Cognitive behavioral therapy enhances psychological and physiological outcomes in high-altitude respiratory patients

Abstract

BACKGROUND

Due to the dry and cold climate, the obvious temperature difference between day and night, and the low oxygen content of the air in the plateau area, people are prone to upper respiratory tract diseases, and often the condition is prolonged, and the patients are prone to anxiety and uneasiness, which may be related to the harshness of the plateau environment, somatic discomfort due to the lack of oxygen, anxiety about the disease, and other factors.

AIM

To investigate the effects of cognitive behavioral therapy (CBT) on anxiety, sleep disorders, and hypoxia tolerance in patients with high-altitude respiratory diseases.

METHODS

A total of 2337 patients with high-altitude-related respiratory diseases treated at our hospital between November 2023 and January 2024 were selected as the study subjects. The subjects’ pre-high-altitude residential altitude was approximately 1700 meters. They were divided into two groups. Both groups were given symptomatic treatment, and the control group implemented conventional nursing intervention, while the research group simultaneously conducted CBT intervention; assessed the degree of health knowledge of the two groups, and applied the Hamilton Anxiety Scale and the Pittsburgh Sleep Quality Index to assess the anxiety and sleep quality of the patients before and after the intervention, respectively. It also observed the length and efficiency of sleep, and detected the level of serum hypoxia inducible factor-1α, erythropoietin (EPO) and clinical intervention before and after intervention. EPO levels, and investigated satisfaction with the clinical intervention.

RESULTS

The rate of excellent health knowledge in the intervention group was 93.64%, which was higher than that in the control group (74.23%; P < 0.05). Before the intervention, there was no significant difference in Hamilton Anxiety Scale and Pittsburgh Sleep Quality Index scores between the two groups (P > 0.05), and after the intervention, the scores of the study group were significantly lower than those of the control group (P < 0.05). There was no significant difference in sleep duration and sleep efficiency between the groups before the intervention (P > 0.05), and after the intervention, the scores of the study group were significantly larger than those of the control group (P < 0.05). There was no significant difference in serum hypoxia inducible factor-1α and EPO between the two groups before intervention (P > 0.05), and both research groups were significantly lower than the control group after intervention (P < 0.05). According to the questionnaire survey, the intervention satisfaction of the study group was 95.53%, which was higher than that of the control group (80.14%; P < 0.05).

CONCLUSION

The CBT intervention in the treatment of patients with high-altitude-related respiratory diseases helps improve patients' health knowledge, relieve anxiety, improve sleep quality and hypoxia tolerance, and improve nursing satisfaction.

Core Tip: In a 2337-patient plateau trial, adding cognitive behavioral therapy to usual care lifted health-knowledge mastery to 94%, halved anxiety and sleep-disorder scores, lengthened effective sleep, and lowered serum hypoxia inducible factor-1α and erythropoietin levels, signaling better hypoxia tolerance. Nursing satisfaction rose to 96%. Cognitive behavioral therapy is a low-cost, high-yield adjunct for high-altitude respiratory patients.

INTRODUCTION

Due to the dry and cold climate, the obvious temperature difference between day and night, and the low oxygen content of the air in the plateau area, people are prone to upper respiratory tract diseases, and often the condition is prolonged, and the patients are prone to anxiety and uneasiness, which may be related to the harshness of the plateau environment, somatic discomfort due to the lack of oxygen, anxiety about the disease, and other factors[1,2]. The emergence of negative emotions such as anxiety may further exacerbate symptoms such as dyspnea, forming a vicious circle. Sleep disorders are also more common in high-altitude areas. Hypoxia, environmental changes, anxiety, and other factors may have a negative impact on the sleep quality of patients with respiratory diseases, and sleep deprivation weakens the immune function of the body, reduces the patient’s tolerance to hypoxia, and slows down the recovery process of the disease[3]. Therefore, active treatment should be accompanied by systematic intervention. Cognitive behavioral therapy (CBT) is a clinical evidence-based psychological intervention approach that has demonstrated significant roles and value in a variety of conditions[4-6]. Although physiological and psychological changes in the human body at high altitudes have been studied to a certain extent, there are relatively few systematic studies on the effects of CBT on improving anxiety, sleep disorders, and hypoxia tolerance in patients with respiratory disorders associated with high altitudes, and there is a lack of sufficient evidence to support its application in this specific population. In this study, we analyzed and evaluated the effects of CBT on 2337 patients with high altitude-related respiratory diseases treated in our hospital through a controlled clinical study, aiming to provide a new auxiliary intervention for the treatment of high altitude-related respiratory diseases, and the related studies are reported as follows.

MATERIALS AND METHODS

General information

A total of 2337 patients with high-altitude-related respiratory diseases treated at our hospital between November 2023 and January 2024 were selected as the study subjects. The subjects’ pre-high-altitude residential altitude was approximately 1700 m. They were divided into the following groups: Group A (425 individuals) consisted of those entering the high-altitude region for the first time (defined as individuals with no prior high-altitude experience) and group B (defined as individuals with at least one prior high-altitude experience) comprised 1912 individuals. This study was approved by the Institutional Review Board of 948^th Army Hospital, People’s Liberation Army (Approval No. ZG-948-011-01), and all participants provided written informed consent before enrolment. To uphold the principle of fairness, the control group was offered the same structured CBT program free of charge immediately after the primary endpoint assessment (day 5). A condensed three-session protocol was delivered by the same certified psychologist within the following week, ensuring that no participant was deprived of potentially beneficial care once efficacy had been established.

The inclusion criteria were as follows: (1) Diagnosis based on symptoms and imaging examinations, conforming to the diagnostic criteria for high-altitude-related respiratory diseases, mainly presenting with cough and dyspnea[7]; (2) Age > 18 years; (3) Moist rales audible in both lungs; and (4) Informed consent to participate in the study. The exclusion criteria were as follows: (1) Comorbidities such as tuberculosis or pulmonary tumors; (2) Systemic immune or hematologic diseases; (3) Psychiatric or cognitive disorders; (4) Inability to cooperate with ventilation therapy; (5) Chronic obstructive pulmonary disease; and (6) Poor clinical compliance.

The patients were divided into a study group (no high-altitude experience) and control group (high-altitude experience). Study group: 425 cases, 312 males and 113 females; age range: 26-63 years, mean age (41.22 ± 5.15) years; 322 cases of high-altitude pulmonary edema, 103 cases of high-altitude pneumonia; disease duration: 4-8 days, average (5.34 ± 1.07) days; education level: 162 with junior high school or below, 191 with high school, and 72 with college or above. Control group: 1912 cases, 1324 males and 588 females; age range: 27-61 years, mean age (40.35 ± 5.16) years; 1198 cases of high-altitude pulmonary edema, 455 cases of high-altitude pneumonia, and 259 cases of high-altitude bronchitis; disease duration: 5-7 days, average (5.41 ± 1.05) days; education level: 814 with junior high school or below, 667 with high school, and 431 with college or above.

There were no statistically significant differences between the two groups in terms of sex, age, or high-altitude experience (P > 0.05), indicating good comparability. All patients received symptomatic treatment, including anti-inflammatory, anti-infective, and oxygen therapies along with nutritional support.

Control group

Patients in this group underwent routine interventions. Health education brochures were distributed to the patients and their families to explain their knowledge of high-altitude-related respiratory diseases and precautions during treatment. Medical staff continuously monitored the patients’ vital signs, emphasizing the necessity of medication and nebulization therapy, and strictly followed medical instructions. Professional sputum drainage guidance was provided, enabling patients to take medication properly and master correct sputum expectoration techniques, thus ensuring airway clearance. Patients were instructed to increase their daily water intake to reduce sputum viscosity. For patients unable to expectorate independently, scheduled suctioning was arranged in strict accordance with standardized procedures. The patients were assisted in changing positions regularly, and back percussion and postural drainage were performed. Vital signs and clinical manifestations were continuously monitored, and if the condition remained stable, the patients were maintained in a semi-recumbent position and scheduled for follow-up visits as per routine cycles.

Study group

The patients in this group received CBT in addition to routine care, as detailed below.

Cognitive interventions: (1) Psychological intervention: Healthcare providers explain the pathogenesis, symptoms, treatment strategies, and prognosis of respiratory diseases in high-altitude environments, enabling patients to accurately and clearly understand their condition, thus reducing fear and anxiety stemming from insufficient knowledge. However, patients were informed about the hypoxic nature of high-altitude areas and its physiological and psychological impacts, helping them to recognize hypoxia as a common physiological phenomenon in such environments. Hypoxia tolerance and confidence were enhanced through adaptive training and appropriate interventions. Face-to-face communication was used to ensure that the patients understood the goals and potential outcomes of CBT, thereby improving treatment compliance and enthusiasm; and (2) Identifying negative cognition: Patients were guided to identify and become aware of negative thoughts in response to disease and hypoxic environments, such as “I will definitely get sick at high altitude” or “the hypoxic environment is terrifying”, and “I cannot bear it”. Patients were instructed to analyze the irrationality and lack of evidence in such thoughts and were encouraged to focus on treatment progress and personal strengths to foster a positive mindset, boosting their confidence in recovery and adaptation to hypoxia.

Behavioral interventions: (1) Relaxation training: Patients were taught various relaxation techniques, such as progressive muscle relaxation, deep breathing, and meditation, to help alleviate physical tension and discomfort during episodes of anxiety or hypoxia, thereby reducing anxiety and enhancing hypoxia tolerance; (2) Coping training: Patients were trained to handle possible situations in high-altitude environments, such as dyspnea or sleep disturbances. Specifically, abdominal breathing was taught to improve ventilation in cases of dyspnea, and good sleep hygiene practices and relaxation methods such as imagery and music therapy were introduced for sleep disturbances; (3) Self-management: Individualized self-management plans were created for each patient based on their personal circumstances, including daily activity scheduling, disease monitoring, medication management, and emotional regulation, to help them effectively manage their condition, enhance their self-efficacy, and gain a sense of disease control; (4) Emotional regulation: Patients were guided and assisted in identifying negative emotions such as anxiety, fear, and worry. They were encouraged to express their emotions openly rather than suppress or ignore them. On this basis, emotion management strategies and techniques were taught, such as cognitive restructuring from rational emotive therapy to adjust thinking patterns during negative emotional states or distraction and positive self-talk to regulate emotional responses; and (5) Sleep improvement: On one hand, good sleep hygiene was introduced, such as maintaining regular schedules, creating a comfortable sleep environment, and avoiding excessive stimulation before bedtime to establish a healthy sleep pattern. Patients were instructed to go to bed only when sleeping and to leave the bedroom immediately after waking; the bed and bedroom were used only for sleep and sex, avoiding other activities such as reading or watching TV to strengthen the conditioned association between bed and sleep. According to clinical conditions, the time spent in bed was limited to approximate the actual sleep time to improve sleep efficiency. As sleep quality improved, the time spent in bed gradually increased until normal sleep patterns resumed.

Social support: Patients were organized to participate in group therapy activities, sharing and supporting each other to recognize that they were not alone and that their emotional responses were common. This alleviates psychological stress and enhances social support. Family support was also emphasized. Family members were encouraged to understand the patient’s disease and psychological state, provide emotional comfort, and provide practical assistance, such as helping with relaxation training and supervising self-management plans. Families were also guided to respond to the patient’s condition appropriately, avoiding excessive concerns or protection, which might increase anxiety.

Observation indicators: (1) Awareness of health knowledge: After the intervention, a questionnaire survey was conducted to assess the patients’ understanding of health knowledge, including basic knowledge of the disease, medication, oxygen therapy, and complication prevention. The questionnaire consisted of 20 multiple-choice questions, with a total score of 100. Scores ≥ 90 were considered excellent, 80-89 good, 60-79 fair, and < 60 poor. The number of cases with excellent and good ratings was also recorded; (2) Anxiety state: The Hamilton Anxiety Scale (HAMA) was used before and 5 days after the intervention to evaluate patients’ anxiety levels. The scale includes 14 items, each rated from 0 to 4, with seven points as the threshold; higher scores indicate more severe anxiety[8]; (3) Sleep status: The Pittsburgh Sleep Quality Index (PSQI) was used before and 5 days after the intervention to evaluate sleep quality, covering seven aspects: Sleep quality, sleep latency, and sleep efficiency. Each item was scored from 1 to 3, with a total score ranging from 7 to 21. Higher scores indicate poorer sleep quality[9]. A sleep monitor was used to measure sleep duration and efficiency over three consecutive tests, and the average values were calculated; (4) Hypoxia tolerance: Peripheral venous blood was collected before and 5 days after the intervention to measure serum levels of hypoxia inducible factor (HIF)-1α and erythropoietin (EPO), strictly following the kit instructions; and (5) Clinical satisfaction: Upon discharge, a self-designed questionnaire was used to assess satisfaction with the intervention measures, environment, effectiveness, and communication. The questionnaire was scored out of 100, with ≥ 90 as very satisfied, 80-89 as satisfied, 70-79 as fair, and < 70 as dissatisfied. Total satisfaction was calculated as the sum of satisfaction.

Statistical analysis

The statistical analysis by SPSS version 25.0 software, for the normal distribution of measurement data expressed as mean ± SD, between the groups to t test; count data expressed by the n (%), between the groups to test. P < 0.05 indicates a statistically significant difference.

RESULTS

Comparison of health knowledge rate between groups

In the post-intervention assessment, the excellent rate of health knowledge in the study group was 93.64%, which was higher than that in the control group (74.23%; P < 0.05; Table 1).

Table 1.

Comparison of health knowledge awareness rate between groups, n (%)

Group	Case	Excellent	Good	General	Bad	Excellent and good
Research group	425	235 (55.29)	163 (38.35)	20 (4.71)	7 (1.65)	398 (93.64)
Control group	1912	518 (27.09)	907 (47.44)	301 (15.74)	186 (9.73)	1425 (74.53)
χ 2						74.073
P value						0.000

Comparison of anxiety status before and after the intervention between groups

There was no significant difference in the HAMA scores between the two groups before the intervention (P > 0.05), and the scores of the study group were significantly lower than those of the control group after the intervention (P < 0.05), as shown in Table 2.

Table 2.

Comparison of Hamilton Anxiety Scale scores before and after intergroup intervention, mean ± SD

Group	Case	Before	After	t	P value
Research group	425	14.42 ± 1.40	6.97 ± 1.12	85.665	0.000
Control group	1912	14.49 ± 1.37	7.74 ± 1.09	168.590	0.001
t		0.949	13.106
P value		0.106	0.010

Comparison of sleep status between groups before and after intervention

The PSQI scores of the study group were significantly lower than those of the control group after the intervention (P < 0.05), and the length and efficiency of sleep were higher than those of the control group (P < 0.05), which was the same between the groups before the intervention (Table 3).

Table 3.

Comparison of sleep status before and after intergroup intervention, mean ± SD

Group	Case	PSQI		Sleep duration (minutes)		Sleep efficiency (%)
		Before	After	Before	After	Before	After
Research group	425	13.11 ± 2.18	5.17 ± 1.08a	309.23 ± 25.84	371.15 ± 31.23a	52.13 ± 7.87	72.18 ± 8.12a
Control group	1912	13.09 ± 2.23	7.43 ± 1.35a	310.19 ± 24.37	329.26 ± 33.34a	52.25 ± 8.03	60.23 ± 9.26a
t		0.168	32.289	0.726	23.694	0.280	24.585
P value		0.867	0.001	0.468	0.001	0.779	0.000

^a P < 0.05, before intervention vs after intervention.

PSQI: Pittsburgh Sleep Quality Index.

Comparison of serum hypoxia-resistant factor level between groups before and after intervention

By detection of the there was no significant difference in serum HIF-1α and EPO between the two groups of patients before intervention (P > 0.05), and both of them were significantly lower in the study group than in the control group after intervention (P < 0.05), as shown in Table 4.

Table 4.

Comparison of serum hypoxia factor levels before and after intergroup intervention, mean ± SD

Group	Case	HIF-1α (ng/mL)		EPO (mIU/L)
		Before	After	Before	After
Research group	425	43.12 ± 4.18	32.19 ± 3.24a	67.25 ± 8.14	33.27 ± 2.23a
Control group	1912	43.09 ± 4.23	37.24 ± 3.15a	67.18 ± 9.02	39.31 ± 2.34a
t		0.133	29.738	0.142	48.697
P value		0.895	< 0.001	0.883	0.001

^a P < 0.05, before intervention vs after intervention.

HIF-1: Hypoxia inducible factor; EPO: Erythropoietin.

Comparison of clinical intervention satisfaction between the groups

Through the questionnaire survey, intervention satisfaction in the study group was found to be 95.53%, which was higher than that in the control group (80.14%; P < 0.05), as shown in Table 5.

Table 5.

Comparison of intergroup clinical intervention satisfaction, n (%)

Group	Case	Very satisfied	Satisfied	Commonly	Unsatisfied	Very satisfied and satisfied
Research group	425	256 (60.24)	150 (35.29)	11 (2.59)	8 (1.88)	406 (95.53)
Control group	1912	622 (32.53)	910 (47.60)	258 (13.49)	122 (6.38)	1532 (80.13)
χ 2						58.273
P value						< 0.001

DISCUSSION

High altitude areas due to low oxygen content, the human body is prone to hypoxia, which may cause a series of respiratory diseases, common plateau pulmonary edema, plateau pneumonia and bronchitis, etc., such diseases on the physical and mental health of the patient and the quality of life caused by the serious impact of the physical and mental pain, not only physiological pain, but also often accompanied by anxiety, sleep disorders, etc., which will further aggravate the condition is not conducive to the treatment and rehabilitation[9,10]. Therefore, while actively conducting symptomatic treatment, it is necessary to pay attention to psychological and sleep interventions.

CBT is a psychological therapy based on cognitive theory and behavioral interventions, and has been widely applied in the medical field in recent years. CBT posits that emotional and behavioral problems stem from distorted beliefs about cognitive processes. By changing patients’ cognitive styles and behavioral patterns, CBT can help relieve psychological stress, improve emotional states, and enhance quality of life[11]. It is an innovative nursing method aimed at altering patients’ existing thinking patterns and behavioral habits, correcting erroneous cognition, eliminating the impact of negative emotions, and reconstructing disease-related perceptions, thereby restoring confidence in treatment.

A study involving patients with chronic bronchitis demonstrated that an observation group receiving CBT intervention had higher quality of life scores and lower psychological status scores than a control group receiving routine nursing guidance[12]. In this study, CBT was administered to patients with high-altitude respiratory diseases. Individualized interventions were designed based on the patients’ clinical conditions, focusing on cognitive and behavioral aspects, such as disease education and self-management.

According to the results of this study, after the intervention, the excellent and good rates of health knowledge awareness in the intervention group reached 93.64%, which was higher than that in the control group (74.23%). Additionally, the HAMA and PSQI scores in the intervention group were significantly lower than those in the control group (P < 0.05), whereas sleep duration and sleep efficiency were better. These findings are consistent with those of previous reports, suggesting that CBT can significantly improve patients’ disease-related knowledge and mitigate adverse psychological states, thereby improving sleep quality.

This effect may stem from CBT’s ability to assess and reconstruct patients’ cognition, address cognitive needs, correct faulty beliefs, reduce fear of disease, and rebuild confidence in treatment, ultimately enhancing motivation for nursing care[13,14]. CBT helps patients identify and change negative thinking patterns and beliefs, thereby lowering anxiety levels related to high-altitude environments and respiratory diseases[15,16]. It also helps patients correct catastrophic thoughts regarding hypoxia and dyspnea - for example, replacing “hypoxia is unbearable” with “although hypoxia is uncomfortable, I can take measures to alleviate it and gradually adapt” - thus alleviating anxiety. In addition, CBT teaches relaxation techniques to help patients relax physically and ease physiological symptoms of anxiety when they feel anxious.

Symptoms such as hypoxia and dyspnea can negatively affect sleep quality, leading to difficulty falling asleep, frequent nighttime awakening, and shallow sleep[17]. CBT improves sleep hygiene habits and modifies cognitive and behavioral patterns associated with sleep, thereby helping manage sleep disorders[18]. Under professional guidance, patients are encouraged to change unhealthy bedtime habits, create a quiet and comfortable sleep environment, and engage in relaxation exercises, such as deep breathing and meditation, before bedtime to improve sleep onset efficiency.

According to the study’s results, both groups showed improved serum HIF-1α and EPO levels after intervention, with the study group showing significantly lower levels than the control group (P < 0.05). EPO is a key hematopoietic regulatory factor that stimulates the proliferation of erythroid progenitor cells when bound to low-affinity receptors and promotes differentiation and maturation when bound to high-affinity receptors[19]. Blood oxygen-carrying capacity is highly dependent on the number and functional state of red blood cells, and erythropoiesis is primarily regulated by EPO[20]. HIF-1α is a nuclear protein produced under hypoxic conditions, which binds to target genes to enhance transcription and mediate adaptive responses to hypoxia[21]. To address the seemingly paradoxical observation that CBT intervention led to a significant reduction in both EPO and HIF-1α levels, we propose a multifactorial interpretation grounded in physiological adaptation and stress-response modulation. First, anxiety and hyperventilation are intricately linked; anxiety-induced hyperventilation can increase oxygen consumption (VO₂) and minute ventilation, leading to a relative hypocapnia and inefficient oxygen utilization. By alleviating anxiety through CBT, patients may exhibit reduced hyperventilation and a more efficient breathing pattern, thereby decreasing overall VO₂. This reduction in metabolic demand attenuates hypoxic stimuli, subsequently downregulating EPO synthesis via a negative feedback loop in renal EPO-producing cells[22]. Secondly, sleep quality is a critical determinant of metabolic efficiency. Fragmented sleep, as seen in anxiety-related insomnia, increases sympathetic tone and metabolic rate, exacerbating hypoxemia[23]. CBT-driven improvements in sleep architecture may enhance tissue oxygen extraction and utilization efficiency, reducing reliance on compensatory erythropoiesis. This finding is supported by studies demonstrating that sleep extension improves mitochondrial function and reduces oxidative stress[24]. Thus, a decline in EPO may reflect more efficient oxygen utilization than impaired hypoxia tolerance.

Regarding the decrease in HIF-1α, it is imperative to consider potential confounders. While our data suggest improved tissue oxygenation as a driver of reduced HIF-1α, anti-inflammatory medications (e.g., corticosteroids or non-steroidal anti-inflammatory drugs) administered during symptomatic treatment could inhibit HIF-1α transcriptional activity via nuclear factor kappa-light-chain-enhancer of activated B cells pathway suppression[25]. To isolate the specific effects of CBT, future studies should include a “basic treatment” control group (patients receiving only anti-inflammatory or oxygen therapy without CBT). This would allow differentiation between CBT-mediated physiological adaptations and pharmacological effects on HIF-1α. Additionally, direct measurement of tissue oxygen saturation via near-infrared spectroscopy could validate whether reduced HIF-1α correlates with improved microcirculatory oxygenation. From a translational perspective, our findings suggest that CBT may serve as an adjunct to reduce pharmacological dependence in high-altitude respiratory management. For instance, minimizing the use of EPO-stimulating agents in patients exhibiting improved oxygen efficiency could mitigate the risk of thrombosis or hypertension. To this end, randomized controlled trials comparing CBT plus basic treatment vs basic treatment alone are warranted to quantify CBT’s additive value in reducing EPO and HIF-1α levels while maintaining clinical stability. Furthermore, wearable devices that enable the real-time monitoring of VO₂ and sleep efficiency could provide objective biomarkers for CBT efficacy in resource-limited, high-altitude settings.

Although CBT does not improve hypoxia directly, it indirectly enhances hypoxia tolerance by alleviating anxiety and improving sleep quality[25]. When anxiety is relieved, the body’s stress response diminishes, physiological indicators, such as heart rate and blood pressure, stabilize, and the body adapts more effectively to hypoxic environments. Moreover, sleep quality promotes recovery and repair, boosts immune function and physiological resilience, and better equips patients to cope with challenges associated with hypoxia[26,27]. Additionally, satisfaction surveys showed that the intervention satisfaction rate in the study group reached 95.53%, which was higher than that in the control group (80.14%). This indicates that CBT improves patient satisfaction with clinical interventions[28]. The present study demonstrated significant reductions in serum EPO and HIF-1α levels after only five days of CBT. However, the physiological half-life of EPO is approximately 5 hours, and the stability of HIF-1α is governed by multiple post-translational regulators, including prolyl-hydroxylase domain enzymes and inflammatory mediators. Consequently, it remains uncertain whether these short-term fluctuations accurately reflect sustained improvements in hypoxic tolerance. Future trials should, therefore, extend the intervention period to 2-4 weeks and incorporate direct hypoxia indicators, such as arterial oxygen partial pressure and oxygen saturation, measured under standardized hypoxic challenges, to provide more robust evidence of CBT-mediated physiological adaptation.

CONCLUSION

In conclusion, applying CBT to the treatment of patients with high-altitude respiratory diseases can effectively improve their health knowledge comprehension, alleviate anxiety, enhance sleep quality, and boost tolerance to hypoxic conditions. This, in turn, improves satisfaction with the nursing services and has significant clinical relevance.

Data sharing statement

No additional data are available.