Anxiety Communication Notes—A Tool to Facilitate Anxiety Management and Improve the Nurse–Patient Relationship in Mental Health Nursing

Abstract Mental health care tends to be dominated by a biomedical perspective at the expense of a more recovery-oriented approach. Research on nurse-led interventions intended to strengthen the patient’s ability to manage anxiety is sparse in this context. The aim of this study was to describe nurses’ experiences of the use of anxiety communication notes in nursing patients experiencing anxiety in mental health inpatient care. Data were collected by interviewing twelve nurses working in two mental health inpatient care wards in southwestern Sweden. Semi-structured interviews were conducted, and qualitative content analysis was used to analyze the data. Findings showed that the use of anxiety communication notes was perceived to provide a nursing structure to foster the development and practice of adaptive anxiety management through a visual representation for mutual understanding of the patient’s anxiety pattern. The nurses could also use the anxiety communication notes to support nurse-patient communication and facilitate increased participation and empowerment in the patients’ anxiety management.


Background
Anxiety can be defined as a feeling of fear or uncomfortable expectation, with physical, psychological, behavioral, and cognitive features (Muir-Cochrane, 2009).The prevalence of anxiety leading to an impaired functional ability is about 8-12% (Muir-Cochrane, 2009) and is often followed by extensive social and emotional suffering for the person (Merikangas, 2017;Muir-Cochrane, 2009).Patients with severe anxiety are very common in mental health inpatient care.A major part of nursing in this context is supporting the anxious patient to cope with their anxiety (Muir-Cochrane, 2009;Sharp et al., 2018).Mental health care has been dominated by a biomedical perspective (Glantz et al., 2019;Sharp et al., 2018) at the expense of a more humanistic view of the patient (Cutcliffe & Barker, 2002;Glantz et al., 2019).The focus of mental health inpatient care is often to suppress symptoms, rather than learning the patient how to cope with their anxiety, which is achieved through drug treatment, observation and monitoring and can result in less time being given to relationship-building and understanding of the basis of the patient's experience of mental illness (Buchanan- Barker & Barker, 2005;Stewart et al., 2009).Furthermore, ward rules and routines, in addition to locked doors, can adversely affect the patient's freedom and may reinforce the patient's disadvantage and increase distance to the nurses (Andersson et al., 2020;Jormfeldt, 2011;Latvala et al., 2000;Pelto-Piri et al., 2013;Tolosa-Merlos et al., 2023).
The humanistic approach focuses overall individual and on processes in recovery, which can create a holistic perspective on mental health care (Barker, 2001).Person-centered care within a mental health care context has been defined as focusing on relationships, respectfulness, recovery, and interpersonal nursing (Gabrielsson et al., 2015).Person-centered care can be personalized based on the patient's expressed needs and can contribute to reduced anxiety in individuals with mental illness by promoting self-control, co-determination, and participation (Arvidsdotter et al., 2013;Morgan & Yoder, 2012).A caring culture characterized by safety thinking and prohibition can create obstacles for nurses in applying a person-centered approach to nursing, as not enough time is allocated to close-to-patient nursing work (Olofsson & Jacobsson, 2001;Tolosa-Merlos et al., 2023).Nurses in mental health care often spend limited time in direct contact with their patients.The time spent with patients is crucial for establishing a therapeutic relationship, which affects the quality of given care (Glantz et al., 2019;Tolosa-Merlos et al., 2023).Stressful working conditions can lead to a judgemental and less responsive attitude to patient needs (Glantz et al., 2019).If the nurses experience helplessness, hopelessness, fear, frustration, rejection, and lack of appropriate skills it can affect the therapeutic relationship in a negative way (Harris & Panozzo, 2019;Sansone & Sansone, 2013;Tolosa-Merlos et al., 2023).
Relational competence is an important aspect of the nursing skill in the mental health nursing inpatient care (McAndrew et al., 2014).The nursing relationship forms the starting point for all collaboration with the patient experiencing anxiety but is also a helpful intervention (Cutcliffe & Barker, 2002).The nurse's attitude of openness and being responsive to the patient's needs are considered key elements and the nurse needs to be watchful of her own prejudices to maintain the good therapeutic relationship (Tolosa-Merlos et al., 2023).Nurses' presence at the ward is meaningful for the patient to make the environment a secure place for recovery (Tolosa-Merlos et al., 2023;Watson, 2006).One of the nurses' main roles is to support patients when they experience acute anxiety (Barker, 2001).According to the Tidal Model, the patient should work toward recovery by exploring and identifying his need for life changes (Barker, 2001;Buchanan-Barker & Barker, 2008).The nurse acts as a safe companion and co-researcher with the patient during the recovery process (Buchanan- Barker & Barker, 2019) where the patient's life world is in focus (Barker, 2001).
Mental health nursing incorporates facilitating conversations where the patient can put difficult experiences into words and identify strategies for how these experiences can be mastered (Barker, 2001(Barker, , 2003)).A trusting care relationship can create the conditions necessary for the patient to work toward their own recovery, despite great suffering (Bjonness et al., 2020;Tofthagen et al., 2017).In a safe nursing relationship, the nurse can help the patient to identify cause of anxiety and encourage to express feelings and facilitate in finding the patient's own meaning in the situation (Peplau, 1952).Establishing trust also requires spending time together with the patient (Barker & Buchanan-Barker, 2009;Molin et al., 2016), and confirming the patient's emotions and perceived life world through active listening (Barker, 2001;Tofthagen et al., 2014).Offering a care environment where the patient feels safe to explore even dark thoughts and emotions is necessary to convey security and be able to meet the patient in an open and non-judgmental way (Gilje et al., 2005).Since anxiety can take destructive forms such as self-harm, especially in the case of difficulties in verbalizing anxiety, nurses and the patient need to jointly identify triggering factors, put the experience into words, and identify constructive strategies for anxiety management (Norman & Borrill, 2015;Sleuwaegen et al., 2017).
The nurse can promote health processes and coping strategies (Pitkänen et al., 2008;Roohafza et al., 2014;Sharp et al., 2018) by showing respect and confidence in the patient's ability (Jörgensen & Rendtorff, 2018;Tofthagen et al., 2017) and the experience of hope can also be strengthened (Hemberg & Wiklund Gustin, 2020;Sharp et al., 2018).Putting difficult experiences into words is an important part of recovery from mental illness and a step toward regaining control (Barker, 2001(Barker, , 2003)).By inviting the patient to participate actively in their care and encouraging the patient to express their needs via narrative, personalized support can be facilitated (Bjonness et al., 2020;Giacco et al., 2018;Hemberg & Wiklund Gustin, 2020;McEvoy et al., 2012).
Nurse-led interventions are sparse but have shown positive efforts on physical and mental health among patients in mental health services (Blomqvist et al., 2019(Blomqvist et al., , 2023;;Jormfeldt et al., 2012).Research have shown increased self-control, autonomy and adopting co-responsibility for treatment (Dodd & Wellman, 2000).Moreover, nurse-led interventions have shown positive results as strengthened patient's ability to understand own emotions and to acquire anxiety management strategies (Sharp et al., 2018), facilitated self-empowerment, increased self-awareness, and coping skills (Ntshingila et al., 2021).Psychoeducation has been found successful by improving patients' anxiety management and strategies for coping with anxiety (Rummel-Kluge et al., 2009;Wong et al., 2016).

Anxiety communication notes
Anxiety communication notes were developed by the first author due to a perceived lack of communication tools for anxiety management to offer patients in mental health inpatient care.The idea of anxiety communication notes was inspired by the Tidal Model (Barker, 2001).The Tidal model emphasizes that it is central for the recovery that the nurse takes advantage of the patient's own language and uses metaphors to support the patient in describing their anxiety.Further, by supporting the patient to tell their own narrative, the nurse can empower them to stake out their recovery from mental illness (Barker, 2001).Anxiety communication notes consist of three colored notes: green (symbolizing manageable anxiety), yellow (symbolizing increasing anxiety), and red (symbolizing panic or very high anxiety) with space to write down individual signs of anxiety (body sensations, thoughts, emotions, and observable signs) and useful individual strategies.The color of each anxiety communication note is meant to serve as a support for communication about the patient's anxiety between the patient and the nurse.Anxiety communication notes were introduced to the patients in psychoeducation groups held at each ward.The groups were offered once a week and lasted for about one hour.All patients in both wards were given the opportunity to participate.The group was given a short lecture on anxiety and anxiety management followed by a group reflection on individual signs of anxiety and helpful strategies based on the color structure (red, yellow, and green) of the anxiety communication notes (Figure 1).
To support understanding of the concept, the patients' proposals of their individual anxiety signs and strategies were written up on a white board during the group reflection, using the color structure of the anxiety communication notes.Patients were also given the opportunity to create their own anxiety communication notes, enlisting the help of other patients and nurses.After creating the anxiety communication notes the patient was encouraged to continue reflecting on their anxiety, practice their chosen strategies and continually improve the content of their anxiety communication notes.Either the nurse or the patient could take the initiative to use the anxiety communication notes, depending on the situation.When using the anxiety communication notes as a communication tool, the nurses encouraged the patient to communicate the color that represented their current anxiety level.When the patient communicated that their anxiety corresponded to the color of yellow or red, the nurses could support by helping the patient to initiate the strategies previously written down on that specific anxiety communication note.When the patient later communicated that their anxiety level had decreased to the green level, the nurse could encourage the patient to talk about the recent anxiety experience and jointly evaluate their cooperation during the ongoing anxiety.The anxiety communication notes were kept in the patient's room at the ward, visible for both the patient and the nurses.The anxiety communication notes were also documented in the patient record and available for all nurses involved in the patient's care.The patients who were using anxiety communication notes were also encouraged to continue using them at home after discharge from the ward.Prior to this study, both participating wards conducted psychoeducation groups on anxiety communication notes, with the purpose of introducing the tool to the patients.Both wards also worked with anxiety communication notes to aid communication between nurses and patients and to support the patient's anxiety management according to the above model.A sample of the Anxiety communication notes is found in the appendix.

Aim
The aim of the study was to describe nurses' experiences of the use of anxiety communication notes in the nursing relationship with patients suffering from anxiety.

Method
A descriptive design (Polit & Beck, 2022) was chosen to describe the subjective experiences of using communication notes in the nursing relationship with patients suffering from anxiety as qualitative content analysis is judged as a suitable method for analyzing interviews of subjective experiences (Graneheim & Lundman, 2004).

Participants
The sample was collected from two general mental health inpatient care wards in public hospitals, located in two different cities in southwestern Sweden.Both wards cared for adult patients with various diagnoses such as depression, anxiety disorders, personality disorders, and eating disorders.Admitted patients were cared for both voluntarily and involuntarily.One of the involved wards had been using anxiety communication notes for about a year, and the other had been using them for 6 to 8 weeks before the interviews were conducted.
Information about the study was provided by the first and second author on two occasions in connection with staff meetings at each workplace.Information was also provided to the nurses via email by the respective head of department.Inclusion criteria were experience in providing support for anxiety management in mental health inpatient care and experience of using the anxiety communication notes.
Participants included in the study were mental health nurses, general nurses, and assistant nurses.Six of the participants were mental health nurses, two were general nurses, three were nursing assistants, and one had an educational background in human science.For the sake of readability, they will be referred to by the collective term 'nurses' in this study, which refers to the 'nursing structure' .Nurses without any experience of the anxiety communication notes were excluded from participation in the study.
A total of 17 nurses were asked to participate in the study, of which 12 nurses were interviewed.Five of the prospective participants didn't meet the inclusion criteria and were therefore not included in the study, all of whom came from the ward that had lesser experience of the anxiety communication notes.The ward with longer experience of the anxiety communication notes had a few more eligible participants who were not interviewed, all of them nursing assistants, who were already well represented in the study.At the ward with longer experience it was well known which nurses had experience of the anxiety communication notes and therefore the selection became more accurate.Ten of the participants were women and two were men.Age ranged from 27 to 65 years, while experience of working in mental health inpatient care ranged from 1-37 years.

Data collection
The interviews were conducted based on a semi-structured interview guide with open-ended questions (Polit & Beck, 2022).They were subjected to a qualitative content analysis according to Graneheim and Lundman (2004).The interviews lasted between 22 and 48 min and were audio-recorded and transcribed verbatim.The interview guide was inspired by Phil Barker's Tidal Model (2001) which aims to raise the reflections about the subject with open-ended questions.Furthermore, the Tidal model aims to take advantage of reflections and metaphors, both verbally and non-verbally, that appear in the dialogue (Barker, 2001).This encouraged participants to share their experiences and thoughts in an open way.The interview guide covered the following questions: "Tell me about your experience using the anxiety communication notes.Please give examples'' ."How do you experience collaboration with the patient concerning anxiety communication notes?" "How does anxiety management experience using anxiety communication notes compare to how you usually work?" "Do you have anything else you would like to add?" When needed, follow-up questions were added, for example "Can you explain what you mean? or "Please tell me more?"The interview guide was sent to participants by email 1 week before the scheduled interview so that they could prepare for the interviews.Preparation by pondering the questions in advance was assumed to provide an opportunity for more extensive reflections and fewer "don't know" answers.The 12 interviews took place between January and March 2020 and were conducted by the first and second authors.Eleven participants were interviewed at their working place and one interview was conducted by telephone.

Data analysis
Data were analyzed using content analysis (Graneheim et al., 2017;Graneheim & Lundman, 2004) focusing on the content of the interviews.Transcribed interviews were read thoroughly several times, both individually and jointly, to gain an overall picture of the content.Subsequently, meaning units were selected.Meaning units were condensed by shortening the units while retaining the meaning and then coded (Graneheim & Lundman, 2004).The first three steps of the content analysis, based on Graneheim and Lundman (2004), were performed separately so as not to be influenced by each other during execution.After joint discussions, subcategories were named.Subcategories represented the content of the interviews and could be divided into additional categories to abstract their content (Graneheim et al., 2017).Results of the interviews were discussed between the authors (Table 1).

Ethical considerations
The study received ethical approval from Swedish Ethics Review Authority, Dnr: 2019-06103.Participants were given detailed oral and written information about the study and about their rights according to the Data Protection Regulation and GDPR (SFS, 2018:218).Prospective participants who met the inclusion criteria, were given information about the purpose and content of the study, the opportunity to ask questions, and told that participation in the study was voluntary and could be ended by the participant, at any time, without any need to express a reason.Before each interview, the participant signed informed consent.
There were no personal or collegial relationships between the interviewer and the participant.

Results
The participants' experiences of anxiety communication notes in the care of patients with anxiety resulted in three categories: A visual representation for mutual understanding of the patient's anxiety, Supporting nurse-patient communication and Empowering the patient's own resources.The three categories resulted in the main theme Providing a nursing structure to foster the development and practice of adaptive anxiety management.

Providing a nursing structure to foster the development and practice of adaptive anxiety management
The nurses described the clear structure of the anxiety communication notes as an advantage.The division of anxiety into three levels, each with its own color, was perceived as making anxiety more concrete and enabled nurses and patients to start from a common structure when talking about the patient's anxiety.The nurses experienced that the structure of the anxiety communication notes could be used to clarify the current anxiety level, the desired mood, and how to jointly find a way to achieve it.The reflections provided words and a structure that could create a common understanding which improved the nurse-patient relationship.They experienced that it could be challenging to maintain a dialogue when remaining present in the patient's anxiety.At the same time, the anxiety communication notes helped them to become more structured in their support of the patient's own resources.In this way they could serve as a tangible support for the nurses in their practical daily work, which brought them a sense of security when meeting patients with anxiety.

A visual representation for mutual understanding of the patient's anxiety
Using anxiety communication notes helped the nurses to learn the patient's anxiety pattern.Dividing anxiety into different color codes could make it easier for the nurses to understand the patient's current anxiety level.
"Yes, but that it is divided into this green, and the yellow and the red, you can…really get…yes!You understand every peak and every valley sort of…" (IP 11) When the anxiety communication notes showed how the patient wanted to be supported, nurses could feel confident in the interventions they were attempting.It enabled an increased understanding and a certainty of knowing the patient's wishes as to which intervention should be chosen in the first place.At the same time, it was not an understanding that came without cost, as it required something from the nurses in the form of an active dialogue, a mutual reflection, and a meeting with the patient where they sat down and worked with the anxiety communication notes together.The joint reflection on the patient's course of anxiety led to useful and clarifying conversations between nurses and patients.Conversations about the anxiety communication notes were experienced as providing a common understanding about the patient's perceived anxiety, which benefited the nursing relationship and promoted a secure collaboration regarding the patient's continued anxiety management.
"It becomes very clear visually…I think if you have something in common to start from, it's easier for the patient to recognize that….itcan also be a [form of] security, right…?" (IP 3)

Supporting nurse-patient communication
The use of anxiety communication notes was perceived as particularly helpful during acute phases of anxiety, as patients often experienced communication difficulties.When using anxiety communication notes, the nurses were able to maintain a dialogue, even when the patient was not verbally communicating, with the intention of clarifying that the initiated anxiety interventions were based on the patient's own wishes, written down on the anxiety communication notes.This could be done by asking the patient what color level (anxiety level) the patient was at and whether the patient wanted to try a certain previously-formulated strategy.It became a way of supporting communication when the patient was feeling too anxious to communicate in their usual manner.
The nurses experienced that when the patient was diagnosed with autism in addition to an anxiety disorder or self-harming behavior, one needed to adjust common strategies.They perceived that the color-coded anxiety levels of the anxiety communication notes made it easier for these patients to both describe and manage their anxiety.Patients with a diagnosis of autism who found it impossible to express themselves verbally when they were anxious, were able to communicate their anxiety level with support from the color of the present anxiety communication notes.
Most nurses experienced non-verbal communication via the anxiety communication notes as a helpful alternative when verbal communication was difficult to achieve.However, some nurses could experience a fear of missing the patient's anxiety if the patient only communicated via the anxiety communication notes.They felt that it was important for the patient to communicate their anxiety verbally to the nurses.
"If you just walk by and then all of a sudden there's a red note sitting there… like oh, how long has it… (laughter) it's just that you have to make it clear by saying it… or, make us aware of when you have like… (anxiety)" (IP 10) These nurses could perceive that the patient was avoiding verbal communication or not taking personal responsibility, which could make some of the nurses more reluctant to use or work with anxiety communication notes.When the patient was more able to communicate, albeit to a limited extent, the colors of the anxiety communication notes could be a helpful way to verbalize their anxiety level.
"Sometimes she got increased anxiety like this and…then she said to me like this…" heading toward red!"She just had to say…and she thought…in retrospect she thought it was so nice…because…she didn't have to explain to me…because then I knew: ice pack" (IP 1).
The color codes created a visual and verbal language between nurses and patients.The anxiety communication notes made the nurses aware of the desired support, which could enable wordless collaboration during the patient's highest anxiety level.The nurses could offer support by following the patients' expressed needs on their anxiety communication notes and appreciated that they could have a continuous dialogue with the patient about their anxiety and ask if it was time for one or the other strategy.
"…reconnect to the (Anxiety communication) notes… now I'm doing the ice, because…at this stage, you've written up that you want ice…do you want ice cubes or do you want an ice-cold shower…? and I think it has helped…because then the patient doesn't have to express…what he wants help with, it is written here…" (IP 7) Knowledge of the patient's needs meant that the nurses could feel confident that the communication tool supported the patient in alleviating anxiety, even if the patient was unable to convey it now.The nurses expressed that some patients described specific wishes for treatment on the anxiety communication notes, for example that they did not want physical contact at high levels of anxiety.Security and clarity could thus be ensured for nurses regarding how nursing interventions were to be carried out.

Empowering patients to use their own resources
The nurses in the study felt that use of anxiety communication notes could support patients in becoming more active participants in their anxiety management and care.The nurses could support the patient in thinking about what was happening during their anxiety attacks and support them to begin reflecting about what could help them gaining better coping skills.By supporting patients to reflect on their situation, more helpful strategies could be discovered, rather than being condemned to repeat what hadn't worked so far.The nurses felt that it could be a strengthening 'aha' experience for the patient to discover that they could choose to cope with their anxiety in different ways and to learn to recognize their warning signs on their own.After creating anxiety communication notes, the patient could be encouraged to continually use them to aid reflection on their anxiety level and possible strategies to deal with their anxiety.Thus, the patient's independent anxiety management skills was supported.
"This is what I think about the anxiety communication notes: they improve the patient's self-reflection about their anxiety and how they can lower their anxiety level" (IP.11) Therefore, the nurses felt that anxiety communication notes could contribute to reducing patient's feelings of helplessness, by making it clear to the patient that they could learn to handle their anxiety independently with the help of the anxiety communication notes, guided, and supported by the nurses.One of the nurses pointed out that the collaboration process with the patient was necessary for empowerment to occur.
"You couldn't just throw the anxiety communication notes to someone who was sitting there and was very anxious and say: write this and write that…" (IP 7) When the patient's anxiety level was green and manageable, nurses considered it time well invested to listen to the patient, reflect on the anxiety experience together and jointly work on the anxiety communication notes to enhance the patient's ability to reflect about their anxiety.The nurses described the follow up of the anxiety communication notes as an important part of the learning process, as well as keeping the anxiety communication notes up to date.During follow up, nurses and patients could jointly go through what had worked well or had not worked well when using anxiety communication notes and discuss whether something should be added or removed.This was particularly important when it had been difficult to alleviate the patient's anxiety when using anxiety communication notes.When the patient's anxiety level had decreased, a joint discussion could take place on what difficulties arose at the critical stage and how the nursés support could be improved if the situation should rise again.
The nurses emphasized the importance of using anxiety communication notes to support more independent anxiety management, as patients would need to manage their anxiety on their own after discharge from the mental health inpatient care ward.To bridge the gap between the mental health inpatient care and the patient's home, anxiety communication notes could be used to involve the patient's relatives in their care, instructing them to pay attention to the patient's signs of anxiety.Involving relatives could empower both the patient and the relative to take initiative for strategies written down on the anxiety communication notes, which could create a sense of security for both the patient and their relatives.

Discussion
Anxiety is a broad concept and research on anxiety and anxiety management often narrows to specific diagnoses, for example personality disorders or different anxiety disorders, or focuses on treatment by psychologists in outpatient care.Studies mainly focusing on anxiety management in mental health inpatient care are sparse, some of them focus on CBT methods (Dodd & Wellman, 2000;Sharp et al., 2018).Most patients in mental health inpatient care, regardless of diagnosis, are struggling with anxiety in their daily life.Nurses often support their anxious patients to use, for example, physical activity, ice packs or breathing exercises, methods that many patients perceive as helpful to reduce the physical symptoms of anxiety (Helgadóttir et al., 2015;Hofmann et al., 2010;Jayakody et al., 2014;Mokadem et al., 2017).Communication, however, is central in caring for patients with anxiety (Muir-Cochrane, 2009).Important elements, when meeting the anxious patient, is staying calm, accepting the person without judgment, reassuring the patient that the anxiety will pass and being available to the patient if more support is needed (Muir-Cochrane, 2009).Many studies show that the nurse-patient relationship is important in the patient's recovery (Barker, 2001;Molin et al., 2016;Tofthagen et al., 2014) and the nurse-patient relationship is also central in the use of anxiety communication notes.The anxiety communication notes can be a useful tool because they support the nurse to guide the patient to a more manageable anxiety and to be able to live with their anxiety instead of the anxiety controlling and limiting their life.The nurse can help the patient to express their anxiety level, both verbally and non-verbally, with support from the colors of the anxiety communication notes.Since anxiety is an individual experience, the nurse needs to explore how the anxiety affects the patient's lifeworld to find an individual care that is experienced as helpful for the patient (Barker, 2001;Muir-Cochrane, 2009).The results show that using the anxiety communication notes to create an individual care plan for the patient, can support the patient to take on a more active role and reduce the patient's maladaptive coping strategies such as self-harm or isolation from others.The anxiety communication notes also support the patient in seeking contact with the nurse and encourage the patient in the use of their own coping strategies written in their anxiety communication notes.The results are supported by previous studies as helpful coping strategies can encourage the patient in seeking support from others rather than isolating or self-harming himself (Roohafza et al., 2014).
Moreover, the result showed that the use of the anxiety communication notes entailed a structure for supporting anxiety management, facilitated collaboration with the patient, and offered an opportunity to reflect upon and discuss anxiety between the patient and the nurse.Joint reflections about anxiety and anxiety management, according to the structure and content of the anxiety communication notes, could help nurses promote an enhanced learning process for the patient around their own experiences with anxiety and anxiety management.This learning process in anxiety management was described by the nurses as empowering patients in using their own resources.The process of creating and using anxiety communication notes was described as strengthening the nurse-patient collaboration and motivating increased patient participation in anxiety management.Previous studies have indicated that supporting the patient in getting to know their emotions and identifying helpful interventions to manage anxiety, is a vital part in the nurse-patient relationship (Barker, 2001;Sharp et al., 2018).The presence of the nurses became natural in the process of creating anxiety communication notes with the patient and encouraging the patient to seek support when their anxiety level was increasing.The anxiety communication notes became a useful tool, and the patients became actively involved in their own care by seeking support with the help of their colored anxiety communication notes.The anxiety communication notes encouraged the nurses to be present as active copartners for the patients and their recovery processes.This is supported by several nursing theorists (Barker, 2001;Peplau, 1952;Watson, 2006).
In promoting the recovery process, the mental health nurse and other nurses need to take advantage of the patient's resources and follow the patient by supporting the patient in identifying triggers for anxiety, observing the patient's needs, and being present in the patient's way to manage their anxiety (Gabrielsson et al., 2016;Giacco et al., 2018;Villaggi et al., 2015).In this study, anxiety communication notes were found to be useful in helping the patient to verbalize and put their anxiety into words by using the structure of the anxiety communication notes.Previous studies have shown that patients in mental health inpatient care often become passive in their own care (Jörgensen & Rendtorff, 2018;Lodge et al., 2017).The passive mental health inpatient role may increase the distance between nurses and patients, focusing mainly on drug therapy, which can decrease the patient's active participation in their own care (Bjonness et al., 2020;Jörgensen & Rendtorff, 2018;Latvala et al., 2000;Olofsson & Jacobsson, 2001).It is central to change the patient's role from passive to an active part in their recovery to avoid that the mental health inpatient care only becomes a storage for the patient.Patients with anxiety need that the nurses support them in discovering strategies for active anxiety management (Barker, 2001;Muir-Cochrane, 2009).In this study the anxiety communication notes were introduced to the patients in psychoeducation groups led by nurses and focusing on anxiety management.Psychoeducation, in groups and individually, can have a positive impact on learning about anxiety and help the patients to take control over their anxiety (Hofmann et al., 2010;Muir-Cochrane, 2009;Wong et al., 2016).Therefore, it is important for nurses to offer their presence for the patient to convert to become the main actor in their own care (Jörgensen & Rendtorff 2018;Lodge et al., 2017;Muir-Cochrane, 2009).According to the results of this study, a motivated and receptive patient was a prerequisite for a successful intervention, which was usually found within a secure nurse-patient relationship, where the patient's narrative was a central part.Giving the patient time was a well-invested nursing intervention, creating conditions for the patient to work toward their own recovery within a trusting nurse-patient relationship (Barker & Buchanan-Barker, 2009;Cutcliffe & Barker, 2002;Molin et al., 2016).Adapting to new patient empowering perspectives in mental health nursing can be experienced as challenging (Bjonness et al., 2020) and the results showed that use of anxiety communication notes strengthening patient as an actor in their own recovery could be experienced as a challenge to the nurse's professional identity.Sharing responsibility and development was welcomed in certain nursing situations but not always in increasing the empowerment of the patient (Bjonness et al., 2020).In this study, nurses expressed a fear of losing verbal communication with the patient when using anxiety communication notes, possibly exposing the nurses fear of encountering anxiety levels so high that unable to express verbally.
The results showed that experiencing fear or uncertainty when carrying out a new approach to nursing can be expressed as reluctance to use it in the intended way.It can take time for nurses to change their perspective, from "manipulative" to understanding patients' behavior as maladaptive coping that could be converted to adaptive coping with support from the whole nursing team.The nurse's perspective may affect the therapeutic relationship and thus the quality of the nursing intervention (Tolosa-Merlos et al., 2023).Patients who do not express their anxiety verbally to the nurse can be seen as more "difficult" and this perspective could result in an increased distance between the nurse and the patient (Masland et al., 2023).Patients that express their anxiety by self-harming behavior or by using maladaptive coping strategies are often perceived as "attention seekers" or even "manipulators" depending on the nursing culture in the ward (Bowers, 2003;Masland et al., 2023;Woollaston & Hixenbaugh, 2008).Distancing from the patient can depend on nurse's lack of understanding and beliefs that giving the patient attention would reinforce maladaptive manipulate coping strategies (Masland et al., 2023).Such beliefs among nurses are affecting the patients and the caring culture at the ward and may result in the patient avoiding seeking support from the nurse, feeling more alienated and reinforce maladaptive coping strategies rather than finding the motivation to explore and develop adaptive coping strategies (Barker, 2001;Masland et al., 2023;Tolosa-Merlos et al., 2023;Woollaston & Hixenbaugh, 2008).The nurse needs to be observant, active, and present to help the patient to find new coping mechanisms from maladaptive to adaptive (Barker, 2001;Gilje et al., 2005;Roohafza et al., 2014).
Anxiety communication notes aim to help nurses to understand the patient's anxiety even when they express the anxiety non-verbally.The anxiety communication notes are not a replacement for verbal communication but can help the patient in putting non-verbal anxiety into words instead of possibly expressing it through self-harm or other destructive means.By doing this, it can be helpful for both nurses and patients.To truly empower the patient, nurses need to meet the patients where they are and adjust the treatment based on the patient's needs (Gabrielsson et al., 2020) to adopt a person-centered perspective and find a common ground (Gabrielsson et al., 2016;Hemberg & Wiklund Gustin, 2020;Lodge et al., 2017).

Limitations
The interview guide was inspired by Phil Barker's Tidal Model (2001) and used open-ended questions to catch participants' experiences and reflections about the anxiety communication notes.One limitation is that the interview guide was not tested before use in this study.If the guide had been tested in a couple of pilot interviews, it could have been given an indication of its function in the interview situation with the possibility of reformulating the questions (Kallio et al., 2016), which could have increased credibility of the study.However, the interview guide was discussed in the research group before it was used.
The inclusion of professional categories other than master level mental health nurses can seen as a limitation due to the varying competence and theoretical anchoring in the sample even though this also could be seen as a strength (Sharp et al., 2018).The varying sample reflect the reality where general nurses and nursing assistants are working side by side in mental health inpatient care.In this study, there was a pre-understanding about the anxiety communication notes.There was a possible risk of bias, since some of the participants knew the background of the anxiety communication notes and could feel pressure to give the 'right' answer (Polit & Beck, 2022).However, to reduce this risk the interviewers had no relationship to the study participants.
The anxiety communication notes were developed by the first author and had been tested with a few patients in the first author's former workplace.The development of the anxiety communication notes was inspired by former patients that had expressed that using the anxiety communication notes had been helpful for them.A pre-understanding of the authors could affect study's credibility (Graneheim & Lundman, 2004) to reduce the risk of the bias of credibility, data were analyzed separately and then discussed in the research group.Categories and subcategories were labeled close to the original statements in order not to jeopardize credibility (Elo et al., 2014).

Conclusions
The main result of this study showed that anxiety communication notes were perceived as a tool to structure nursing activities that could enable a learning process about anxiety and strengthen collaboration within the nurse-patient relationship.The anxiety communication notes contributed to strengthened nurse-patient communication and better understanding of the patient's anxiety.In the development of person-centered nursing approaches may challenge the traditional perception of identity among mental health nurses.

Implication
Accessible methods in anxiety management could encourage nursing staff in general and master level mental health nurses to work more constructive with patients' anxiety management in mental health inpatient care.Studies that illuminate the patient's perspective on anxiety management is an area that needs further research.Since anxiety is a fundamental and common dimension of all kinds of mental health conditions it is essential to conduct further studies regarding the use of anxiety communication notes as a tool in nursing to manage anxiety among patients in different mental health care contexts.

Figure 1 .
Figure 1.examples of individual anxiety communication notes.

Table 1 .
an example of the analysis process.
You can talk to the patient, like this, is it time for…?that you can tune in, that you can, always have the communication… You can talk to the patient and tune in, have a continuous dialogue about their course of anxiety Verbal communication supporting nurse-patient communication You can put it on paper: how you feel and the early symptoms of anxiety and clarify them for the people around.Writing down early symptoms and clarifying the anxiety for the people around.Written communication supporting nurse-patient communication It's a great instrument to show…how you feel…if you have difficulty expressing yourself… the tool can show how you feel despite communication difficulties Wordless communication supporting nurse-patient communication