The Influence of Slow Deep Breathing Technique on Inpatient Anxiety

Abstract


INTRODUCTION
The Anxiety and Depression Association of America assesses that anxiety affects one person in every 25 British people. Women have more anxiety than men and usually occurs between the ages of 35-55 years. The American Psychiatry Association (APA) reports that 8.3% of the population experience anxiety which usually occurs in women 55-60%. Community survey also shows 3-5% of adults experience anxiety with a lifetime prevalence of more than 25%.
Approximately 15% of patients who operate are anxious, and 25% occur while seeking treatment. Disturbance Anxiety usually begins in early adulthood, between the ages of 15 and 25, and increases by the age of 35 years old [1].
Inpatient care is a hospital treatment process that often triggers stress and anxiety in patients [2]. Anxiety is a common emotional response experienced by inpatients and can affect their physical and psychological recovery. Excessive anxiety can worsen patients' health conditions, increase pain levels, disrupt sleep, weaken the immune system, and prolong the recovery period [3].
Anxiety needs attention and intervention because the patient's emotional state affects the patient's bodily functions. High stress can affect the physiological part of the body, which is characterized by increased blood pressure, increased pulse frequency, and increased respiratory rate. The role of the nurse is needed to intervene in patients.
Nurses can do therapy such as relaxation therapy, distraction, recovery, and imagination [1].
One of the non-pharmacological approaches being considered is the use of a breathing technique known as Slow Deep Breathing [4]. This technique involves taking slow and deep breaths, as well as exhaling slowly. Slow Deep Breathing is associated with the activation of the parasympathetic nervous system, which plays a role in reducing stress and calming the autonomic nervous system [5]. In the context of inpatients, this breathing technique has the potential to reduce anxiety and improve patient well-being [6].  Figure 1).

RESULTS
Eight articles met the inclusion criteria ( Figure 1)  There was a significant difference between the treatment group and the control group in terms of anxiety levels (p=0.000), pulse rate (p=0.000), and respiratory rate (p=0.001). However, no significant differences were found between the two groups in systolic blood pressure (p=0.459), diastolic blood pressure (p=0.901), MAP (p=0.461), and SaO2 (p=0.717).
Additional findings: Age and experience can influence anxiety levels. There is a significant difference with a p-value of 0.000, indicating that the intervention group is better at reducing anxiety levels compared to the control group. Additionally, an analysis of the mean difference in anxiety levels between the intervention and control groups was conducted, yielding the same p-value (p = 0.000). Research Design: Quasi experiment with non equivalent control group pre test and post test design Sample: 30 patients were devided into two groups: treatment group (n=15) and control group (n=15) Variables: Independent variabel: slow deep breathing Dependent variabel: anxiety Instrument: Zung Self Rating Anxiety Scale used to asses anxiety scores Analysis: independent t-test After being given deep breathing relaxation therapy for 3 days to the intervention group, there was a significant difference in value between the control group and the intervention group with a p value of 0.002 <0.05 Additional findings: In this study, anxiety can be influenced by several factors, one of which is the environment of the hemodialysis room, there is no influence between gender and anxiety level.
Deep breathing exercises produce positive and effective results to reduce anxiety levels in patients at certain periods. The results of various studies state that this is an intervention with low risk and low cost.

Anxiety
Slow deep breathing intervention can be categorized as an external factor influencing anxiety [14], [16]. The success of slow deep breathing in reducing anxiety has been proven through several literature studies mentioned in Table 1. Slow deep breathing is a relaxation technique that involves deep and slow breathing, which can help reduce autonomic nervous system activity and stimulate the parasympathetic nervous system [15]. In various journal articles, research results on the slow deep breathing method were conducted within a range of 15 to 30 minutes. In this exercise, participants were instructed to practice breathing at a slower and deeper rhythm. The exercise was performed for a maximum of 3 days to achieve the desired effect [11], [13], [10], [1], [14], [16].
Therefore, slow deep breathing intervention can influence anxiety by reducing physiological responses associated with anxiety, such as blood pressure, heart rate, and respiratory rate [16].
In the context of the research studies mentioned in Table 1 [19].
Furthermore, the physical and social environment in hospitals or care facilities also has an impact on patient anxiety [12]. A comfortable, peaceful, and disturbance-free environment provides a sense of security and comfort for patients, which in turn can reduce anxiety levels [20]. Factors such as excessive noise, lack of privacy, or unclean conditions can increase patient anxiety. Additionally, positive social interactions with healthcare staff and support from family and friends can also contribute to reducing patient anxiety [21]. Paying attention to and creating a supportive environment can help reduce factors that can increase anxiety in inpatient and preoperative patients [22].
With adequate access to information, good therapeutic communication, and creating a supportive environment, we can reduce the levels of anxiety in inpatient and preoperative patients. This holistic approach helps patients feel more prepared, informed, and supported during their treatment period, which ultimately can enhance their experience and minimize any anxiety they may experience.

Internal Factors that Influence Anxiety
Age, gender, education, health condition, and prior hospitalization experience are internal factors that can influence the level of anxiety in inpatient and preoperative patients [10], [15], [1], [16], [14] . The age of the patient can affect the perceived level of anxiety, with older patients possibly experiencing higher anxiety due to physical limitations, concerns about slower recovery, or previous experiences with medical procedures [23]. On the other hand, younger patients may experience anxiety related to concerns about the procedure's outcome, long-term impact, or limitations in activities they will face [24].
Furthermore, studies indicate that gender can also play a role in patients' anxiety, with women tending to have higher levels of anxiety than men in the context of healthcare [25]. Hormonal differences, social roles, or differing perceptions of health and recovery may be factors influencing these differences [26].
Education level can also influence patient anxiety [13]. Patients with higher education levels may feel more prepared and have a better understanding of their medical condition and the procedures to be performed, leading to lower levels of anxiety [27]. On the other hand, patients with lower education levels may feel less confident or have difficulty understanding the information provided to them, which can increase their anxiety levels [28].
The patient's health condition itself can also contribute to the level of anxiety [12].
Patients with serious or chronic illnesses tend to experience higher levels of anxiety due to concerns about complications, changes in their daily lives, or the long-term impact of their condition [29]. Additionally, patients with a history of mental illnesses, such as anxiety disorders or depression, may be at a higher risk of experiencing more intense anxiety [30].
One of the internal factors that affect the patient's anxiety level is hormones. In a state of anxiety, there is activation of the limbic system. This system will stimulate the release of hormones from the hypothalamus, namely corticotropic releasing hormone (CRH). This hormone directly inhibits hypothalamic GnRH secretion from its production site in the arcuate nucleus. This process likely occurs through the augmentation of endogenous opioid secretion. Increased CRH will stimulate the release of endorphins and adrenocorticotropic hormone (ACTH) into the blood. Increased ACTH levels will cause an increase in blood cortisol levels which causes anxiety [31] Endorphins are hormones known as happiness triggers that are produced in the central nervous system. Endorphin hormones can reduce blood pressure, pulse, and respiratory rate and can create a happy atmosphere and provide positive feelings so as to minimize feelings of fear and anxiety (10). In addition, the central nervous system will also produce phenylethylamine which will affect the midbrain to secrete GABA order to obtain specific insights.

CONFLICT OF INTEREST
The author states that there is no conflict of interest in writing this article.

AUTHOR CONTRIBUTIONS
All authors contributed to the review process.
First author conducted article search and literature review. After completing the manuscript, each author reviewed the findings.