1Department of Mental Health Nursing, Sekolah Tinggi Ilmu Kesehatan Pertamedika, Jl.Bintaro 10, South Jakarta 12240, Indonesia
2Department of Mental Health Nursing, Universitas Indonesia, Jl.Prof.Dr.Bahder Djohan, West Java 16424, Indonesia
Corresponding Author’s Email: fajriyah.na@gmail.com
Abstract
Anxiety is a psychosocial problem that is often experienced by patients with hypertension because it harms daily life activities. Signs of anxiety affect various physiological, affective, psychological, behavioral, and social aspects. This study determines to explore and provide how community mental health nurses contribute to patient, family, and community to developmental assessment, intervention and monitoring in health service. This is a case study of middle age (49 to 51 year old) hypertension patients who for three to five years suffered from a focus on the condition of illness, fear of non-specific consequences, reveal physiological changes, life changes, trouble with the family, less able to solve problems, lack of concentration, and forgetfulness. The researcher, as a psychiatric nurse conducted a physical and psychological assessment and found that the patient had a subtle gap between his hypertension, family issues, and support group, prolonging the healing process. Goal setting and a psychosocial therapy program for psychiatric nursing were developed to address physical, psychological, spiritual, and social needs through an assessment of unpleasant experiences, problem- solving skills, and support systems. The psychological intervention provided by the psychiatric nurse included generalist and specialist therapies that supported the patient within a single system. This determination was made in collaboration with the community health center nurses and mental health cadres, holistically as part of monitoring and supporting the patient’s mental health improvement. This conclusion is early detection of the psychosocial of anxiety development can reduce symptoms and enhance constructive skill, implemented independently, by the family, and by community groups.
Introduction
Hypertension is the most common cardiovascular disease experienced by humans throughout the world, causing increased morbidity and mortality every year. The prevalence of hypertension in Asian based on surveys of the population aged ≥18 years is 25.8%, taking prescribed hypertension medication is 9.5%, and 0.1% of the population takes their medication even though they have never been diagnosed with hypertension by health workers (Hoshide et al., 2023). It is estimated that there will be an increase in the number and proportion of the population experiencing hypertension so that hypertension becomes 1 of the 12 indicators of a healthy family and has minimum service standards in the health sector. Hypertension experienced by a person often results in coronary heart failure, stroke, and congestive heart disease, which is 6 times the risk of occurring in individuals. Hypertension often shows many symptoms, thus causing emotional stress on individuals. An increase in uncontrolled emotions gives rise to various responses as a reaction to reduce the impact of emotional stress (Elsaid et al., 2021). The responses received by individuals form the perception that hypertension can be a traumatic experience and even a threat to daily life. Anxiety is a mental health problem that is included in the group of emotional mental disorders with a prevalence of 6% of the population and will continue to increase. Anxiety is a feeling of discomfort, restlessness, uncertainty, worry, or fear caused by anticipation of a threat of danger, the source of which is often unspecified or unknown to the individual. Anxiety is a mental problem that is often experienced by people in everyday life, especially with physical health problems such as hypertension. Anxiety will get worse if it occurs and is experienced for a long
time and continuously, thus harming physical health. Signs of anxiety symptoms can be found in the physiological aspect, including rapid breathing, heart palpitations, gastric complaints, dry mouth, muscle tension and even sweating. Psychological aspects include feelings of anxiety, worry, and fear (Devassy et al., 2023). Efforts to handle anxiety patients can take the form of prevention, anticipation strategies, and crisis management as well as treatment provided based on health services according to mental nursing care standards. Nursing actions for anxiety patients can be provided by combining several types of therapy including generalist nursing interventions and specialist psychiatric nursing interventions with individual, family, and group approaches. The main principle of mental nursing therapy is to reduce signs of symptoms and increase the problem-solving abilities of patients, families, and community groups. Generalist psychiatric nursing therapy by providing deep breathing exercises, distraction, spiritual activities, and five-finger hypnosis. Specialist psychiatric nursing therapy with an individual approach, namely cognitive therapy, progressive muscle relaxation, thought therapy, and behavioral thought therapy. Generalist nursing interventions and family psychoeducation can improve patients' cognitive, affective, and psychomotor abilities in dealing with health. Cognitive therapy is a technique that can be used when someone wants to consciously eliminate disturbing thoughts and unwanted thoughts. Family psychoeducation therapy and supportive therapy are also specialist psychiatric nursing interventions capable of increasing the family's ability to control and reduce signs of anxiety symptoms due to the physical illness they are suffering from.
From the introduction, the existing gaps addressed by this study are to begin with the fragmentation of approaches, by exploring structured, synergistic mental health nursing interventions for patients, caregivers, and family groups simultaneously. The second point is the lack of exploration of specific psychosocial mechanisms explaining the hypertension-anxiety cycle within the family system. Furthermore, the limited application of cognitive therapy to individuals, by adapting it to address maladaptive thought patterns at the caregiver, family, and group levels. Moreover, the lack of explicit focus on the psychological burden of caregivers as direct subjects of intervention. Lastly, the scarcity of in-depth contextual evidence from case studies in real family settings, which this research aims to address.
Methodology
Study Design and Sample
This research was a Case Study with an observational descriptive research design. The research aimed to gain an in-depth and contextualized understanding of life experiences of hypertension patients who experience anxiety. This research technique presents cases with almost the same characteristics and the same treatment and intervention. Case information is obtained directly (through home visits) from patients, caregivers, and family groups of hypertension sufferers who experience anxiety. This allows patients to express their natural problems freely and openly about their health condition. This study used heterogeneous or maximum variation sampling to capture diverse perspectives and conditions. The sample consisted of five cases, each representing a distinct profile based on the key variables central where people aged 49-52 years, experiencing chronic hypertension who recorded at the health center in Jakarta, take medication regularly at the health center, and willing to follow the procedure to completion. Researchers obtained samples according to the criteria along with supporting information with the help of community health center nurses and mental health cadres in conducting screening until the intervention was completed.
Assessment and Observation
The anxiety diagnosis guide uses the hamilton rating scale for anxiety with interpretation score not anxious (<14), mild anxiety (14-20), moderate anxiety (21-27), severe anxiety (28-41), and panic (42- 56). A semi-structured interview guide adapted from Stuart's adaptive stress model theory to explore an in-depth assessment of predisposing factors, precipitating factors, stressors assessment, coping sources, and coping mechanisms. The nursing interventions provided: a) generalist psychiatric nursing is deep breathing techniques, spirituality, and b) specialized psychiatric nursing are: 1) cognitive therapy: identifying unpleasant experiences that cause negative thoughts and rationalization of negative
thoughts. 2) family psychoeducation therapy: identifying problems in caring for sick family members and caring for sick family members, family stress management, management of family burdens, benefits of support systems, evaluation of the benefits of psychoeducation. 3) supportive therapy: identifying family capabilities and support sources inside and outside the family and using existing support sources within the family, monitoring, and barriers, using support sources outside the family, monitoring, and barriers, evaluate outcomes and barriers to resource use. The research location was carried out in the private homes of patients and caregivers, as well as the community service hall for family groups. Generalist psychiatric nursing intervention was carried out in 2 meetings, each meeting lasting 30 minutes. Specialized psychiatric nursing interventions are carried out in stages starting from the patient, then the caregiver, and the family group. The total number of meetings was 10 meetings, each meeting 40-45 minutes for 30 days for each patient.
Signs and Symptoms | Patient Ability | Care Giver Ability |
P1 Mrs.49 years old, sick in the last 3 years, history of hereditary disease. Physiological: Difficulty sleeping at night, dizziness, stiff neck, BP 165/110 mmHg, easily tired. Cognitive: Focus on the condition of illness, fear of non-specific consequences, reveal physiological changes, life changes, trouble with the family, less able to solve problems, lack of concentration, and forgetfulness. Affective: Worried, afraid, sad. Behavioral: Talk fast, daily activities decrease. Social: Sometimes indifferent and difficult to interact with, does not participate in social activities. | Able to pray, take medication, keep feelings bottled up more. | The main caregivers are husband and children, able to use health services to help patients. |
P2 Mrs. S, 50 years old, sick for the last 5 years, history of hereditary disease. Physiological: Difficulty sleeping at night, dizziness, stiff neck, BP 160/100 mmHg, easily tired. Cognitive: Focus on the condition of illness, fear of non-specific consequences, reveal physiological changes, confusion, changes in life, trouble with the family, and forgetfulness. Affective: Worried, afraid, sad, annoyed. Behavioral: Talks fast, daily activities decrease, sometimes blames others. Social: Sometimes indifferent and difficult to interact with, does not participate in social activities. | Able to pray, take medication, keep feelings bottled up more. | The main caregivers are husband and children, able to use health services to help patients. |
P3 Mrs. N, 50 years old, sick in the last 4 years, history of hereditary disease. Physiological: Difficulty sleeping at night, dizziness, stiff neck, BP 160/100 mmHg, easily tired. Cognitive: Focus on the condition of illness, fear of non-specific consequences, reveal physiological changes, life changes, trouble with the family, sometimes having difficulty concentrating and forgetfulness. Affective: worried, afraid, sad. Behavioral: Talks fast, decreases daily activities, and sometimes gets angry with himself. Social: Sometimes indifferent and difficult to interact with, does not participate in social activities. | Holding onto feelings more, being able to pray, taking medication. | The main caregiver is the husband, able to use health services to help patients. |
P4 Mrs.Y, 52 years old, sick in the last 4 years ago, history of hereditary disease. Physiological: difficulty sleeping at night, dizziness, with stiff neck, BP 165/110 mmHg, easily tired. Cognitive: focus on the condition of illness, fear of non-specific consequences, reveal physiological changes, trouble the child, life changes, sometimes have difficulty concentrating and forgetfulness. Affective: worried, afraid, sad, sometimes alert Behavioral: talk fast, daily activities decrease, sometimes blame others. Social: sometimes indifferent and difficult to interact with, does not participate in social activities. | Holding onto feelings more, being able to pray, taking medication. | The main caregiver is a child, able to use health services to help patients. |
P5 Mrs.W, 51 years old, sick in the last 4 years, has a history of hereditary disease. Physiological: difficulty sleeping at night, dizziness, stiff neck, BP 165/100 mmHg, easily tired. Cognitive: focus on the condition of illness, fear of non-specific consequences, reveal physiological changes, trouble with the family, life changes, sometimes have difficulty concentrating and forgetfulness. Affective: worried, afraid, sad. Behavioral: talks fast, daily activities decrease, sometimes blames others. Social: sometimes indifferent and difficult to interact with, does not participate in social activities. | Holding onto feelings more, being able to pray, taking medication. | The main caregiver is the husband, able to use health services to help patients. |
*Type: P1: Patient 1st; P2: Patient 2nd, P3: Patient 3th; P4: Patient 4th; P5: Patient 5th
Ethical Consideration
The study was approved by the Research Ethics Committee, Regional General Hospital, Health Department of the Special Capital Region Provincial Government Jakarta, Indonesia, with approval number 3036/DL.01 on 17 April 2025.
This research study complies with 7 standards as social values, scientific values, equitable distribution of burdens and benefits, risks, inducements/exploitation, confidentiality and privacy, and consent. Informed consents researchers explain the aims, benefits, procedures, and rights during participation. After all patients and caregivers understand, they sign informed consent without coercion and voluntarily.
Results
Evaluations carried out at each meeting illustrate significant changes in the abilities as well as a reduction in signs and symptoms of anxiety can be seen in Table 2.
Psychosocial Anxiety Therapy: Implementation of Nursing Interventions | P1 | P2 | P3 | P4 | P5 | ||||||||||
ss | pa | cg | ss | pa | cg | ss | pa | cg | ss | pa | cg | ss | pa | cg | |
M1-2: Generalist therapy by nurses: Health education regarding hypertension and anxiety, practicing relaxation, distraction and spirituality. | 21 | 6 | 1 | 20 | 5 | 1 | 21 | 5 | 1 | 22 | 5 | 1 | 21 | 5 | 1 |
M3: Cognitive Therapy: identifying unpleasant experiences that cause negative thoughts and rationalization of first negative thoughts. Family Psychoeducation: identifying problems in caring for sick family members and caring for sick family members. | 17 | 7 | 2 | 19 | 6 | 2 | 19 | 6 | 2 | 19 | 6 | 2 | 18 | 6 | 2 |
M4: Cognitive Therapy: rationalization of second negative thoughts. Family Psychoeducation: family stress management. | 15 | 8 | 3 | 17 | 7 | 3 | 17 | 7 | 3 | 16 | 7 | 3 | 16 | 7 | 3 |
M5: Family Psychoeducation: management of family burdens, and the benefits of support systems. | 12 | 9 | 5 | 14 | 8 | 5 | 14 | 8 | 5 | 14 | 8 | 5 | 13 | 8 | 3 |
M6: Family Psychoeducation: evaluation of the benefits of psychoeducation. | 9 | 9 | 6 | 13 | 8 | 6 | 12 | 8 | 5 | 10 | 8 | 6 | 9 | 8 | 6 |
M7-8: Supportive Therapy: identifying family capabilities and support sources inside and outside the family and using existing support sources within the family, monitoring, and barriers. | 8 | 11 | 8 | 8 | 10 | 8 | 10 | 10 | 8 | 7 | 10 | 8 | 7 | 10 | 8 |
M9: Supportive Therapy: using support sources outside the family, monitoring, and barriers. | 5 | 12 | 9 | 5 | 11 | 9 | 7 | 11 | 9 | 4 | 11 | 8 | 4 | 11 | 9 |
M10: Supportive Therapy: evaluate outcomes and barriers to resource use. | 3 | 13 | 10 | 3 | 12 | 10 | 3 | 12 | 10 | 2 | 12 | 10 | 2 | 12 | 10 |
* Type: P1: Patient 1st; P2: Patient 2nd; P3: Patient 3th; P4: Patient 4th; P5: Patient 5th M: meeting; SS: signs and symptoms; pa: patient ability; cg: caregiver ability.
The changes experienced include a decrease in the number of signs and symptoms of anxiety and an increase in the number of abilities of patients, caregivers and family groups. Patient 1: The patient experienced a decrease in symptoms, including a focus on the illness, fear of unspecific consequences, reported physiological changes, changes in life, inconvenience to the family, poor concentration, and forgetfulness. The final evaluation revealed one persistent intrusive thought, namely, changes in life. The family was able to identify the problem, care for the family, modify the environment, make decisions, and utilize health services. The family group was able to utilize resources within and outside the family. Patient 2: The patient experienced a decrease in symptoms, including a focus on the illness, fear of unspecific consequences, reported physiological changes, changes in life, inconvenience to the family, and poor concentration. The final evaluation revealed two persistent intrusive thoughts, namely,changes in life. The family was able to identify the problem, care for the family, modify the environment, make decisions, and utilize health services. The family group was able to utilize resources within and outside the family. Patient 3: The patient experienced a decrease in symptoms, including a focus on the illness, fear of unspecific consequences, reported physiological changes, life changes, family inconvenience, poor concentration, and forgetfulness. The final evaluation revealed one persistent intrusive thought, namely, "being a burden to the family." The family was able to identify the problem, care for the family, modify the environment, make decisions, and utilize health services. The family group was able to utilize resources within and outside the family. Patient 4: The patient experienced a decrease in symptoms, including a focus on the illness, fear of unspecific consequences, reported physiological changes, life changes, family inconvenience, poor concentration, and forgetfulness. The final evaluation revealed one persistent intrusive thought, namely, "being a burden to the family." The family was able to identify the problem, care for the family, modify the environment, make decisions, and utilize health services. The family group was able to utilize resources within and outside the family. Patient 5: The patient experienced a decrease in symptoms, including a focus on the illness, fear of nonspecific consequences, and reported physiological changes, changes in life, family inconvenience, poor concentration, and forgetfulness. The final evaluation revealed one persistent intrusive thought, namely, being a family inconvenience. The family was able to identify the problem, care for the family, modify the environment, make decisions, and utilize health services. The family group was able to utilize resources within and outside the family.
Discussion
Nursing interventions with cognitive therapy, family psychoeducation, and supportive therapy were given a steady down trend in anxiety symptoms and a sharp ability to overcome anxiety while experiencing hypertension. The family can care for and facilitate the patient and the family can use support sources within and outside the family in overcoming health problems. After being given nursing care, the physiological symptoms had fallen, including headaches, stiff neck, and fatigue. Physiological changes in anxiety with physical problems such as hypertension are influenced by the work of the sympathetic nervous system which results in muscle tension, difficulty sleeping, increased vital signs, decreased appetite, and pain. Signs of physiological symptoms decreased after being given nursing care by nurses and specialist nurses. The deep breathing technique with a 4-7-8 count performed on patients can reduce anxiety levels and improve quality of life. The breathing pattern reduces stress levels and improves decision-making at work. The effect of deep breathing on the level of concentration, attention, and stress in adults significantly reduces the level of cortisol which functions in metabolism and regulates a person's energy, especially in conditions of stress and threat. Deep breathing for 4 weeks reduces systolic and diastolic blood pressure, decreases the work rate of the heart, has a calming effect, and improves mental health so that a person can make the right decisions thereby increasing performance in emergencies and critical situations. The same spiritual action is assigned positive thinking, acting and hoping, so that it can reduce physical response blood pressure, dizziness, vertigo, sleep problems, disruption of eating patterns, and disruption of daily activities (Steghaus & Poth, 2024). These symptoms are experienced by adult and elderly patients so that they experience physical decline which affects the decline in daily activities and disruption of the health quality.
Cognitive therapy by negative thoughts from becoming rationalization positive thoughts affects the metabolic work of increased blood pressure and blood lipids are considered significant risk factors for developing hypertension. Cognitive therapy leads to a significant decrease and blood lipids in total cholesterol levels. Perception and lifestyle changes have been recommended as a means to better blood pressure and lipid management (Baourda & Panagiotakos, 2025). Which can reduce physical symptoms in the form of temporarily slowing down the functioning of the body's organ systems thereby reducing signs of physiological symptoms of anxiety in the form of dizziness and vertigo. Signs of cognitive symptoms that have are focus on the condition of the disease, fear of the consequences of the disease, physiological changes, changes in life, and difficulty concentrating. Cognitive therapy aims to increase the ability to control intrusive thoughts which result in anxiety resulting in discomfort, feeling worried, sad, lack of motivation, feeling guilty, focusing on specific things, changing self-concept, being
impatient, and letting go of obstacles. Therefore, was effective in reducing anxiety levels as indicated by changes in disturbing thoughts such as not focusing on carrying out daily activities, regretting past events that have occurred, loss of interest in activities, laziness about bathing and praying, and even suicidal thoughts. Anxiety patients' affective responses that occur are part of their emotions in dealing with problems which are also influenced by the time, duration, and intensity of the stressors experienced (Li et al., 2021).
Caregivers and families have an important role in the healing process mental health of hypertension patients who experience anxiety (Woldring et al., 2024). Family psychoeducation therapy aimed at reducing anxiety and physical problems (Dolan et al., 2021) due to hypertension, as well as being effective in preventing the expression of negative emotions and the burden of caring for patients in the first episode of psychosis, in addition, to support from families can reduce pain and increase the resilience of body functions in dealing with illness (Mou et al., 2022). Signs of decreased productivity are caused by an increase in blood pressure which is assumed to affect limitations in daily activities. Signs in the social aspect are shown by difficulty interacting and not participating in social activities in the community. After being given cognitive therapy and family psychoeducation, it showed a decrease in negative symptoms. Thus, it could be explained that family support was a source of patient coping strength in overcoming the health problems they experienced.
Supportive therapy by a group of family members and caregivers who have the same health and psychosocial problems. Social and environmental support also influences physical and psychosocial health. Unresolved health problems in the family system will have a negative psychological and physical impact on other family members who care for the patient 24 hours a day. So, caregivers also need support from other families who have the same problems. Supportive therapy aims to optimize the role of the family as a source of social support for other patients and families in sharing and exchanging opinions and experiences in caring for patients to reduce the burden on the family (Garland et al., 2022). The benefits of it include being able to express feelings related to problems experienced, share experiences, and express needs (Pawar et al., 2018). So that patients, families, and support groups can discuss, suggest, explain, and help in resolving the problems they are experiencing so that the physical and psychological illnesses they are experiencing are resolved. Nevertheless, increases the family's ability to provide group support in the form of health information, sharing experiences, and emotional support, able to resolve its problems, open communication, the roles, functions, and responsibilities of family members being implemented, the involvement of all family members effectively, control of behavior, and family functions in further plans for future life.
Limitations
There are several limitations to this study. The concomitant use of conventional drugs may have biased the results. Unique subjective signs and symptoms may affect the objectivity of the results. Uncontrollable causal factors need to be minimized. This limitation could also the small sample size of studies may have led to inadequate power to detect significant effects and a lack of ability to make statistical generalisability.
Conclusion
This study states that providing generalist mental nursing therapy, cognitive therapy, family psychoeducation, and supportive therapy simultaneously can reduce signs of anxiety symptoms in physiological, affective, behavioral, and social aspects. Likewise, caregivers and family groups can solve problems in caring for family members with hypertension and anxiety sufferers. With the involvement of families and family groups, the level of physical and mental health in the community system can be increased. These results recommend mental health interventions as collaborative actions in health services both in clinical services and community services so that they can be applied to all levels of society. In addition, there is a need for ongoing qualitative research with larger and more varied sample sizes and exploring the use of other interventions.
Conflict of Interest
The authors declare that they have no conflicts of interest.
Acknowledgement
The authors would like to thank all participants for their valuable time spent on this study.
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