Journal of Psychiatric and Mental Health Nursing, 2000, 7, 443–448

© 2000 Blackwell Science Ltd 443

Staff development, anxiety and relaxation techniques: a pilotstudy in an acute psychiatric inpatient settingH. DODD1 & N. WELLMAN2

1Clinical Nurse Specialist, Oxfordshire Mental Healthcare NHS Trust, Warneford Hospital, Headington, OxfordOX3 7JX & 2Senior Research Nurse, Oxfordshire Mental Healthcare NHS Trust & University of Oxford,Department of Psychiatry, Warneford Hospital, Headington, Oxford OX3 7JX, UK

DODD H. & WELLMAN N. (2000) Journal of Psychiatric and Mental Health Nursing7, 443–448

Staff development, anxiety and relaxation techniques: a pilot study in an acutepsychiatric inpatient setting

Psychiatric inpatients often complain of problems with anxiety, but a computerised search

of the nursing literature failed to find any publications detailing nurse-led, individual or

group anxiety management work specifically aimed at psychiatric inpatient populations. In

the UK, psychiatric inpatient populations are characterized by people with clinical diag-

noses of schizophrenia and major affective and personality disorders. This is a very differ-

ent population from that treated in the vast majority of published trials of cognitive and

other approaches to anxiety management. A pilot study was conducted on four psychiatric

acute admission wards to determine the practicality of treating a convenience sample of

psychiatric inpatients with self-reported anxiety problems along broadly cognitive lines.

Patients attended a course of three anxiety management groups (AMGs) run by nurses and

were given homework and other exercises to complete. Patients reported significant reduc-

tions in anxiety after completion of the treatment. The AMGs were facilitated by staff

nurses under the supervision of a clinical nurse specialist, and not by fully trained thera-

pists as in most treatment studies relating to anxiety. Further studies, particularly ran-

domized controlled trials, are needed to explore the efficacy and practicality of nurses

delivering brief psychological interventions to psychiatric inpatients.

Keywords: acute admission ward, anxiety management group, cognitive behavioural

therapy, nurse facilitators, psychiatric inpatients, relaxation

Accepted for publication: 26 May 2000

Correspondence:

H. Dodd

Oxfordshire Mental Healthcare

NHS Trust

Warneford Hospital

Headington

Oxford

OX3 7JX

UK

Introduction

Almost everyone experiences anxiety feelings from time to

time. Anxiety feelings are generally particularly prevalent

when individuals are faced with stressors such as exami-

nations, interviews for jobs or visits to the dentist or to

hospital. Anxiety can be conceptualized along a continuum

stretching from the pathologically low (where the avoid-

ance of danger may be impaired), through a range of

normal response to threat, up to severe anxiety disorders

where functioning is impaired by excessive and dispropor-

tionate anxiety responses.

Medical and psychiatric disorders and the treatments for

these conditions may generate both severe and prolonged

anxiety feelings in vulnerable subjects; in light of this Fishel

(1998) has argued that it is important for nurses to be

able to evaluate and assess anxiety symptoms. Similarly,

Teasdale (1995) has stressed the importance of accurate

nursing assessment in the management of dysfunctionally

anxious hospitalized patients.

H. Dodd & N. Wellman

444 © 2000 Blackwell Science Ltd, Journal of Psychiatric and Mental Health Nursing 7, 443–448

Anxiety disorders and their treatment have been exten-

sively described elsewhere; see, for instance, Beck (1976),

Burns (1989), and Hackman (1997). Fishel (1998) has

described a number of hospital settings that provoke

anxiety responses in patients; however, there appears to

be very little literature describing anxiety reactions to

hospitalization for acute psychiatric disorders or to effec-

tive nursing interventions for the management of these

problems.

In 1998, nursing staff became concerned about the man-

agement of anxiety symptoms in patients admitted to local

psychiatric acute admission units; this led to the establish-

ment of a staff nurse development group facilitated by the

first author (HD). This group was established within the

Oxfordshire Mental Healthcare NHS Trust with the aim

of exploring and attempting to alleviate this problem.

The group decided to use cognitive behavioural therapy

(CBT) techniques in an action research/collaborative model

to attempt to fill a gap in service provision and improve

patient care. The members of the staff nurse development

group were to be taught CBT techniques by the first author

who is a clinical nurse specialist in CBT. These nurses

would then use CBT techniques within their own inpatient

clinical areas. The members of the staff nurse develop-

ment group identified that although relaxation groups for

patients were regularly held on their wards, there was no

cohesive or corporate view of anxiety management in the

inpatient population and the main treatments for anxiety

symptoms appeared to be pharmacological.

A computerized search of the nursing literature failed

to find any publications detailing nurse-led, individual or

group anxiety management work specifically aimed at

inpatient psychiatric populations. The majority of pub-

lished studies on anxiety disorders including most of the

randomised controlled trial literature focused on outpa-

tient populations with primary anxiety disorders. In con-

trast to this, in the UK, psychiatric acute admission wards

currently serve inpatient populations consisting primarily

of individuals suffering from psychotic disorders, major

affective disorders and serious personality disorders (Sains-

bury Centre for Mental Health 1998) with high levels of

psychiatric comorbidity. Thus the authors considered that

an eclectic and flexible approach would be necessary for

the success of any interventions undertaken by the group

with this patient population.

This pilot study set out to investigate and explore

nursing approaches using a psychological model (CBT) in

the management of anxiety in a setting that is unpre-

dictable, has a high turnover of patients and short length

of stay. In these areas, constant pressure on staffing levels

and rapid turnover of staff add to the difficulties of oper-

ating a consistent therapeutic programme.

The members of the staff nurse group were taught the

theory and practical application of CBT in clinical prac-

tice. The group agreed that each ward should pilot an

anxiety management group (AMG), linked to existing

relaxation groups. Group members would systematically

assess the efficacy of CBT approaches on each of the five

acute units and feed this information back to the develop-

ment group. The development group would then review

this evidence and identify the most appropriate and effec-

tive approaches to employ in the facilitation of the anxiety

management groups. This method of research aims at con-

tinual improvement of practice from a locally generated

evidence base.

For patients, the treatment goals were to improve their

understanding of the symptoms of anxiety, to gain an intro-

duction to a variety of techniques for managing anxiety, to

provide an informal setting for discussion and for the

exchange of individual experiences of anxiety, and to

facilitate the development of interpersonal relationships

between individual participants.

The above goals generated a framework from which

staff nurse group members would gather information on

patient anxiety themes (similarities), on the types of inter-

ventions most commonly used within the groups, on the

subjective views of the patients – identifying the interven-

tions they found most useful – and also on the difficulties

in forming and running therapeutic groups in high pres-

sure acute psychiatric inpatient areas.

Methods

In each of the participating wards, managerial support was

obtained for the establishment of anxiety management

groups. Additional to this, a regular time slot in the ward

programme was allocated to the group and collaboration

was obtained from each patient’s named primary nurse.

Co-facilitators for the groups were also identified, as was

a nurse trainee to support the group during facilitator

holidays and sickness.

The AMGs were designed to benefit patients who had

been hospitalized in acute psychiatric admission wards of

a specialist NHS mental health care Trust. Patient diag-

nosis had no bearing on accessibility to the programme.

The basic inclusion criteria for patients were their sub-

jective experience of anxiety symptoms at a level that

impeded the ability of those patients to function as they

would like.

Only four out of the five units were able to start and

sustain AMGs. Despite support from the ward managers

and multidisciplinary team members, staff retention prob-

lems and poor staffing levels impeded the ability of the staff

nurses to operate these groups. An AMG referral form (see

Anxiety management for inpatients

© 2000 Blackwell Science Ltd, Journal of Psychiatric and Mental Health Nursing 7, 443–448 445

Appendix) was designed that permitted both self-referral

by patients and referral by primary nurses. The referral

form served a number of purposes: it recorded basic demo-

graphic information together with diagnoses, it provided

an opportunity for primary nurses to discuss the AMG

with their patients, and it provided information to the

AMG facilitators, decreasing patient assessment time.

The reverse side of the referral form contained a pa-

tient care-plan specifically related to the AMG. This was

designed to aid facilitators in preparing the groups and

in documenting group interventions in patients’ general

nursing care plans and progress notes. The referral form

was also designed to be used in care-planning meetings

and multidisciplinary handovers in order to communicate

patient progress and help all members of the multidiscipli-

nary team to support patients in their AMG homework.

To facilitate this, the referral form contained staff-rated

visual analogue scales of the impact of the AMG on patient

progress in specific areas, together with a rating of overall

progress. The multidisciplinary team also rated the facili-

tator’s information exchange about the patients in han-

dovers and ward rounds. These ratings were gathered to

help the nurse facilitators in recognizing self-improvement

within their own role and are thus not reported here.

The referral form enabled nurses to assess each patient

individually and also prepare each group to meet the

specific needs of its own participants. All patients joining

the AMGs completed a Beck Anxiety Inventory (BAI; Beck

1987) and a modified, inpatient-specific Activities of Daily

Living (ADL) prior to joining the AMG and again at the

end of the third AMG session.

This was a naturalistic study of a pilot clinical develop-

ment on a group of busy acute psychiatric admission units

providing a service to 18–65-year-old patients in Oxford-

shire. The study thus employed a convenience sample of

consecutively admitted patients who complained of prob-

lems with anxiety. As reported above, the inclusion

criteria were simply the subjective complaint of anxiety

symptoms and the exclusion criteria were florid psychotic

symptoms, or organic brain impairment.

During the three-month trial period, four wards ran

AMGs, so that in addition to regular pre-existing re-

laxation groups, each patient who entered the program

attended three group sessions, each of 75 min duration,

over the course of one week. Each group was cofacilitated

by one member of the staff nurse development group

working together with an occupational therapist or

physiotherapist.

In the first of the three group sessions, the facilitators

worked with the patients to identify their individual

anxiety-related problems. The facilitators introduced

these group members to a cognitive model of anxiety

(Kennerley 1990), the central premise of this model being

that feared situations are avoided owing to aversive phys-

iological responses caused by negative perceptions held by

the individual. Copies of a pamphlet detailing the basis of

this model together with a range of relaxation techniques

(Kennerley 1990) were distributed to group members. The

relaxation techniques were to be used in conjunction with

tape-recorded muscular relaxation exercises, including

controlled deep breathing. The group facilitators helped

subjects practice these exercises during the initial session,

while emphasizing the importance of regular practice, and

also provided subjects with a chart for monitoring the

somatic symptoms of anxiety. The facilitators also encour-

aged patients to make use of a number of individualized

distraction techniques and encouraged them to attend the

regular ward relaxation groups and make use of opportu-

nities for physical activity, such as using the hospital multi-

gym and other exercise equipment. The group worked to

set goals for its members and to encourage collaboration

with structured anxiety-control ‘homework’ exercises,

which would be reviewed in subsequent sessions.

The second AMG session aimed to review the anxiety-

related ‘homework’ activities set for patients and also

sought to reinforce the pairing of patient attendees in a

‘buddy’ system. The ‘buddy’ system involves pairs of sub-

jects working together on their homework; this technique

encourages the development of relationships within the

group and successful completion of graded tasks through

the members of each pair supporting one another and

sharing the event. A further aim of this session was to help

patients refine and personalize the anxiety management

techniques they had learned in the first session. This session

also introduced patients to the identification and challeng-

ing of negative thoughts using the ‘ABC method’ – (A)

Antecedents (situations), (B) Thoughts/Beliefs about the

situation, and (C) Emotions (the emotional response medi-

ated by the thoughts or beliefs) – of separating thoughts

and feelings based on events that the subject finds anxiety

provoking (Clarke 1992), and to the testing of evidence by

the self-rated of measurement of thought and emotion and

by demonstrated changes in behaviour. At the end of the

session, subjects agreed further homework exercises with

the facilitators and were asked for their feedback on the

functioning of the group.

The third and final AMG session opened with a review

of subjects’ progress with their homework exercises and

then focused on modifying and increasing subject’s abili-

ties to analyse and control their anxiety-related cognitions,

emotions, and behaviour. At the end of this final session

subjects were asked for their feedback and completed the

rating scales again. This included a feedback questionnaire

on the key tools used in the AMG.

H. Dodd & N. Wellman

446 © 2000 Blackwell Science Ltd, Journal of Psychiatric and Mental Health Nursing 7, 443–448

Results

Twenty-three patients attended the anxiety management

groups (one of these patients attended twice, completing

two three-session courses). The mean age of patients was

40.6 years (SD = 11.9) and these subjects had varying

primary clinical diagnoses; see Table 1. Seventeen patients

completed Beck Anxiety Inventories prior to attending the

anxiety management groups and eleven of these seventeen

patients completed BAIs after attending all three AMG ses-

sions. Mean score on the BAI fell significantly (Wilcoxon

Z = -2.823, P = 0.005, 2-tailed) from 29.9 ± 2.7 (range

13–49) prior to subjects attending the groups, to 18 ± 3

(range 8–18) after the completion of the three groups.

Subjects who attended all three groups also reported a

highly significant reduction in functional impairment as

measured by their scores on the ADL questionnaire. ADL

impairment scores fell from a mean of 20 ± 2.3 (range

0–35) pre-program to a mean of 10.3 ± 1.6 (range 0–24)

after completion of the group program (Wilcoxon Z =-3.623, P = >0.001, 2-tailed).

At the end of the three groups, patients were asked for

feedback on their view of the various component parts of

the anxiety management programme; the results are shown

in Table 2.

Members of the multidisciplinary ward teams were

asked to rate their views of the relative value, to them, of

the information contained within patients’ AMG referral

form/care-plan document, in specific settings. This rating

used a 10-point scale, with higher scores indicating greater

value attached to information contained in the document

(see Table 3).

Discussion

Looking beyond primary diagnoses, the authors and their

colleagues can recall many years of clinical practice in

which psychiatric inpatients have regularly reported dis-

tressing and sometimes crippling problems with anxiety.

The nursing literature has paid very little heed to this issue

despite the real distress experienced by many of our clients

during their inpatient admissions. This pilot study has

demonstrated that anxiety management groups specifically

focused on helping adult acute psychiatric inpatients with

subjective anxiety problems may be both possible and effi-

cacious. This was an uncontrolled and naturalistic study,

which used a convenience sample comprised of patients

with a range of clinical diagnoses. This sample character-

ized by people with diagnoses of schizophrenia, bipolar

disorder and major depression, while typical of the popu-

lation of most UK acute psychiatric admission wards, is

very different from the patient populations reported in

the vast majority of published trials of cognitive and other

approaches to anxiety management. The apparent success

of this pilot study suggests a need for larger randomized

controlled trials of anxiety management techniques in psy-

chiatric inpatients with major mood and psychotic disor-

ders. Small subject numbers and a lack of control groups

limits the emphasis that can be placed on the statistical out-

comes of this study, but patient and staff feedback on the

groups was strongly positive. Furthermore, the significant

reduction in patients’ self-reported impairment scores on

the ADL questionnaire suggests that the AMG work may

have helped them to feel more comfortable in the hospital

setting and thus become better able to use to use its

resources and milieu to speed their recovery.

From the verbal and written feedback of the patients,

the most effective interventions were those modifying

Table 1Patients’ primary case-note diagnosis

Diagnosis Male Female Percentage

Depression 4 8 53Schizophrenia 4 2 26Bipolar Disorder 1 3 17Alcoholism 1 0 4

Table 2Patients’ views of individual elements of the treatment programme

Mean Rangesatisfaction

Individual elements of programme score

Relaxation group 8.63 5–10Patient’s own relaxation tapes 8.50 5–10Sharing experiences with others 7.86 5–10Deep breathing exercises 7.33 1–10Progressive muscle relaxation tape 7.31 1–10Managing anxiety handout 7.20 1–10Increased understanding of anxiety 6.71 1–10Specific distraction techniques 6.31 1–10Buddy system (homework done with others) 6.08 1–10Homework exercises 5.83 1–10

This table records the results of the feedback questionnaires given tosubjects at the end of the treatment programme, rated on a 1–10 scale(higher score = greater satisfaction). All subjects were asked to recordtheir views of the relative helpfulness of individual aspects of the treatment programme.

Table 3Staff ratings of the value of information contained in patient AMGdocumentation

Value to staff of information contained Mean Rangein AMG documentation score

Information useful in staff handovers 6.58 4–9Information of use in caring for the 5.78 4–7

specific patient attendeesInformation of value in ward-rounds/ 5.75 3–9

clinical review meetings

Anxiety management for inpatients

© 2000 Blackwell Science Ltd, Journal of Psychiatric and Mental Health Nursing 7, 443–448 447

cognitive, behavioural, and physiological difficulties. This

echoes the findings of Clarke (1999), suggesting that nor-

malizing the experience of anxiety and finding a method of

self-management is a powerful factor in the early stages of

treatment. This may have given the patients some increased

sense of self-control and autonomy during their stay in hos-

pital. The ability to take responsibility for some of their

treatment and treatment goals while collaborating with the

group facilitators and their peers undoubtedly added to

their sense of involvement in and understanding of their

treatment. Verbal feedback from the patients was that the

groups were helpful overall and had made some impact on

their anxiety. They also had expected the course or treat-

ment to be longer. This was overcome in several cases by

patients attending more than once, or by attending as day

patients after discharge.

It should be noted that subjects in this pilot study did

not receive a full course of treatment from a trained and

certificated therapist as would be typical in a CBT trial.

The subjects in this study participated in a series of three

groups facilitated by trained nurses under the supervision

of a CBT trained clinical nurse specialist (HD). Group

facilitators were taught some CBT theory by the first

author and this formal teaching was reinforced through

regular weekly clinical supervision sessions. The initial

indications from this very limited pilot study are that brief

cognitive behavioural interventions delivered by nurses

may be efficacious, though this will need to be tested in

carefully designed randomized controlled trials. In a health

service characterized by a scarcity of trained therapists,

the possibility of cost-effectively delivering psychological

interventions which improve patient outcomes should be

of widespread interest to clinicians and service managers.

Acknowledgments

The authors would like to thank Sue Edwards, Hannah

Pearson, Ali Rumjon and Beth Sharratt for their help with

this project.

References

Beck A.T. (1976) Cognitive Therapy and the Emotional Disor-ders. Meridian, New York.

Beck A.T. (1987) The Beck Anxiety Inventory. Harcourt Brace

Janovich Inc, New York.

Burns D.D. (1989) The Feeling Good Handbook. William

Morrow, New York.

Clark D.A. (1992) Depressive, anxious and intrusive thoughts in

psychiatric inpatients and outpatients. Behavioural ResearchTherapy 30, 93–102.

Clarke D.M. (1999) Anxiety Disorders: why they persist and

how to treat them. Behaviour Therapy and Research 37, S5–

S27.

Fishel A.H. (1998) Nursing management of anxiety and panic.

Mental Health Nursing Interventions for the Generalist Nurse331, 135–151.

Hackman A. (1997) The transformation of meaning in cognitive

therapy. In: Transformation of Meaning in Psychological Therapies: Integrating Theory and Practice. (eds. Power M. &

Brewin C.R.) Wiley, Chichester.

Kennerley H. (1990) Managing Anxiety: A Training Manual.Oxford University Press, Oxford.

Sainsbury Centre for Mental Health (1998) Acute Problems: aSurvey of the Quality of Care in Acute Psychiatric Wards.Sainsbury Centre Publications, London.

Teasdale K. (1995) Theoretical and practical considerations

on the use of reassurance in the nursing management of

anxious patients. Journal of Advanced Nursing 22, 79–

86.

H. Dodd & N. Wellman

448 © 2000 Blackwell Science Ltd, Journal of Psychiatric and Mental Health Nursing 7, 443–448

APPENDIX ONE

ANXIETY MANAGEMENT AND RELAXATION GROUP-REFERRAL FORMPatient identifiers:

Can you describe the situations or places where you feel anxious?

Have you been treated or had any formal experience of anxiety management before? (If so, explain)

Are you going to be in hospital for more than two weeks? YES � NO �

Are you able or prepared to attend a group for three separate sessions? YES � NO �

Doing work outside of the group is very important. Would you be willing to carry this out? YES � NO �

Are you taking any medication specifically for your anxiety? (If so, please state below)

THANK YOU FOR THIS INFORMATIONAMG CARE PLAN

PROBLEM GOALS INTERVENTIONS1.

2.

3.

1 5 10LEAST SATISFACTORY MOSTHELPFUL HELPFUL

FOR TEAM ONLY: (Please rate each question using the above scale)� Feedback from: Care Plan � � How has the Homework Helped your patients �

Handovers � � Has using the AMG Tools helped in reducing PRN meds �

Ward Rounds � � Completing the referral form with the patient �