American Journal of Critical Care. 2009;18: 169-172 doi:10.4037/ajcc2009867
Copyright © 2009 by the American Association of Critical-Care Nurses.
A regular feature of the American Journal of Critical Care, Clinical Evidence Review unveils available scientific evidence to answer questions faced in contemporary clinical practice. It is intended to support, refute, or shed light on healthcare practices where little evidence exists. To send an eLetter or to contribute to an online discussion about this article, visit www.ajcconline.org and click "Respond to This Article" on either the full-text or PDF view of the article. We welcome letters regarding this feature and encourage the submission of questions for future review.
Relaxation: A Self-Care Healing Modality Reduces Harmful Effects of Anxiety
By
Margo A. Halm, RN, PhD, CNS-BC.
Margo A. Halm is a clinical nurse specialist and director of nursing research and quality at United Hospital in St Paul, Minnesota, where she leads and mentors staff in principles of clinical research and evidence-based practice.
Corresponding author: Margo A. Halm, RN, PhD, CNS-BC, United Hospital - Mailstop 60316, 333 N. Smith Ave, St Paul, MN 55102 (e-mail: margo.a.halm{at}allina.com).
Anxiety, a state of uneasiness or apprehension toward a vague or nonspecific threat, is prevalent in cardiac patients. Estimates are as high as 70% to 80% during the acute phase,1,2 and it persists long-term in 20% to 25% of patients. Anxiety inflicts its toll through 3 major pathways. In the physiological pathway, anxiety affects the muscu-loskeletal system by causing muscular tension; the autonomic nervous system by arousing sympathetic responses; and the psychoneuroendocrine system (hypothalamic-pituitary-adrenal axis) by triggering secretion of catecholamines and glucocorticoids (see Figure
). The psychological pathway elevates negative mood states, whereas the social-behavioral pathway promotes disconnection from self and others and stress inhibition with resultant unhealthy lifestyle behaviors.3,4 The deleterious effects of this psychophysiological stress response are troublesome because anxiety is an independent predictor of arrhythmic/ischemic complications and increased mortality in cardiac patients.4
As part of autonomous nursing practice, relaxation is an integrative therapy that calms the mind and body by reducing sympathetic nervous system activity. The resultant relaxation response is characterized by lower respiration, heart rate, blood pressure, myocardial oxygen consumption, and muscle tone. The beauty of relaxation is that it can be used in any setting, and only a basic set of instructions and a quiet, comfortable environment are needed. The relaxation response, consisting of a mental device, passive attitude, and decreased muscle tone,5 may be evoked through many techniques.
Techniques generally focus on progressive muscle relaxation (active tensing and relaxing of muscles) or passive muscle relaxation (focusing on words like "relax" during exhalation). Similarly, autogenic training involves passive concentration and slow repetition of single words or phrases on exhalation—"my right leg is heavy" or "my heartbeat is calm"—to induce muscle relaxation and promote vasodilatation. Often practiced with relaxation, imagery reframes situations to positive images, lowering the stress response mediated by psychoneuroendocrine interactions. Thus, imagery may be added to increase or decrease sensations of weight (rag doll, floating) or soothe away bothersome thoughts (fluffy clouds, leaf floating downstream).6 Like relaxation, imagery is a learned skill because it takes practice to use the right brain. Also, the more senses one uses (sight, smell, touch, taste, sound), the more cortical areas of the brain are involved and the more images affect physiology. Regardless of the technique, relaxation gives attention to breath. Diaphragmatic breathing involves focusing on slow, deep, rhythmic breaths, inhaling through the nose and exhaling through the mouth. These techniques reduce the "fight or flight" response and thereby promote parasympathetic activity. This clinical review assesses available evidence on the effectiveness of relaxation and imagery in reducing anxiety in cardiac patients.
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Methods
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The strategy included searching MEDLINE, CINAHL, Cochrane, Joanna Briggs, and TRIP databases. Key words included cardiac, angina, myocardial infarction, anxiety, relaxation, and imagery. Only randomized studies were included.
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Results
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Five randomized trials and 2 meta-analyses were retrieved (Table 1). With more than 2700 patients studied, most trials were conducted in cardiac rehabilitation and outpatient settings; however, 1 meta-analysis13 included 4 inpatient trials. Common sample characteristics included being white, male, 50 to 60 years old, and married. Cumulative findings revealed that relaxation produced small, significant reductions in state anxiety. Although 1 meta-analysis12 found similar anxiety reduction for the relaxation interventions part of stress management versus complex psychological programs, another13 found greater anxiety reduction for grade 2 (full sessions with multiple techniques) compared with grade 1 (brief session) or grade 3 (extended sessions with cognitive skills) relaxation training.
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Recommendation Based on Current Evidence
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Available studies provide class I evidence for the effects of relaxation on anxiety (Table 2); however, research is needed on more diverse cardiac samples (eg, females, younger and older patients). Small but significant reductions in anxiety can be expected, with greater effects from more intensive relaxation training. Therefore, to reduce the harmful effects of anxiety on patient outcomes, cardiovascular nurses can encourage patients to participate in cardiac rehabilitation after discharge and can influence rehabilitation programs at their hospital or in their community to offer full relaxation training with multiple techniques, such as cognitive-behavioral restructuring and meditation. As van Dixhoorn and White’s13 meta-analysis concluded, "If one wants to implement relaxation therapy, better do it well."
Although evidence suggests greater effects of intensive training, cardiovascular nurses have a chance to begin teaching patients simple relaxation techniques in the hospital setting. In the biopsychosocial model, the mind and body are seen as connected bidirectionally. In a recent survey,15 almost half of critical care nurses ranked anxiety as harmful and more than three-fourths believed that anxiety management was very important. Most commonly used interventions were anti-anxiety medications and communication or information techniques; teaching relaxation was reported only 21% to 40% of the time. Thus, the biopsychosocial model provides a framework to assist nurses in expanding their repertoire of anxiety management strategies and empowering patients to learn self-healing modalities that interrupt major anxiety pathways, thereby contributing to secondary prevention.
In a more recent national survey of critical care nurses,16 the vast majority (96%) perceived integrative therapies as helpful for managing anxiety. Significant proportions of respondents reported personal and professional use of relaxation (87%) and guided imagery (76%), which were viewed as legitimate by most. At least 56% of patients or families requested relaxation techniques (versus 12% for imagery). Indeed, integrative therapies resonate with patients’ desire to have options, control, and influence over their care.17 As Tracy and Lindquist’s18 model advocates, critical care nurses play a key role in facilitating patient access to and the delivery of integrative therapies, potentially influencing satisfaction of patients and their families, safety of patients, and biopsychosocial outcomes—not to mention satisfaction among staff.
Despite common barriers of lack of training and knowledge, most critical care nurses in a large national survey16 expressed an overwhelming openness to, and desire for, additional education and availability of integrative therapies for patients, patients’ families, and nurses. Based on current research evidence and the interest of critical care nurses, educational programs on relaxation and imagery are clinical practice priorities that may provide clinicians with the knowledge to teach the relaxation response to cardiac patients. Disch and Kreitzer17 also urge critical care nurses to examine their beliefs about integrative therapies, talk with patients and families about their use of integrative therapies, and collaborate with researchers investigating the effectiveness of integrative therapies as groundwork to facilitate dialogue on how these therapies can be incorporated into existing care patterns (rather than viewing them as "add-on" or separate techniques from mainstream clinical practice). By doing so, nurses can promote truly holistic care environments. Incorporating such therapies into our self-care practices also nurtures our bodies, minds, and spirits—allowing us to be more fully present and able to share with patients the full arsenal of therapies that could help them heal.
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REFERENCES
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