What Preventative Measures Can Nurses Take/Implement to Reduce Anxiety in Patients With COPD?

Abstract

Background

 COPD is a chronic systematic lung disease caused by exposure to harmful gases and particles, noticeably cigarette smoking. anxiety is strongly linked to COPD causing deterioration and exacerbation of the physical and mental conditions of the patients. there is an increasing attitude to recruit nurses for supporting universal health care coverage. In the context of COPD, several intervention approaches can be provided by nurses to improve the mood status of the patients leading to improvement in their quality of life. The study aims at addressing the nurse-delivered preventive intervention to reduce the anxiety that would lead to improvement in the quality of life of patients with COPD.

Method

The study design was a literature review. For the study, the review question was framed in terms of population, intervention, outcome, and study design. According to the inclusion and exclusion criteria search was conducted utilizing PubMed/Medline, Cumulative Index to Nursing and Allied Health Literature (CINHAL with full text), Embase, ProQuest, and PsycINFO databases. Anxiety and the quality of life were the primary outcomes of the review.

Results

Five papers were identified discussing cognitive behavior therapy, pulmonary rehabilitation, and relaxation responses techniques in patients with COPD and can be implemented by the nursing staff.

Conclusion

 There are different intervention approaches the nurse can adopt to reduce anxiety in the context of COPD. Experienced nurses should individualize the selection of the approach according to the patient’s needs.

Keywords: cognitive behavior therapy, nurse, anxiety, COPD, chronic obstructive pulmonary disease.

Introduction

Anxiety is strongly associated with chronic medical disorders ¹ including respiratory diseases ², cardiac disorders ³, and inflammatory bowel disease ⁴ to name a few. The coupling of anxiety and medical disorders deserves attention because of the association with negative outcomes including increased disability and mortality ^5,6. The rational explanation of the coupling of anxiety and chronic medical disorder is multifaceted. Anxiety may be a part of the pathophysiology of a medical disorder, a psychological response to illness, or an untoward effect of medications ⁶. Anxiety is recognized as apprehensive anticipation of stress (danger, worries) with extreme somatic symptoms of tension ⁷(Hill et al., 2008). Specific anxiety-related disorders include generalized anxiety disorder(GAD), panic attacks (PA) disorder, and post-traumatic stress disorder.

Chronic obstructive pulmonary disease (COPD) is an inflammation of the airway leading to the destruction of the lung tissue and persistent airflow limitation. Dyspnea is the hallmark complaint. The patient may suffer from cough and sputum production as well. Cigarette smoking is the main cause of COPD that enhances tissue destruction leading to hypoxia and eventually aggravating dyspnea ⁸. Other risk factors include exposure to air pollution, occupational pollution, asthma, severe respiratory infection in childhood, and low socioeconomic status ⁹. COPD is associated with systematic morbidities including systematic inflammation and muscle dysfunction as well as systematic comorbidities such as cardiovascular disease and mental disorders ¹⁰.

Compared to the general population, anxiety disorders, GAD, and PA have the highest rate (10-15%) in patients with COPD ¹¹. GAD was estimated to affect 10-33% of patients with COPD ¹². The prevalence of panic attacks in patients with COPS reached up to 67% ¹³. The predictive value for anxiety in patients with COPD was up to 80%, however, nearly 30% receive treatment ^14,15. It was reported that nearly more than half of patients with COPD suffer from anxiety with around 33% of them having GAD and 41% having PA ¹⁶. Moreover, patients with COPD are ten times at risk of panic attacks than the general population ¹⁷.

The impact of anxiety on the quality of life of patients with COPD deserves undivided attention. Anxiety was documented to aggravate COPD patient disability ². Moreover, anxiety was significantly associated with impairment of functional status ¹⁸, daily activities ¹⁹, and health-related quality of life including physical and mental health perception correlated to emotions, social activity, bodily pain, and mental well-being ^20,21. Patients with COPD tend to be socially isolated and withdraw from social activities and interactions ²². Moreover, the poor emotional function was reported to be a risk factor for survival in female patients with COPD ²³. Furthermore, anxiety aggravates the clinical condition of COPD patients with increasing lung symptoms, the severity of dyspnea, and hospital admission ²⁴. Acute exacerbation needs hospital admission increases among patients with COPD and anxiety ²⁴. Therefore, anxiety was reported to be a risk factor for hospital readmission in COPD patients with poor quality of life ^24–26.

Recently, Selective serotonin reuptake inhibitors (SSRIs) are recommended for the treatment of anxiety in patients with COPD. Serotonin was reported to mediate dyspnea in COPD and anxiety via increasing the cerebral sensitivity to carbon dioxide ^27–29. Therefore, inhibiting serotonin action reduces dyspnea and anxiety simultaneously making SSRIs favorable medications for patients with anxiety in the context of COPD.

Non-pharmacological nurse-led intervention plays a fundamental role in enhancing the effect of medical treatment. Nurse-led intervention can reduce anxiety in patients with COPD as well as promote long-term quality of life. Pulmonary rehabilitation (PR) exercise was published and recommended by the American College of Sports Medicine, the American Thoracic Society/European Respiratory Society, and the American Association of Cardiovascular and Pulmonary Rehabilitation ⁹. It is proved effective in decreasing dyspnea and enhancing physical performance as well as health-related quality of life ³⁰. The PR aims at improving the physiological and psychological pathological manifestations of COPD and restoring the functional capacity to the highest possible level ³¹. It is a personalized intervention that requires a patient-nurse relationship to identify specific treatable traits pertaining to a particular patient ³². Appropriate implementation of PR is cost-effective in reducing shortness of breath, improving physical performance, and consequently promoting the quality of life ³³. The concept of PR is adopted by Eastern culture as well. Tai Chi is an exercise-based therapy that is popular in China and becoming popular worldwide. Tai Chi is composed of psychological treatment and physical exercise. It was proved that Tai Chi is equivalent to PR intervention with persistent effect ³⁴.

There is accumulating evidence supporting the benefits of physical activity in improving the clinical condition of patients with COPD in terms of exacerbation and hospital admissions ³⁵. The impairment of exercise capacity in patients with COPD was reported to be a significant determinant of COPD burden in moderate to severe conditions ³⁶. However, it is emphasized that patients with COPD are reluctant to participate in physical activities due to shortness of breath, fatigue, comorbidities, and psychosocial factors ^35,37(Burge et al., 2020)(Fiorentino et al., 2020). Low physical activity participation, consequently, leads to muscle deconditioning that aggravates shortness of breathing and further compromises the physical capacity of the patients to participate in any physical activity ^38,39. Therefore, it is suggested that physical activity can interrupt this vicious circle and promote health-related quality of life ⁴⁰. Moreover, physical activity integration in the treatment of COPD would reduce health care costs by reducing mortality, frequency of hospital admissions, and promoting the quality of life ⁴¹. A recent study suggested promoting a healthy attitude toward physical fitness and health appraisal in patients with COPD to escalate the tendency of patients with COPD to participate in physical activity intervention ⁴².

Self-education is a proven intervention in promoting health-related quality of life and decreasing the frequency of hospital readmissions among patients with COPD ⁴³. Self-management constitutes encouraging smoking cessation ⁴⁴ and physical activity participation ^45,46. Moreover, self-education improves adherence to medications and the appropriate use of inhalers ⁴⁷. In a recent study, nurses can deliver telephone health coaching to patients with COPD that can enhance physical activity, encourage patients to adhere to a care plan, reduce the need for antibiotics, and improve inhaler use technique ⁴⁷.

Recently, telemonitoring (also called telemedicine, telehealthcare, and telecare) has emerged as a promising intervention for improving COPD clinical outcomes ⁴⁸. Telemonitoring aims at reducing the frequency of exacerbation and hospital admission resulting in cutting down healthcare costs ^49,50. In patients with COPD, symptoms, heart rate, oxygen saturation, and the peak expiratory flow rate are monitored remotely ⁵⁰. A recent randomized controlled study concluded that telemonitoring of COPD symptoms accelerated early treatment of COPD with an improvement in lung function and functional status ⁵¹. Telemonitoring involving patient-nurse communication, information processing, and response with tailored feedback was proved to be effective in increasing the quality of life of COPD patients ⁵². A recent study involving primary care-based nurse-assisted home telemonitoring showed a significant reduction in the number of hospital admissions and emergency department attendances ⁵³. Thus, telemonitoring can allow nurses to play a crucial role in the management of anxiety in COPD patients in terms of early recognition, treatment adherence, and participation in a specific set of psychotherapeutic interventions ⁵⁴.

Cognitive-behavioral therapy (CBT) is a psychotherapeutic approach for treating a wide range of psychiatric disorders. A systematic review study concluded that CBT intervention can provide prompt symptom alleviation for COPD patients suffering from anxiety resulting in minimizing the need for further mental health care ⁵⁵. A recent study showed that CBT can be beneficially applied in the context of anxiety in patients with COPD ⁵⁶ as a complementary intervention to improve anxiety and quality of life ⁵⁷. Furthermore, CBT decreases COPD symptoms, encourages exercise therapy, enhances medication adherence, and diminishes exacerbation leading to augmentation of the quality of life ⁵⁵ and anxiety ⁵⁸. However, a systematic review study found that there is limited evidence supporting the superiority of CBT to conventional care in improving long-term anxiety in patients with COPD ^21,59. There is an increasing attitude to deliver CBT by psychiatric as well as general nurses ⁶⁰.  Accumulating evidence support that nurse partitioner is in an advantageous position to provide CBT for patients with anxiety ⁶¹ with positive outcomes ⁶². A recent study documented that CBT can be delivered by a trained respiratory nurse ⁶³.

Given the serious impact of anxiety on the physical outcomes of patients with COPD, the current review attempts to address the nurse-delivered preventive intervention to reduce the anxiety that would lead to improvement in the quality of life of patients with COPD.

Method

The current study is a literature review. The review question was framed in terms of population, intervention, outcome, and study design (PIOS). Participants were patients with stable COPD irrespective of severity, age, gender, race, or comorbidities. Interventions should be conservative. The outcome was focused on the quality of life and anxiety. The primary outcome is favored because interventions are more targeted to the primary outcomes ⁶⁴. The study design for the sourced research studies was not limited to a specific place or institution where the study was carried out aiming to encompass the most possible interventions worldwide. However, recent studies, within the past 10 years, were favored.

Based on the PIOS, the inclusion criteria included patients with COPD of varying severities, interventions restricted to those carried out by nurses without subspeciality restriction, interventions targeting the quality of life or anxiety, and study design encompassing clinical trials, reviews, and reports and within the last ten years. The exclusion criteria included patients with COPD exacerbation, intensive care admission, or at end-of-life, interventions where the nurse is not involved, depression as an outcome, and old studies of more than 10 years. The language of the selected papers was restricted to English. Studies written in English or translated into English were considered.

Electronic databases were searched to select papers relevant to the review question of the study. The electronic databases included PubMed/Medline, Cumulative Index to Nursing and Allied Health Literature (CINHAL with full text), Embase, ProQuest, and PsycINFO. The search terms included COPD, COAD, anxiety, quality of life, hospital admission, and hospitalization using “AND” and “OR” as operands and MeSH terms.

The selected studies were assessed personally according to the corresponding appraisal tools including Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). The selected studies were filtered by the title. Titles that did not imply the selective criteria are removed. The abstract and the body of filtered studies were examined to select the finally eligible studies for the review. Therefore, the selected papers were considered eligible for review when the selection criteria were verified. Ethical issues do not apply.

Results

Five major papers have been found to meet the inclusion criteria of the study. The papers suggest CBR, PR, relaxation, and psychological screening as preventive measures that can be conducted by nurses for patients with COPD to prevent anxiety.

1. (Heslop-Marshall et al., 2018), England, conducted a randomized controlled study to investigate if respiratory nurses can deliver one-to-one CBT sessions to reduce anxiety as measured by the Hospital Anxiety and Depression Scale (HADS) Anxiety Subscale ⁶⁵ as well as being cost-effective. Patients with COPD and anxiety were randomized into two groups one group received CBT sessions and the other group received self-help leaflets. Anxiety, depression, and quality of life were assessed at three time points: baseline, three months (primary outcome), and six and twelve months (secondary outcomes) without interruption of conventional medical care. The EuroQol-5D (EQ-5D 3L ) questionnaire was used to estimate quality-adjusted life-years. A cost-effectiveness analysis was conducted from the perspective of a National Health Service hospital (NHS). The study included all patients with COPD irrespective of the level of severity and high HADS score (≥8) with no other mental health disorders nor receiving medications for mental disorders.

Four respiratory nurses were recruited to provide CBT; 2 nurses had a post-graduate diploma in CBT and 2 nurses received CBT training. Random nurse-led CBT sessions were video-recorded to assess fidelity and skills. Monthly clinical supervision to optimize the CBT skills and augment self-confidence.

The study found 898 COPD patients with anxiety (HADS-Anxiety subscale ≥ 8). In total, 236 patients reached the first end-point of 3 months (primary outcome), 115 patients in the CBT group, and 121 in the leaflet-arm group. At 3 months, the study found that there was a statistically significant improvement in mean HADS-Anxiety scores in the CBT group compared to the self-help leaflet group. The nurses scored highly on the focus/structure of the CBT, therapeutic relationship, and providing feedback to patients. CBT was found to be less expensive. The reduction in expenses was driven by a reduction in hospital admission and emergency department attendances. Using EQ-5D 3L, CBT sessions were found to be superior to only self-help leaflets in improving the quality of life for patients with COPD and anxiety.

The study revealed that respiratory nurses can play a role in reducing anxiety in patients with COPD. Receiving the proper training, nurse-delivered one-to-one CBT intervention can effectively reduce anxiety with a reduction in costs.

2. (Tselebis et al., 2013) conducted an observational study on patients with COPD and anxiety to investigate the impact of PR programs on altering the symptoms of anxiety and whether the disease stage of severity determines the outcome. Over 4 years, all eligible patients attending the PR program were recruited for the study. Those with severe comorbidities endangering life were excluded such as patients with angina pectoris, myocardial infarction, and heart failure. Anxiety was assessed with the Spielberger State-Trait Anxiety Inventory (SSTAI) ⁶⁶. PR program was followed for 3 months. The patient received 3 sessions per week with each session lasting 50 minutes. The PR program is composed of respiratory physiotherapy, respiratory muscle training, aerobics on a bicycle ergometer and treadmill, and muscle strengthening. Oxygen supplementation was ensured.

At baseline, the mean SSTAI score was higher in patients with COPD than that in the general population. At discharge from the program, SSTAI was shown to be statistically reduced in males and females compared to the corresponding gender in the general population. This means that anxiety is more prevalent in patients with COPD than in the general population. Implementation of PR proved effective in reducing the anxiety symptoms in those patients. In the implementation of a stepwise multiple regression analysis using variation in anxiety as the dependent variable, neither age, gender, education years, nor percentages of forced expiratory volume for 1 min (independent variables) were different. Therefore, it can be concluded that anxiety is an independent factor of these variables.

The study is observational research pointing to the positive impact of PR in improving anxiety in patients with COPD irrespective of age, gender, education years, or respiratory condition of patients. Consequently, nurses can adopt this approach to reduce anxiety in patients with COPD. The nurse should not consider age, gender, education years, and/or the respiratory condition of patients as determinant factors.

3. (Hardy et al., 2014) interest focused on motivational interviewing. The authors theorized that the integration of nurse-delivered psychological-oriented motivational intervention in primary care for patients with COPD would have a positive impact on patients with COPD and anxiety. Therefore, the study aimed to explore the possibility of incorporating psychological screening and intervention into COPD reviews in primary care facilities. The proposed outcomes were the effect of nurse training on their knowledge and confidence, the impact of motivational interviewing on PR referral, and the reduction of anxiety.

The authors conducted observational research to achieve the aim of the study. The nurses were recruited to receive new psychological training. The new screening and intervention pathway was integrated into the current COPD review. Generalized Anxiety Disorder 7 (GAD7) was used for anxiety assessment. Besides, the pathway included a sympathetic talk and short advice as appropriate, self-management education, assessment of lung functions, and encouraging onward referral to PR. Patients with COPD were recruited from primary care facilities with moderate to severe breathing conditions. The training course developed for patients with diabetes was adopted. The nurses received 2 hours of training for this study. Information about anxiety and the impact on chronic patients was provided. Moreover, the nurses received training on how to screen for anxiety, use severity scales, and apply risk assessments. The benefits of PR were delivered as well. How to use a motivational approach and refer patients to PR were taught to the recruited nurses. Paper sheets were used for data collection.

Self-evaluation questionnaire before and after nurse training revealed an increase in the level of confidence of the trained nurses. After the intervention, the patients showed acceptance of the nurse-delivered program as well as augmented motivation to combat the clinical condition. About 75% of eligible patients for PR accepted the referral.

Nurse-delivered motivational interviewing was proved to be a promising approach to preventing and reducing anxiety in patients with COPD at the primary care level. The patients can receive self-management education, and motivation to manage COPD disease and breathing problems, and willingly accept a referral to PR programs. Implemented by nurses, motivational interviewing lays no extra burden on other healthcare providers and there are no extra costs as well.

4. (Hyland et al., 2016) explored the preferences of patients with COPD for different relaxation techniques. The purpose of the study was to find out the most preferable relaxation technique for use as a self-help intervention in clinical practice to reduce anxiety among patients with COPD. A mixed-methods approach was used to achieve the aim of the study. Six techniques were explained to the patients. Focusing on breathing was excluded because focusing on the negative experience of breathlessness may increase the negative cognition with developing or worsening anxiety. The chosen relaxation techniques were counting from 1-to 5 over and over in the patient’s mind, repeating meaningless words, progressive muscle relaxation, and generating positive emotions. Other techniques include imagining a nice place where one feels happiness and relaxation and performing a simple form of Kundalini yoga.

Twenty inpatients were recruited and gave informed consent to participate in the study over a 3-month period. The patients showed video clips of the six techniques at the bedside. Patients were instructed to attempt each technique once with a short gap of one minute between each. Patients were asked about their preference for each technique and whether one was going to repeat the technique at home or not. In addition, patients had to rate each technique on a scale from 1-to 10 where 10 equals very effective. Feelings about each technique were reported. The comments of patients during the interview were transcribed and analyzed.

The study found diversity among patients with COPD in the preferred technique and why one was chosen over the other. Most of the patients in the study preferred to use the thinking-of-a-nice-place technique. Progressive relaxation and counting were chosen to a lesser extent. Therefore, it was concluded that the patient should not be coerced to perform one relaxation technique over another. The free choice should be given to the patients with guidance on the proper performance to optimize the gains.

5. (Reaves & Angosta, 2021) investigated the influence of relaxation response on phycological and physiological status in patients with COPD. The study was investigating the Relaxation Response Meditation Technique (RRMT) that was developed by Dr. Herber Benson to combat the natural fight-and-flight response to minimize anxiety ⁶⁷. The main aim of the study was to assess the effect of RRMT on anxiety in patients with COPD. Other purposes included assessing the reduction of perception of dyspnea and improvement of physiological responses upon the implementation of RRMT.

The author conducted a quasi-experiment with a pre-and post-test design with a single group of patients with COPD. Twenty-five patients were recruited at a single PR clinic. The patients were more than 40 years old and diagnosed by the clinician with COPD in stages 2-4 ⁶⁸. Those patients who received psychological medications or suffering from mental health problems, as well as patients with compromising comorbidities, were excluded. The State-trait Anxiety Inventory (STAI) and Modified Borg 0-10 scale (MBS) were applied for the evaluation of anxiety. A pre-recorded audio instruction was written by an Advanced Holistic Nurse Board Certified (AHN-BC) practitioner and recorded by the researcher. The patient was allowed to listen to the recorded tap for 10 min. The anxiety level was assessed before and after listening to the recorded tap.

The study showed that implementation of the RRMT significantly reduced anxiety, and perception of dyspnea, and improved the physical parameters of patients with COPD. Improvement of anxiety was documented by lowering post-intervention scores on the STAI Questionnaire and MBS score. Therefore, The RRMT was proved to be a useful relaxation approach in the management of anxiety in patients with COPD.

These findings encourage the integration of the RRMT into the PR program with a promising outcome on anxiety in patients with COPD. The proposed relaxation technique is simple and can be delivered by a trained nurse. 

Discussion

 COPD is a chronic systematic lung disease caused by exposure to harmful gases and particles, noticeably cigarette smoking ^68,69. Dyspnea and shortness of breath are the most characteristic symptoms of COPD. Moreover, dyspnea has serious impacts on the emotional aspect of patients. Patients with COPD suffering from recurrent attacks of dyspnea usually experience fear, anxiety, and panic ^70,71. Consequently, leading normal live activities is limited not only by the physical condition but by the apprehension of death and suffocation as well ². Therefore, anxiety is strongly linked to COPD. It was reported that nearly 90% of patients with COPD suffer from anxiety ⁷². Moreover, anxiety is associated with symptoms severity, hindering of daily physical activity, increased rate of hospital readmissions, disability, and comorbidities ⁷³.

It is worth noting that nurses constitute up to 50% of the working force of health care providers ⁷⁴. Therefore, there is an increasing attitude to recruit nurses for supporting universal health care coverage. Relying heavily on nurses would allow improvement of healthcare provision to a wide range of the population. In the context of COPD, dyspnea and anxiety management can be approached through different interventions including CBT, physical activity, proper self-education and self-management, PR, and telemonitoring.

Cognitive-behavioral therapy

Accumulating evidence demonstrated how CBT can be a promising therapy for anxiety in patients with COPD ⁷⁵. CBT is a goal-oriented, time-sensitive, systematically structured procedure that focuses on the dysfunction of behaviors, cognitions, and emotions. In the context of COPD, the implementation of CBT enhances perceived self-efficacy and motivation by directing the behavior toward the proper management of the physical condition ^76,77. Moreover, CBT, in the context of COPD, was documented to reduce physical and mental symptoms, encourage physical activity and exercise therapy, improve quality of life, and enhance treatment adherence ^63,78.

Nurses can provide CBT with great efficacy. A recent randomized controlled trial found promising results were found when CBT was delivered by the respiratory nurse in an on-to-one style for around 4 sessions; it was proved that nurse-led CBT reduced anxiety symptoms effectively by promoting the quality of life, reduction of hospital admissions, and lowering exacerbation necessitating emergency visits rendering nurse-led CBT cost-effective ^{57,59,61,79,80}. Several studies involved nurses who conducted CBT therapy (Goodyer et al., 2017; Zhang et al., 2019). As a counselor, primary care mental health nurse-delivered self-help preventive cognitive therapy to patients with COPD. As a result, a significant increase in the quality of life was noticed after over 12 months compared to treatment as usual ⁸³. The multidisciplinary approach to treating COPD cases with anxiety allowed nurses to be involved in the CBT intervention either based on face-to-face interviews or via telephone-delivered ⁸⁴. A recent study involving nurse-delivered CBT showed medium-term improvement in anxiety and quality of life ⁸⁵. Furthermore, CBT can be delivered by respiratory nurses who take care of patients with COPD under certain conditions ⁸⁶. Moreover, training PR nurses on the basics of CBT skills could be a possible strategy for applying for PR programs in the future ⁸⁷.

The current study agrees with the literature in emphasizing the important role the respiratory nurse can play to improve anxiety in patients with COPD. Our study found that patients with COPD are more in contact with respiratory nurses. Therefore, it is a good opportunity to provide CBT to patients. The study conducted by Heslop-Marshall et al., (2018) documented that the respiratory nurse can provide one-to-one CBT interventions with promising results. The approach appealed to the patients as well. Moreover, nurse-led CBT intervention was proved to be cost-effective ⁸⁸.

Pulmonary rehabilitation

Patients with COPD are at risk of mental disorders including anxiety that can impact their physical and pulmonary efficiencies ⁸⁹. Therefore, PR is recommended to be provided to all patients with COPD to alleviate anxiety ⁹⁰ with consequent improvement of the quality of life ^91,92 and reduction in hospital admissions ⁹³. The guidelines of the Official Task Force of the American Thoracic Society (ATS) and the European Respiratory Society (ERS) recommend the implementation of PR in the context of COPD to improve the quality of life and reduce the emotional mental disorders ^94,95. PR is a patient-oriented multidisciplinary therapeutic program ⁹¹ for improving the physical and mental health status of patients with chronic respiratory disease and enhancing long-term compliance to treatment and healthy behaviors ⁹⁶. Moreover, PR can be provided in hospital-based outpatient and inpatient settings, in community-based settings, and at home ⁹⁷.

Although PR is usually provided by physiotherapists, nurses are increasingly participating in a generic role including exercise testing, promotion of health status, encouraging self-management, healthy and active lifestyle education, directing the patient to avoid health problems, rehabilitation, and evaluation. Moreover, nurses can play an advanced role in PR provision as care providers, counselors, educators, leaders, and case managers ⁹⁸. The most important nurse-led intervention in PR is education. The patient needs to understand the relation between a healthy and active lifestyle and the improvement of the health status and the reduction of symptoms in terms of anxiety and dyspnea ⁹⁹. In this context, the nurse can provide a holistic approach on daily basis to allow the patient to adhere to PR programs ^100,101.

In agreement with the previous studies, Tselebis et al., (2013) concluded that PR was a promising approach to reducing anxiety in both males and females suffering from COPD. The influence of PR was found to be independent of the patients’ age, gender, education, and breathlessness status. The nursing staff can provide PR with promising results ⁹⁰.

Relaxation Techniques

Generating a relaxation response to neutralize the stress response of anxiety to distressing stimuli has been the focus of literature ¹⁰². The relaxation response is a compilation of inter-related adjustment mechanisms that are provoked when the distressed individual involves in mental or physical activities that passively distract the thoughts from the distressing stimulus ¹⁰³.  Several studies support the effectiveness of relaxation training in reducing anxiety as well as the quality of life in patients with chronic illnesses ^104–106. Patients with COPD suffer from psychological distress leading to difficulties in adapting and coping mechanisms. Therefore, anxiety is a psychological response as a result of the psychological distress of COPD breathlessness exacerbation ¹⁰⁷.

Different relaxation techniques have been proposed to reduce anxiety in patients with chronic physical disorders such as COPD. Such relaxation techniques include taped messages, guided imagery ¹⁰⁸, muscle relaxation ¹⁰⁹, listening to music ¹¹⁰, and mindfulness ¹¹¹. Other types of relaxation techniques include yoga, meditation ¹¹², tai chi, and qi gong ³⁴ oriental techniques.

In this context, 2 papers were found discussing the influence of relaxation techniques on reducing anxiety in patients with COPD. Hyland et al. (2016) found that while many relaxation techniques were found to be effective in reducing anxiety in chronically ill patients, the preferences of patients determine the outcomes in terms of continuation of the practice, previous acquaintance with the technique, and personal inclination. Moreover, Hyland et al. (2016) emphasized the appropriate choice of relaxation technique. Mindfulness focusing on breathing may augment the negative experience of breathlessness (dyspnea) leading to disappointing results. Therefore, it was concluded that appropriate relaxation techniques should be advised and personal preferences should be encouraged ¹¹³.

A relaxation meditation technique introduced by Dr. Benson in 1975 ⁶⁷ has been adopted for treating anxiety in chronically ill patients ^114,115. Benson’s relaxation meditation technique was considered a suitable non-pharmacological approach to reducing anxiety in patients with chronic illnesses. The basic idea of Benson’s relaxation techniques is the creation of relaxation response to encounter the natural fight-and-flight response to distressing stimuli ^67,115. The RRMT based on Benson’s relaxation technique is composed of 4 simple steps. The person makes herself comfortable sitting in a relaxed position with eyes closed or with a soft gaze. Relaxation of the body starts from the toes and up to the head. Then, the person breathes comfortably at a pace and repeats a relaxing word (e.g., “calm” or “relax”). The nonresistant attitude is maintained ¹¹⁶.

Reaves & Angosta, (2021), the current chosen study, conducted a  quasi-experiment with a pre-and post-test design to evaluate the efficacy of RRMT in reducing anxiety in patients with COPD. Anxiety was concluded to be reduced after implementing the intervention. Therefore, it was evidenced that RRMT can be a promising intervention for reducing anxiety in COPD and can be implemented for patients with other chronic conditions ¹⁰⁶. The advantage of Benson’s relaxation technique is that it is simple and easy to implement by nurses as well as cost-effective ¹¹⁷.

Motivational Interviewing

Motivational Interviewing was first introduced by Willian Miller in 1983 to help change the behavior of alcoholics to manage alcohol problems ^118,119. Motivational Interviewing is a cornerstone of the behavior change process aiming to explore and resolve uncertainty about health behavior to advance change. Moreover, Motivational Interviewing allows individuals to find out why and why one should change and recruit the resources and skills to augment the change process ¹²⁰. The domain of implementation of Motivational Interviewing includes the prevention of unhealthy behavior ¹²¹, substance abuse ¹²², eating disorders ¹²³, and gambling behavior ¹²⁴as well as management of chronic illnesses such as diabetes, neurovascular disorders, and cardiovascular disease ¹²⁰. Four intersecting are involved in Motivational Interviewing including engaging in an active relationship, concentrating on one problem to change, igniting inner desires to change, and setting a reasonable and effective plan to change ¹¹⁹.

Patients with COPD are not currently screened or assessed for mental health disorders namely anxiety. Moreover, recommendations with self-management or PR are not provided using a motivational intervention approach. Furthermore, COPD nurse has limited time to carry out the routine COPD review. Therefore, any additional screening or assessing duties are not practicable. To provide a concise and brief motivational interview for a patient with COPD in the primary clinics, Hardy et al. (2014) conducted an observational research study. The author concluded that motivational intervention can be delivered by nurses after receiving a short training with significant efficacy and promising results in reducing anxiety. The patients could do self-management and address their breathing problems after receiving the nurse-delivered motivational interview. Moreover, the motivational interviewing approach enabled the patient to decide willingly to be engaged in a PR program for their good ¹²⁵. Therefore, COPD nurses in the primary clinic can take over the job and screen patients with COPD for anxiety and deliver adequate referrals to the PR program with patients’ satisfaction and good outcome.

Conclusion

In conclusion, the nurse can deliver different interventions to reduce anxiety in the context of  COPD. However, the experienced and well-trained nurses should individualize the selection of the intervention according to the patient’s needs. the nurse-led intervention was proved as effective as that provided by an experienced practitioner. Although CBT and PR are the most significantly proven interventions to reduce anxiety in the context of  COPD, other interventions can be applied with varying degrees of success including relaxation techniques and Motivational Interviewing.

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