Program of Research: Studies and their Hypotheses
by Jean Johnson, RN, PhD

Sensation Theory: "Discrepancy between expected and experienced physical sensations (what is felt seen, heard, tasted, and smelled) during a threatening experience will result in distress."

Then research on, if procedure and sensation information does reduce distress:

- works because inaccurate expectations are decreased

- can be incomplete "typical" sensations

- best is preparatory information describing typical sensations

- not include statements about intensity of sensation

- worked in children with cast removal

- in adults with endoscopy

- in adults pain of ischemia in arm

Must make sure the sensations are adequate

Information – endoscopy

Sensations in various steps – related to past experience

i.e., needle stick, drowsiness

size of tube in relation to pencil (familiar objects)

changes of light in room

M.D. touching with finger

air in stomach or fullness

Procedure information not enough – time, patient attire, consent, diet, med. premed., personnel, radiation hazards, equipment, aftercare with endoscopy – not related to message fearfulness, degree of competency by M.D., thruthfulness, perceived helpfulness, ease of understanding, amount of dread.

Appropriate Patient Education for Dia. Test

1. What if sensation information lead subjects to believe the procedure was not dangerous?

Both groups rated the ???? advance.

2. What if the sensory information subjects anticipated less intense pain to begin with?

Added a control group and there weren’t any differences in pain ratings.

3. Subjects developed strategies for coping with pain, thus moods were reported before and after information given – no significant changes.
4. Were sensory information people concentrating more on the arms and the pain sensation?

Half were asked to work multiple problems during the ??????.

Others half asked to concentrate on their arms = no difference.

5. Data on power of suggestion:

i.e., did they experience sensation because they were described (suggested to them)?

Subjects told to expect specific sensations did not report these feelings any more frequently than those not told.

= Giving patients prior sensory information did not make them feel sensations not really induced by the procedure.

6. How do patients react to being told 1 or 2 typical sensations and not all of them? (no difference)

Thus, patients may have reduced stress even if nurses can only provide partial description of sensations.

Define our A6 as psychoeducational care:

3 domains of content:

1. Providing patients with health-related information – about events, procedures, or sensations they are likely to experience.

Also provide information about self-care actions to be performed – i.e., ask for pain med. PRN, stop smoking.

A Better Way to Calm the Patient Who Fears the Worst

In 1950s as a surgical nurse, Dr. Jean Johnson "had a hunch" that patient’s distress during and after OR procedures could be reduced by patient teaching. Very common scene today but what kind of teaching or information you’ll make patients fearful and anxious.

This innovation in patient-teaching technique…

The sensory information approach to patient teaching is based on the observation – well documented in psychology and behavioral science – that a person’s emotional response during a threatening event depends on whether his expectations of what he will perceive through his senses are actually borne out by the experience.

…she began a research program that eventually included several lab experiments and several major clinical studies.

The laboratory experiments w ere designed to isolate the effect of providing sensory information in a controlled environment before attempting to measure the reduction of distress in a clinical setting.

The threatening event to which subjects were exposed in the laboratory was ischemic pain of the arm. The pain was induced by inflating a blood pressure cuff on the arm to 250 mm. Hg, and having the subject exercise the affected arm by squeezing a hand dynamometer. In the first experiment, 20 male university student volunteers were randomly assigned to hear two messages. One group heard a description of typical sensations subjects usually experienced – pressure, tingling, aching, numbness, and the sight of paleness or blueness of the fingernails. The other group heard a description of the procedure used to produce the ischemic pain.

During the time the arm was ischmic, each subject was asked to rate the intensity of the physical sensation he was experiencing and how much distress he felt from the sensation.

The result? The intensity ratings did not differ significantly for the two groups; but, as expected, the subjects who received a description of the typical sensations reported lower distress than the subjects who received a description of the procedure.

1. What if the sensation information led those subjects to believe that the event was less dangerous…

Subjects in both groups reported that they perceived the experiment to be low in danger.

2. Perhaps the sensory information subjects anticipated that the pain would be either less intense or less distressing than the others. To rule out this explanation, all the subjects – after they had received their respective information message, but before the cuff was inflated – reported how intense and how distressing they thought the sensations would be. Reports from the two groups did not differ significantly.
3. The possibility that fear caused certain subjects to develop strategies for coping with the event might explain the results obtained. All subjects reported their moods before…

The first clinical study was done in a gastroendoscopic clinic. Ninety-nine patients were randomly assigned to one of three preparation groups. One group heard the sensory information and saw photographs of patients at different stages of the examination. The specific sensations included the following: the prick of the needle followed by drowsiness, change in lighting, throat swabbing, the feel of the doctor’s fingers in the mouth, the introduction of a flexible tube the thickness of a pencil, swallowing, holding the bit piece in the mouth, and fullness in the stomach.

The second group heard information and saw photographs of the clinical area, treatment room, and equipment. A step-by-step explanation of the procedure…

A control group receive the routine preparation.

Patients who hear the sensory description display less distress during the examination than patients who received the procedural message or the routine clinic preparation. …indicators of distress – the amounts of sedative required; heart-rate changes, tension in the hands and arms, gagging during tube passage; and restlessness during the first 15 minutes of the procedure. "The very first clinical study of sensation information was so beneficial to the patients that the clinical immediately adopted it.

"We want to determine if the sensation-teaching technique was relevant to children under threat, so we tested it in a children’s orthopedic clinic."

Eighty-four children – 6 to 11 years of age – who were to have casts removed were randomly distributed among three groups. One group heard this description of the usual sensations: They were told that they would see the doctor, hear the buzz of the saw, and feel vibrations and tingling, but they were assured they would not be cut; that they would see chalky dust flying around, feel a little warmth in the cast, but it would not burn them; and the limb exposed would feel stiff, and for a while might seem lighter than the other arm or leg.

Another group heard a description of the procedure, and the third group received the routine preparation. During cast removal, the children were observed by two researchers, each independently scoring the children’s behavior for degree of distress based on facial tension, clenched fists, feet extension, rotation or rigidness, attempts to pull away, kicking, hitting, whining, screaming, crying, and other signs. As with the adults, the children who heard the sensory information showed the lowest degree of distress.

…women 18 to 25 years of age having pelvic exams. The women – all of whom had previously had pelvic examination – received four different kinds of information:

1. A control group heard why it was important to have the pelvic exam.
2. The second group received instruction in relaxation. The women in this group were taught how to relax the abdomen and how to do abdominal breathing, and they were given an opportunity to practice.
3. The third group heard sensory information included with the procedural steps of the exam. Some of the sensations mentioned were the coldness of the stirrups, discomfort of the exam table, coldness of instruments, feel of wetness, the clicking sound of the speculum, pressure on the abdomen, the feeling of a bowel movement, and intravaginal pressure.

Results: the relaxation instruction alone did not help the patients to be more calm or cooperative during the procedure. But, the relaxation instruction combined with the sensation information got the best results. …they didn’t report being less frightened, although they kept their legs apart, their hands did not drift, and their pulse rates were lower – all signs of less distress… They asked themselves, however, if such information would reduce distress when the threatening event lasted several days.

The selection of surgical patients provided an opportunity to examine not only the long-term effect of sensory information, but also to compare its effectiveness with another type of preparatory information, namely, exercise instruction.

The patients – all scheduled for elective cholecystectomy at a large private hospital – were divided into six groups:

1. The first group received only general information
2. The second group received only procedural information
3. The third, only sensory information
4. The fourth, only exercise instruction
5. The fifth heard both exercise instruction and procedural information
6. The six heard both exercise instruction and sensory information

Exercise instruction, given at the bedside, included deep breathing, coughing, leg exercises, turning in bed, and getting out of bed. A book illustrating the exercises was available to the patients, and the research nurses assisted the patients in practicing the activities until mastery was achieved.

Procedure information described services the staff would perform – skin preparation, physician visits, intravenous infusion, transfer to operating room and recovery room, and postoperative diet.

The sensory information included some procedural information; however, the emphasis was on the sensations that surgical patients usually experience: the feeling of light-headedness and sleepiness after medication; the sensations of burning, smarting, and pulling at the incision site, and of tenderness, sensitivity, pressure, and sharp traveling pain in the area of the operation; a general feeling of tiredness, dryness of the mouth, cramping, and some discomfort and weakness in movements; finally, the feeling of pulling and pinching when the stitches are removed. This group was instructed to request pain medication if it was needed.

Patients were observed for three days post-op…

The number of doses of parenteral analgesic that the patients received from midnight the day of surgery to midnight of the third post-op day was significantly less in those who had exercise instruction. These patients received an average of 1.65 fewer doses than patients who did not receive the exercise instructions. In addition, they ambulated more frequently.

The greatest beneficial effect of exercise and sensory information occurred in patients who had a higher degree of pre-op fear. The relatively fearful patients who received exercise instruction reported greater feelings of well-being and happiness and less fear, helplessness, and anger than patients who did not receive exercise instruction.

For patients reporting relatively high pre-op fear, both procedure and sensation information tended to reduce feelings of helplessness and anger, but only sensory information tended to reduce the level of fear.

The sensory information was most dramatic in significantly reducing the length of hospitalization and in having lasting effectiveness after discharge. Patients in both procedure and sensory information groups had shorter stays than those in the general information groups, but only the mean for the sensory group was statistically significant. …an average of slightly over one day less than the general information patients.

Follow-up calls six weeks after the operations revealed that the various types of information had a significant effect on how many days after discharge the patients ventured outside their homes. In the general information group, the average was 6.8 days; for those in the procedure information group, it was 4.7 days; and for those in the sensory information group, it was 3.3 days.

…the behavioral patterns of the patients revealed that the most significant factor in assisting them to cope during the procedures was the sensory information.

… colleagues studied varied widely in age, social and economic status, and race. The threatening events varied in setting from simple to complex clinical situations and procedures; and in duration, from less than two minutes to several days and weeks. Painful and painless, intrusive and nonintrusive events were studied.

"There is absolutely no question that pre-op exercise and deep breathing make a tremendous contribution to the reduction of post-op complications. No patient should go to surgery without receiving that nursing care. Similarly, we know now that providing sensory information preparatory to a nursing or medical procedure reduces patient distress during the procedure and, as in the surgical study, can have long-lasting benefits.

"Our research has demonstrated that the combination of both types of information gets the best results. It’s like two compatible drugs that work in separate ways to achieve a single result – patient recovery and well-being. Both types of information should definitely be an integral part of all nursing care."

Utilize Research

How to Include Sensory Information in Your Patient Teaching

Here’s how you can do it:

1. Identify the steps of the most common procedures.
2. List what you perceive would have a sensory effect on the patient (whatever relates to seeing, touching, smelling, tasting, hearing).
3. Ask present patients for their perceptions. For example: How did you feel during the procedure?
4. Select the typical sensory experiences described by 50% or 60% of the patients.
5. Choose several words to describe the sensations.
6. Use the patient’s words.
7. Give this sensory information to new patients in the process of preparing them for the procedure.
8. Hit the high points, the things that almost everybody perceives.
9. Use the word "pain" sparingly. Some procedures cause discomfort, …

But when sensations are described by patients as painful, use the word "pain."

Let that be your reward. Compare patients who haven’t received sensory information with those who have on outcomes. You’ll find that nurses have to spend less time with the informed patients and you’ll see that these patients are more comfortable and cooperative after the procedure. With surgical patients, you can keep track of the postoperative course, amount of pain medication needed, whether your patients are ambulating freely, whether they seem less nervous than others and whether they are easier to take care of.

Program of Research: Studies and Their Hypothesis

Jean Johnson, RN, PhD

        Johnson, J. (1973). Effects of accurate expectations about sensations on the sensory and distress components of pain. Journal of Personality and Social Psychology, 27, 261-267.

HO: Accurate expectations about the physical sensations to be experienced reduces the distress caused by painful stimuli.

        Johnson, J., Morrissey, J. F., & Leventhal, H. (1973). Psychology preparation for an endoscopic examination. Gastointestinal Endoscopy, 19, 180-182.

HO: Sensory information about a distressing procedure will lower distress in patients more than procedural information.

        Johnson, J., Kirchhoff, K., & Endress, M. P. (1975). Altering children’s distress behavior during orthopedic cast removal. Nursing Research, 24, 404-410.

HO: The discrepancy between expected and experienced physical sensations (What is felt, seen, heard, tasted, and smelled) during a threatening experience will result in distress.

        Johnson, J. E., Rice, V. H., Fuller, S. S., & Endress, P. M. (1978). Sensory information, instruction in a coping strategy, and recovery from surgery. Research in Nursing and Health, 1, 4-17.

RQ: What is the relative contribution of instruction in a specific coping strategy and two types of information intervention on both subjective and objective indicators of recovery.