Reichian elongation effect in anxiety and quality of life in nursing students : a randomized clinical trial

This study aims to evaluate of Reichian Elongation effect in anxiety and quality of life in nursing students. This is a prospective randomized clinical trial (Registration: RBR-2y6qcg). 143 nursing students were interviewed. The General Identification, the State-Trait Anxiety Inventory (STAI), The World Health Organization Quality of Life (WHOQOL-BREF) and MINI (Mini International Neuropsychiatric Interview) questionnaires were used. 33 received the intervention and 37 belonged to the control group. The evaluation of the elongation effect was conducted by 1, 3 and 5 months. Before intervention, experimental group presented higher trait (p= 0.005) and state anxiety mean (p= 0.049), compared to control group. There was a decrease in the state anxiety mean with 1 (p= 0.028), 3 (p= 0.031) and 5 months (p= 0.010) in experimental group. Physical (p= 0.002), psychological (p= 0.010) and social relations domain (p= 0.026) showed an increase in quality of life. Reichian Elongation contributes in reducing the symptoms of anxiety and improving the students’ quality of life.

Thus, this study aims to answer the main question: What is the Reichian Elongation effects in anxiety and quality of life in nursing students? The objective was to evaluate of practicing Reichian Elongation in anxiety and quality of life in nursing students from the Federal University of Alagoas (UFAL).

Methodolody
This is a prospective randomized clinical trial. The randomized clinical trial is a type of experimental study that aims to assess the effect of a given intervention on health. It is considered the most effective means of obtaining evidence in clinical practice and, in order to develop it, it is necessary that the researcher actively plans and intervenes throughout the development of the study (Oliveira, Velarde & Sá, 2015).
The intervention (Reichian Elongation) was planned in advance and the exposure was controlled by the researchers. The location of the research was the undergraduate nursing course from UFAL, A.C. Simões Campus. In our study, the inclusion criteria were as follows: students aged 18 years or older enrolled between the first and eighth periods of the nursing course in the semester 2017.1. We excluded those who gave up the course during data collection and who were in the 9th and 10th periods acting as a trainee outside the UFAL.
This study was approved by the Research Ethics Committee (REC) of UFAL and the Brazilian Registry of Clinical Trial.
All nursing students were invited to participate in the initial moment of the research, except those who were in a supervised internship outside UFAL. A total of 143 nursing students from UFAL, A.C. Simões Campus were interviewed to trace signs and symptoms of anxiety. Of these 70 participated in the clinical trial. For the division of the experimental and control groups, the simple random sampling method was used by lot. The following questionnaires were used: the General Identification Questionnaire, the State-Trait Anxiety Inventory (STAI), The World Health Organization Quality of Life (WHOQOL-BREF) questionnaire and MINI (Mini International Neuropsychiatric Interview). The student approach was made from electronic contact (email) and via telephone. Finally, to ensure the subject anonymity was defined a code number in ascending order as the interviews were happening. Development, v. 9, n. 10, e9419109284, 2020 (CC BY 4.0) | ISSN 2525-3409 | DOI: http://dx.doi.org/10.33448/rsd-v9i10.9284 6 MINI is a structured interview used for evaluation and screening of mental disorders based on the Diagnostic and Statistical Manual of Mental Disorder and needs to be used by a trained individual for application (Sheehan et al., 1998).
It is a self-applicable scale that can be used individually or in groups (Capitão & Tello, 2004).
State anxiety refers to a transient emotional state and is characterized by subjective feelings of tension that may vary in intensity over time. Trait anxiety is a personal, relatively stable disposition, to respond to stressful situations and there is a tendency to perceive a greater number of situations as threatening (Spielberger, Gorsuch, & Lushene, 1970).
The WHOQOL-abbreviated is an instrument that allows quality of life analizes through four domains: physical, psychological, social relations and environment that was validated in Portuguese (Fleck et al., 2000).
Among the interviewees, 33 students who received the intervention of Reichian Elongation were selected, and 37 were control group. The Reichian Elongation meetings were once a week for one hour during five months. The evaluation of the anxiety effects of elongation was conducted in three phases: Baseline: for a month of the training; Follow up: for 3 months of the training; Deadline: for 5 months of the training. In those three moments, STAI, WHOQOL and general identification questionnaire were reapplied. The reapplication of those questionnaires was made in the experimental and control groups.
For the data analysis was used SPSS 20 software. The Statistical analysis included chisquare test, t test, logistic regression and statistical correlation. The significance of p value < 0,05 was used to measure the probability level. All tests were applied with 95% confidence level.
The results of suicide risk in the experimental group (12 -36.4%) and control group (13 -35.1%) was similar. Most students of experimental group presented a high risk (7 -21.2%), requiring immediate care (Table 3). Students had some complaints and it was analyzed at the beginning and throughout the execution of the Reichian Elongation. The headache symptom was more present in the fifth month of the control group (p = 0.036) ( Table 4). It noticed the number of the experimental student group has decreased after having those symptoms of tiredness, insomnia, and Research, Society and Development, v. 9, n. 10, e9419109284, 2020 (CC BY 4.0) | ISSN 2525-3409 | DOI: http://dx.doi.org/10.33448/rsd-v9i10.9284 difficulty concentrating in class, impatience, headaches, suffering in advance and irritability.
Only two groups have related difficulty to increase of dealing with slow people (Table 4).
Anxiety and related symptoms have decreased in the experimental group. Students had an increase in the amount of evaluative tests during the course but that didn't work as a trigger to increase the level of Anxiety among them (Table 4). Students were increased and became part of research or extension groups which could require more overload and impair the anxiety evaluation but didn't work (Table 4). Physical activity practices were decreased in the experimental group and increased in the control group. There were higher anxiety scores by the STAI in the experimental group, although it didn't interfere (Table 4). Both groups started using less medication during the development of this research and reported a very good experience of fewer stressful episodes in the last month (Table 4). The domains of quality of life were analysed and through pathological anxiety and social interactions domains presented higher averages in Reichian Elongation group, while control group presented a decrease ( Table 5). The physical and environment domains presented higher averages in the group that performed the Reichian Elongation. There was also a small increase in the averages in these domains in control group (Table 5).
There was a decrease in the mean of state anxiety in one (F(1.69)= 5.048, p= 0.028), showed an increase in the mean of quality of life in 1, 3 and 5 months, compared to the control group (Table 5).

Discussion
This study showed most nursing students of UFAL have suffered of mental disorder, but the GAD was the most present among them. Anxiety is common in most people; however, it is only classified as a pathological disorder when you have extreme intensity and duration (Cavaler & Gobbi, 2013). There are two concepts of anxiety: the state-anxiety refers to a transitory emotional state characterized by subjective feelings of tension that may vary in intensity over time; and trait-anxiety refers to a personal disposition, relatively stable and people who have anxiety reply to stressful situations and also have tendency to perceive a greater number of situations as threatening (Gama, 2008).
In GAD, the anxiety is persistent and is not restricted to a single fact. Insomnia is common in Students. Also their difficulty of concentrating in classes, impatience, headache, difficulty of dealing with slow people, suffering due to anticipation and irritability could contribute to the lower quality of life of students and interfere in the daily academic activities.
was impairment in their sleep. This study showed worse of quality of sleep has a direct relation to trait anxiety (Coelho, Lorenzini, Suda, Rossini & Reimão, 2010). Another study was conducted in Hong Kong (Cheung et al., 2016) found 661 nursing students were recruited in the survey, 484 (73.2%) had sleep problems. This study showed presence of insomnia in students in the current research may be related to signs and symptoms of anxiety and may interfere in performance and well-being.
Moreover, those complaints were related to family problems and academic activities that students are experiencing. That makes their lives to perform academic demands, Noteworthy a small portion of students were interviewed had psychological support, also is essential for maintaining the mental health, especially when they face exhaustive routines, pressure for production. In addition, other problems can cause them strong emotional tension. Nursing students have disregarded their illness or even believed that overcome the problems without professional support.
Study conducted in Taiwan found anxiety in nursing students increased gradually before entering their clinical stage (Sun et al., 2016). Students who are enrolled in the university face new, unknown and threatening world and will need support and they are learning a good environment to develop themselves (Nogueira- Martins & Nogueira-Martins, 1985).
A study in Rio Grande do Sul, Brazil, evaluated 167 university students and identified 77 (46.1%) anxiety cases (mild, moderate and severe) (Brandtner & Bardagi, 2009), a lower result was found in the current study. Anxiety disorder was greater than in results that were found in the literature. The present study presented the proposal of achievement of Reichian Elongation and its effect on anxiety's signs and symptoms in nursing students that improved their quality of life. This result was perceived by the improvement in anxiety scores and averages of the quality of life domains among those students as compared to the control group.
In study, some students reported they did not experience stressful events. This may have contributed to decrease in anxiety scores and quality of life. Or, this can be a reflection of Reichian Elongation effect by allowing students to take care of themselves, look more at themselves, cover less themselves and worry less. Difficulties may appear seeing them lighter and less stressful. It is no useful to take care of the body and forgetting the psychological.
This study identified an increase in psychological and social relationships domains in their students who participated of the Reichian Elongation.  (Song & Lindquist, 2015). In Thailand, a study declared 89 nursing students were doing meditation (29 students) and biofeedback (29 students) and also had reduced anxiety (Ratanasiripong, Park, Ratanasiripong & Kathalae, 2015).
Mental Health strategies have been used to reduce anxiety levels in students and should be encouraged in academic area. This fact is aiming to improve their mental health.
Biofeedback, meditation and Reichian Elongation are good examples for the best results.
Even anxiety was the most frequent mental disorder in this sample a special attention should be given to major depressive episode, recurrent, with melancholic and agoraphobia in nursing students. Mental disorder is a risk factor for suicide attempt. Among students, risk of suicide was present and that's so important people improve their management of the course.
University and professors are attentive to warning signs that refer cases of mental health among students. Thus, the results of this research are important and deserve academic discussions related to their mental health care.
A study conducted in Pelotas, Rio Grande do Sul, Brazil, evaluated 1560 young people were regarding of suicidal risk and identified a frequency of 8.6% cases .
The current study identified 41 (28.7%) cases in 143 young students. This leads to an immediate concern on how to conduct and monitor that severe situation. Furthermore, students need an assistance programs at the university. Those services can bring new services to improve quality of life in students until the end of the course (Osse & Costa, 2011).
Another study conducted in Rio Grande do Sul, Brazil, evaluated 1.621 young people, of these 20.9% had anxiety disorder and 8.6% risk of suicide. Those results showed anxiety disorder was significantly associated with risk of suicide. This reinforces how importance is the greater attention to the risk of suicide in university students with anxiety disorders (Rodrigues et al., 2012). This study related to intense demand studies, difficulty in adjusting to environment academic, difficulties in moving from their city of origin, among others and through suicide ideation and suicide attempts in the academic context (Silva & Azevedo, 2018). In addition, university students are struggling of individual, family, social and economic repercussions that involve suicidal behavior.
A study pointed out how important is to evaluate emotional well-being during the graduation and emotional support services (Brandtner & Bardagi, 2009). University should be a place of training, health and well-being. Some universities have created psychopedagogical support offices and programs to prevent suicide among students (Gonçalves, Freitas, & Sequeira, 2011). Thus, university and professors have an important work in having an early perception of psychological problems among their students and they can contribute more in referring them to specialized services (Gonçalves, Freitas, & Sequeira, 2011).
Reichian Elongation maybe is one of the care strategies in promoting mental health by nurses or other health professionals. The advantages are the low-cost care and an effective reduce in anxiety symptoms. The innovation of nursing care based on light technologies such as Reichian Elongation can thus contribute to improve the quality of life in patients or the nursing team. Limitations of this study must be considered. There were losses in follow-up due to absences in practices and unsuccessful attempts to contact the telephone.

Final Considerations
The Reichian Elongation reduced anxiety symptoms and improved the quality of life of the nursing students. This improvement can bring physical and psychological gains and, consequently, make this public more participative and productive in the academic area.
It is recommended that studies be carried out with shorter follow-up time, with the aim of better therapeutic adherence for the same outcome.