Evaluation of the Magic Island: Relaxation for Kids, compact disc

Abstract

Managing post-operative pain continues to elude health care professionals despite children's reports of severe pain. Although research has demonstrated that guided imagery is a beneficial complementary treatment for pain, clinicians rarely incorporate it into their practice. This study evaluated the effectiveness of a guided imagery audio compact disc (CD) in reducing post-operative pain, increasing relaxation, and stimulating imagery in children by child life specialists in the clinical setting. This cross sectional study compared pain and relaxation scores before and after the use of the CD. Sixteen children (7 to 12 years of age) reported pain on a 0 to 10 scale and relaxation on a 1 to 5 scale, and answered questions about what they imagined. Pain scores were significantly decreased, with no significant differences in relaxation scores. Findings support that school-age children are capable of using guided imagery, and relaxation may not be necessary to achieve pain reduction.

Full text

290 PEDIATRIC NURSING/September-October 2009/Vol. 35/No. 5
Evaluation of the M a g i c
Island: Relaxation for
K i d s ©Compact Disc
Managing children’s post-
operative pain continues to
be a challenge because
nearly 50% of children
report severe pain after surgery
( G a u t h i e r, Finley, & McGrath, 1998;
LaMontagne, Hepworth, & Salisbury,
2001). Effective post-operative pain
management can lead to shorter
lengths of stay in the hospital and bet-
ter coping and emotional well being
after discharge (Lambert, 1996).
Analgesic medications are the most
common form of pain management
used with children post-operatively.
H o w e v e r, studies re p o r t that pediatric
patients suffer moderate to severe pain
during hospitalization even after re c e i v -
ing analgesics (Gauthier et al., 1998;
Gillies, Smith, & Parry-Jones, 1999;
Pölkki, Pietilä, & Ve h v i l ä i n e n - J u l k u n e n ,
2003). The Agency for Health Care
Policy and Research and the American
Society of Anesthesiologists have
developed guidelines that re c o m m e n d
the combination of pharm a c o l o g i c a l
and non-pharmacological techniques
to manage childre n ’ s pain (Acute Pain
Management Guideline Panel, 1992;
American Society of Anesthesiologists,
2004). Pain results from the re c i p r o c a l
relationship of sensory and aff e c t i v e
components of a noxious stimulus
(Melzak & Casey, 1968). There f o re ,
when a non-pharmacological interv e n-
tion is combined with a pharm a c o l o g i c
agent for the management of post-
operative pain, both sensory and aff e c -
tive pain may be reduced, more than
with medication alone.
The need for interventions that
reduce childre n ’s acute pain on a short -
t e rm basis is growing as a result of the
continued demand for outpatient sur-
g e r y, shortened hospital stays, and dif-
ficulties with pain management in the
home. Non-pharmacologic cognitive
i n t e r ventions, such as guided imagery,
reduce or alter the pain experience
t h r ough focus on a thought or image,
t h e r eby competing for the attention of
painful sensations (McCaul & Malott,
1984). Thus, imagery has the potential
to modify pain by diverting attention to
a pleasant, non-painful stimulus.
Relaxation can be used to facilitate
i m a g e ry and may reduce pain by
diminishing the effects of stress, dis-
tress, anxiety, or muscle tension
( M c C a f f e r y & Pasero, 1999). The pur-
pose of this study was to evaluate the
e f fectiveness of a guided imagery CD
in reducing post-operative pain and
i n c r easing relaxation in children. A sec-
ond goal was to evaluate the eff e c t i v e -
ness of the CD to stimulate imagery in
school-age children.
L i t e r a t u r e Review
Age Related to Pain and Imagery
Studies have shown that school-age
c h i l d r en are able to describe their inten-
sity of pain and appropriately make
Objectives and the
CNE posttest can be
found on pages 296-297.
Continuing
Nursing
Education
Series
Managing post-operative pain continues to elude health care professionals despite children’s reports of
severe pain. Although research has demonstrated that guided imagery is a beneficial complementary treat-
ment for pain, clinicians rarely incorporate it into their practice. This study evaluated the effectiveness of a
guided imagery audio compact disc (CD) in reducing post-operative pain, increasing relaxation, and stimu-
lating imagery in children by child life specialists in the clinical setting. This cross sectional study compared
pain and relaxation scores before and after the use of the CD. Sixteen children (7 to 12 years of age) report-
ed pain on a 0 to 10 scale and relaxation on a 1 to 5 scale, and answered questions about what they imag-
ined. Pain scores were significantly decreased, with no significant differences in relaxation scores. Findings
support that school-age children are capable of using guided imagery, and relaxation may not be necessary
to achieve pain reduction.
Myra Martz Huth
Nancy M. Daraiseh
Melissa A. Henson
S h a r on M. McLeod
Myra Martz Huth, PhD, RN, is Assistant
Vice President, Center for Pro f e s s i o n a l
E x c e l l e n c e - R e s e a rch and Evidence-Based
Practice, Cincinnati Childr e n ’s Hospital
Medical Center, Cincinnati, OH.
Nancy M. Daraiseh, PhD, is a Researc h
Associate, Center for Pro f e s s i o n a l
E x c e l l e n c e - R e s e a rch and Evidence-Based
Practice, Cincinnati Childr e n ’s Hospital
Medical Center, Cincinnati, OH.
Melissa A. Henson, BS, CCLS, is a Child Life Specialist, Cincinnati Childre n ’s Hospital
Medical Center, Cincinnati, OH.
S h a ron M. McLeod, MS, CTRS, CCLS, is Senior Clinical Dire c t o r , Division of Child Life,
Cincinnati Childre n ’ s Hospital Medical Center, Cincinnati, OH.
Acknowledgments: The authors would like to acknowledge and thank Scott Byington,
MHSA, CCLS, for his eff o r ts in the initial stages of the study and to the children who part i c-
ipated in this study.
Statement of Disclosure : The authors re p o r ted no actual or potential conflict of interest in
relation to this continuing nursing education art i c l e .

PEDIATRIC NURSING/September-October 2009/Vol. 35/No. 5 291
suggestions on pain-relieving methods
to their caregivers (Pölkki et al., 2003).
C h i l d ren use vivid imaginations in their
daily life, and can use this skill of imag-
ination and fantasy to provide thera-
peutic distraction (Lambert, 1996).
Children’s involvement in images
peaks between the ages of 8 to 12
years old (Olness & Kohen, 1996), and
as children develop, they increase their
ability to focus and pay attention
(Thomas, 1985). School-age childre n
can, and do, use imagery and have the
capacity to create and become
absorbed in vivid mental images as if
they were real (Huth, Van Kuiken, &
B r oome, 2006).
Guided Imagery
I m a g e r y interventions have been
examined as methods of contro l l i n g
pain and distress in children during
intrusive procedures (Broome,
Rehwaldt, & Fogg, 1998; Jeffs, 2007;
Pederson, 1995; Smart, 1997). Few
studies have re p o r ted the eff e c t i v e n e s s
of using guided imagery or non-phar-
macological techniques in the relief of
post-operative pain in children (Huth,
B roome, & Good, 2004; Lambert ,
1996; Pölkki, Pietilä, Vehviläinen-
Julkunen, Laukkala, & Kiviluoma,
2008).
L a m b e r t (1996) taught 26 childre n
and adolescents (7 to 19 years of age)
ways to relax and use their imagina-
tions before and after general surg e r y.
The study consisted of 52 patients ran-
domly assigned to an experimental
g roup or a control group. This tech-
nique incorporated individualized child
selected images into relaxation exerc i s -
es, and included suggestions for heal-
ing, minimal pain, and an uncomplicat-
study described pre v i o u s l y, Huth and
colleagues (2006) analyzed how chil-
d ren in the treatment group used
i m a g e r y before and after surg e ry. On
an investigator developed diary, chil-
d r en documented the reason for listen-
ing to the imagery tape, level of re l a x -
ation, and what they imagined while lis-
tening to the tape. Data re p o r ted fro m
a subset of 36 patients showed 78% of
the patients used the tape 24 hours
after surg e ry most often for pain man-
agement, relaxation, and sleep.
C h i l d r en used the imagery tape more
f r equently at home after surg e ry than
b e f o r e surg e ry. When children listened
to the tape, they most often imagined
going to the park, as suggested in the
s c r i p t .
Most re c e n t l y, a randomized con-
t r olled trial tested the effectiveness of
i m a g e r y and relaxation in school-age
c h i l d r en (8 to 12 years) with a guided
i m a g e r y CD (Pölkki et al., 2008). Sixty
c h i l d r en were randomly assigned to the
t r eatment or control group. The tre a t -
ment group listened to a 20-minute CD
that suggested pain-relieving imagery
and relaxation. Children in the tre a t -
ment group re p o rte d significantly less
pain than the control group immediate-
ly after the intervention, but not 1 hour
l a t e r. Nurses caring for the childre n
w e r e the data collectors, which may
i n t r oduce bias. Other study limitations
include integrity of the treatment and
lack of control for the amount and type
of opioid in effect at the time the inter-
vention was given.
M e t h o d s
Despite evidence in the literature
that supports the use of guided
i m a g e r y to reduce pain, anxiety, and
s h o r ter hospital stays, there is an
absence of re s e a r ch evaluating the
validity of a guided imagery interv e n -
tion. There f o r e, the overall purpose of
the study was to establish content
validity for the Magic Island: Relaxation
for Kids©CD (Mehling, Highstein, &
D e l a m a rt e r, 1990) and substantiate it
as an effective intervention in re d u c i n g
post-operative pain in children. The
re s e a r ch questions that guided this
study were :
• Does the use of the Magic Island:
Relaxation for Kids audio CD lead
to decreased pain and incre a s e d
relaxation in school-age childre n
who have undergone surg e ry ?
• Does the use of the Magic Island:
Relaxation for Kids audio CD stim-
ulate the imagination in school-age
c h i l d ren who have undergone sur-
g e r y ?
ed re c o v e r y. Children in the experimen-
tal group experienced lower post-oper-
ative pain ratings and shorter hospital
stays than the control group. Tw e n t y
c h i l d ren indicated they used this strate-
gy for pain control and sleep while hos-
pitalized. A limitation of this study was
that the amount of opioid in effect at
the time of the intervention was not
c o n t r o l l e d .
In a descriptive study, 52 Finnish
school-age children were interv i e w e d
after surg e r y to obtain their experi-
ences with pain relief methods while
hospitalized. Children re p o r ted 13 dif-
f e rent types of self-initiated methods
they used to relieve pain. Ninety-eight
p e rcent of the children used distraction,
31% used imagery, and 8% used re l a x-
ation (Pölkki et al., 2003).
In another experimental design,
Huth and colleagues (2004) randomly
assigned 73 school-age children (7 to
12) having a tonsillectomy and/or ade-
noidectomy to an imagery tre a t m e n t
g roup or an attention-control gro u p .
C h i l d ren (n= 36) in the tre a t m e n t
g roup watched a professionally devel-
oped videotape on the use of imagery
and then listened to an audiotape 1
week before surg e ry. They also listened
to the audiotape after surg e r y and at
home after discharge. Results indicated
significantly lower pain and anxiety 1 to
4 hours after surg e r y in the tre a t m e n t
g roup when analgesics and trait anxi-
ety were controlled. However, there
w e r e no significant diff e rences at home
22 to 27 hours after discharge. A limi-
tation of this study was the inability to
p rovide a sham treatment for the atten-
t i o n - c o n t rol group that would not act as
d i s t r a c t i o n .
Based on the larger experimental
Ta b le 1.
Sample Description (N= 17)
Descriptive Demographic To t a l
Av e r age Age 9.7 (S D = 1.9)
R a c e W h i t e
A f ri c a n - A m e ri c a n
A s i a n
M u l t i - r a c i a l
11 ( 6 5 % )
3 ( 1 7 % )
1 ( 6 % )
2 ( 1 2 % )
G e n d e r M a l e
Fe m a l e
8 ( 4 7 % )
9 ( 5 3 % )
S u r ge ryA p p e n d e c t o my
To n s i l l e c t o m y / a d e n o i d e c t o my
Mass ex c i s i o n
Right total parotidectomy / right mandible resection
Fracture closure
Fe mur fra c t u r e
E x p l o r a t o r y laparotomy/small bowel resection/
a p p e n d e c t o m y
8 ( 4 7 % )
3 ( 1 7 % )
2 ( 1 2 % )
1 ( 6 % )
1 ( 6 % )
1 ( 6 % )
1 ( 6 % )
Evaluation of the Magic Island: Relaxation for Kids©Compact Disc

292 PEDIATRIC NURSING/September-October 2009/Vol. 35/No. 5
Design
A cross-sectional pre / p o s t - t e s t
design was used. Children hospitalized
over a 7-month period for a variety of
s u rgeries (see Table 1) were given the
guided imagery interv e n t i o n .
Participants and Setting
The setting was a 475-bed, quater-
n a r y care pediatric hospital and
re s e a rch center in the midwest. A con-
venience sample of 17 childre n
between the ages of 7 and 12 years of
age who had recently undergone sur-
g e r y were enrolled in the study.
C h i l d ren needed to understand and
communicate in English because the
CD was re c o rde d in English. Only
c h i l d r en with significant developmen-
tal delays, a diagnosed mental illness,
or a neuro-muscular disorder were
excluded from the study.
Measures
Demographic information for the
child, including sex, age, and race,
was obtained from the child and con-
f i rmed in the chart. The type of surg i -
cal pro c e d u re perf o r med was also
obtained from the child’s chart.
Relaxation and Pain
An 8-question tool was used to col-
lect data re g a rding relaxation and pain
levels as well as details of what the
child imagined after listening to the
CD. This questionnaire was used in
p revious re s e a rch (Huth et al., 2004).
Relaxation and pain scores were
obtained pre- and post-interv e n t i o n .
Relaxation was assessed using a 5-
point Likert scale (1 = “very re l a x e d
like a limp rag doll” to 5 = “very
tense”). Pain was assessed using a
modified version of the Oucher. The
numeric scale was converted to a 0 to
10 scale with the author’s perm i s s i o n .
The original Oucher is a self-re p o r t
m e a s u re of pain intensity for childre n
3 to 12 years of age that has been
used in a variety of settings (Beyer,
Vi l l a rru el, & Denyes, 1995). Childre n
may use a numeric scale (0 to 100) or
a 7-point picture photographic scale
of one child (Black, Hispanic , or
White) demonstrating increasing lev-
els of discomfort. In this study, all sub-
jects chose the numeric scale.
Psychometric studies have estab-
lished the content and construct valid-
ity of the original Oucher scale (Beyer
& Aradine, 1986, 1987, 1988; Beyer,
McGrath, & Berde, 1990). A study
with 7- to 12-year-old children who
had tonsillectomy pain demonstrates
the high test-retest reliabilities at two
separate time points (r= 0.96 and r=
0.99, respectively) (Huth et al., 2004).
ed to examine the re l a t i o n s h i p
between pain and relaxation before
and after listening to the CD. Post-hoc
e f fect size was calculated using
C o h e n ’ s d. A Spearman corre l a t i o n
c o e fficient was obtained to determ i n e
the relationship between pain and
relaxation after the interv e n t i o n .
Answers to questions re g a rd i n g
i m a g e ry outcomes were categorized
using content analysis. All analyses
w e r e carried out at a 0.05 level of sig-
n i f i c a n c e .
Results
Description of Sample
Nine female and 8 male childre n
with a mean age of 9.7 (S D = 1.9) par-
ticipated in the study; 11 were White
(65%), 3 African American (17%), 1
Asian (6%), and 2 multi-racial (12%).
One child assented but did not part i c -
ipate. Additionally, 2 children and 3
p a ren ts refused par ticipation. The
most frequent type of surg e ry per-
f o rmed was an appendectomy (47%,
n= 8). These demographics are pre-
sented in Table 1.
Pain and Relaxation
Comparisons of pain and re l a x -
ation scores before and after the child
listened to the guided imagery CD are
shown in Figure 1. One child’s pain
s c o res were missing. Mean pain
s c o r es before the CD were 4.31 (S E =
0.61) and after the CD were 2.75, (S E
= 0.49, t[15] = 3.49, p= 0.0033). A
l a r ge post-hoc effect size for pain
reduction was calculated at 0.87
(Cohen, 1988). Eleven (68.7%) chil-
d ren re p o r ted less pain, 4 (25%)
re p o r ted no change, and 1 (6.2%)
child re p o r ted slightly higher pain after
listening to the CD.
Mean relaxation scores were 2.09
(S E = 0.23) prior to the CD and after
the CD were 1.66 (S E = 0.14).
D e c r easing relaxation scores indicate
m o r e relaxation. Thus, there were no
significant diff e rence in re l a x a t i o n
s c o r es (t[15] = 2.05, p= 0.0583).
T h e r e was a moderate effect size for
relaxation (0.51). Eight (50%) of the
c h i l d ren re p o r ted more re l a x a t i o n
after listening to the CD, 6 (37.5%)
had no change, and 2 (12.5%) re p o r t-
ed less relaxation. A corr e l a t i o n
between imagery and relaxation after
listening to the CD indicated a medi-
um relationship that was not signifi-
cant (r= 0.33, p= 0.22).
Imagination
Listening to the CD stimulated the
imagination of 14 (82%) of the 17
A l t e r nate reliability between three ver-
sions of the Oucher pain scale in 3- to
1 2 - y e a r -old children having surg i c a l
or dental pain were strong (r= 0.88 to
0.99), positive, and significant (Beyer
& Aradine, 1986).
C h i l d ren were asked if they imag-
ined themselves being on a “magic
island” or another place. If so, the
child was also asked, “What did
you...see, hear, smell, touch, feel, and
taste?” Finally, children were asked
what they liked and disliked about the
CD.
Intervention
Magic Island: Relaxation for Kids
(Magic Island) is a 52-minute step-by-
step audio guide using music and nar-
ration to teach children how to re l a x .
Beginning with a tension-release exer-
cise to loosen tight muscles and
relieve physical stress, and with a
b a c k g round of music, the story t e l l e r
depicts an imaginary journey by hot
air balloon to a magic island. The child
is encouraged to breathe deeply, to
i m p rove oxygen circulation and calm
the body. Magic Island f e a t u r es thre e
relaxation tools: tension/release exer-
cises, deep breathing, and guided
i m a g e r y to quiet the mind and expand
the imagination.
Procedure
Institutional Review Board appro v a l
was obtained for this study, and pre -
t reatment verbal consent and assent
w e re obtained from parents and chil-
d ren . Participants were identified and
re c ruited during post-surg e ry re c o v -
e r y on two designated inpatient surg i -
cal units by their child life specialist.
The use of guided imagery is a part of
the standard of care in this medical
c e n t e r, and written consent is not usu-
ally obtained. Child life specialists
explained the guided imagery pro c e s s
to parents and children after obtaining
a g reement to participate in the study.
Following documentation of an initial
pain and relaxation score, the child
was provided with a headset and a
p o r table CD player to listen to the
Magic Island audio re c o r ding (Mehling
et al., 1990). After the CD was com-
pleted, pain and relaxation score s
w e re once again obtained from the
child by the child life specialist. Then
the 8-item imagery assessment ques-
t i o n n a i re was completed.
Statistical Analysis
Analysis was perf o r med using the
Statistical Analysis System (SAS 9.2).
Descriptive and frequency analyses
w e re used to summarize demographic
variables. A paired t-test was conduct-

PEDIATRIC NURSING/September-October 2009/Vol. 35/No. 5 293
c h i l d r en. Three (18%) children did not
imagine being on a magic island or
a n y w h e re else. The most fre q u e n t l y
re p o r ted senses were visual (82%),
a u d i t o r y (76%), and tactile (76%). The
least re p o r ted sense was taste (29%).
Table 2 lists the frequency of answers
on the senses used and the images
elicited. For example, a child may
have visualized several things such as
flowers, trees, birds, and water. In
answer to the question, “What did or
d i d n ’ t you like about the CD?”, eight
c h i l d r en stated they liked every t h i n g ,
four liked how it made them feel, and
t h ree liked all of the CD. The thre e
c h i l d r en who did not imagine anything
also disliked the CD, and stated it was
“annoying,” “weird,” and didn’t like
“what they were talking about.” Six
c h i l d r en made comments about the
p a r ts of the CD they didn’t like. For
example, “the beginning,” “the
s t r etching part,” “made me sleepy. ”
Figure 1.
Comparison of Pain and Relaxation Scores
Ta ble 2.
F r e q u e n c y of Answ e r s to the Image r y Assessment Questionnaire
Q u e s t i o n I m a ge s F r e q u e n c y Pe rcent Responding
What did you see? 8 2 %
Animals/living creatures
Wa t e r
P l a n t s / f l o we r s
Pe o p l e
N a t u r e
S a n d
8
8
7
4
4
3
What did you hear? 7 6 %
Animals/living creatures
Pe o p l e
Wa t e r
7
6
5
What did you touch? 7 6 %
A n i m a l s
S a n d / b e a c h
B a l l o o n
R o c k s
Tr e e s / p l a n t s
4
4
3
3
3
What did you fe e l ? 7 1 %
Ta c t i l e
A f f e c t i ve
8
3
What did you smell? 6 5 %
Fo o d
P l a n t s / f l o we r s
Not know
5
5
3
What did you taste? 2 9 %
N o t h i n g
Fo o d
O c e a n
8
4
1
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294 PEDIATRIC NURSING/September-October 2009/Vol. 35/No. 5
Two specifically commented on the
ending, and one child “wanted to hear
m o re about the island.”
Validity
To the investigators’ knowledge, no
studies have been conducted to
assess validity of a guided imagery
audio CD (or tape) since this study’s
inception. There f o re, the Magic Island
CD was given to 3 guided imagery
e x p e r ts for review and to establish
content validity. The group of expert s
consisted of two PhD-pre p a r ed pedi-
atric professionals, a nurse re s e a rc h e r,
a psychologist, and a highly experi-
enced child life professional who cur-
rently uses the Magic Island CD in her
daily practice. Overall, all thre e
e x p e r ts were in agreement that the
audio CD provided children with a
wide variety of sensory identification
o p p o r tunities. Weaknesses included
the length of the narrative (52 min-
utes, considered possibly too long)
and lack of opportunities for touch
and taste.
Discussion
In this study, children who used an
i m a g e r y audio CD had lower self-
re p o r ted pain from pre- to post-inter-
vention but no significantly incre a s e d
relaxation. There f o r e, there were
mixed findings to re s e a rch question 1.
The effect for pain is similar to other
findings in which imagery re d u c e d
post-operative pain in the hospital or
a m b u l a t o r y setting (Huth et al., 2004;
L a m b e r t, 1996; Pölkki et al., 2008).
The lack of a treatment effect on
relaxation is a new finding and has not
been previously supported or re f u t e d
in the literature on guided imagery
with children. Hypnotic methods do
not necessarily result in re l a x a t i o n
because a cognit ive process of
absorption occurs (Barber, 1996).
Thus, it is plausible to think that chil-
d ren were absorbed in the imaginative
p rocess of the CD and not the re l a x -
ation. It is interesting to note that 9
(53%) children had difficulty under-
standing the meaning of the word
“ relaxation.” Their parents often pro-
vided explanations to the meaning of
the word “relaxation.” Furt h e r, the
lack of significance between pain and
relaxation after the intervention may
s u p p o r t the previous arguments but
may also be a result of the small sam-
ple size.
T h e re is little empirical evidence
that supports childre n ’s imagery abili-
ty and content. Our findings support
re s e a rch question 2. Others have also
found that school-age children are
a variety of coping methods to
a d d r ess the stress of pain, illness, and
hospitalization.
Health care professionals may
need a training session on administra-
tion of any imagery CD that is used.
For example, information on deep
b r eathing, muscle relaxation, imagery,
and listening to the CD will provide the
health care professional with the abili-
ty to answer questions from childre n
and their parents (Huth et al., 2006).
Assessment of the child’s likes and
dislikes, current distress/anxiety level,
and past coping strategies used during
pain will help prevent distress when
listening to the CD. Olness and Kohen
(1996) have stressed the import a n c e
of letting children know they can
imagine going any place. In fact, let-
ting a child tailor the imagery content
may increase their imaging ability. In
the event a child does become dis-
t r essed when listening to the CD, the
child and parent can be instructed to
t u rn off the CD and notify the health
c a r e professional (Huth et al., 2006).
Documentation of the child’s re a c t i o n
to the CD and current pain level is
n e c e s s a r y because this is a therapeu-
tic intervention. Using an imagery CD
re q u i res minimal time from health
c a r e professionals (Lambert, 1996).
F u r t h e r , an imagery CD is a low-cost
i n t e r vention that has the potential to
result in improved coping and pain
management both in the hospital and
at home.
Health care professionals should
encourage children and parents to use
cognitive-behaviora l pain-re l i e v i n g
methods, such as imagery, re l a x a t i o n ,
and breathing techniques. Eff e c t i v e
pain management can lead to short e r
lengths of stay and better coping and
emotional well being after discharg e .
These techniques can be re i n f o rced at
d i s c h a r ge and used at home. These
p r e l i m i n a r y findings can be used to
e n s u re that health care pro f e s s i o n a l s
a r e using a guided imagery interv e n -
tion that is supported by empirical evi-
dence. Future re s e a rch could focus on
comparing imagery CDs that are indi-
vidualized to the child’s favorite place
or activity to a standardized imagery
CD. Research that explored capturing
c h i l d r e n ’ s attention capacity during
times of stress and pain would also
advance pediatric nurses’ knowledge
and understanding of imagery.
Conclusion
This study examined the efficacy of
a commercial guided imagery CD in
reducing school-age childre n ’ s post-
operative pain, increasing re l a x a t i o n ,
able to imagine their favorite or famil-
iar people, places, and animals (Huth
et al., 2006; Lee & Olness, 1996;
S m a r t, 1997). The findings from this
study indicate that 82% of the childre n
re p o rted being on a magic island. This
is similar to previous re p o r ts in which
the majority of children imagined
going to the place suggested in the
audio tape or CD (Huth et al., 2006;
S m a r t, 1997). Children in this study
w e re able to deviate from the CD
because they imagined other content,
such as flora, animals and pets, and
people. Likewise, Huth and colleagues
(2006) re p o r ted that children imagine
animals and pets, but also imagined
familiar places, sports events, and
special events. Children in this study
w e re able to use their senses to see,
h e a r, touch, feel, smell, and taste. As
identified by the content experts and
collaborated by the children in this
s t u d y, taste was a weakness of the
senses re p r esented on the CD.
I m a g e r y evokes mental images that
involve the senses (Naparstek, 1994).
The frequency of senses used by
school-age children during imagery
has not been previously re p o r t e d .
A d d i t i o n a l l y, the content validity of a
guided imagery audio CD has not
been established. There f o re, these
results can help ensure that health
c a re professionals use an interv e n t i o n
that has pre l i m i n a r y validity testing.
Limitations
Several limitations should be con-
s i d e r ed when interpreting these find-
ings. Most importantly is the lack of
randomization and lack of a contro l
g roup. Second, there was no contro l
for the medications given, the type of
s u rg e r y, or the number of days since
the surg e r y and intervention. Finally,
the small sample size limits generaliz-
a b i l i t y. Intere s t i n g l y, power analyses
after data collection indicated that
e f fect size for the reduction of pain
was large and moderate for re l a x a t i o n .
Implications for Practice
And Research
Despite these limitations, this study
p rovides evidence that children ages
7- to 12-years-old were able to use
guided imagery in the hospital setting.
Cognitive distraction is a fre q u e n t
coping strategy used by school-age
c h i l d ren. There f o re, health care pro-
fessionals should use this interv e n t i o n
to give children a sense of control and
assist them in coping during hospital-
ization. Both imagery and re l a x a t i o n
on the CD may provide the child with

PEDIATRIC NURSING/September-October 2009/Vol. 35/No. 5 295
and stimulating imagery. Imagery was
e f fective in reducing childre n ’s re p o r t-
ed pain but was ineffective in incre a s-
ing relaxation. These findings support
that relaxation is not necessary for
pain reduction. Children were able to
use their senses and imagine going to
a magic island when listening to the
CD. Thus, there is pre l i m i n a r y content
validity for this guided imagery CD.
Health care professionals need to be
educated to administer non-pharm a-
cologic interventions, such as guided
i m a g e r y. It is hoped that this pilot
study will assist health care pro f e s -
sionals in implementing therapeutic
i n t e r ventions for children who contin-
ue to suffer pain. Children and pare n t s
should expect and demand care
based on re s e a rch findings.
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