Sample Nursing Paper on Stress Management for Patients with Rheumatoid Arthritis

This week’s learning activity will consist of the following:

  • Visit the PRIME nursing website and review the case study titled “Stress Management for Patients with Rheumatoid Arthritis”:

Summarize the article and respond to the following questions in 200 to 300 words:

1-What sampling technique was used in this study?

2-What concerns might you have about reliability and validity in this study, and why? Explain.

3-Were there any flaws or discrepancies in the study? Why or why not?


Stress Management for Patients with Rheumatoid Arthritis

A 40-year-old woman with rheumatoid arthritis (RA) presented to her nurse practitioner for a follow-up visit at the rheumatology clinic. After being diagnosed with moderate RA 18 months earlier, the patient began treatment with methotrexate, a conventional disease-modifying antirheumatic drug (DMARD). After more than a year of successful disease management, the patient experienced several flare-ups with swelling and pain in her hand joints, which began 2 months prior to her recent clinic visit. Around the same time, she received a promotion at work and was experiencing increased job-related stress. After conducting tests that indicated high levels of inflammatory markers, the patient’s rheumatologist prescribed a TNFα-inhibitor in combination with methotrexate.

In her visit with the rheumatology clinic’s nurse practitioner, the patient expressed concerns about financial obligations and her new work demands, wondering whether these stressors contributed to her recent flare-ups. “I’m worried that stress will make my symptoms worse,” she said. “I’m already taking several medications, and the new one has a big co-pay. Are there any other options to relieve my stress and help my symptoms? Will exercise help?”


Affecting approximately 1% of the population, RA is a chronic autoimmune disease that targets the synovial membrane of diarthrodial joints. RA can cause joint damage, leading to intense disability, and an increased chance of mortality. Clinical studies have provided evidence that psychological stress can exacerbate symptoms of the disease.1As summarized below, some research has shown that patients with RA can benefit from nonpharmacological, behavioral interventions to combat psychological stress. Furthermore, these interventions are generally safe and cost-effective.

In an article published in a 2011 issue of the journal Immunology and Allergy Clinics of North America, rheumatologists Courtney McCray and Sandeep Agarwal reviewed studies on psychological stress relating to the development and exacerbation of RA.1 Minor stressful events such as financial obligations, workplace stress, and daily hassles have consistently shown a strong association with worsening symptoms of RA. For example, in a 5-year prospective study, RA patients with relatively high daily stress levels had more joint swelling than counterparts with low daily stressors.2 In another study, mood disturbances in patients with RA were correlated with changes in levels of inflammatory biomarkers and increased joint pain. 3

In some studies, major psychological stressors-such as natural disasters, the death of a relative, or serious family illness-have been associated with increased synovial inflammation and exacerbation of autoimmune symptoms.1 However, studies on the impacts of major stressors are limited, and the results generally are not consistent. Questions about the association of major stressors and RA disease activity thus cannot be fully answered with the existing evidence.

Given the more consistent evidence associating minor stressors with RA exacerbation, it is fitting to ask whether behavioral interventions that target these stressors may significantly reduce disease activity and symptoms, as well as improve the quality of life for patients suffering from this disease. In their 2011 article, McCray and Agarwal reviewed findings from research on the effects of various psychological and behavioral stress management interventions.1 Key points from the review are summarized as follows.

Cognitive Behavioral Therapy

Cognitive behavioral therapy (CBT) involves guided training by a therapist, using techniques of relaxation, goal setting, and changes in negative thoughts in order to reduce pain.1 In a study conducted by Sharpe and coworkers, patients with RA who participated in 8 weekly sessions of CBT experienced significant reductions in joint stiffness, depression, and C-reactive protein (CRP) levels.4 The researchers also reported reductions in anxiety levels and disability scores in the CBT group. Other studies have revealed that CBT is associated with significant reductions in pain, anxiety and pain-related behaviors.1 In contrast, some research has shown no significant effects of CBT on outcomes of RA disease activity. More consistent evidence indicates that CBT may be a successful intervention for helping patients with RA cope with pain, improve self-efficacy, and reduce symptoms of depression.1

Tai Chi

Tai Chi, a Chinese martial art, requires mental focus and combines slow, graceful movements in an effort to improve cardiopulmonary function, balance, flexibility, and strength. A number of studies have provided significant evidence for the benefits of tai chi in patients with RA. For example, a clinical study of 15 RA patients performing tai chi showed a significant reduction in the number of swollen joints as well as increases in lower limb strength and endurance.5 However, similar studies have reported no significant improvements in RA patients who performed tai chi. Recognizing that limited research exists on the effects of tai chi for inhibiting RA disease activity, McCray and Agarwal suggest that the potential benefits of this stress-reducing exercise in alleviating RA symptoms and improving the overall quality of life should not be dismissed.1


In popular culture, yoga is generally associated with positive effects on mood and fitness. The effects of yoga on patients with RA have not been studied extensively. Badsha and coworkers reported the results of an 8-week study in which RA patients participated in a structured yoga program.6 The exercise group experienced significant improvements in disease activity assessment scores and reduced levels of disability, pain perception, and depression. A lack of research limits conclusions on the stress-reducing effects of yoga on RA disease activity. However, net benefits of this exercise form on flexibility, endurance, and mood have been demonstrated in people without RA, suggesting that these same benefits would be experienced by RA patients.1


Often led by rheumatology nurse specialists, RA patient education programs have been documented to improve patient knowledge and understanding of behaviors such as relaxation and exercise that have the potential to diminish disease symptoms. Published studies have shown that patient education is associated with short-term reductions in disability, pain, and depression, as well as enhanced knowledge and adherence to treatment. However, limited research on the long-term effects of educational interventions reflects uncertainty about the outcomes.1


Psychological and behavioral stress management interventions cannot replace conventional and biologic disease-modifying therapies for patients with moderate to severe RA. Nonetheless, when used as adjunct therapy, nonpharmacological interventions have demonstrated some promise in reducing symptoms of the disease. In addition, these complementary therapies are generally safe and inexpensive.

Future studies are needed to assess the benefits of psychological and behavioral stress interventions. Despite conflicting studies, the literature consistently shows an association between minor stressors and pain, an indicator of increased RA disease activity. Although published literature reveals conflicting results concerning the association between stress and autoimmune disease, the fact that stress interventions can positively impact the patient’s overall well-being should be recognized.1 Until more research on this disease area is conducted and published, health care providers will have to rely on a basic understanding of the potential role of stress in autoimmune diseases. With this understanding and the existing evidence, nurse specialists and physician assistants in rheumatology settings can guide patients in choosing effective stress management therapies.


  1. McCray, CJ, Agarwal SK. Stress and autoimmunity. Immunol Allergy Clin North Am. 2011;31(1):1-18.
  2. Feigenbaum SL, Masi AT, Kaplan SB.  Prognosis in rheumatoid arthritis. A longitudinal study of newly diagnosed younger adult patients. Am J Med. 1979;60(3):377-384.
  3. Affleck G, Urrows S, Tennen H, Higgins P, Pav D,Aloisi R. A dual pathway model of daily stressor effectson rheumatoid arthritis. Ann Behav Med. 1997;19:161-170.
  4. Sharpe L, Sensky T, Timberlake N, Ryan B, Allard S. Long-term efficacy of a cognitive behavioural treatment from a randomized controlled trial for patients recently diagnosed with rheumatoid arthritis. Rheumatology (Oxford). 2003;42:435-441.
  5. Uhlig T, Fongen C, Steen E, et al. Exploring Tai Chi in rheumatoid arthritis: a quantitative and qualitative study. BMC Musculoskelet Disord. 2010;11:43.
  6. Badsha H, chhabra V, Leibman C, et al. The benefits of yoga for rheumatoid arthritis: results of a preliminary, structured 8-week program. Rheumatol Int. 2009;29(12):1417-1421.