Townsend (2009) describes anxiety as an overarching worry or "feelings of uncertainty and helplessness" (p. 15) Anxiety is placed on a continuum from mild to panic and associated with perceptual alterations that range from established coping mechanisms to inability to cope with one's environment.
Someone experiencing mild anxiety is typically unaffected by the onslaught of physiological effects and learning is enhanced. The level of anxiety is inversely proportionate to its effects on cognition; the ability to learn, to concentrate and to comprehend diminishes equally as the level of anxiety progresses to the panic state (Townsend, 2009). While mild anxiety can actually enhance learning, moderate to severe anxiety hinders learning. There are core concepts that outline an anxiety disorder; experienced distress, behaviors become maladaptive, psychological implications, sense of helplessness, and loss of contact with reality are all dependent on severity (Townsend, 2009).
Under a cloud of anxiety, all calmness and focused cognition are hindered by distress; an acute sympathetic nervous system (SNS) overhaul. The body enters a fight or flight mode, which is crucial to survival in the wild but can become detrimental in today's world where threats to survival are not as common. This SNS response to external stimuli creates physiological changes. The physiological changes ultimately lead to learned behavioral changes. As humans experience the change our behavior reflects adaptation to the physiological changes and environmental stimuli (Townsend, 2009). This exemplifies an adaptation method crucial to survival.
Common treatments for anxiety are psychotropics, drugs that influence the mental state of the individual (Townsend, 2009). Like all drugs, there are side-effects and no drug is perfect. More importantly, as we begin to alter the chemistry within our brains, we also alter the receptors therein. These changes in brain chemistry begin to inhibit daily functioning and can leave a patient with a choice of anxiety or numbing medications. Therefore, nurses have a moral imperative to treat an anxiety patient beyond pharmacological means; education and recognition of the antecedent, response, and behavior are essential in treating anxiety disorders.
Anxiety can be a normal physiological response that aids in coping with stress brought on by a heightened sense of danger or unpredictable event. This supplies humans with a protective barrier to emotional and environmental stressors, much like our immune system aiding in our defense against invasive organisms or foreign bodies. And, just like with the immune system, the defense mechanisms have the potential to become overwhelming and deteriorate one's well-being. As anxiety pervades into one's learning or ability to perceive the environment, it becomes a disorder, and all benefits are lost. The response no longer serves a purpose but becomes maladaptive. The psychological implications and sense of helplessness are both dependent on the severity of the anxiety (Townsend, 2009).
Although direct causes or triggers may not be seen, symptoms of anxiety can be detected by a diligent nurse. Symptoms of anxiety such as nail biting, pacing, yawning, and fidgeting are all recognizable symptoms that a nurse ought to recognize. Breathing relaxation exercises (BRE) have been shown to decrease anxiety in hospitalized & pre-operative patients, including those who have had traumatic experiences. The theory behind the breathing relaxation exercises is that deep, regular breathing returns adequate oxygen to the circulating blood, thereby reducing the effects of increased anxiety ["irregular, shallow breathing" leads to "lethargy and physiological distress"] (p. 134, Wong, Chair, Leung, & Chan, 2014). Simple breathing relaxation techniques reduced anxiety in patients under increased stress; furthermore, the study by Wong et al. (2014) aimed to use brief educational interventions (BEI) to improve outcomes between two groups of post-op patients. BEIs are described as simple BRE, pre-operative information and "what to expect" postoperatively. Proving that an informed patient will often yield the best prognosis. Results revealed that there were improvements associated with pain, anxiety, and sleep after simple BRE (Wong et al., 2014). Educational interventions, such as recognizing and then reducing anxiety, would likely impede the building anxiety.
Nurses and patients learning to address signs and symptoms may be the crux of the anxiety disorders. Anxiety takes many forms and as it worsens, can restrict all rationale. When is it feasible for a patient to recognize anxiety, or furthermore recognize the source of such anxiety during the moment of acute anxiety?
The effects of anxiety can be disturbing to or even go unnoticed by the person experiencing them. In a study comparing patients with higher anxiety levels associated with coronary heart disease (CHD) and individuals with mild-moderate anxiety levels, an increased level of cortisol in the waking hours was seen in the patients with higher reported anxiety levels (Merswolken, Deter, Siebenhuener, Orth-Gomer, & Weber, 2012), thus showing a connection between anxiety and cortisol. An increased anxiety level is likely to produce an increase in cortisol on a consistent basis. This increase in cortisol places the body on high alert, as needed to respond to the antecedent; in the case of anxiety disorders, the antecedent is not one of extreme danger. If this antecedent is as simple as sitting for an exam or engaging in social contact, the rise in cortisol and SNS response is likely to affect the social interaction or exam score negatively. The act of thinking while experiencing heightened cortisol levels tends to be less assiduous and more frantic. This challenges the ability to provide a negative feedback control mechanism to the person experiencing anxiety, which is exactly what cognitive behavioral therapy (CBT) aims to provide.
CBT is part of an emerging field of psychology known as applied behavior analysis (ABA), and can be challenging to implement. The treatment of CBT aims to recognize sources of behavior and in doing so, implement behavior that promotes coping or is a non-detrimental behavior. In addition to CBT, a mindfulness approach is thought to enhance the effectiveness of CBT. This new approach, mindfulness-based cognitive therapy (MBCT) aims to shut down the psychological experience, therefore decreasing or inhibiting the cortisol release and physiological sense of anxiety (Kaviani, Javaheri, & Hatami, 2011). Kaviani et al. (2011) suggest that mindfully recognizing thoughts of depression as just that, thoughts, depression can be objectively recognized and separated from the subject of self. The same approach can be applied to anxiety. A patient experiencing anxiety can simply recognize the anxiousness as a thought, a feeling, something that is occurring in the mind and respond in kind. By mindfully recognizing the thought as it is, then exploring said thought cognitively, the subject is likely to find a new, more fitting response to the source of their anxiety.
ABA and CBT follow models of learning; the experience of an antecedent, or stimulus, is followed by the response, or behavior. Methods of MBCT include sitting meditation, walking meditation, yoga and mindful-breathing in the wake of stress or anxiety. These methods implemented by Kaviani et al. (2011) showed a decrease in the experience of anxiety, more specifically decrease in "negative automatic thoughts and dysfunctional attitudes" in subjects during exam periods (p. 292). The ability to be mindful in the face of anxiety can be difficult, but with proper educational interventions, patients can begin to achieve mindfulness.
Patients are humans too.
With each physiological disease, there is some psychological component, and with each psychological disease, there is some physiological component. Therefore, we as nurses must maintain the person as a whole, including the mind, body, and spirit. We cannot treat the body without treating the mind, thus we cannot treat the mind without the body. Lachman (2009) states that the nurse practices with compassion for the individual and their "inherent dignity" without reservation to their "personal attributes" or "nature of health problems." Keeping this provision in mind, we as nurses must maintain the ability to recognize each individual's psychological needs and be aware of their fluctuating psychological states just as we must be aware of physiological changes. If we are to only focus on the patient's physiological needs as they prepare for surgery; how will we address their post-operative concerns?
Surgery alone can be scary to the individual. As nurses, we must validate and by asking and listening we will then be able to address concerns. Once concerns are addressed, nurses can better aim their treatment on informing or educating the patient. We must be sure to assess the patient's knowledge level and understanding, much the same as we are to assess their vital signs. Aiding in their recovery or treatment should go beyond handing over a prescription and saying "good luck." Nurses must ensure an understanding of the treatment. And in many cases, the treatment's course or outcome is heavily influenced by their understanding and willingness to participate.
Delve deep and correct the underlying problem.
As the nurse's commitment is to the public, whom the nurse serves (Lachman, 2009). The nurse plays a pivotal role in the healthcare team. By acquiring the patient's trust and creating an empathetic environment, the nurse is more likely to have a greater impact on the client's self-care. Ultimately improving the prognosis. Nurses obligations are first and foremost, the patient's well-being. Promoting appropriate and correct self-care can be the most beneficial, proactive measure.
We cannot prevent recurring infections without first treating the underlying problem. The evidence of medicine-resistant bacteria is present and antibiotics are losing effectiveness. By following this example, we look beyond the bacteria causing the infection and address the bacterias placement. Creating new policies that aim to institute proactive measures in patients through education and understanding, such as implementing and promoting hygiene (hand washing) and explaining that probiotic flora is essential. As the first provision states, nurses are to treat all patients equally, excluding differences in social and economic respects. Implying that a nurse should start with an assessment of the basic understanding of hygiene, or what ails the patient. Before assuming the patient knows how to correctly wash their hands. If the patient understands that washing with soap, water, and friction, then they are more likely to increase the prevention of recurring infections. Once a basic understanding is met, the underlying issue can be corrected.
Much like a patient experiencing an anxiety disorder, are we to discuss pharmacological methods without first explaining mindfulness methods? The pharmacological methods often have great success initially, but once the medications are discontinued the anxiety disorder is likely to return. Possibly a relapse can occur as the brain adjusts to the psychotropics or the patient decides to stop the medication. The patient is either trapped in a pharmaceutical cloud or under the weight of their anxiety. To aid in the escape, the nurse must first assess the patients understanding of their disorder. After a proper assessment only then can the nurse continue the nursing process, developing a plan and implementing the interventions. For example, explaining to the patient a mindfulness approach to recognizing the source and encourage exploration of their thoughts in relation to the anxiety. In educating the patient of anxiety disorders, the nurse is likely to prevent a relapse of the disorder. Anxiety is not typically a condition that evaporates after it runs its course. Fully explaining anxiety and mindfulness to a patient can take more than a few minutes, the task may require multiple meetings.
Update the setting with resources available to (almost) everyone.
In today's economical and political systems, reducing costs is of great importance. What must we sacrifice in order to reduce costs? This is in a time where repeated, scheduled clinical or hospital visits can certainly stalemate the system. Anxiety is likely to increase as patients are rushed in and out of offices, left feeling ignored as a nurse charts on a screen, or left ignored in a stagnant waiting room. With today's technology, telenursing may be more beneficial than ever, and especially in patients suffering from anxiety disorders. Cases, where the patient experiences an unfamiliar environment, can increase anxiety, and if the patient's anxiety stems from the hospital or clinical setting, a home-health nurse or telenurse can offer viable substitutions. Offering more personalized care may not necessarily demand more time, but allow the patient to feel as if they received more time from the nurse.
Improving the healthcare environment in which the nurse practices is a key element to excellence. Lachman (2009) explains that the ethical nurse promotes the values of nursing through their personal approach as well as their fellow nurse's approach to the healthcare environment. The individual nurse upholds and challenges others to uphold all the provisions of the American Nurses Association (ANA) code of ethics. By doing so, the nurse exhibits excellence in practice as well as promoting excellence.
Promoting excellence, can and should reach to the community. After all, nurses serve their public. Education on diet, hygiene, and overall health is essential for challenging the community to excellence. Much like working with anxiety, educating the patient of their anxiety and challenging, or rather encouraging the exploration of their thoughts and fears is essential to treatment. Challenge, not only our patients but ourselves and our fellow nurses (or student nurses) to practice excellence by going beyond the clinical setting. Instituting proactive measures in the community is certain to improve the healthcare setting as a whole.
Available information, purposeful education, and spreading awareness are paramount to success in relation to improving patient outcomes. Treating a patient with pharmacological interventions is a small part of a nurses goal; although it may dominate the daily routine with extra protective measures and extra security precautions to prevent abuse. Educational interventions should be the bulk of the anxiety disorder treatment programs.
Often in parallel with short-term, pharmacological interventions, educational based treatments are most successful for long-term treatment. Patients suffering from anxiety disorders will likely benefit from acknowledgement of the source and corrective techniques to recognize and reduce the onset of anxiety. Much of the basis of CBT or MBCT are to take a moment to pause and reflect on the source of the disorder. The more likely a patient is to recognize the source of anxiety then the more likely they are to maintain control over anxiety. And with anxiety, like any disease, what could be better than exemplifying control over what ails the patient. By providing information, education and recognition, ownership and control can shift from the nurse's caring hands to the patient's autonomous hands
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