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Therapeutic Nursing Interventions : Anxiety and Fear in Tuberculosis Patients

Lareka Young

Old Dominion University


Therapeutic Nursing Interventions Paper : Anxiety and Fear in Tuberculosis Patients

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

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.


“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


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


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

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

communication techniques such as active listening, silence, encouraging client to verbalize

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

important to be build a trusting relationship between the nurse and client.

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

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

anxiety in tuberculosis patients.

Nursing Interventions


“The goal in psycho education is to help patients understand what is happening to them,

normalize it, correct misperceptions, facilitate self-management by increasing knowledge, and

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

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.

The Generalized Anxiety Disorder- 7 Item Scale (GAD-7) is a self-administered 7 item

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

also help healthcare staff individualize treatment to each client.

Mindfulness and Acceptance

Mindfulness and acceptance based behavioral techniques include increasing awareness of

present experiences, practicing nonjudgmental acceptance and increasing valued-driven actions

(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

feelings are not complete facts (Shepardson, 2016).

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

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


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


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


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

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

as being helpful in managing disease and 1% perceived relaxation techniques as harmful.

Although this study was not specific to TB and anxiety, it supported that relaxation techniques

are helpful when coping with diseases.

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

materials for staff and patients would be purchased for reference.


Psychoeducation, mindfulness and acceptance are some interventions that can be

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?

Further research is needed to test the efficacy of social support groups in addressing anxiety and

fear in tuberculosis patients.

In conclusion, psychoeducation, mindfulness and acceptance and relaxation techniques

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

easily implemented into clinical practice.


Andrade, Elizabeth Da Trindade de, Hennington, Élida Azevedo, Siqueira, Hélio Ribeiro de,

Rolla, Valeria Cavalcanti, & Mannarino ,Celina. (2015). Perspectives of Patients, Doctors

and Medical Students at a Public University Hospital in Rio de Janeiro Regarding

Tuberculosis and Therapeutic Adherence. PLoS ONE, 10(9), E0137572.

Cramer, Lauche, Langhorst, Dobos, & Paul. (2013). Characteristics of patients with internal

diseases who use relaxation techniques as a coping strategy. Complementary Therapies in

Medicine, 21(5), 481-486.

Kim, Hyeun-Sil, & Kim, Eun Joo. (2018). Effects of Relaxation Therapy on Anxiety Disorders:

A Systematic Review and Meta-analysis. Archives of Psychiatric Nursing, 32(2), 278-


Shepardson, R., Funderburk, J., & Weisberg, R. (2016). Adapting Evidence-Based, Cognitive-

Behavioral Interventions for Anxiety for Use with Adults in Integrated Primary Care

Settings. Families, Systems, & Health, 34(2), 114-127.

Stein, M., & Craske, M. (2017). Treating Anxiety in 2017: Optimizing Care to Improve

Outcomes. JAMA, 318(3), 235-236.

Wang, X. B., Li, X. L., Zhang, Q., Zhang, J., Chen, H. Y., Xu, W. Y., … Hou, G. (2018). A

Survey of Anxiety and Depressive Symptoms in Pulmonary Tuberculosis Patients With

and Without Tracheobronchial Tuberculosis. Frontiers in psychiatry, 9, 308.


Wright, K. B., Bell, S. B., Wright, K. B., & Bell, S. B. (2003). Health-related Support Groups on

the Internet: Linking Empirical Findings to Social Support and Computer-mediated


Communication Theory. Journal of Health Psychology,8(1), 39-54.