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Lareka Young
The purpose of this paper is to define a clinical problem, review the literature for
appropriate research supported nursing interventions, critique current practice and provide a plan
for changing or adapting clinical practice. More specifically, this paper will discuss the clinical
problem of anxiety and fear amongst patients a diagnosed with latent and active tuberculosis
(TB). The setting consists of a local health department that consists of 4 clinic services;
immunizations, family planning, sextually transmitted infections and community health. The
community health team is who works with the tuberculosis patients. The community health
team consists of five nurses who perform various job duties involving the health and well-being
of the community.
Clinical Problem
When working with patients and family members of client’s diagnosed with tuberculosis,
I often notice the issue of anxiety and fear . This is an issue because it is often unaddressed by
the healthcare provider. This issue really stood out to me after having a patient die in the hospital
due to complications of TB. It was evident that the client and his wife prolonged seeking treatment
due to fear and anxiety. Once I was notified of the client’s differential TB diagnosis, the disease
process was extremely advanced. A majority of the clients are in denial and think that that they
have been misdiagnosed. Clients and their family members often times do not fully understand
the disease and are usually extremely upset about their diagnosis. According to Stein and Craske
(2017), anxiety typically occurs during stressful periods. Characteristics of anxiety can be
described as feelings of worry, avoidance and physical symptoms such as tachycardia, dyspnea
and gastrointestinal distress (Stein & Craske, 2017). The clients are also often fearful and
uncomfortable when we enter their homes wearing personal protective equipment. Some cultures
THERAPEUTIC NURSING INTERVENTIONS PAPER 3
even associate the disease with “poor housing conditions, lack of sanitation, alcohol abuse, tobacco
and other drugs and HIV/AIDS” (Andrade, Hennington, Siqueira, Rolla, & Mannarino, 2015, p.
2).
“Tuberculosis remains one of the deadliest communicable diseases. In 2014, 9.6 million
people developed TB and 1.5 million died from TB” (Wang et al., 2018, p. 2). According to
Andrade et al. (2015), TB is the primary cause of death by a curable infectious disease. “The
psychiatric status of patients with TB has attracted increasing attention because psychiatric
illnesses such as anxiety and depression have been confirmed to be associated with poor treatment
outcomes in TB patients” (Wang et al., 2018, p. 4). Because of this, it is extremely important to
address the mental health of TB patients because of its potential of hindering the treatment
outcomes.
Current Practice
Currently, there are no policies in place to address the anxiety and fear of patients
diagnosed with TB. During the initial encounter, the public health nurse introduces themselves
and explains their role in the client’s care. A full medical history of the client is completed,
which includes asking about any history of mental health illnesses. Handouts and booklets
regarding the diagnoses and medications prescribed are also provided to the client and or family
members.
The informal mechanisms for addressing patient anxiety include sitting with the client to
thoroughly explain the disease process, provide an overview of the current treatment plan and
actively listen and address any concerns the client or family members may have. Family
members are always encouraged to attend because oftentimes it is difficult for the client to
THERAPEUTIC NURSING INTERVENTIONS PAPER 4
absorb all the information being communicated. Family members are usually able to grasp the
information and vocalize any questions or concerns to clarify information. I also use therapeutic
feelings. I also ask about any personal or spiritual values or beliefs that may affect treatment so
that we can come up with a plan to address it. At times, I use touch such as placing my hand on
the shoulder of a client or giving a hug to provide comfort and support to clients.
The formal mechanisms used to address anxiety and fear are usually very general and
basic therefore it may not satisfy all of the needs of the client and family members. Taking the
time to explain and listen to the client and showing empathy may be more valuable than
completing a medical history and providing handouts and brochures. Because the treatment
course of TB is a minimum of six months for active cases and three months for latent cases, it is
Literature Support
Andrade et al., (2015) performed a research article to view the perspectives or patients,
doctors and medical students at a public university hospital in Rio de Janeiro, Brazil regarding
tuberculosis and therapeutic adherence. The data obtained was from semi- structured
individual interviews, focus group interviews, participant observation and a field journal.
Twenty- three patients, seven doctors and 15 medical students were included in the study.
This article revealed that the “stigma surrounding TB hinders diagnosis and increases the
likelihood of non-adherence to treatment” (Andrade et al., 2015). The fear of transmitting the
disease and experiencing the stigma (even after being non-infectious), was mentioned as an
enabler of self-segregation by the patients. One doctor in the study revealed that TB is
THERAPEUTIC NURSING INTERVENTIONS PAPER 5
associated with these ideas and factors: a frightening and serious disease, lack of knowledge of
transmission routes and treatment; being surrounded by fear, concern, sadness and prejudgment;
and the idea of death. The patients revealed feelings and experiences of discrimination,
rejection, concern, fear, distrust in the diagnosis, apprehension, guilt, aversion to medication,
nervousness, inability, sadness, surprise, desperation and fear of being contagious. All of these
feelings and experiences can lead to anxiety and fear in TB patients. One of the main reasons for
TB patients to abandon treatment were disregard of the patient’s beliefs and conceptions about
health and sickness. In the Brazilian culture, symptoms are associated with diseases; therefore,
when symptoms subside, the individual feels cured and feels like they no longer need treatment.
Reports from this study show that a good bond between the patient and healthcare staff make it
easier to maintain continuity of care and treatment adherence. Nursing interventions such as
psychoeducation, mindfulness and acceptance and relaxation techniques can be used to address
Nursing Interventions
Psychoeducation
“The goal in psycho education is to help patients understand what is happening to them,
help provide a rationale for other interventions” ( Shepardson, Funderburk, & Weisberg, 2016).
This can give client’s some reassurance regarding their feelings of anxiety and fear. Client’s
need to know that what they are feeling is not out uncommon and there are ways to positively
address these feelings. This will be a great opportunity for clients to fully open up about their
feelings and emotions regarding their tuberculosis diagnosis. Addressing the anxiety will be
easier once the client has fully expressed their feelings. Explaining information regarding
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anxiety and providing handouts due to the different learning styles of clients and client’s not
being able to absorb all information at the time (Shepardson et al., 2016).
The plan to implement this intervention would be to first search or create a questionnaire
regarding anxiety and its symptoms to be able to recognize when psychoeducation is needed. I
would also order resources, handouts and educational materials to aid in providing satisfactory
psychoeducation to patients. I believe that part of the reason why anxiety and fear in our TB
patients is not addressed because it has not been properly assessed by healthcare personnel.
questionnaire used to identify probable cases of generalized anxiety. Asking clients to complete a
short self-reporting questionnaire like such can allow clinicians to track the severity of anxiety
and treatment response as time goes on (Stein & Craske, 2017). Utilizing this instrument will
(Shepardson, 2016). “Making client’s aware that it is possible to have anxious thoughts and
feelings and are not attempt to avoid or control them but instead simply notice them”
(Shepardson, 2016, p. 117). For example, client’s may not want to talk about their diagnosis to
family or friends because they think that others will be judgmental. Negative thoughts and
Prior to implementing this intervention into current practice, a web-based training would
need to be conducted to give healthcare staff a better insight of how mindfulness and acceptance
THERAPEUTIC NURSING INTERVENTIONS PAPER 7
can be implemented. Implementation can be utilized in the beginning of treatment when anxiety
and fear is recognized. Educational materials would also be purchased for staff and patients to
reference.
Relaxation Techniques
Kim, H.S., & Kim, E.J., (2018) performed a systematic review with meta-analysis to
determine the effectiveness of relaxation therapy on anxiety disorders. Seven thousand, five
hundred and seventy-one studies were reviewed by two researches and 166 were selected.
Thirty-nine articles were determined eligible after being independently reviewed. Out of the 39
eligible articles, 16 were included in the review after the others were excluded based on selection
criteria and improper quality. The selected papers were published between 1988 and 2014.
Twelve studies utilized Treatment-as-usual and the remaining 4 utilized cognitive behavior
therapy.
The overall effect of relaxation therapy on symptoms of anxiety was significant, which
indicated a medium-high effect (Kim, H.S., & Kim E.J., 2018). The results of the meta-analysis
provide evidence that relaxation techniques reduce symptoms of anxiety, depression, phobia and
worry in patients with anxiety. “Relaxation based therapy, regardless of its technique, could be
used as a form of nonpharmacologic treatment for reducing the severity of symptoms in people
with anxiety disorders” (Kim, H.S, & & Kim E.J., 2018). It is a cost effective and use
intervention for nurses to apply to client with anxiety disorders in the community and clinical
settings.
Another study was conducted by Cramer, Lauche, Langhorst, Dobos and Paul (2013) in
Germany to determine the use of relaxation techniques and its benefit versus its harm. The
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participants included all patients who were referred to the Department of Internal and Integrative
Medicine within a three-year period. Two thousand, eight hundred and four patients were
referred to the department, and 2,486 patients agreed to participate in the study. Questionnaires
were used to gather data for the study. Two hundred and seventy-two (10.9%) did not answer
the question regarding relaxation techniques, 1, 139 (45.8%) reported not using relaxation
techniques, and 1,075 (43.2%) reported having used relaxation techniques (Cramer et al., 2013).
Of those who reported having used relaxation techniques , 60.3% reported relaxation techniques
Although this study was not specific to TB and anxiety, it supported that relaxation techniques
Guided imagery and breathing techniques are two types of relaxation therapies that could
be implemented into clinical practice. The type of relaxation therapy utilized by the public
health nurse can be decided based on the individual being treated. Relaxation techniques can be
implemented in clinical practice after recognizing anxiety and fear in the clients. Educational
Summary
implemented by healthcare staff to address the anxiety and fear in patients diagnosed with TB,
but they are not the only interventions that could be helpful in managing anxiety and fear in the
clients. Health related support groups have become more common in recent years. Research
has been conducted regarding the relationship between social support and health outcomes and
has proven that is it beneficial to both mental and physical health (Wright & Bell, 2003). Does
the use of support group reduce the fear and anxiety associated with tuberculosis patients?
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Further research is needed to test the efficacy of social support groups in addressing anxiety and
can be used to aid in addressing the anxiety and fear of tuberculosis patients. Anxiety in
tuberculosis patients is linked with negative treatment outcomes. It is evident that anxiety has
not been routinely assessed or addressed in TB clients, therefore implementing these nursing
interventions will address that problem. These interventions are all cost effective and can be
References
Andrade, Elizabeth Da Trindade de, Hennington, Élida Azevedo, Siqueira, Hélio Ribeiro de,
Rolla, Valeria Cavalcanti, & Mannarino ,Celina. (2015). Perspectives of Patients, Doctors
Cramer, Lauche, Langhorst, Dobos, & Paul. (2013). Characteristics of patients with internal
Kim, Hyeun-Sil, & Kim, Eun Joo. (2018). Effects of Relaxation Therapy on Anxiety Disorders:
284.
Shepardson, R., Funderburk, J., & Weisberg, R. (2016). Adapting Evidence-Based, Cognitive-
Behavioral Interventions for Anxiety for Use with Adults in Integrated Primary Care
Stein, M., & Craske, M. (2017). Treating Anxiety in 2017: Optimizing Care to Improve
Wang, X. B., Li, X. L., Zhang, Q., Zhang, J., Chen, H. Y., Xu, W. Y., … Hou, G. (2018). A
doi:10.3389/fpsyt.2018.00308
Wright, K. B., Bell, S. B., Wright, K. B., & Bell, S. B. (2003). Health-related Support Groups on
doi:10.1177/1359105303008001429