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(Chest. 2003;123:941-948.)
© 2003 American College of Chest Physicians

Distraction Therapy With Nature Sights and Sounds Reduces Pain During Flexible Bronchoscopy*

A Complementary Approach to Routine Analgesia

Gregory B. Diette, MD, MHS; Noah Lechtzin, MD, MHS; Edward Haponik, MD, FCCP; Aline Devrotes, RN and Haya R. Rubin, MD, PhD

* From the Divisions of Pulmonary and Critical Care Medicine (Drs. Diette, Lechtzin, and Haponik) and General Internal Medicine (Dr. Rubin), Johns Hopkins University School of Medicine, Baltimore, MD; and Johns Hopkins Hospital (Ms. Devrotes), Baltimore, MD.

Correspondence to: Gregory B. Diette, MD, MHS, Room 7400, 1830 East Monument St, Baltimore, MD 21205; e-mail: gdiette{at}jhmi.edu


   Abstract
TOP
 Abstract
Introduction
 Materials and Methods
 Results
 Discussion
 References
 
Study objectives: To determine whether distraction therapy with nature sights and sounds during flexible bronchoscopy (FB) reduces pain and anxiety.

Design: Randomized controlled trial.

Setting: Teaching hospital in Baltimore, MD.

Patients: Consecutive adult patients (n = 80) undergoing FB with conscious sedation.

Intervention: Nature scene murals were placed at the bedside, and patients were provided a tape of nature sounds to listen to before, during, and after the procedure. Patients assigned to the control group were not offered either the nature scene or the sounds.

Measurements and results: The primary outcomes were patient ratings of pain control (a 5-point scale ranging from poor to excellent) and anxiety. In a multivariate ordinal logistic regression model, the odds of better pain control were greater in the intervention patients than in the control patients (odds ratio [OR], 4.76; 95% confidence interval [CI], 1.35 to 16.7), after adjustment for age, gender, race, education, health status, and dose of narcotic medication. Older patients and patients with better health status reported significantly less pain. There was no difference in patient-reported anxiety between the two groups (OR, 0.87; 95% CI, 0.39 to 1.96).

Conclusions: Distraction therapy with nature sights and sounds significantly reduces pain in patients undergoing FB. Although the precise mechanism of this beneficial effect requires further investigation, clinicians should consider this nonintrusive strategy in addition to standard analgesic medications in patients undergoing painful, invasive procedures.

Key Words: bronchoscopy • distraction • nonpharmacologic • pain


   Introduction
TOP
 Abstract
 Introduction
Materials and Methods
 Results
 Discussion
 References
 
Patients in the United States are increasingly demanding better health care, including the proper treatment of pain.1 2 To formalize the right of patients to expect proper pain assessment and management, organizations such as the Joint Commission on Accreditation of Healthcare Organizations have introduced new standards for hospitals and other health-care settings to maintain accreditation.1 2 The Joint Commission on Accreditation of Healthcare Organizations1 standards apply to the management of chronic medical conditions and the relief of pain during invasive procedures, and they encourage clinicians to effectively assess and treat pain in patients. Flexible bronchoscopy (FB) is an example of an invasive procedure that can be frightening and painful for patients.3 4 5 There is room to improve the management of pain during FB, as many patients experience pain6 despite the common use of premedication analgesics and sedatives.5 In addition, because these medications have side effects, including respiratory depression and cardiovascular instability,7 it would be useful to develop nonpharmacologic approaches to improving the patient experience with painful procedures. The use of less medication may speed recovery from the procedure and facilitate the timely discharge of patients from the hospital.

Nonpharmacologic practices, such as guided imagery, hypnosis, and distraction, have been effective in improving patient experiences during stressful or painful medical procedures.8 9 Distraction therapy is a technique in which sensory stimuli are provided to patients in order to divert their attention from an unpleasant experience.10 The use of nature scenes and sounds is an effective tool for distraction and has been successful in a variety of patient settings, including perioperative care, phlebotomy, and burn care.8 11 12 The benefit of nonpharmacologic approaches to analgesia during FB, however, has not been evaluated adequately. Studies regarding the use of these approaches in FB have been limited to music therapy, and the results of these studies have been inconsistent.

The purpose of this investigation was to determine whether the use of nature sights and sounds during FB reduces anxiety and pain, and, secondarily, whether it improves patient satisfaction with the procedure.


   Materials and Methods
TOP
 Abstract
 Introduction
 Materials and Methods
Results
 Discussion
 References
 
Subjects
The protocol was approved by the Joint Committee on Clinical Investigation at Johns Hopkins University, and all subjects provided verbal consent for participation in the study. All consecutive adult patients (ie, those >= 18 years of age) who were undergoing FB in the Endoscopy Suite at Johns Hopkins Hospital were considered for inclusion in the study. Patient exclusion criteria were as follows: (1) non-English speaker; (2) the presence of encephalopathy or other significant alteration of mental status; (3) sensory deficits that precluded the use of a visual and auditory aid; or (4) contact isolation since it would interfere with patients’ handling of personal cassette recorders.

Intervention
Patients in the intervention group were offered the possibility of viewing a nature scene and listening to a tape of nature sounds by their bedside (Bedscapes; Healing Environments International; Glenford, NY) before, during, and after the FB. The mural consisted of a 42 x 52-inch photographic quality mural of a mountain stream in a spring meadow that was mounted by the bedside in the recovery area (Fig 1 ). The scene was mounted from the ceiling of procedure rooms so that patients could view it while supine, during the procedure. A continuous tape of complementary nature sounds (eg, water in a stream or birds chirping) was played with a portable tape player that patients listened to with headphones. Patients in the treatment group were shown how to use the tape recorder and were free to turn it on or off and to adjust the volume. Patients assigned to the control group received neither the nature scene nor the nature sounds. No other aspects of the procedure for either group were controlled by the study protocol. Patients were not told about the study objectives or how to utilize the nature scene intervention, and bronchoscopists administered the sedative and analgesic medications based on their usual practices. No FBs were performed by study investigators.



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  		Figure 1.. Nature scene used in intervention. Used with permission of Healing Environments International.

 
Outcome Measures
The primary outcomes were patient-reported anxiety and pain during the procedure. Pain was measured by a question that asked how well pain had been controlled during the procedure (ie, poor, fair, good, very good, or excellent). This question has been used previously as an outcome measure in bronchoscopy patients.5 Anxiety was measured with a six-item short version of the state of anxiety measure from the Spielberger State-Trait Anxiety Inventory (S-STAI), a self-completed survey that asked patients to rate whether they felt calm, tense, upset, relaxed, content, or worried on a 4-point ordinal scale (1, not at all; 2, somewhat; 3, moderately so; 4, very much so).13 The items are summed and normalized to a scale with scores ranging from 20 (low) to 80 (high). The mean value (SD) for a working adult population is 35.7 (10.4) for men and 35.2 (10.6) women. Sample size estimates were for 38 subjects in each group, based on an anticipated ability to detect a difference of 6 points between groups, with a power 0.80 and {alpha} of 0.05. A 6-point difference in S-STAI was shown in a study of patients receiving music therapy during colonoscopy.14

Secondary outcomes included the ability to breathe during FB (poor to excellent), the willingness to return for another FB if needed, and the rating of the bronchoscopy area (ie, privacy, safety, and overall assessment).

Patients completed a survey with baseline information while waiting to begin the procedure, and a follow-up survey was administered on the second day following the procedure. The second survey asked about symptoms since the procedure, satisfaction with care, the quality of the information given by staff about the procedure, and the memory of and discomfort during the FB. Outpatients completed the form and returned it by mail. Inpatients’ forms were collected from their hospital room by study staff. For patients who were unable to complete the form on their own, a study member administered the survey in person or by phone. Anxiety and pain during the procedure were assessed on the second day following the procedure because we were concerned about the effect that narcotics and anxiolytics would have on the ability to complete the survey immediately.

Independent Variables
Information about the patients and the procedure was collected on standardized data collection forms from bronchoscopists and patients as part of an ongoing family of studies of FB performed at this institution. This information included patient demographic information (ie, age, gender, race, health status, and education), comorbid illnesses (eg, asthma and COPD), smoking status, indication for the procedure, sampling methods used (ie, BAL, transbronchial biopsy, brushing, and needle aspiration), medication used, and medication doses.

Statistical Analysis
Baseline information about patients and details of the procedure were compared in the two study groups using means and proportions, as appropriate. Statistical tests used in bivariate analyses included {chi}2 test and Student t test. The significance level was selected as p < 0.05. Multivariate models were developed for analyses of the two major outcomes (ie, anxiety and pain) using ordinal logistic regression. Ordinal logistic regression, an adaptation of logistic regression, can be used to estimate relationships between an ordinal dependent variable and a set of independent variables.15 Independent variables for these models included patient age, gender, race, education, and health status. A dose of midazolam (an anxiolytic) was included in the anxiety model, and a dose of fentanyl (an analgesic) was included in the pain model.

Missing data were handled using a prespecified strategy. For variables for which there were no more than 10% missing data, we used results from respondents with complete data to substitute the median value for ordinal and continuous variables, and the mode for nominal variables. For variables with > 10% missing data, an imputation algorithm was used.16 17 Only one variable (pain) required imputation. Analyses were repeated with and without imputation. The results were similar in both analyses, and only the values using the imputed variable are presented. Data were analyzed using a software package (Stata, version 5.0; Stata Corporation; College Station, TX).

Data Collection
The study was conducted from May to August 2000. Recruitment continued until at least 38 evaluable patients in each group had completed the study. Data collection efforts for all outstanding data forms ceased 2 weeks after the last required patient file was completed.

Patient Assignment
The unit of assignment to intervention or control status was an entire day of FB procedures. Randomization was not feasible at the level of the individual, as the recovery area has multiple patients in a common area. It would not have been possible to isolate a control patient from the view of the nature scene in our bronchoscopy unit. Thus, all patients undergoing FB on a given day were assigned to intervention or control status. The allocation schedule was generated by having a study member place equal numbers of intervention and control assignments in opaque envelopes. Each day at 4:00 PM, two other study members (not those who filled the envelopes) opened one of the envelopes to determine the next day's assignment. In this manner, the nursing staff in the bronchoscopy unit could have time to prepare the suite (ie, put up or take down the scenes), but bronchoscopists could not know the assignment at the time that they scheduled their patients (nonemergency FBs are scheduled by 4:00 PM each day for the following day). Masking bronchoscopists to the intervention or to the control status of each patient was not practical, but bronchoscopists were not told of study end points. Because FBs are performed on several inpatient and ambulatory specialty services at our institution, in general, multiple bronchoscopists would perform procedures on any given day.


   Results
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
Discussion
 References
 
During the study period, 108 patients underwent FB in the bronchoscopy unit at Johns Hopkins Hospital, of whom 4 were not eligible (altered mental status, 2 patients; non-English speaker, 1 patient; deaf, 1 patient). Of 104 eligible patients, 80 (76.9%) were enrolled into the study (intervention group, 41 patients; control group, 39 patients). Four patients refused participation, and 20 patients were not offered enrollment because the nursing staff were too busy with clinical duties (Fig 2 ). Eligible nonenrollees were not significantly different than enrollees by age (mean, 51.4 vs 53.8 years, respectively; p = 0.52) or gender (56.5% vs 46.8% male, respectively; p = 0.41), although nonenrollees were more likely than enrollees to be nonwhite (50.0% v. 33.8%, respectively; p = 0.05). Nonenrollment rates among eligible patients were similar on intervention and control days (24.1% vs 22.0%, respectively; p = 0.80). FBs were performed by 13 different bronchoscopists (range, 1 to 19 study patients per bronchoscopist), and 61.5% of bronchoscopists performed the procedure on both intervention and control patients. Only one bronchoscopist performed FBs on > 10 study patients (total, 19 patients; intervention group, 9 patients; control group, 10 patients). Individual bronchoscopists were not significantly more likely to be represented in either group (p = 0.28).



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  		Figure 2.. Patient flow through the study.

 
There were slight differences in patient characteristics among those in the intervention and control groups (Table 1 ). Intervention group patients were more likely than control group patients to be female (61.0% vs 44.7%, respectively), African American (39.0% vs 28.2%, respectively), and college educated (51.8% vs 41.7%, respectively), although their health status was slightly more likely to be poor or fair (68.3% vs 64.1%, respectively). The mean anxiety levels assessed just prior to the procedure were nearly identical in the two groups. None of these differences was statistically significant.


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  		Table 1.. Baseline Characteristics of Study Groups

 
The primary indications for the procedure were similarly likely in the two groups to be for evaluations that rule out carcinoma (ie, lung masses and/or adenopathy), for the evaluation of infiltrative processes, and for surveillance for rejection and infection in lung transplant recipients (Table 2 ). Intervention group patients were more likely than were control group patients to undergo BAL, transbronchial biopsy, and brushing of the proximal airways, and were less likely to undergo transbronchial needle aspiration. The mean doses of medications used during the procedures to control pain (ie, topical lidocaine solutions and IV fentanyl) were similar in the two groups, as was the average dose of the anxiolytic medication midazolam.


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  		Table 2.. Procedure Characteristics of Study Groups*

 
Outcomes
Bivariate Analyses: In bivariate analyses (Table 3 ), patients in the intervention group were 43% more likely to report pain control as being very good or excellent (not statistically significant), but there was no apparent difference in the mean level of anxiety between the intervention and control groups (44.8 vs 45.6, respectively; p = 0.84). Comparing intervention group patients to control group patients, pain control was reported as very good or excellent by 29.3% vs 20.5% of patients, respectively, and as poor or fair by 2.4% vs 15.4% of patients, respectively. Pain was associated with bronchoscope insertion in 11% of intervention patients, while 15% of control group patients reported such discomfort. There was no significant difference in medication use between patients reporting "better" pain control and those reporting "worse" pain control. Patients were 63% more likely to report the ability to breathe as being "very good" or "excellent" than were patients in the control group, although this difference did not reach statistical significance. No indicators of patient satisfaction were significantly different in the two groups, although intervention patients were somewhat more likely to rate privacy during the procedure (78.0% vs 71.8%, respectively; p = 0.51) and the overall rating of the facility (87.8% vs 79.5%, respectively; p = 0.31) as being very good or excellent.


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  		Table 3.. Unadjusted Outcomes by Study Group*

 
Multivariate Analyses: In multivariate analysis, pain control was significantly better in the intervention group compared with the control group during the procedure (p = 0.015) [Table 4 ]. Older patients and patients with better health status reported significantly less pain. More education also was associated with better pain control (p = 0.051). On the other hand, there was no significant effect of the intervention on reported anxiety (Table 5 ), even after adjustment for patient age, gender, race, education, health status, and dose of midazolam used. Patients with better health status had significantly less anxiety (p < 0.001). To further assess the potential overlapping effects of midazolam and fentanyl on patient reports of anxiety and pain, we reran multivariate analyses, adding the fentanyl dose to the anxiety model and the midazolam dose to the pain model. Neither medication was significantly associated with the outcomes, and the effect of treatment assignment was similar to that of the original models.


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  		Table 4.. Multivariate Analysis of Predictors of Better Pain Control*

 

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  		Table 5.. Multivariate Analysis of Predictors of Greater Anxiety*

 
Adverse Events
There was one adverse event in the treatment group and none in the control group. A patient who was listening to a tape of nature sounds urinated while on the bronchoscopy table. The patient felt that this had occurred because of hearing sounds of running water.


   Discussion
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
References
 
In this prospective, randomized clinical trial, we have shown that pain can be reduced during an invasive procedure through the use of a nontraditional, nonpharmacologic intervention. Exposure to nature sights and sounds before, during, and after bronchoscopy is a safe, inexpensive (approximately $249 for the reusable mural and tape) means to enhance analgesia, with none of the risks or side effects caused by medications. Contrary to what we had expected, we found no evidence that this intervention affected patient anxiety during the procedure.

The past decade has seen tremendous technologic developments in medicine. Despite these advances, patients have increasingly been seeking low-technology, alternative medical therapies,18 suggesting that patients may be not be completely satisfied with the current approaches to care. Distraction therapy is a technique in which patient attention is focused on a pleasant stimulus and away from a stressful or painful one. It often involves having patients look at pictures or videos and listen to music or other sounds. Burn patients who were assigned to watch nature videos had less pain and anxiety during dressing changes than patients in a control group.11 Patients who listened to music while undergoing GI endoscopic procedures reported less anxiety and greater satisfaction than a comparison group.14 19 The only previous studies20 21 of distraction during FB utilized music and yielded conflicting results. Dubois et al20 found that patients who had been assigned to music during the procedure had greater comfort and less coughing, while Colt et al21 found no difference in anxiety between patients who listened to relaxation music compared with control subjects. Although music is not a directly comparable distraction technique to nature sights and sounds, our findings are consistent with both studies in that we found that distraction reduced pain and had no effect on anxiety. It is noteworthy that patients in the intervention group reported superior pain relief even though they had undergone more invasive, potentially more painful, procedures than had control group patients. That these patients did not require higher does of analgesics or sedation during bronchoscopy is remarkable, and it suggests that the intervention might have exerted a drug-sparing effect as the mean dosages of drugs administered were similar between groups. It is also important that older patients reported significantly less pain. Because of their vulnerability to the untoward effects of pharmacologic options, the use of distraction therapy might help to enhance patient safety.

Studies have demonstrated the positive effects of nature on humans and also have provided evidence that distraction techniques can be beneficial in aversive situations. The biophilia hypothesis suggests that humans are genetically predisposed to respond positively to nature. This can result in positive adaptive responses.22 College students report that views of nature compared to views of urban scenes promoted the resolution of psychological stress.23 Patients recovering from gall bladder surgery had shorter hospital stays, required fewer analgesics, and received fewer negative comments in nursing notes if they were in a hospital room with a view of trees than if they had views of a brick wall.24 Wilson and Ulrich22 hypothesized that our positive reaction to nature may be based on physiologic changes that occur after brief exposures to nature scenes (eg, changes in plasma levels of catecholamines and other mediators). As in earlier studies of pain,5 25 26 we found that increased levels of education, better health status, and increasing age were associated with less pain during FB. The effect of health status is especially illuminated by the present study. Compared to patients in the study by Lechtzin et al,5 those in the present study had similar levels of education, yet markedly worse health status (66% vs 31%, respectively, reported poor or fair health). Notably, in this sicker population, only 21% of control patients reported very good or excellent pain control, while 62% reported it in the study by Lechtzin et al.5 Less healthy patients may metabolize drugs differently than other patients and may have other comorbidities that contribute to pain. Lower education may be associated with increased pain due to suboptimal communication between patients and health-care providers. Thirty-five percent of inner-city hospital patients have inadequate health literacy, and this can lead to inappropriate preparation for tests and procedures.27 Older patients have been shown to obtain more pain relief than younger patients from the same dose of narcotics. This is likely due to decreased volume of distribution and plasma clearance in older adults. The dose of narcotic was not predictive of pain control. This finding is expected, as the administered dose is titrated by clinicians to achieve a desired effect. As in a previous investigation, discomfort with nasal insertion of the bronchoscope was an important patient concern.5 Such pain was reported less often in our intervention patients (11% vs 15% in control subjects).

While our intervention did not affect anxiety, we were able to confirm that patients are, on average, anxious at the time of the procedure. The mean S-STAI in our patients was similar to that (S-STAI, 42.6) of the population undergoing bronchoscopy in the study by Colt et al.21 There are several possible explanations for the lack of impact of distraction therapy on anxiety that we observed. Anxiety experienced in the time surrounding FB may be more closely related to the fear of the FB findings rather than to any aspect of the procedure itself. If this is the case, nature sights and sounds during the procedure may alleviate pain but not anxiety. Alternatively, the nature scene intervention simply may not have an anxiolytic effect or the S-STAI may not adequately respond to changes in anxiety in this setting.

There are limitations to this study. Study subjects were intentionally given very little information about how to use the nature sights and sounds to limit any potential influence of extra attention from the investigators on their experience. Due to this, some patients reportedly had difficulty adjusting the volume on the headphones and were at times frustrated by the auto-reverse mechanism on the tape players. These problems may have decreased the efficacy of the intervention. The study was conducted at a single center in which most of the bronchoscopists perform FBs using similar techniques. A multicenter study would increase the generalizability of our findings. It is unlikely that our findings are attributable to the characteristics of individual bronchoscopists, as most bronchoscopists were represented in both groups and were distributed homogeneously by treatment group. Our primary outcomes were patient-oriented and subjective. Physiologic measures, such as plasma catecholamine levels, may have provided evidence on how the intervention works but were beyond the scope of this study. Although the most obvious effect on our primary outcome measure might occur through direct effects on the patient, other influences of the bronchoscopy environment can be envisioned. We did not measure whether the use of nature sights and sounds (Bedscapes) influenced our bronchoscopists and nursing staff in their approach to the procedure. Many experienced bronchoscopists share the view that a calm, supportive practice environment contributes to the patient's tolerance of FB and enhances the opportunities for success. The current observations are consistent with this anecdotal impression, but we did not appraise whether technical modifications of FB on the part of the bronchoscopists occurred in intervention patients. More information about the factors impacting on bronchoscopist performance is needed.

Despite these limitations, this investigation extends the medical application of distraction therapy and identifies an important low-cost opportunity to enhance bronchoscopy practice. This randomized, controlled trial demonstrated that an inexpensive, easy-to-use, and safe intervention was successful in decreasing pain in patients undergoing FB. The current investigation lends further support to the importance of addressing pain control and anxiety as distinct considerations during bronchoscopy. Neither this principle nor the potential role of nonpharmacologic interventions such as distraction therapy are generally addressed in the standard pulmonary practice of bronchoscopy or in current bronchoscopy texts. The study confirmed that patients undergoing FB are anxious. In order to optimize the patient experience, bronchoscopists need to recognize that anxiety is present and attempt to reduce it. While this can be accomplished with anxiolytics, nonpharmacologic techniques also might be developed as a way to safely improve the experience of our patients. As patients continue to show an increasing interest in alternative medicine, clinicians may rightfully be reluctant to implement therapies that have not undergone scientific scrutiny. By subjecting less traditional methods to scientifically rigorous studies, we can learn the value of alternative therapeutic interventions. We have now seen that distraction therapy with nature sights and sounds (ie, Bedscapes) can improve pain control and should be considered for routine clinical use during invasive procedures such as FB.


   Acknowledgements
 
We offer our gratitude to the nurses of the Johns Hopkins Hospital Endoscopy Unit for helping with this study. We acknowledge the generous contribution of murals, tapes, and tape recorders by Joe August, President of Healing Environments International, Inc. Finally, we thank Charles M. Wiener, MD, Vice Chairman of Medicine, for setting the tone for this project with his commitment to biophilia.


   Footnotes
 
Abbreviations: FB = fiberoptic bronchoscopy; S-STAI = Spielberger State-Trait Anxiety Inventory

Johns Hopkins Medicine supported the personnel involved in the Bronchoscopy Quality Improvement Project. Supplies for the study (screens, tapes, and tape recorders) were provided by Healing Environments International.

Received for publication May 3, 2002. Accepted for publication August 12, 2002.


   References
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
 References
 

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