved by consensus.
Following the recommendations of Meader et al. [28], based on the
Grading of Recommendations Assessment, Development and Evaluation
system [29], risk of bias, inconsistency, indirectness, imprecision, and
publication bias of the results of each meta-analysis were assessed. The
level of meta-analysis quality was reduced by one degree for each factor
that was present. Thus, a meta-analysis without any factors present will
provide high quality evidence, whereas if it presents three or more factors,
the quality of the evidence would be very low.

2.5. Data analysis

Following the recommendations of Cooper, Hedges, and Valentine

[30], a random effects model was used for the meta-analysis to
improve the generalisation of the findings to any guided imaginary
intervention before surgery. For differences between the experimental
and the con-trol groups, we calculated Cohen’s d with 95% confidence
intervals as effect size. We defined the effect size following Cohen’s
rule-of-thumb, small effect is between 0.2 and 0.5, moderate effect is
above 0.5, and larger effect is above 0.8 [31].
The Q test was used for the analysis of heterogeneity, together with the
2
degree of inconsistency (I ) of Higgins, Thompson, Deeks, and Alt-man
[32]. In the case of heterogeneity between studies or the presence
 Complementary Therapies in Clinical Practice 38 (2020) 101077 Analyses were performed using the Comprehensive Meta-Analysis

of attrition or reporting bias, the sign test was used instead of meta- 3.3 software.
analysis. To carry out the sign test [33], we counted how many trials 3. Results
found a guided imagery intervention to be positive in comparison with
usual care and how many trials found it to be negative. Through this A total of 1094 records were identified in databases, in addition, seven
we tested a null hypothesis, the number of trials with positive results is
records were also found by hand and inverse searches. Thus, 1101 records
equal to the number of trials with negative results. Therefore, a P-
were found, and after removing duplicates, 716 records were extracted. Of
value < 0.05 shows statistical differences between positive and neg-
atives studies. these records, 580 were excluded after reading the title since they were not
In order to assess the publication bias, we evaluated the relevant and a further 136 records were screened by reading title and
asymmetry of the funnel plot with the Begg’s test [34] and the Egger’s abstract. Thus, 31 full texts were assessed for eligibility.
test [35] and we carried out the Trim and Fill method [36]. In the
Begg’s and Egger’s tests, a P-value < 0.10 suggests publication bias
[30]. The Trim and Fill method computes the combined effect Additional records identified
considering a possible publica-tion bias [36]. through other sources
Sensitivity analyses were carried out to investigate the robustness (n = 7)
of the findings. We used the leave-one-out method: given k studies,
per-forming k-1 meta-analyses, removing one study and analysing the
remaining k-1 studies each time.

Records after duplicates removed

(n = 716)
Screening

Records excluded after

Records screened
reading title and abstract
(n = 136)
(n = 105)

Full-text articles
Full-text articles
excluded:
assessed for eligibility
Eligibility

(n = 31) Intervention not

preoperative (n = 2)

No RCT (n = 5)
Studies included in
qualitative synthesis Language (n = 1)
(n = 21)
Repeated samples (n =2)
Included

Studies with enough

data to be included in
quantitative synthesis
(meta-analysis)
(n = 8)

Fig. 1. Flow diagram of the study selection process.

3
C. Alvarez�-García and Z.S¸. Yaban Complementary Therapies in Clinical Practice 38 (2020) 101077

Two were excluded since the intervention was not carried out preop-
eratively [11,37], five were excluded since they were not RCT [38–42],
one was excluded since it was written in Arabic [43], and two were
excluded because the samples were repeated [44,45]. Finally, 21
articles were included in the qualitative synthesis and eight in the
quantitative synthesis, as the other studies only reported the direction
of the effect, but they did not present enough numerical results to
perform a meta-analysis. The flow diagram in Fig. 1 shows the search
and selection process.
3.1. Risk of bias
The risk of bias within every individual trial is detailed in Table 2.
The overall risk of bias was high, since there were 12 trials at high risk
of bias, so it is sufficient to affect the interpretation of the results. There
was not a high risk of selection bias in any of the trials but it was
unclear if a performance bias could be detected in 12 of the trials, and
six trials presented a high risk of this bias. However, this is inherent in
psycho-logical interventions due to the difficulty of performing blind
studies on patients. The detection bias was unclear in nine trials and
high in four trials. The biggest problem was the high risk of attrition
bias in nine trials, which made a meta-analysis of this information
impossible. Finally, the reporting bias was only high in three trials; this
bias also made meta-analysis impossible.
3.2. Effectiveness of the guided imagery intervention in the
preoperative period
The outcomes of this systematic review were divided into four
areas: preoperative anxiety in children; postoperative pain in children;
pre-operative anxiety in adults, and postoperative pain in adults (see
Ap-pendix A, which shows the articles included in the systematic
review). Finally, the results of the meta-analysis were presented.
3.2.1. Preoperative anxiety in children
Only the trial of Vagnoli, Bettini, Amore, De Masi, and Messeri [46]
assessed preoperative state anxiety in children between 6 and 12 years old
after using guided imagery individually 1 h before the surgery and
immediately before the induction of anesthesia. A significant effect was
found when the children were exposed to guided imagery during the
induction of anesthesia in comparison with the control group who were
treated with normal preoperative care (P < 0.001; d ¼ 3.71).
3.2.2. Postoperative pain in children
Huth and Broome [47], Lambert [48], and Vagnoli et al. [46] studied
the effect of guided imagery on postoperative pain. All the trials found
that the guided imagery intervention in the preoperative period
reduced postoperative pain before the discharge (P ¼ 0.125 in the
sign test). Although all the trial show that the guided imagery is
effective to reduce postoperative pain the number of studied is not
enough to show statis-tical differences.
3.2.3. Preoperative anxiety in adults
The trials we found assess state anxiety and trait anxiety
separately. Eight trials assessed state anxiety, two of them [49,50] did
not find a positive effect of guided imagery in comparison with the
group with usual care, while six of the trials [51–56] found a positive
effect although only three studies found statistical differences [54–56].
There was a higher number of studies that showed that guided
imagery im-proves preoperative state anxiety in adults but it was not
enough to find statistical differences (P ¼ 0.145).
Ten trials assessed trait anxiety, nine of them [51,52,54,57–62]
found that the guided imagery intervention reduced trait anxiety in
comparison with usual care, although statistical differences were only
found in four studies [57–60]. The intervention was more effective
when it was individualised instead of using a CD. There was only one
trial [63] which did not show that the guided imagery intervention
reduced trait anxiety. The sign test showed that trait anxiety can be
reduced with guided imagery (P ¼ 0.011).
3.2.4. Postoperative pain in adults
Twelve trials assessed postoperative pain after one preoperative
guided imagery intervention. Ten trials [50,51,53,54,56,59–61,64,65]
found that the intervention reduced acute pain postoperatively
although only two [56,59] found statistical differences; while two
[63,66] did not find a positive effect of the guided imagery. The sign
test showed that preoperative guided imagery is effective in reducing
acute postoperative pain (P ¼ 0.019).

Table 2
Analysis of the methodological quality of the included studies.
Trial Selection bias Performance bias Detection bias Attrition bias Reporting bias Overall risk of
bias
Random sequence Allocation Blinding participants Blinding of outcome Incomplete Selective
generation concealment and personnel assessment outcome data Reporting
Alam et al. [54] – – Þ – þ – High
Attias et al. [57] ? – ? ? þ – High
Attias et al. [58] – – ? ? – – Moderate
Billquist et al. [49] – – Þ þ þ – High
Danhauer et al. [50] – – – ? – – Moderate
Foji et al. [51] – ? ? ? – – Moderate
Forward et al. [59] – – Þ þ – Þ High
Haase et al. [66] – – – – þ – High
Huth et al. [47] – – Þ þ – – High
Lambert et al. [48] ? – ? ? þ – High
Laurion et al. [64] ? ? ? – – – Moderate
Manyande et al. [63] ? ? ? ? þ – High
Marques dos Santos – – – – – – Low
Felix et al. [55] Moderate
Mohebi et al. [52] ? ? ? ? – –
O’Mathùna [60] – ? Þ – þ – High
Pijl et al. [62] – – ? – – – Low
Renzi et al. [65] – ? ? þ – – Moderate
Shenefelt [53] – – ? – þ Þ High
Stein et al. [62] – – ? ? þ – High
Tusek et al. [45] – – Þ ? – Þ High
Vagnoli et al. [46] – – ? – – – Low

4
C. Alvarez�-García and Z.S¸. Yaban
3.2.5. Quantitative synthesis of the studies
A meta-analysis was performed for the outcomes that presented in
more than one study without attrition and reporting bias. Meta-
analyses could not be carried out for outcomes in children and
preoperative state anxiety in adults and are only reported for
preoperative trait anxiety and postoperative pain in adults.
For preoperative trait anxiety in adults, a meta-analysis was per-formed
with four trials [51,52,58,61] that reported enough data to perform a meta-
analysis. The combined effect showed a moderate effect (n ¼ 333; d ¼
0.64; 95% CI ¼ 0.97, 0.31) (Fig. 2). A guided imagery intervention in the
preoperative period is therefore effective in reducing trait anxiety
preoperatively (P < 0.001). A moderate heterogeneity was found among
2 shown to be effective in reducing postoperative pain in adults, supporting
the results of these individual studies (Q(3) ¼ 6.43; P ¼ 0.092; I ¼
53.35%). The funnel plot analysis (Fig. 3), the Begg’s test (P
¼ 1.00) and the Egger’s test (P ¼ 0.61) suggest that there was no pub-
lication bias. There was no significant difference between the estimation of
the pooled effect considering the possible publication bias by the Trim
and Fill method, and the previously calculated pooled effect (d ¼
0.62; 95% CI ¼ 0.97, 0.31) varied by 6.43%. The leave-one-out
method yielded variations in the combined estimate under 25.04%
(from 0.547 to 0.799). We consider the result of the meta-analysis as
highly
to moderately precise because of the lack of bias in the included studies,
but there were only a small number of studies which could be included.
According to postoperative pain in adults, four trials [50,51,64,65]
reported enough data to perform a meta-analysis. The combined effect
showed a low effect (n ¼ 318; d ¼ 0.24; 95% CI ¼ 0.46, 0.02) (Fig. 4). A
guided imagery intervention in the preoperative period is therefore effective
in reducing acute postoperative pain (P ¼ 0.035). A very low heterogeneity
was found among the results of these individual studies (Q(3) ¼ 2.02; P ¼
2 since the most of the trials reported incomplete outcome data. Our
0.569; I ¼ 0%). The funnel plot analysis (Fig. 5), the Begg’s test (P ¼
1.00) and the Egger’s test (P ¼ 0.92) suggest that there was no publication
bias. There was no significant difference between the estimation of the
pooled effect considering the possible publication bias by the Trim and Fill
method, and the previously calculated pooled effect (d ¼ 0.24; 95% CI ¼
0.46, 0.02) varied by 2.02%. The leave-one-out method yielded variations
in the combined estimate from 6.72% (d ¼ 0.254) to 39.50% (d ¼ 0.144),
and the results of the meta-analyses turned out to be non-statistically
significant in only one case. We consider the result of the meta-analysis as
highly to moderately precise because of the lack of bias in the included
studies and their homogeneity, but there was not a high number of studies
included.
4. Discussion
The aim of our study was to analyse the effect of guided imagery
Fig. 2. Meta-analysis and forest plot for the effect of a preoperative guided imagery intervention in preoperative anxiety reduction in adults.
5
Complementary Therapies in Clinical Practice 38 (2020) 101077
prior to surgery in children and in adults to reduce preoperative anxiety and
acute postoperative pain. We were only able to find one trial which
assessed preoperative anxiety in children, and it was effective with a large
effect size. Also in children, three trials were found regarding postoperative
pain, and all of them found guided imagery effective in reducing acute
postoperative pain, as in previous reviews [22]. In adults, although most of
the studies showed a reduction in preoperative state anxiety with a
preoperative guided imagery intervention, no sta-tistical differences were
found but statistical differences were found when guided imagery was used
to relieve trait anxiety before the sur-gery. Finally, guided imagery was
previous studies [23].
Following our results, it appears beneficial to use guided imagery
preoperatively because the cost of this intervention is cheap since it
can be applied using a CD. However, some trials have shown that it is
more effective when it is applied by one trained person, such as a
nurse, during the preoperative period [53,57]. During preoperative
care, nurses have to pay attention to the physiological, psychological
and sociocultural aspects of a patient to provide holistic care: using
guided imagery will help patients where there is a probability of high
state anxiety during surgery or poor postoperative outcomes. Rao and
Kemper [67] suggest that online training in guided imagery for health
pro-fessionals is feasible and effective; the training of nurses to use
this intervention in clinical practice does not have to be a significant
challenge.
Our results are high-moderate precise for the adult population
since the meta-analysis was performed with studies without significant
bias but the number of trials included in the meta-analysis was low
results for children would have to be confirmed with future trials of high
quality, since the reduced number of studies and the incomplete
outcome data made a meta-analysis impossible; however, preliminary
results show that guided imagery is also effective in reducing
preoperative anxiety and postoperative pain in children. These results
are in line with pre-vious systematic reviews which assessed other CT
interventions for pain reduction, such as hypnosis [17] or music [18] in
a paediatric population.
Future studies could determine the dose-response more effectively to
reduce preoperative anxiety and postoperative pain, since every study
followed a different protocol in applying the intervention of guided imagery.
Some of the trials started to use guided imagery one week before the
surgery while others used it only once just before surgery, and some of
them used guided imagery intraoperatively or postoperatively as well.
Subgroups analyses were impossible due to the lack of studies since they
did not report numerical results. Due to the same reason, it
C. Alvarez�-García and Z.S¸. Yaban Complementary Therapies in Clinical Practice 38 (2020) 101077

Fig. 3. Funnel plot for publication bias in preoperative anxiety in adults.

Fig. 4. Meta-analysis and forest plot for the effect of a preoperative guided imagery intervention in postoperative pain reduction in adults.

was impossible to perform a meta-analysis of the state anxiety data in
adults or children.
4.1. Conclusion
Guided imagery is an easy and low-cost intervention which could
be applied preoperatively by nurses to reduce preoperative anxiety
and acute postoperative pain in children and adults. More research is
necessary to confirm these finding in the paediatric population and in
the case of state anxiety in adults. The dose-response effect of guided
imagery also has to be determined in relieving preoperative anxiety
and postoperative pain.
4.2. Implications for clinical practice
and that leads to more pain in the postoperative period. Nurses can
use guided imagery to reduce preoperative anxiety and achieve better
postoperative results. Hospitals should assess the implementation of
guided imagery interventions routinely or in patients at known risk of
high preoperative anxiety or postoperative pain. Training in guided
imagery seems feasible and should begin to be included in university
courses as well as continuous professional development.
Funding
This research did not receive any specific grant from funding
agencies in the public, commercial, or not-for-profit sectors.
Declaration of competing interest

A large number of patients feel anxious before a surgical operation, None.

6
C. Alvarez�-García and Z.S¸. Yaban Complementary Therapies in Clinical Practice 38 (2020) 101077

Fig. 5. Funnel plot for publication bias in postoperative pain in adults.

Appendix A. Articles included in the systematic review

Study Method Setting Participants Surgery Interventions Outcomes Tools Results

Measures
Alam et al. Single- Northwest Adults Skin cancer GI CD (n ¼ 50), once a State and 6-item short-form Mean change (SEM) in
[54] center University excision of the face day starting at least 4 trait of the STAI (6–24) state anxiety between
RCT Hospital, United days before the anxiety and and Analog scale before and after the
States surgery, pain (100-mm intervention: GI 10.32
intraoperatively and in horizontal line) (0.33)*; CG 8.51 (0.25).
the waiting room after Mean change (SEM) in
the surgery. CG (n ¼ trait anxiety between
51). before and after the
intervention: GI 9.62
(0.31); CG 9.63 (0.38).
Mean change (SEM) in
pain between before
and after the
intervention: GI 0.51
(0.26); CG 0.23 (0.22).
Attias et al. RCT Israel Adults No information GI (n ¼ 58). GI CD (n ¼ Trait VAS (0–10) Trait anxiety before –
[57] 62). CG (n ¼ 48). anxiety after the intervention:
GI 5.08–1.59 (P <
0.0001)*; GI CD
4.86–3.41 (P < 0.001);
CG 4.90–5.09 (P ¼
0.95).
Attias et al. Single- Bnai-Zion Medical Adults General surgery GI (n ¼ 60), before the Trait VAS (0–10) Trait anxiety before-
[58] center Center, Haifa, surgery. GI CD (n ¼ anxiety after the intervention:
RCT Israel 60), before the GI 5.41–1.78 (P <
surgery. CG (n ¼ 60). 0.0001)*; GI CD
4.91–3.51 (P <
0.0001); CG 4.93–5.34
(P ¼ 0.15).
Billquist Single- Loyola University Adult Vaginal or GI CD (n ¼ 18), once a State STAI (40–160) State anxiety
et al. [49] center Medical Center abdominal pelvic day for a week before anxiety baseline-after the
RCT Female Pelvic floor surgery the surgery. CG (n ¼ intervention-6 weeks:
Medicine and 20). GI normal, increase,
Reconstructive decrease; CG normal,
Surgery, Chicago, increase, decrease.
United States
Danhauer Single- Gynecological Adults Colposcopy GI CD (n ¼ 56), before State STAI (20–80) and State anxiety before-
et al. [50] center Oncology Section de surgery and anxiety and VAS (0–100) after the surgery: GI
RCT at the Wake Forest intraoperatively. CG pain 48.9 � 13.0–45.3 �
University (n ¼ 58). 15.7; CG 46.8 �
Comprehensive 14.6–44.2 � 13.6. Pain
Cancer Center, before – after the
United States surgery: GI 44.7 �
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Study Method Setting Participants Surgery Interventions Outcomes Tools Results

Measures
23.0–46.5 � 26.5; CG
48.7 � 20.8–51.7 �
26.3.
Foji et al. Single- Vasei Hospital of Adults Angiography GI CD (n ¼ 31), before State-trait STAI (State-trait State-trait anxiety
[51] center Sabzevar affiliated the surgery. CG (n ¼ anxiety and →40–160) before – after the
RCT to the Medical 31). pain (State and Trait → intervention: GI
University of 20–80) and Pain 103.67 � 13.9–89.25 �
Sabzedar, Iran Scale (0–10) 11.03 (P < 0.001); CG
148.02 � 1.29–102.54
� 1.30 (P ¼ 0.98). State
anxiety before – after
the intervention: GI
53.06 � 1.2–45.16 �
1.2 (P < 0.001); CG
53.32 � 0.9–53.35 �
0.8 (P ¼ 0.93). Trait
anxiety before – after
the intervention: GI
50.46 � 7.31–44.09 �
7.75 (P < 0.001); CG
49.12 � 5.44–49.22 �
5.27 (P ¼ 0.73). Pain
after the surgery: GI
5.52 � 1.82; CG 5.84 �
1.80.
Forward Single- Saint Clare’s Adults Knee or hip GI CD (n ¼ 75), Trait NVAS (0–10) and Proportion of
et al. [59] center Health System in replacement preoperative day 0, anxiety and NPRS (0–10) participants in each
RCT Denville, New surgery postoperative day 0, pain treatment group who
Jersey, United postoperative day 1 experienced 50% trait
States and postoperative day anxiety decrease after
2. CG (n ¼ 74). each GI intervention
and between the start
and end of the study:
GI Anxiety 2-Anxiety 1
0.431 (65)*, Anxiety 4-
Anxiety 3 0.500 (38)*,
Anxiety 6-Anxiety 5
0.526 (38)*, Anxiety 8-
Anxiety 7 0.578 (45)*,
Anxiety 8-Anxiety 1
0.906 (64); CG Anxiety
2-Anxiety 1 0.016 (62),
Anxiety 4-Anxiety 3
0.000 (37), Anxiety 6-
Anxiety 5 0.121 (33),
Anxiety 8-Anxiety 7
0.226 (31), Anxiety 8-
Anxiety 1 0.855 (62).
Proportion of
participants in each
treatment group who
experienced 25% pain
decrease after each GI
intervention and
between the start and
end of the study: GI,
Pain 2-Pain 1 0.235
(51)*, Pain 4-Pain 3
0.200 (55)*, Pain 6-
Pain 5 0.222 (63)*,
Pain 8-Pain 7 0.309
(53)*, Pain 8-Pain 1
0.620 (50); CG, Pain 2-
Pain 1 0.019 (52), Pain
4-Pain 3 0.020 (50),
Pain 6-Pain 5 0.078
(64), Pain 8-Pain 7
0.037 (54), Pain 8-Pain
1 0.679 (53).
Haase et al. Single- Germany Adults Resection of a GI CD (n ¼ 20), three Pain during VAS (0–100) There were no
[66] center primary colorectal time a day, two days rest and differences between
RCT carcinoma before the surgery, while groups for subjective
intraoperatively and coughing pain intensity at rest
one week after the or while coughing at
surgery. CG (n ¼ 18).
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(continued )

Study Method Setting Participants Surgery Interventions Outcomes Tools Results

Measures
any time (each P >
0.15).
Huth et al. Multi- Tertiary care Children Ambulatory GI CD (n ¼ 36), before Trait STAIC (20–80) Trait anxiety measure
[47] center children’s hospital, surgery of the surgery, after the anxiety and and Oucher scale before-after the
RCT a children’s tonsillectomy or surgery and at home. sensorial (0-100-point intervention 1 h after
hospital surgery adenoidectomy, or CG (n ¼ 37). and numeric scale) and the surgery: GI 30.67
center, one tonsillectomy and affective FAS (0–1) � 6.51–28.64 � 7.26*;
community adenoidectomy pain CG 34.27 � 7.55–31.54
hospital, and two � 8.49. Affective pain
ambulatory baseline, before and
surgery settings in after the intervention
Southeastern 1 h after the surgery:
Wisconsin, United GI 0.64 � 0.22–0.54 �
States 0.21 (P < 0.01) - 0.49
� 0.27–0.45 � 0.26*;
CG 0.59 � 0.26–0.49 �
0.28. Pain before and
after the intervention
1 h after the surgery
and in the home post-
discharge: GI 45.97 �
25.77–30.42 � 26.06
(P < 0.01) - 30.70 �
26.99–25.97 � 26.48*;
CG 42.43 �
28.81–31.89 � 28.92.
Lambert Single- University Children Elective surgery GI (n ¼ 26), State STAIC (20–80) Mean difference in
et al. [48] center Hospitals Rainbow preadmission visit anxiety and and Numeric Pain state anxiety
RCT Babies & approximately 1 week pain Scale (0–10) postoperatively: GI
Children’s before the surgery. CG -1.00; CG 2.04. Pain
Hospital, (n ¼ 26). postoperatively: GI
Cleveland, Ohio, 3.9*; CG 4.4.
United states
Laurion Single- Ambulatory Adults Gynecologic GI CD (n ¼ 28), 2 times Pain VAS (0–10) Preoperative pain: GI
et al. [64] center surgical center in laparoscopic a day before the 1.0 � 2.4; CG 1.5 � 2.7.
RCT New England surgery surgery, during the Pain on PACU arrival:
patient’s surgery and GI 1.9 � 3.3; CG 2.4 �
in the Post-Anesthesia 3.0. Pain in PACU
Care Unit. CG (n ¼ 28). after 1 h: GI 2.9 � 2.7;
CG 3.5 � 2.6. Pain on
PACU discharge: GI
1.5 � 1.5*; CG 2.4 �
1.6.
Manyande Single- St Mark’s Hospital Adults Colorectal or anal GI CD (n ¼ 26) Trait STAI (80–160) and There was not different
et al. [63] center surgery Preoperative day and anxiety and VAS between the groups in
RCT subsequently pain trait anxiety before,
CG (n ¼ 25) after the intervention,
the first or the second
postoperative day.
There was not different
between the groups in
pain before the
surgery, the first or the
second postoperative
day.
Marques dos Single- Large teaching Adults Video-laparoscopic GI CD (n ¼ 12), State STAI (20–80) State-anxiety before-
Santos center hospital in the bariatric surgery preoperative period. anxiety after the intervention:
Felix et al. RCT interior of Minas CG (n ¼ 12). GI 47.50 � 2.61–43.00
[55] Gerais state, Brazil � 3.54 (P ¼ 0.001)*;
CG 47.67 � 3.82–46.83
� 3.76 (P ¼ 0.005).
Mohebi et al. Single- Sabzevar Behesti Adults Hernioraphy GI CD (n ¼ 28), 1 h State and STAI (20–80) State anxiety before-
[52] center Hospital, Iran surgery before the surgery. CG trait after the intervention:
RCT (n ¼ 28). anxiety GI 46.84 � 9.00–35.89
� 6.14 (P < 0.001); CG
39.75 � 8.63–38.20 �
8.07 (P < 0.001).
Trait anxiety before-
after the intervention:
GI 45.12 � 9.14–52.56
� 10.59 (P < 0.001);
CG 39.29 � 8.51–39.98
� 8.41 (P < 0.001).
O’Mathùna Medical Center at Adults Head and neck VAS (100-mm) Trait anxiety before
[60] Wright-Paterson outpatient surgery and after the
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(continued )

Study Method Setting Participants Surgery Interventions Outcomes Tools Results

Measures
Single- Air Force Base in GI CD (n ¼ 22), two Trait intervention: GI 25.32
center Ohio, United States times before the anxiety and mm–11.86 mm*; CG,
RCT surgery. CG (n ¼ 22). pain same anxiety at
baseline and more
anxiety just before the
surgery. Pain 1 h and
2 h after the
intervention: One
hour postoperatively,
pain scores for those in
the GI group were close
to being significantly
lower (P ¼ 0.057) and
were significantly
lower at 2 h (P ¼
0.041).
Pijl et al. Multi- Slotervaart Adults Laparoscopic GI CD (n ¼ 43), once a Trait APAIS (6–30) and Trait anxiety: GI 15.2
[61] center Hospital, cholecystectomy day during a period of anxiety and VAS (0–10) � 5.9; CG 16.4 � 5.9.
RCT Amsterdam, and 7 days before surgery. pain Pain (day of surgery):
Red Cross Hospital, CG (n ¼ 52) GI 3.4 � 1.8; CG 3.0 �
Beverwijk, 1.8. Pain (day 1): GI
Netherlands 2.5 � 1.6; CG 2.47 �
1.7.
Renzi et al. Single- Italy Adults Anorectal surgery GI CD (n ¼ 43), once 1 Pain VAS (0–10) Postoperative pain: GI
[65] center h before entering the 3.2 � 1.4; CG 4.1 � 2.1.
RCT operating room, once
or twice during
surgery depending on
the duration of the
operation, and at least
twice within 48 h after
surgery before
discharge. CG (n ¼ 43).
Shenefelt Single- United States Adults Surgery for GI (n ¼ 13), at the State 0-to-10 Subjective State anxiety: Start GI
[53] center removal of benign beginning of the anxiety and Units of 3.31 (0–7); GI CD 3.38
RCT or malignant skin surgery. GI CD (n ¼ pain Discomfort scale (0–8); CG 3.15 (0–10).
lesions 13), at the beginning of 10 min GI 1.77 (0–5);
the surgery. CG (n ¼ GI CD 2.31 (0–6); CG
13). 2.46 (0–8). 20 min GI
1.00 (0–3)*; GI CD 2.27
(0–5); CG 2.64 (0–7).
End GI 0.77 (0–3); GI
CD 0.77 (0–3); CG 1.15
(0–4). 10 Post-
operatory GI 0.38
(0–3); GI CD 0.69 (0–4);
CG 1.15 (0–5). Pain:
Start GI 0.38 (0–2); GI
CD 0.31 (0–2); CG 0.46
(0–4). 10 min GI 0.15;
GI CD 0.31; CG 0.54.
20 min GI 0.10; GI CD
0.64; CG 0.09. End GI
0.08; GI CD 0.08; CG
0.08. 10 min post-
operatory GI 0.00; GI
CD 0.15; CG 0.08.
Stein et al. Single- Columbia Adults Coronary artery GI (n ¼ 14), once a Trait HADS (0–21) Trait anxiety
[62] center University Medical bypass graft day, every day, for one anxiety baseline, 1 week
RCT Center, United week before the postoperatively and 6
States surgery and months
intraoperatively. CG postoperatively: GI
(n ¼ 18). 7.10 � 3.55–5.10 �
3.80–5.14 � 3.18; CG
7.16 � 5.54–7.11 �
5.03–3.94 � 3.60.
Tusek et al. Single- The Cleveland Adults Colorectal surgery GI CD (n ¼ 65), twice State 100 mm linear Mean change in state
[45] center Clinic Foundation, each day for three days anxiety and analog scale, twice anxiety: 30 ( 95; 50)*;
RCT Ohio, United States before the surgery and pain daily beginning CG 0. Median increase
for six days after the three days in the worst pain: GI
surgery. CG (n ¼ 65). preoperatively 42.5 ( 60; 90)*; 72.5
and ending six ( 30; 100). Median
days increase in least pain:
postoperatively GI 12.5 ( 70; 82.5)*;
CG 30 ( 40; 92.5).
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(continued )

Study Method Setting Participants Surgery Interventions Outcomes Tools Results

Measures
Vagnoli Single- Meyer Children’s Children Minor surgery GI (n ¼ 30), 1 h before State m-YPAS (23–100) State anxiety during
et al. [46] center Hospital in (hernias, phimosis, the surgery and anxiety and and FLACC (0–10) the induction of
RCT Florence, Italy and endoscopies/ immediately before pain anesthesia: GI 39.6 �
biopsies- the induction of 4.5*; CG 83.7 � 16.2.
gastroscopies and anesthesia. CG (n ¼ Pain 2 h after the
colonoscopies) 30). surgery, immediately
after waking up and
before starting to take
analgesics: GI 4.5 �
2.1*; CG 7.7 � 1.8.
Note. APAIS ¼ Amsterdam Preoperative Anxiety and Information Scale; CG ¼ Control Group; FAS ¼ Facial Affective Scale; FLACC ¼ Face, Legs, Activity, Cry,
Consolability Scale; GI ¼ Guided Imagery; HADS ¼ Hospital Anxiety and Depression Scale; m-YPAS ¼ Modified Yale Preoperative Anxiety Scale; NPRS ¼ Numeric
Pain Rating Scale; NVAS ¼ Numeric Visual Anxiety Scale; STAI ¼ State-trait Anxiety Inventory; STAIC ¼ State-trait Anxiety Inventory for Children; VAS ¼ Visual
Analog Scale.
*P < 0.05 in comparison with CG with standard care.

Research interest

Her research interests include complementary/alternative/integrative medicine, oncology, breast cancer, postoperative urinary retention,
orthopedia, nursing care, nursing diagnosis, and wound care.

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12

B. SUMMARY

Effects of guided images before surgery on children and adults to reduce preoperative anxiety and
postoperative acute pain. one trial was found that assessed preoperative anxiety in children, and was
effective with a large effect size. Also in children, three trials were found regarding postoperative pain, and
they all found guided imagery that was effective in reducing acute postoperative pain. In adults, although
most studies show reduced preoperative anxiety states with preoperative guided image interventions, no
statistical differences were found but statistical differences were found when guided imagery was used to
eliminate pre-operative anxiety anxiety. Finally, guided images have proven to be effective in reducing
postoperative pain in adults.

Following our results, it seems useful to use guided imagery before surgery because the cost of this
intervention is cheap because it can be applied using a CD. However, several trials have shown that it is
more effective when applied by one trained person, such as a nurse, during the preoperative period. During
preoperative care, nurses must pay attention to the physiological, psychological and sociocultural aspects of
the patient to provide holistic care: using guided imagery will help patients where there is a high likelihood
of state anxiety during surgery or poor postoperative outcomes.

Guided imagery is an easy and inexpensive intervention that can be applied before surgery by nurses to
reduce preoperative anxiety and acute postoperative pain in children and adults. The dose-response effect of
guided imagery must also be determined in relieving preoperative anxiety and postoperative pain. A large
number of patients feel anxiety before surgical operations, and that causes more pain in the postoperative
period. Nurses can use guided imagery to reduce preoperative anxiety and achieve better postoperative
results. Hospitals must assess the implementation of guided imagery interventions routinely or in patients
who are known to be at high risk of experiencing preoperative anxiety or postoperative pain.

PENUGASAN 2

 Keywords

1. Imajination
2. Inhale
3. Exhale
4. Relaxation
5. Visualization
6. Comfortable position
7. Close the eyes
8. Open the eyes
9. Breathe slowly
10. Lengthen the breathe
11. Enjoy the sensation of the energy
 12. Wiggle the fingers
13. Focusing on the breathe
14. Cleansing refreshing breathe

 Comments

in my opinion this video has many benefits. This video indirectly teaches how to do guided imagery
techniques such as relaxation. by learning the techniques in this video we can also practice to focus.
Unfortunately, the duration of this video is too short. The image shown is not very attractive. the music in
this video is also not cool enough, so it is difficult to be able to focus attention, if people who have
difficulty concentrating then by seeing this video they are not optimal in doing the techniques they teach.
But overall this video is good. if this video is given an opportunity to be improved, surely this video will be
more perfect and can be trending.

PENUGASAN 3

Peran:
Nova as Nurs N
Reza as Px

Nurse N: "Good morning, sir. I am Nurse Nova. Can you give me your name and date of birth?"
Reza: "Good morning, nurse. My name is Reza and my date of birth is August 8, 2000."
Nurse N: "Okay, Mr. Reza. How are you today? "
Reza: "I still feel anxious about my weight loss lately."
Nurse N: "Are there any problems that disturb your mind, sir?"
Reza: "Yes, Nurse. It's been a week I have suffered from insomnia.
Nurse N: "Ah, I see. Sir, well sir it seems like you need to do relaxation techniques, if I ask you to look and
imagine some guided images, are you willing? "
Reza: "What benefits do I get after doing it, Nurse?"
Nurse N: "That can make you more relaxed and maybe it can reduce your insomnia and also reduce your
anxiety, sir."
Reza: "Is that not dangerous for me, Nurse?"
Nurse N: "oh no, sir."
Reza: "How do you convince me that guided imagery will be okay for me?"
Nurse N: "One time when I felt stressed with my work. I did this guided image and it worked, sir. So don't
worry, sir. "
Reza: "Okay. So, what should I do now?"
Nurse N: "Wait a minute and I'll give you a video and some calming images, and then listen to some
instructions from me later.
Reza: "Only that? Easy, Nurse."
Nurse N: "Yes, sir. Please do it seriously and keep concentrating, sir, in order to get a maximum result."
Reza: "Okay, Nurse. I'll try to do it."
Nurse N : Let's get started. Breathe slowly and regularly. Now close your eyes, regulate your breath, inhale
exhale, relax and relax. Your pulls and exhalations make you more relaxed, more relaxed. Inhale, exhale,
you are very relaxed, very relaxed. Now draw, imagine a very beautiful and comfortable place that you
enjoy. Attention to your breathing, breathing and exhaust your breath makes you deeper.
allow your mind to think that you deserve to be in this beautiful and comfortable world. Take your breath
away your breath, with each breath you take, you are increasingly enjoying the beauty with you in it, enjoy
the beauty and tranquility of your special place, listen to the beautiful birds chirping the amount of fragrant
scent as the flowers bloom. Relax Rilex, look around you, touch the river water that runs in front of you,
cool calm, calm, very cool air and look at your body, you make Rilex and make it relaxed, your muscle
tension disappears slowly by feeling the beauty in your special place. You are more relaxed and more
relaxed. Inhale, exhale, slowly open your eyes, and for a moment, feel the goodness of this new therapy.
Nurse N: "How are you feeling now, sir?"
Reza: "I feel more relaxed and calm now, Nurse."
Nurse N: "I'm glad to hear you're fine."
Reza: "Thank you for helping me, Nurse."
Nurse N: "This is my duty, sir. Oh yes you can do this therapy yourself at home sir"
Reza: "How many times a day can I do this therapy myself?"
Nurse Y: "You can do this therapy twice a day."
Reza: "Thank you, Nurse. Thank you."
Nurse N: "Okay, thank you for your cooperation, I will leave you, if you need help, you can press the
switch next to you."
Reza: "Okay, Nurse."
Nurse N: "Good morning, miss. I hope you get well soon. Have a nice day."