Assignment Prompt & Instructions
**files (3)**
– ## Attemptfeedback.docx
– ## CapstonePartIIintrucctions.docx
– ## CapstoneProject1.docx
**## Attemptfeedback.docx**
Attempt feedback
Overall, you did well. The Capstone should focus in one clinic setting within Miami-Dade to make it realistic. In the Review of Literature, expand on what you have already found but in futher details.
**## CapstonePartIIintrucctions.docx**
Capstone Part II: Review of Literature
**CAPSTONE: PART II due 10/4/2025 by 11:59pm**
1. Review of Literature:
– Review and discuss literature: Synthesize at least 10 primary research studies and/or systematic reviews; do not include summary articles. This section is all about the scientific evidence rather than someone else's opinion of the evidence. Do not use secondary sources; you need to get the article, read it, and make your own decision about quality and applicability to your question even if you did find out about the study in a review of the literature. This is a synthesis rather than a study-by-study review. Address the similarities, differences, and controversies in the body of evidence.
2. Analyze and apply knowledge directly to your PICOT- The studies that you cite in this section must relate directly to your PICOT question.
3. Provide precise body of evidence for your Practice Change- Include Nurses as leaders in this project, statistics, cost, impact on healthcare.
4. Discuss objectives for your practice change, Why is change necessary?
5. Discuss where the problem exists, why it exists, what is the preposition for change. Include information from your PICOT.
6. Apply all that is relevant to the problem. For example: Pros vs Cons, current state of problem
NOTE: It should not reflect your opinion, but rather Evidence Based Practice should be applied
-After completing a literature search on interventions addressing your chosen health problem, write a review that evaluates the strengths and weaknesses of all the sources you have found, compare anc constrast.
-Use appropriate APA 7th Ed. Scholarly, peer-reviewed, and research articles cited should be within the last five years.
-This section should be minimum 4-6 pages long (not including the title and reference page).
-Use proper in-text citations with a properly formatted reference list.
-All papers must be written APA in the 3rd person.
**Rubric Capstone II.docx**
**Submission**
Text Editor
_Word count: 0_
**Drag files here**
Maximum size: 512 MB
**or**
**Details & Information**
CRITERIA OUTSTANDING VERY GOOD GOOD UNACCEPTABLE
Integration of
Knowledge
25 points
Thoroughly selected
and present an
appropriate
Evidence Based
Practice for the
health problem and
change.
25
Briefly selected and
present an
appropriate
Evidence Based
Practice for the
health problem and
change.
20
Vaguely selected
and present an
appropriate
Evidence Based
Practice for the
health problem and
change.
15
Did not select and
present an
appropriate
Evidence Based
Practice for the
health problem and
change.
0
Topic Focus
25 points
The health problem
is focused narrowly
enough for the
scope of this
assignment. A topic
statement provides
direction for the
paper. The topic is
consistently well
thought out,
thorough offers
insight into the topic,
and includes cited
evidence to support
the topic.
25
The health problem
is focused but
lacks direction. The
paper is about a
specific topic, but
the writer has not
established a
position. The topic
is somewhat well
thought out, offers
limited insight into
the topic, but does
not include cited
evidence to support
the topic.
20
The health problem
is too broad for the
scope of this
assignment.
15
The health problem
is unclear or
unrelated to the
discussion topic
with little or no
supporting
evidence.
0
Depth of
Discussion and
Cohesiveness
25 points
In-depth discussion
and elaboration in all
sections of the
paper.
Ties together
information from all
sources. Paper flows
from one issue to
the next with no
headings. The
author’s writing
demonstrates an
understanding of the
relationship among
material obtained
from all sources
Mostly, it ties
together information
from all sources.
In-depth discussion
and elaboration in
most sections of
the paper.
Mostly, it ties
together
information from all
sources. Paper
flows with only
some
disjointedness. The
author’s writing
demonstrates an
understanding of
the relationship
among material
obtained from all
sources.
The writer has
omitted content.
Quotations from
others outweigh the
writer’s own ideas
excessively.
Sometimes ties
together
information from all
sources. The paper
does not flow.
Disjointedness is
apparent. The
author’s writing
does not
demonstrate an
understanding of
the relationship
between material
obtained from all
sources.
Cursory discussion
in all the sections
of the paper or brief
discussion in only a
few sections.
It does not tie
together
information. Paper
does not flow and
appears to be
created from
disparate issues.
Headings are
necessary to link
concepts. Writing
does not
demonstrate an
understanding of
any relationship.
25 20
15
0
Spelling and
Grammar
10 points
Fewer than 5
grammatical,
spelling,
capitalization, or
punctuation errors.
Required word count
has been met.
8
More than 5 but
fewer than 10
grammatical,
spelling,
capitalization &
punctuation errors
Required word
count is 25 words
below the minimum
required count.
6
More than 10
grammatical,
spelling,
capitalization &
punctuation errors
Required word
count is 50 words
below the minimum
required count.
5
An unacceptable
number of spelling
and/or grammar
mistakes.
Required word
count is more than
50 words below the
minimum required
count.
0
Sources
10 points
Over 5 current
sources, of which at
least 3 are peer-
review journal
articles or scholarly
books. Sources
include both general
background sources
and specialized
sources. Special-
interest sources and
popular literature
and acknowledged
as such if they are
cited. All websites
utilized are
authoritative.
5 current sources,
of which at least 2
are peer-review
journal articles or
scholarly books. All
websites utilized
are authoritative.
Fewer than 5
current sources or
fewer than 2 of 5
are peer-reviewed
journal articles or
scholarly books. All
websites utilized
are credible.
Fewer than 5
current sources or
fewer than 2 of 5
are peer-reviewed
journal articles or
scholarly books.
Not all websites
utilized are credible,
and/or sources are
not current.
Citations
5 points
Fewer than 5
incomplete citations
and/or quotations,
and APA format
errors
5
More than 5 but
fewer than 10
incomplete
citations and/or
quotations, and
APA format errors.
4
More than 10
incomplete
citations and/or
quotations, or APA
format errors.
3
The citation style is
inconsistent or
incorrect. It does
not cite sources.
**## CapstoneProject1.docx**
2
**Nurse-Led Deep Breathing Intervention to Reduce Mild Anxiety in Adult Primary Care Patients in a Community Clinic in Miami-Dade County**
Anisleidy Alvarez
Florida National University
MSN Capstone Project-DAX-DL01
Dr. Carmen Lazo
May 23, 2026
**Nurse-Led Deep Breathing Intervention to Reduce Mild Anxiety in Adult Primary Care Patients in a Community Clinic in Miami-Dade County**
Anxiety disorders are among the most common conditions among adult patients in the United States and are poorly treated in primary care. The National Center for Health Statistics reports that in 2022, about one in five of adults aged 18 and older had symptoms of anxiety, with the highest rates found in younger adults and in people living in lower-income households (Terlizzi & Zablotsky, 2024). It's not only an individual problem as anxiety also creates significant health care expenses. Anxiety disorders collectively cost the United States healthcare system tens of billions of dollars per year, with increased emergency department visits, unnecessary specialist referrals, and diminished workforce productivity (Banushi et al., 2023).
Even with this high prevalence, mild anxiety is often underdiagnosed and is not adequately treated in primary care, where most persons with anxiety symptoms seek care. Mild anxiety patients who do not receive treatment are at great risk of the symptoms escalating to more severe anxiety, poor functioning and more frequent use of emergency services. Poor anxiety regulation also has a negative impact on treatment adherence of comorbid physical conditions, increasing healthcare utilization and costs.
The purpose of this capstone project is to evaluate whether a nurse-led 2-minute deep breathing educational intervention improves self-reported anxiety symptoms among adults with mild anxiety symptoms receiving care in a community primary care clinic in Miami-Dade County over an eight-week period. The proposed intervention aims to provide a simple, low-cost, evidence-based strategy that promotes self-management and improves emotional well-being in a vulnerable population.
**PICOT**
The prevalence of mild anxiety is a topic of increasing clinical interest in outpatient primary care, especially in diverse, urban communities where care for mental health is scarce. The following PICOT question guides this capstone project:
_In adult patients presenting with mild anxiety symptoms in a community primary care clinic in Miami-Dade County (P), does teaching a 2-minute nurse-led deep breathing exercise (I), compared to no structured breathing intervention (C), reduce self-reported anxiety levels (O) over eight weeks (T)?_
The population includes adults 18 years and older with mild anxiety symptoms presenting to primary care clinics in Miami-Dade County. This population often has limited access to mental health specialists and limited structured anxiety management during regular clinic visits.
The intervention is a brief 2-minute-deep breathing technique to be taught by the nurse to each patient at the clinic visit, combined with an instructional card to be printed and given to the patient for practicing at home. Controlled breathing is effective at engaging the Parasympathetic Nervous System (PNS) which reduces the physiological stress response and self-reported anxiety (Magnon et al., 2021). The comparison is standard care, which means routine clinical management without any structured breathing instruction.
The expected outcome is improvement in patient-reported anxiety symptoms following implementation of the nurse-led intervention. When available, Patient-reported symptom improvement may be discussed during routine follow-up visits as part of standard patient care. May be used as part of standard clinical assessment to monitor symptom improvement. Studies have shown that brief, structured breathwork exercises show significant decrease in physiological arousal and increase of mood compared to control conditions (Balban et al., 2023). The eight weeks is a reasonable amount of time to observe regular practice effects and is convenient in a capstone course that is structured on a semester basis.
**Vulnerable Population and Setting**
The target population for this intervention includes adults with mild anxiety symptoms receiving care in community primary care clinics in Miami-Dade County, Florida. This population often experiences multiple social and healthcare barriers that may contribute to delayed recognition and treatment of anxiety symptoms. Many adults receiving care in community clinics may have coexisting chronic conditions, limited access to mental health specialists, and limited exposure to structured behavioral health interventions during routine primary care visits. As a result, primary care settings frequently serve as the first and sometimes only point of access for individuals seeking support for mental health concerns.
Miami-Dade County has a population that is one of the most culturally and linguistically diverse in the United States, with over 70% of the county's residents identifying as Hispanic and/or Latino (U.S Census Bureau, 2025). The stigma attached to mental health, low mental health literacy and a preference for physical explanations of distress over psychiatric explanations are commonly mentioned as cultural factors hindering help-seeking in this population (Forcén et al., 2023). Structural factors are also constraints to receiving mental health treatment: language, insurance status, cost of treatment, and transportation. The evidence shows that Hispanic and Latino adults are much less likely than adults of other races and ethnicities to receive mental health care, despite having clinically meaningful symptoms (Forcén et al., 2023).
Anxiety disorders affect nearly one in five adults nationwide and is one of the most underdiagnosed conditions in primary care, with studies showing that only approximately 20% of affected patients receive appropriate treatment (Banushi et al., 2023; National Institute of Mental Health, 2024). Social determinants of health add to vulnerability in Miami-Dade and further increase this gap. A stressful urban environment, the economic instability, stressors related to immigration, and social isolation make the situation ripe for anxiety symptoms to continue and intensify without some degree of intervention. A straightforward, low cost, culturally appropriate approach, like deep breathing led by nurses, is therefore clinically appropriate and highly needed for this population.
**Proposal and Intervention Plan**
The proposed intervention is a 2-minute-deep breathing exercise taught to each adult patients with mild anxiety symptoms by a trained nurse during his or her usual primary care clinic in a community clinic in Miami-Dade County. The intervention includes instruction on slow diaphragmatic breathing with controlled inhalation and prolonged exhalation, an approach shown to promote relaxation and reduce anxiety-related physiological arousal through activation of the parasympathetic nervous system .The educational session is delivered individually by the nurse at the point of care and requires minimal time to implement during routine patient education. Patients will also receive a bilingual educational handout to encourage continued practice of the breathing technique at home. (Magnon et al., 2021).
The resources required for implementation are minimal and include printed bilingual instruction cards, a standardized nurse teaching script, and a brief staff orientation session. It does not require a special setup or extra space and is very easy to do in a busy outpatient clinic.
The proposed intervention is low-cost and feasible for implementation in a community primary care clinic. Resources required include printed bilingual educational handouts for patients, estimated at approximately $50 to $75, and a brief staff orientation session incorporated into regular nursing meetings without additional staffing expenses. Because the intervention is integrated into routine patient education, no additional personnel or specialized equipment are required. The low-cost nature of this intervention supports feasibility within an eight-week academic semester timeline.
Involved in the intervention are bedside registered nurses teaching, Advanced practice nurses managing the intervention and adherence to the protocol, and the primary care physicians who identify patients during clinic visits. Clinic administrative staff support scheduling and patient education coordination and scheduling support.
The implementation timeline takes place in three phases. In week 1 and 2 staff education takes place, and all patient materials are prepared and printed. From week 3 to 6, the nurses teach deep breathing techniques to patients during their routine clinic visits, and the patients practice deep breathing at home with the deep breathing instruction card. During weeks 7 and 8, nurses will reinforce patient education and encourage continued use of the deep breathing technique during routine follow-up visits.
**Theoretical Framework**
This capstone project is largely based on Dorothea Orem's Self-Care Deficit Nursing Theory. Nurses in Orem's framework are educators who recognize the patient's deficits in self-care and fill that gap with knowledge and skills so that the patient can maintain his or her health independently. According to Bekaert (2025) health education is a component of nursing, which is built upon Orem's theory, in which the nurse assists individuals in meeting their self-care needs by demonstrating and facilitating their ability to cope with stress and manage their emotional state. The 2-minute-deep breathing exercise directly targets the patient's self-care deficit by offering a practical and repeatable tool that patients can use independently to help with mild anxiety symptoms outside of the clinic and at the end of the intervention period.
The intervention is implemented at the organizational level in the clinic, using Kurt Lewin's Change Theory. Lewin's model has three stages; Unfreezing, Change and Refreezing. In unfreezing, clinic staff are taught about the high prevalence of undiagnosed and unmanaged anxiety and the evidence supporting brief breathing techniques. The deep breathing teaching educational approach is introduced into regular nursing practice during the change phase. During the refreezing stage, the nurse-led deep breathing educational approach may become incorporated into routine patient education for adults with mild anxiety symptoms, supporting sustainability beyond the capstone timeline. Lewin's model is one of the most commonly used models in nurse-led change in healthcare organizations as it provides a simple structure to help guide complex changes to practice (Harrison et al., 2021). Combined, Orem's and Lewin's models guarantee the patient-centered and organizationally sustainable nature of the intervention. Orem leads direct patient care and Lewin leads institutional change for sustaining it.
**Conclusion**
Mild anxiety symptoms in people within primary care settings are prevalent, sometimes overlooked, and linked to diminished quality of life and heightened healthcare usage, especially among vulnerable groups facing obstacles to mental healthcare access. In culturally diverse areas like Miami-Dade County, socioeconomic determinants of health, such as restricted access to behavioral healthcare, linguistic obstacles, economic instability, and mental health stigma, may lead to postponed treatment and exacerbated symptoms. This capstone project suggests a nurse-led, 2-minute deep breathing educational intervention as a viable, cost-effective, and evidence-based approach to assist adults with mild anxiety symptoms in a community primary care clinic in Miami-Dade County. The intervention, principally informed by Orem’s Self-Care Deficit Nursing Theory and reinforced by Lewin’s Change Theory, fosters patient self-management and facilitates integration into standard nursing practice. The proposed intervention is pragmatic, achievable within an eight-week academic timeframe, and possesses the capacity to enhance patient-reported anxiety symptoms while promoting overall emotional well-being. Educational interventions in primary care may enhance quality of life and mitigate the course of anxiety symptoms when implemented early in treatment.
**References**
Balban, M. Y., Neri, E., Kogon, M. M., Weed, L., Nouriani, B., Jo, B., Holl, G., Zeitzer, J. M., Spiegel, D., & Huberman, A. D. (2023). Brief structured respiration practices enhance mood and reduce physiological arousal.
_Cell Reports Medicine_,
_4_(1), 1–15. https://doi.org/10.1016/j.xcrm.2022.100895
Banushi, B., Brendle, M., Ragnhildstveit, A., Murphy, T., Moore, C., Egberts, J., & Robison, R. (2023). Breathwork Interventions for Adults with Clinically Diagnosed Anxiety Disorders: A Scoping Review.
_Brain Sciences_,
_13_(2), 256. https://doi.org/10.3390/brainsci13020256
Bekaert, S. (2025). Repositioning health education as a core nursing function: a commentary.
_Journal of Research in Nursing_. https://doi.org/10.1177/17449871251358627
Forcén, F. E., Flórez, M. C. V., Medina, R. B., Zambrano, J., Pérez, J. H., Rodríguez, A. M., & Santos, L. H. (2023). Deconstructing cultural aspects of mental health care in Hispanic/Latinx people.
_Psychiatric Annals_,
_53_(3), 127–132. https://doi.org/10.3928/00485713-20230215-02
Harrison, R., Fischer, S., Walpola, R. L., Chauhan, A., Babalola, T., Mears, S., & Le-Dao, H. (2021). Where Do Models for Change management, Improvement and Implementation meet? a Systematic Review of the Applications of Change Management Models in Healthcare.
_Journal of Healthcare Leadership_,
_13_(2), 85–108. https://doi.org/10.2147/JHL.S289176
Magnon, V., Dutheil, F., & Vallet, G. T. (2021). Benefits from one session of deep and slow breathing on vagal tone and anxiety in young and older adults.
_Scientific Reports_,
_11_(1). https://doi.org/10.1038/s41598-021-98736-9
National Institute of Mental Health. (2024).
_Any Anxiety Disorder_. Www.nimh.nih.gov; National Institute of Mental Health. https://www.nimh.nih.gov/health/statistics/any-anxiety-disorder
Terlizzi, E. P., & Zablotsky, B. (2024). Symptoms of Anxiety and Depression Among Adults: United States, 2019 and 2022.
_National Health Statistics Reports_,
_213_, CS353885. https://doi.org/10.15620/cdc/64018
U.S Census Bureau. (2025).
_QuickFacts: Miami-Dade County, Florida_. Census Bureau QuickFacts; United States Census Bureau. https://www.census.gov/quickfacts/fact/table/miamidadecountyflorida/BZA115223
**## CapstoneProject1.docx**
2
**Nurse-Led Deep Breathing Intervention to Reduce Mild Anxiety in Adult Primary Care Patients in a Community Clinic in Miami-Dade County**
Anisleidy Alvarez
Florida National University
MSN Capstone Project-DAX-DL01
Dr. Carmen Lazo
May 23, 2026
**Nurse-Led Deep Breathing Intervention to Reduce Mild Anxiety in Adult Primary Care Patients in a Community Clinic in Miami-Dade County**
Anxiety disorders are among the most common conditions among adult patients in the United States and are poorly treated in primary care. The National Center for Health Statistics reports that in 2022, about one in five of adults aged 18 and older had symptoms of anxiety, with the highest rates found in younger adults and in people living in lower-income households (Terlizzi & Zablotsky, 2024). It's not only an individual problem as anxiety also creates significant health care expenses. Anxiety disorders collectively cost the United States healthcare system tens of billions of dollars per year, with increased emergency department visits, unnecessary specialist referrals, and diminished workforce productivity (Banushi et al., 2023).
Even with this high prevalence, mild anxiety is often underdiagnosed and is not adequately treated in primary care, where most persons with anxiety symptoms seek care. Mild anxiety patients who do not receive treatment are at great risk of the symptoms escalating to more severe anxiety, poor functioning and more frequent use of emergency services. Poor anxiety regulation also has a negative impact on treatment adherence of comorbid physical conditions, increasing healthcare utilization and costs.
The purpose of this capstone project is to evaluate whether a nurse-led 2-minute deep breathing educational intervention improves self-reported anxiety symptoms among adults with mild anxiety symptoms receiving care in a community primary care clinic in Miami-Dade County over an eight-week period. The proposed intervention aims to provide a simple, low-cost, evidence-based strategy that promotes self-management and improves emotional well-being in a vulnerable population.
**PICOT**
The prevalence of mild anxiety is a topic of increasing clinical interest in outpatient primary care, especially in diverse, urban communities where care for mental health is scarce. The following PICOT question guides this capstone project:
_In adult patients presenting with mild anxiety symptoms in a community primary care clinic in Miami-Dade County (P), does teaching a 2-minute nurse-led deep breathing exercise (I), compared to no structured breathing intervention (C), reduce self-reported anxiety levels (O) over eight weeks (T)?_
The population includes adults 18 years and older with mild anxiety symptoms presenting to primary care clinics in Miami-Dade County. This population often has limited access to mental health specialists and limited structured anxiety management during regular clinic visits.
The intervention is a brief 2-minute-deep breathing technique to be taught by the nurse to each patient at the clinic visit, combined with an instructional card to be printed and given to the patient for practicing at home. Controlled breathing is effective at engaging the Parasympathetic Nervous System (PNS) which reduces the physiological stress response and self-reported anxiety (Magnon et al., 2021). The comparison is standard care, which means routine clinical management without any structured breathing instruction.
The expected outcome is improvement in patient-reported anxiety symptoms following implementation of the nurse-led intervention. When available, Patient-reported symptom improvement may be discussed during routine follow-up visits as part of standard patient care. May be used as part of standard clinical assessment to monitor symptom improvement. Studies have shown that brief, structured breathwork exercises show significant decrease in physiological arousal and increase of mood compared to control conditions (Balban et al., 2023). The eight weeks is a reasonable amount of time to observe regular practice effects and is convenient in a capstone course that is structured on a semester basis.
**Vulnerable Population and Setting**
The target population for this intervention includes adults with mild anxiety symptoms receiving care in community primary care clinics in Miami-Dade County, Florida. This population often experiences multiple social and healthcare barriers that may contribute to delayed recognition and treatment of anxiety symptoms. Many adults receiving care in community clinics may have coexisting chronic conditions, limited access to mental health specialists, and limited exposure to structured behavioral health interventions during routine primary care visits. As a result, primary care settings frequently serve as the first and sometimes only point of access for individuals seeking support for mental health concerns.
Miami-Dade County has a population that is one of the most culturally and linguistically diverse in the United States, with over 70% of the county's residents identifying as Hispanic and/or Latino (U.S Census Bureau, 2025). The stigma attached to mental health, low mental health literacy and a preference for physical explanations of distress over psychiatric explanations are commonly mentioned as cultural factors hindering help-seeking in this population (Forcén et al., 2023). Structural factors are also constraints to receiving mental health treatment: language, insurance status, cost of treatment, and transportation. The evidence shows that Hispanic and Latino adults are much less likely than adults of other races and ethnicities to receive mental health care, despite having clinically meaningful symptoms (Forcén et al., 2023).
Anxiety disorders affect nearly one in five adults nationwide and is one of the most underdiagnosed conditions in primary care, with studies showing that only approximately 20% of affected patients receive appropriate treatment (Banushi et al., 2023; National Institute of Mental Health, 2024). Social determinants of health add to vulnerability in Miami-Dade and further increase this gap. A stressful urban environment, the economic instability, stressors related to immigration, and social isolation make the situation ripe for anxiety symptoms to continue and intensify without some degree of intervention. A straightforward, low cost, culturally appropriate approach, like deep breathing led by nurses, is therefore clinically appropriate and highly needed for this population.
**Proposal and Intervention Plan**
The proposed intervention is a 2-minute-deep breathing exercise taught to each adult patients with mild anxiety symptoms by a trained nurse during his or her usual primary care clinic in a community clinic in Miami-Dade County. The intervention includes instruction on slow diaphragmatic breathing with controlled inhalation and prolonged exhalation, an approach shown to promote relaxation and reduce anxiety-related physiological arousal through activation of the parasympathetic nervous system .The educational session is delivered individually by the nurse at the point of care and requires minimal time to implement during routine patient education. Patients will also receive a bilingual educational handout to encourage continued practice of the breathing technique at home. (Magnon et al., 2021).
The resources required for implementation are minimal and include printed bilingual instruction cards, a standardized nurse teaching script, and a brief staff orientation session. It does not require a special setup or extra space and is very easy to do in a busy outpatient clinic.
The proposed intervention is low-cost and feasible for implementation in a community primary care clinic. Resources required include printed bilingual educational handouts for patients, estimated at approximately $50 to $75, and a brief staff orientation session incorporated into regular nursing meetings without additional staffing expenses. Because the intervention is integrated into routine patient education, no additional personnel or specialized equipment are required. The low-cost nature of this intervention supports feasibility within an eight-week academic semester timeline.
Involved in the intervention are bedside registered nurses teaching, Advanced practice nurses managing the intervention and adherence to the protocol, and the primary care physicians who identify patients during clinic visits. Clinic administrative staff support scheduling and patient education coordination and scheduling support.
The implementation timeline takes place in three phases. In week 1 and 2 staff education takes place, and all patient materials are prepared and printed. From week 3 to 6, the nurses teach deep breathing techniques to patients during their routine clinic visits, and the patients practice deep breathing at home with the deep breathing instruction card. During weeks 7 and 8, nurses will reinforce patient education and encourage continued use of the deep breathing technique during routine follow-up visits.
**Theoretical Framework**
This capstone project is largely based on Dorothea Orem's Self-Care Deficit Nursing Theory. Nurses in Orem's framework are educators who recognize the patient's deficits in self-care and fill that gap with knowledge and skills so that the patient can maintain his or her health independently. According to Bekaert (2025) health education is a component of nursing, which is built upon Orem's theory, in which the nurse assists individuals in meeting their self-care needs by demonstrating and facilitating their ability to cope with stress and manage their emotional state. The 2-minute-deep breathing exercise directly targets the patient's self-care deficit by offering a practical and repeatable tool that patients can use independently to help with mild anxiety symptoms outside of the clinic and at the end of the intervention period.
The intervention is implemented at the organizational level in the clinic, using Kurt Lewin's Change Theory. Lewin's model has three stages; Unfreezing, Change and Refreezing. In unfreezing, clinic staff are taught about the high prevalence of undiagnosed and unmanaged anxiety and the evidence supporting brief breathing techniques. The deep breathing teaching educational approach is introduced into regular nursing practice during the change phase. During the refreezing stage, the nurse-led deep breathing educational approach may become incorporated into routine patient education for adults with mild anxiety symptoms, supporting sustainability beyond the capstone timeline. Lewin's model is one of the most commonly used models in nurse-led change in healthcare organizations as it provides a simple structure to help guide complex changes to practice (Harrison et al., 2021). Combined, Orem's and Lewin's models guarantee the patient-centered and organizationally sustainable nature of the intervention. Orem leads direct patient care and Lewin leads institutional change for sustaining it.
**Conclusion**
Mild anxiety symptoms in people within primary care settings are prevalent, sometimes overlooked, and linked to diminished quality of life and heightened healthcare usage, especially among vulnerable groups facing obstacles to mental healthcare access. In culturally diverse areas like Miami-Dade County, socioeconomic determinants of health, such as restricted access to behavioral healthcare, linguistic obstacles, economic instability, and mental health stigma, may lead to postponed treatment and exacerbated symptoms. This capstone project suggests a nurse-led, 2-minute deep breathing educational intervention as a viable, cost-effective, and evidence-based approach to assist adults with mild anxiety symptoms in a community primary care clinic in Miami-Dade County. The intervention, principally informed by Orem’s Self-Care Deficit Nursing Theory and reinforced by Lewin’s Change Theory, fosters patient self-management and facilitates integration into standard nursing practice. The proposed intervention is pragmatic, achievable within an eight-week academic timeframe, and possesses the capacity to enhance patient-reported anxiety symptoms while promoting overall emotional well-being. Educational interventions in primary care may enhance quality of life and mitigate the course of anxiety symptoms when implemented early in treatment.
**References**
Balban, M. Y., Neri, E., Kogon, M. M., Weed, L., Nouriani, B., Jo, B., Holl, G., Zeitzer, J. M., Spiegel, D., & Huberman, A. D. (2023). Brief structured respiration practices enhance mood and reduce physiological arousal.
_Cell Reports Medicine_,
_4_(1), 1–15. https://doi.org/10.1016/j.xcrm.2022.100895
Banushi, B., Brendle, M., Ragnhildstveit, A., Murphy, T., Moore, C., Egberts, J., & Robison, R. (2023). Breathwork Interventions for Adults with Clinically Diagnosed Anxiety Disorders: A Scoping Review.
_Brain Sciences_,
_13_(2), 256. https://doi.org/10.3390/brainsci13020256
Bekaert, S. (2025). Repositioning health education as a core nursing function: a commentary.
_Journal of Research in Nursing_. https://doi.org/10.1177/17449871251358627
Forcén, F. E., Flórez, M. C. V., Medina, R. B., Zambrano, J., Pérez, J. H., Rodríguez, A. M., & Santos, L. H. (2023). Deconstructing cultural aspects of mental health care in Hispanic/Latinx people.
_Psychiatric Annals_,
_53_(3), 127–132. https://doi.org/10.3928/00485713-20230215-02
Harrison, R., Fischer, S., Walpola, R. L., Chauhan, A., Babalola, T., Mears, S., & Le-Dao, H. (2021). Where Do Models for Change management, Improvement and Implementation meet? a Systematic Review of the Applications of Change Management Models in Healthcare.
_Journal of Healthcare Leadership_,
_13_(2), 85–108. https://doi.org/10.2147/JHL.S289176
Magnon, V., Dutheil, F., & Vallet, G. T. (2021). Benefits from one session of deep and slow breathing on vagal tone and anxiety in young and older adults.
_Scientific Reports_,
_11_(1). https://doi.org/10.1038/s41598-021-98736-9
National Institute of Mental Health. (2024).
_Any Anxiety Disorder_. Www.nimh.nih.gov; National Institute of Mental Health. https://www.nimh.nih.gov/health/statistics/any-anxiety-disorder
Terlizzi, E. P., & Zablotsky, B. (2024). Symptoms of Anxiety and Depression Among Adults: United States, 2019 and 2022.
_National Health Statistics Reports_,
_213_, CS353885. https://doi.org/10.15620/cdc/64018
U.S Census Bureau. (2025).
_QuickFacts: Miami-Dade County, Florida_. Census Bureau QuickFacts; United States Census Bureau. https://www.census.gov/quickfacts/fact/table/miamidadecountyflorida/BZA115223
**## Attemptfeedback.docx**
Attempt feedback
Overall, you did well. The Capstone should focus in one clinic setting within Miami-Dade to make it realistic. In the Review of Literature, expand on what you have already found but in futher details.
**## CapstonePartIIintrucctions.docx**
Capstone Part II: Review of Literature
**CAPSTONE: PART II due 10/4/2025 by 11:59pm**
1. Review of Literature:
– Review and discuss literature: Synthesize at least 10 primary research studies and/or systematic reviews; do not include summary articles. This section is all about the scientific evidence rather than someone else's opinion of the evidence. Do not use secondary sources; you need to get the article, read it, and make your own decision about quality and applicability to your question even if you did find out about the study in a review of the literature. This is a synthesis rather than a study-by-study review. Address the similarities, differences, and controversies in the body of evidence.
2. Analyze and apply knowledge directly to your PICOT- The studies that you cite in this section must relate directly to your PICOT question.
3. Provide precise body of evidence for your Practice Change- Include Nurses as leaders in this project, statistics, cost, impact on healthcare.
4. Discuss objectives for your practice change, Why is change necessary?
5. Discuss where the problem exists, why it exists, what is the preposition for change. Include information from your PICOT.
6. Apply all that is relevant to the problem. For example: Pros vs Cons, current state of problem
NOTE: It should not reflect your opinion, but rather Evidence Based Practice should be applied
-After completing a literature search on interventions addressing your chosen health problem, write a review that evaluates the strengths and weaknesses of all the sources you have found, compare anc constrast.
-Use appropriate APA 7th Ed. Scholarly, peer-reviewed, and research articles cited should be within the last five years.
-This section should be minimum 4-6 pages long (not including the title and reference page).
-Use proper in-text citations with a properly formatted reference list.
-All papers must be written APA in the 3rd person.
**Rubric Capstone II.docx**
**Submission**
Text Editor
_Word count: 0_
**Drag files here**
Maximum size: 512 MB
**or**
**Details & Information**
CRITERIA OUTSTANDING VERY GOOD GOOD UNACCEPTABLE
Integration of
Knowledge
25 points
Thoroughly selected
and present an
appropriate
Evidence Based
Practice for the
health problem and
change.
25
Briefly selected and
present an
appropriate
Evidence Based
Practice for the
health problem and
change.
20
Vaguely selected
and present an
appropriate
Evidence Based
Practice for the
health problem and
change.
15
Did not select and
present an
appropriate
Evidence Based
Practice for the
health problem and
change.
0
Topic Focus
25 points
The health problem
is focused narrowly
enough for the
scope of this
assignment. A topic
statement provides
direction for the
paper. The topic is
consistently well
thought out,
thorough offers
insight into the topic,
and includes cited
evidence to support
the topic.
25
The health problem
is focused but
lacks direction. The
paper is about a
specific topic, but
the writer has not
established a
position. The topic
is somewhat well
thought out, offers
limited insight into
the topic, but does
not include cited
evidence to support
the topic.
20
The health problem
is too broad for the
scope of this
assignment.
15
The health problem
is unclear or
unrelated to the
discussion topic
with little or no
supporting
evidence.
0
Depth of
Discussion and
Cohesiveness
25 points
In-depth discussion
and elaboration in all
sections of the
paper.
Ties together
information from all
sources. Paper flows
from one issue to
the next with no
headings. The
author’s writing
demonstrates an
understanding of the
relationship among
material obtained
from all sources
Mostly, it ties
together information
from all sources.
In-depth discussion
and elaboration in
most sections of
the paper.
Mostly, it ties
together
information from all
sources. Paper
flows with only
some
disjointedness. The
author’s writing
demonstrates an
understanding of
the relationship
among material
obtained from all
sources.
The writer has
omitted content.
Quotations from
others outweigh the
writer’s own ideas
excessively.
Sometimes ties
together
information from all
sources. The paper
does not flow.
Disjointedness is
apparent. The
author’s writing
does not
demonstrate an
understanding of
the relationship
between material
obtained from all
sources.
Cursory discussion
in all the sections
of the paper or brief
discussion in only a
few sections.
It does not tie
together
information. Paper
does not flow and
appears to be
created from
disparate issues.
Headings are
necessary to link
concepts. Writing
does not
demonstrate an
understanding of
any relationship.
25 20
15
0
Spelling and
Grammar
10 points
Fewer than 5
grammatical,
spelling,
capitalization, or
punctuation errors.
Required word count
has been met.
8
More than 5 but
fewer than 10
grammatical,
spelling,
capitalization &
punctuation errors
Required word
count is 25 words
below the minimum
required count.
6
More than 10
grammatical,
spelling,
capitalization &
punctuation errors
Required word
count is 50 words
below the minimum
required count.
5
An unacceptable
number of spelling
and/or grammar
mistakes.
Required word
count is more than
50 words below the
minimum required
count.
0
Sources
10 points
Over 5 current
sources, of which at
least 3 are peer-
review journal
articles or scholarly
books. Sources
include both general
background sources
and specialized
sources. Special-
interest sources and
popular literature
and acknowledged
as such if they are
cited. All websites
utilized are
authoritative.
5 current sources,
of which at least 2
are peer-review
journal articles or
scholarly books. All
websites utilized
are authoritative.
Fewer than 5
current sources or
fewer than 2 of 5
are peer-reviewed
journal articles or
scholarly books. All
websites utilized
are credible.
Fewer than 5
current sources or
fewer than 2 of 5
are peer-reviewed
journal articles or
scholarly books.
Not all websites
utilized are credible,
and/or sources are
not current.
Citations
5 points
Fewer than 5
incomplete citations
and/or quotations,
and APA format
errors
5
More than 5 but
fewer than 10
incomplete
citations and/or
quotations, and
APA format errors.
4
More than 10
incomplete
citations and/or
quotations, or APA
format errors.
3
The citation style is
inconsistent or
incorrect. It does
not cite sources.
**## CapstoneProject1.docx**
2
**Nurse-Led Deep Breathing Intervention to Reduce Mild Anxiety in Adult Primary Care Patients in a Community Clinic in Miami-Dade County**
Anisleidy Alvarez
Florida National University
MSN Capstone Project-DAX-DL01
Dr. Carmen Lazo
May 23, 2026
**Nurse-Led Deep Breathing Intervention to Reduce Mild Anxiety in Adult Primary Care Patients in a Community Clinic in Miami-Dade County**
Anxiety disorders are among the most common conditions among adult patients in the United States and are poorly treated in primary care. The National Center for Health Statistics reports that in 2022, about one in five of adults aged 18 and older had symptoms of anxiety, with the highest rates found in younger adults and in people living in lower-income households (Terlizzi & Zablotsky, 2024). It's not only an individual problem as anxiety also creates significant health care expenses. Anxiety disorders collectively cost the United States healthcare system tens of billions of dollars per year, with increased emergency department visits, unnecessary specialist referrals, and diminished workforce productivity (Banushi et al., 2023).
Even with this high prevalence, mild anxiety is often underdiagnosed and is not adequately treated in primary care, where most persons with anxiety symptoms seek care. Mild anxiety patients who do not receive treatment are at great risk of the symptoms escalating to more severe anxiety, poor functioning and more frequent use of emergency services. Poor anxiety regulation also has a negative impact on treatment adherence of comorbid physical conditions, increasing healthcare utilization and costs.
The purpose of this capstone project is to evaluate whether a nurse-led 2-minute deep breathing educational intervention improves self-reported anxiety symptoms among adults with mild anxiety symptoms receiving care in a community primary care clinic in Miami-Dade County over an eight-week period. The proposed intervention aims to provide a simple, low-cost, evidence-based strategy that promotes self-management and improves emotional well-being in a vulnerable population.
**PICOT**
The prevalence of mild anxiety is a topic of increasing clinical interest in outpatient primary care, especially in diverse, urban communities where care for mental health is scarce. The following PICOT question guides this capstone project:
_In adult patients presenting with mild anxiety symptoms in a community primary care clinic in Miami-Dade County (P), does teaching a 2-minute nurse-led deep breathing exercise (I), compared to no structured breathing intervention (C), reduce self-reported anxiety levels (O) over eight weeks (T)?_
The population includes adults 18 years and older with mild anxiety symptoms presenting to primary care clinics in Miami-Dade County. This population often has limited access to mental health specialists and limited structured anxiety management during regular clinic visits.
The intervention is a brief 2-minute-deep breathing technique to be taught by the nurse to each patient at the clinic visit, combined with an instructional card to be printed and given to the patient for practicing at home. Controlled breathing is effective at engaging the Parasympathetic Nervous System (PNS) which reduces the physiological stress response and self-reported anxiety (Magnon et al., 2021). The comparison is standard care, which means routine clinical management without any structured breathing instruction.
The expected outcome is improvement in patient-reported anxiety symptoms following implementation of the nurse-led intervention. When available, Patient-reported symptom improvement may be discussed during routine follow-up visits as part of standard patient care. May be used as part of standard clinical assessment to monitor symptom improvement. Studies have shown that brief, structured breathwork exercises show significant decrease in physiological arousal and increase of mood compared to control conditions (Balban et al., 2023). The eight weeks is a reasonable amount of time to observe regular practice effects and is convenient in a capstone course that is structured on a semester basis.
**Vulnerable Population and Setting**
The target population for this intervention includes adults with mild anxiety symptoms receiving care in community primary care clinics in Miami-Dade County, Florida. This population often experiences multiple social and healthcare barriers that may contribute to delayed recognition and treatment of anxiety symptoms. Many adults receiving care in community clinics may have coexisting chronic conditions, limited access to mental health specialists, and limited exposure to structured behavioral health interventions during routine primary care visits. As a result, primary care settings frequently serve as the first and sometimes only point of access for individuals seeking support for mental health concerns.
Miami-Dade County has a population that is one of the most culturally and linguistically diverse in the United States, with over 70% of the county's residents identifying as Hispanic and/or Latino (U.S Census Bureau, 2025). The stigma attached to mental health, low mental health literacy and a preference for physical explanations of distress over psychiatric explanations are commonly mentioned as cultural factors hindering help-seeking in this population (Forcén et al., 2023). Structural factors are also constraints to receiving mental health treatment: language, insurance status, cost of treatment, and transportation. The evidence shows that Hispanic and Latino adults are much less likely than adults of other races and ethnicities to receive mental health care, despite having clinically meaningful symptoms (Forcén et al., 2023).
Anxiety disorders affect nearly one in five adults nationwide and is one of the most underdiagnosed conditions in primary care, with studies showing that only approximately 20% of affected patients receive appropriate treatment (Banushi et al., 2023; National Institute of Mental Health, 2024). Social determinants of health add to vulnerability in Miami-Dade and further increase this gap. A stressful urban environment, the economic instability, stressors related to immigration, and social isolation make the situation ripe for anxiety symptoms to continue and intensify without some degree of intervention. A straightforward, low cost, culturally appropriate approach, like deep breathing led by nurses, is therefore clinically appropriate and highly needed for this population.
**Proposal and Intervention Plan**
The proposed intervention is a 2-minute-deep breathing exercise taught to each adult patients with mild anxiety symptoms by a trained nurse during his or her usual primary care clinic in a community clinic in Miami-Dade County. The intervention includes instruction on slow diaphragmatic breathing with controlled inhalation and prolonged exhalation, an approach shown to promote relaxation and reduce anxiety-related physiological arousal through activation of the parasympathetic nervous system .The educational session is delivered individually by the nurse at the point of care and requires minimal time to implement during routine patient education. Patients will also receive a bilingual educational handout to encourage continued practice of the breathing technique at home. (Magnon et al., 2021).
The resources required for implementation are minimal and include printed bilingual instruction cards, a standardized nurse teaching script, and a brief staff orientation session. It does not require a special setup or extra space and is very easy to do in a busy outpatient clinic.
The proposed intervention is low-cost and feasible for implementation in a community primary care clinic. Resources required include printed bilingual educational handouts for patients, estimated at approximately $50 to $75, and a brief staff orientation session incorporated into regular nursing meetings without additional staffing expenses. Because the intervention is integrated into routine patient education, no additional personnel or specialized equipment are required. The low-cost nature of this intervention supports feasibility within an eight-week academic semester timeline.
Involved in the intervention are bedside registered nurses teaching, Advanced practice nurses managing the intervention and adherence to the protocol, and the primary care physicians who identify patients during clinic visits. Clinic administrative staff support scheduling and patient education coordination and scheduling support.
The implementation timeline takes place in three phases. In week 1 and 2 staff education takes place, and all patient materials are prepared and printed. From week 3 to 6, the nurses teach deep breathing techniques to patients during their routine clinic visits, and the patients practice deep breathing at home with the deep breathing instruction card. During weeks 7 and 8, nurses will reinforce patient education and encourage continued use of the deep breathing technique during routine follow-up visits.
**Theoretical Framework**
This capstone project is largely based on Dorothea Orem's Self-Care Deficit Nursing Theory. Nurses in Orem's framework are educators who recognize the patient's deficits in self-care and fill that gap with knowledge and skills so that the patient can maintain his or her health independently. According to Bekaert (2025) health education is a component of nursing, which is built upon Orem's theory, in which the nurse assists individuals in meeting their self-care needs by demonstrating and facilitating their ability to cope with stress and manage their emotional state. The 2-minute-deep breathing exercise directly targets the patient's self-care deficit by offering a practical and repeatable tool that patients can use independently to help with mild anxiety symptoms outside of the clinic and at the end of the intervention period.
The intervention is implemented at the organizational level in the clinic, using Kurt Lewin's Change Theory. Lewin's model has three stages; Unfreezing, Change and Refreezing. In unfreezing, clinic staff are taught about the high prevalence of undiagnosed and unmanaged anxiety and the evidence supporting brief breathing techniques. The deep breathing teaching educational approach is introduced into regular nursing practice during the change phase. During the refreezing stage, the nurse-led deep breathing educational approach may become incorporated into routine patient education for adults with mild anxiety symptoms, supporting sustainability beyond the capstone timeline. Lewin's model is one of the most commonly used models in nurse-led change in healthcare organizations as it provides a simple structure to help guide complex changes to practice (Harrison et al., 2021). Combined, Orem's and Lewin's models guarantee the patient-centered and organizationally sustainable nature of the intervention. Orem leads direct patient care and Lewin leads institutional change for sustaining it.
**Conclusion**
Mild anxiety symptoms in people within primary care settings are prevalent, sometimes overlooked, and linked to diminished quality of life and heightened healthcare usage, especially among vulnerable groups facing obstacles to mental healthcare access. In culturally diverse areas like Miami-Dade County, socioeconomic determinants of health, such as restricted access to behavioral healthcare, linguistic obstacles, economic instability, and mental health stigma, may lead to postponed treatment and exacerbated symptoms. This capstone project suggests a nurse-led, 2-minute deep breathing educational intervention as a viable, cost-effective, and evidence-based approach to assist adults with mild anxiety symptoms in a community primary care clinic in Miami-Dade County. The intervention, principally informed by Orem’s Self-Care Deficit Nursing Theory and reinforced by Lewin’s Change Theory, fosters patient self-management and facilitates integration into standard nursing practice. The proposed intervention is pragmatic, achievable within an eight-week academic timeframe, and possesses the capacity to enhance patient-reported anxiety symptoms while promoting overall emotional well-being. Educational interventions in primary care may enhance quality of life and mitigate the course of anxiety symptoms when implemented early in treatment.
**References**
Balban, M. Y., Neri, E., Kogon, M. M., Weed, L., Nouriani, B., Jo, B., Holl, G., Zeitzer, J. M., Spiegel, D., & Huberman, A. D. (2023). Brief structured respiration practices enhance mood and reduce physiological arousal.
_Cell Reports Medicine_,
_4_(1), 1–15. https://doi.org/10.1016/j.xcrm.2022.100895
Banushi, B., Brendle, M., Ragnhildstveit, A., Murphy, T., Moore, C., Egberts, J., & Robison, R. (2023). Breathwork Interventions for Adults with Clinically Diagnosed Anxiety Disorders: A Scoping Review.
_Brain Sciences_,
_13_(2), 256. https://doi.org/10.3390/brainsci13020256
Bekaert, S. (2025). Repositioning health education as a core nursing function: a commentary.
_Journal of Research in Nursing_. https://doi.org/10.1177/17449871251358627
Forcén, F. E., Flórez, M. C. V., Medina, R. B., Zambrano, J., Pérez, J. H., Rodríguez, A. M., & Santos, L. H. (2023). Deconstructing cultural aspects of mental health care in Hispanic/Latinx people.
_Psychiatric Annals_,
_53_(3), 127–132. https://doi.org/10.3928/00485713-20230215-02
Harrison, R., Fischer, S., Walpola, R. L., Chauhan, A., Babalola, T., Mears, S., & Le-Dao, H. (2021). Where Do Models for Change management, Improvement and Implementation meet? a Systematic Review of the Applications of Change Management Models in Healthcare.
_Journal of Healthcare Leadership_,
_13_(2), 85–108. https://doi.org/10.2147/JHL.S289176
Magnon, V., Dutheil, F., & Vallet, G. T. (2021). Benefits from one session of deep and slow breathing on vagal tone and anxiety in young and older adults.
_Scientific Reports_,
_11_(1). https://doi.org/10.1038/s41598-021-98736-9
National Institute of Mental Health. (2024).
_Any Anxiety Disorder_. Www.nimh.nih.gov; National Institute of Mental Health. https://www.nimh.nih.gov/health/statistics/any-anxiety-disorder
Terlizzi, E. P., & Zablotsky, B. (2024). Symptoms of Anxiety and Depression Among Adults: United States, 2019 and 2022.
_National Health Statistics Reports_,
_213_, CS353885. https://doi.org/10.15620/cdc/64018
U.S Census Bureau. (2025).
_QuickFacts: Miami-Dade County, Florida_. Census Bureau QuickFacts; United States Census Bureau. https://www.census.gov/quickfacts/fact/table/miamidadecountyflorida/BZA115223
**## Attemptfeedback.docx**
Attempt feedback
Overall, you did well. The Capstone should focus in one clinic setting within Miami-Dade to make it realistic. In the Review of Literature, expand on what you have already found but in futher details.
**## CapstonePartIIintrucctions.docx**
Capstone Part II: Review of Literature
**CAPSTONE: PART II due 10/4/2025 by 11:59pm**
1. Review of Literature:
– Review and discuss literature: Synthesize at least 10 primary research studies and/or systematic reviews; do not include summary articles. This section is all about the scientific evidence rather than someone else's opinion of the evidence. Do not use secondary sources; you need to get the article, read it, and make your own decision about quality and applicability to your question even if you did find out about the study in a review of the literature. This is a synthesis rather than a study-by-study review. Address the similarities, differences, and controversies in the body of evidence.
2. Analyze and apply knowledge directly to your PICOT- The studies that you cite in this section must relate directly to your PICOT question.
3. Provide precise body of evidence for your Practice Change- Include Nurses as leaders in this project, statistics, cost, impact on healthcare.
4. Discuss objectives for your practice change, Why is change necessary?
5. Discuss where the problem exists, why it exists, what is the preposition for change. Include information from your PICOT.
6. Apply all that is relevant to the problem. For example: Pros vs Cons, current state of problem
NOTE: It should not reflect your opinion, but rather Evidence Based Practice should be applied
-After completing a literature search on interventions addressing your chosen health problem, write a review that evaluates the strengths and weaknesses of all the sources you have found, compare anc constrast.
-Use appropriate APA 7th Ed. Scholarly, peer-reviewed, and research articles cited should be within the last five years.
-This section should be minimum 4-6 pages long (not including the title and reference page).
-Use proper in-text citations with a properly formatted reference list.
-All papers must be written APA in the 3rd person.
**Rubric Capstone II.docx**
**Submission**
Text Editor
_Word count: 0_
**Drag files here**
Maximum size: 512 MB
**or**
**Details & Information**
CRITERIA OUTSTANDING VERY GOOD GOOD UNACCEPTABLE
Integration of
Knowledge
25 points
Thoroughly selected
and present an
appropriate
Evidence Based
Practice for the
health problem and
change.
25
Briefly selected and
present an
appropriate
Evidence Based
Practice for the
health problem and
change.
20
Vaguely selected
and present an
appropriate
Evidence Based
Practice for the
health problem and
change.
15
Did not select and
present an
appropriate
Evidence Based
Practice for the
health problem and
change.
0
Topic Focus
25 points
The health problem
is focused narrowly
enough for the
scope of this
assignment. A topic
statement provides
direction for the
paper. The topic is
consistently well
thought out,
thorough offers
insight into the topic,
and includes cited
evidence to support
the topic.
25
The health problem
is focused but
lacks direction. The
paper is about a
specific topic, but
the writer has not
established a
position. The topic
is somewhat well
thought out, offers
limited insight into
the topic, but does
not include cited
evidence to support
the topic.
20
The health problem
is too broad for the
scope of this
assignment.
15
The health problem
is unclear or
unrelated to the
discussion topic
with little or no
supporting
evidence.
0
Depth of
Discussion and
Cohesiveness
25 points
In-depth discussion
and elaboration in all
sections of the
paper.
Ties together
information from all
sources. Paper flows
from one issue to
the next with no
headings. The
author’s writing
demonstrates an
understanding of the
relationship among
material obtained
from all sources
Mostly, it ties
together information
from all sources.
In-depth discussion
and elaboration in
most sections of
the paper.
Mostly, it ties
together
information from all
sources. Paper
flows with only
some
disjointedness. The
author’s writing
demonstrates an
understanding of
the relationship
among material
obtained from all
sources.
The writer has
omitted content.
Quotations from
others outweigh the
writer’s own ideas
excessively.
Sometimes ties
together
information from all
sources. The paper
does not flow.
Disjointedness is
apparent. The
author’s writing
does not
demonstrate an
understanding of
the relationship
between material
obtained from all
sources.
Cursory discussion
in all the sections
of the paper or brief
discussion in only a
few sections.
It does not tie
together
information. Paper
does not flow and
appears to be
created from
disparate issues.
Headings are
necessary to link
concepts. Writing
does not
demonstrate an
understanding of
any relationship.
25 20
15
0
Spelling and
Grammar
10 points
Fewer than 5
grammatical,
spelling,
capitalization, or
punctuation errors.
Required word count
has been met.
8
More than 5 but
fewer than 10
grammatical,
spelling,
capitalization &
punctuation errors
Required word
count is 25 words
below the minimum
required count.
6
More than 10
grammatical,
spelling,
capitalization &
punctuation errors
Required word
count is 50 words
below the minimum
required count.
5
An unacceptable
number of spelling
and/or grammar
mistakes.
Required word
count is more than
50 words below the
minimum required
count.
0
Sources
10 points
Over 5 current
sources, of which at
least 3 are peer-
review journal
articles or scholarly
books. Sources
include both general
background sources
and specialized
sources. Special-
interest sources and
popular literature
and acknowledged
as such if they are
cited. All websites
utilized are
authoritative.
5 current sources,
of which at least 2
are peer-review
journal articles or
scholarly books. All
websites utilized
are authoritative.
Fewer than 5
current sources or
fewer than 2 of 5
are peer-reviewed
journal articles or
scholarly books. All
websites utilized
are credible.
Fewer than 5
current sources or
fewer than 2 of 5
are peer-reviewed
journal articles or
scholarly books.
Not all websites
utilized are credible,
and/or sources are
not current.
Citations
5 points
Fewer than 5
incomplete citations
and/or quotations,
and APA format
errors
5
More than 5 but
fewer than 10
incomplete
citations and/or
quotations, and
APA format errors.
4
More than 10
incomplete
citations and/or
quotations, or APA
format errors.
3
The citation style is
inconsistent or
incorrect. It does
not cite sources.
**## CapstoneProject1.docx**
2
**Nurse-Led Deep Breathing Intervention to Reduce Mild Anxiety in Adult Primary Care Patients in a Community Clinic in Miami-Dade County**
Anisleidy Alvarez
Florida National University
MSN Capstone Project-DAX-DL01
Dr. Carmen Lazo
May 23, 2026
**Nurse-Led Deep Breathing Intervention to Reduce Mild Anxiety in Adult Primary Care Patients in a Community Clinic in Miami-Dade County**
Anxiety disorders are among the most common conditions among adult patients in the United States and are poorly treated in primary care. The National Center for Health Statistics reports that in 2022, about one in five of adults aged 18 and older had symptoms of anxiety, with the highest rates found in younger adults and in people living in lower-income households (Terlizzi & Zablotsky, 2024). It's not only an individual problem as anxiety also creates significant health care expenses. Anxiety disorders collectively cost the United States healthcare system tens of billions of dollars per year, with increased emergency department visits, unnecessary specialist referrals, and diminished workforce productivity (Banushi et al., 2023).
Even with this high prevalence, mild anxiety is often underdiagnosed and is not adequately treated in primary care, where most persons with anxiety symptoms seek care. Mild anxiety patients who do not receive treatment are at great risk of the symptoms escalating to more severe anxiety, poor functioning and more frequent use of emergency services. Poor anxiety regulation also has a negative impact on treatment adherence of comorbid physical conditions, increasing healthcare utilization and costs.
The purpose of this capstone project is to evaluate whether a nurse-led 2-minute deep breathing educational intervention improves self-reported anxiety symptoms among adults with mild anxiety symptoms receiving care in a community primary care clinic in Miami-Dade County over an eight-week period. The proposed intervention aims to provide a simple, low-cost, evidence-based strategy that promotes self-management and improves emotional well-being in a vulnerable population.
**PICOT**
The prevalence of mild anxiety is a topic of increasing clinical interest in outpatient primary care, especially in diverse, urban communities where care for mental health is scarce. The following PICOT question guides this capstone project:
_In adult patients presenting with mild anxiety symptoms in a community primary care clinic in Miami-Dade County (P), does teaching a 2-minute nurse-led deep breathing exercise (I), compared to no structured breathing intervention (C), reduce self-reported anxiety levels (O) over eight weeks (T)?_
The population includes adults 18 years and older with mild anxiety symptoms presenting to primary care clinics in Miami-Dade County. This population often has limited access to mental health specialists and limited structured anxiety management during regular clinic visits.
The intervention is a brief 2-minute-deep breathing technique to be taught by the nurse to each patient at the clinic visit, combined with an instructional card to be printed and given to the patient for practicing at home. Controlled breathing is effective at engaging the Parasympathetic Nervous System (PNS) which reduces the physiological stress response and self-reported anxiety (Magnon et al., 2021). The comparison is standard care, which means routine clinical management without any structured breathing instruction.
The expected outcome is improvement in patient-reported anxiety symptoms following implementation of the nurse-led intervention. When available, Patient-reported symptom improvement may be discussed during routine follow-up visits as part of standard patient care. May be used as part of standard clinical assessment to monitor symptom improvement. Studies have shown that brief, structured breathwork exercises show significant decrease in physiological arousal and increase of mood compared to control conditions (Balban et al., 2023). The eight weeks is a reasonable amount of time to observe regular practice effects and is convenient in a capstone course that is structured on a semester basis.
**Vulnerable Population and Setting**
The target population for this intervention includes adults with mild anxiety symptoms receiving care in community primary care clinics in Miami-Dade County, Florida. This population often experiences multiple social and healthcare barriers that may contribute to delayed recognition and treatment of anxiety symptoms. Many adults receiving care in community clinics may have coexisting chronic conditions, limited access to mental health specialists, and limited exposure to structured behavioral health interventions during routine primary care visits. As a result, primary care settings frequently serve as the first and sometimes only point of access for individuals seeking support for mental health concerns.
Miami-Dade County has a population that is one of the most culturally and linguistically diverse in the United States, with over 70% of the county's residents identifying as Hispanic and/or Latino (U.S Census Bureau, 2025). The stigma attached to mental health, low mental health literacy and a preference for physical explanations of distress over psychiatric explanations are commonly mentioned as cultural factors hindering help-seeking in this population (Forcén et al., 2023). Structural factors are also constraints to receiving mental health treatment: language, insurance status, cost of treatment, and transportation. The evidence shows that Hispanic and Latino adults are much less likely than adults of other races and ethnicities to receive mental health care, despite having clinically meaningful symptoms (Forcén et al., 2023).
Anxiety disorders affect nearly one in five adults nationwide and is one of the most underdiagnosed conditions in primary care, with studies showing that only approximately 20% of affected patients receive appropriate treatment (Banushi et al., 2023; National Institute of Mental Health, 2024). Social determinants of health add to vulnerability in Miami-Dade and further increase this gap. A stressful urban environment, the economic instability, stressors related to immigration, and social isolation make the situation ripe for anxiety symptoms to continue and intensify without some degree of intervention. A straightforward, low cost, culturally appropriate approach, like deep breathing led by nurses, is therefore clinically appropriate and highly needed for this population.
**Proposal and Intervention Plan**
The proposed intervention is a 2-minute-deep breathing exercise taught to each adult patients with mild anxiety symptoms by a trained nurse during his or her usual primary care clinic in a community clinic in Miami-Dade County. The intervention includes instruction on slow diaphragmatic breathing with controlled inhalation and prolonged exhalation, an approach shown to promote relaxation and reduce anxiety-related physiological arousal through activation of the parasympathetic nervous system .The educational session is delivered individually by the nurse at the point of care and requires minimal time to implement during routine patient education. Patients will also receive a bilingual educational handout to encourage continued practice of the breathing technique at home. (Magnon et al., 2021).
The resources required for implementation are minimal and include printed bilingual instruction cards, a standardized nurse teaching script, and a brief staff orientation session. It does not require a special setup or extra space and is very easy to do in a busy outpatient clinic.
The proposed intervention is low-cost and feasible for implementation in a community primary care clinic. Resources required include printed bilingual educational handouts for patients, estimated at approximately $50 to $75, and a brief staff orientation session incorporated into regular nursing meetings without additional staffing expenses. Because the intervention is integrated into routine patient education, no additional personnel or specialized equipment are required. The low-cost nature of this intervention supports feasibility within an eight-week academic semester timeline.
Involved in the intervention are bedside registered nurses teaching, Advanced practice nurses managing the intervention and adherence to the protocol, and the primary care physicians who identify patients during clinic visits. Clinic administrative staff support scheduling and patient education coordination and scheduling support.
The implementation timeline takes place in three phases. In week 1 and 2 staff education takes place, and all patient materials are prepared and printed. From week 3 to 6, the nurses teach deep breathing techniques to patients during their routine clinic visits, and the patients practice deep breathing at home with the deep breathing instruction card. During weeks 7 and 8, nurses will reinforce patient education and encourage continued use of the deep breathing technique during routine follow-up visits.
**Theoretical Framework**
This capstone project is largely based on Dorothea Orem's Self-Care Deficit Nursing Theory. Nurses in Orem's framework are educators who recognize the patient's deficits in self-care and fill that gap with knowledge and skills so that the patient can maintain his or her health independently. According to Bekaert (2025) health education is a component of nursing, which is built upon Orem's theory, in which the nurse assists individuals in meeting their self-care needs by demonstrating and facilitating their ability to cope with stress and manage their emotional state. The 2-minute-deep breathing exercise directly targets the patient's self-care deficit by offering a practical and repeatable tool that patients can use independently to help with mild anxiety symptoms outside of the clinic and at the end of the intervention period.
The intervention is implemented at the organizational level in the clinic, using Kurt Lewin's Change Theory. Lewin's model has three stages; Unfreezing, Change and Refreezing. In unfreezing, clinic staff are taught about the high prevalence of undiagnosed and unmanaged anxiety and the evidence supporting brief breathing techniques. The deep breathing teaching educational approach is introduced into regular nursing practice during the change phase. During the refreezing stage, the nurse-led deep breathing educational approach may become incorporated into routine patient education for adults with mild anxiety symptoms, supporting sustainability beyond the capstone timeline. Lewin's model is one of the most commonly used models in nurse-led change in healthcare organizations as it provides a simple structure to help guide complex changes to practice (Harrison et al., 2021). Combined, Orem's and Lewin's models guarantee the patient-centered and organizationally sustainable nature of the intervention. Orem leads direct patient care and Lewin leads institutional change for sustaining it.
**Conclusion**
Mild anxiety symptoms in people within primary care settings are prevalent, sometimes overlooked, and linked to diminished quality of life and heightened healthcare usage, especially among vulnerable groups facing obstacles to mental healthcare access. In culturally diverse areas like Miami-Dade County, socioeconomic determinants of health, such as restricted access to behavioral healthcare, linguistic obstacles, economic instability, and mental health stigma, may lead to postponed treatment and exacerbated symptoms. This capstone project suggests a nurse-led, 2-minute deep breathing educational intervention as a viable, cost-effective, and evidence-based approach to assist adults with mild anxiety symptoms in a community primary care clinic in Miami-Dade County. The intervention, principally informed by Orem’s Self-Care Deficit Nursing Theory and reinforced by Lewin’s Change Theory, fosters patient self-management and facilitates integration into standard nursing practice. The proposed intervention is pragmatic, achievable within an eight-week academic timeframe, and possesses the capacity to enhance patient-reported anxiety symptoms while promoting overall emotional well-being. Educational interventions in primary care may enhance quality of life and mitigate the course of anxiety symptoms when implemented early in treatment.
**References**
Balban, M. Y., Neri, E., Kogon, M. M., Weed, L., Nouriani, B., Jo, B., Holl, G., Zeitzer, J. M., Spiegel, D., & Huberman, A. D. (2023). Brief structured respiration practices enhance mood and reduce physiological arousal.
_Cell Reports Medicine_,
_4_(1), 1–15. https://doi.org/10.1016/j.xcrm.2022.100895
Banushi, B., Brendle, M., Ragnhildstveit, A., Murphy, T., Moore, C., Egberts, J., & Robison, R. (2023). Breathwork Interventions for Adults with Clinically Diagnosed Anxiety Disorders: A Scoping Review.
_Brain Sciences_,
_13_(2), 256. https://doi.org/10.3390/brainsci13020256
Bekaert, S. (2025). Repositioning health education as a core nursing function: a commentary.
_Journal of Research in Nursing_. https://doi.org/10.1177/17449871251358627
Forcén, F. E., Flórez, M. C. V., Medina, R. B., Zambrano, J., Pérez, J. H., Rodríguez, A. M., & Santos, L. H. (2023). Deconstructing cultural aspects of mental health care in Hispanic/Latinx people.
_Psychiatric Annals_,
_53_(3), 127–132. https://doi.org/10.3928/00485713-20230215-02
Harrison, R., Fischer, S., Walpola, R. L., Chauhan, A., Babalola, T., Mears, S., & Le-Dao, H. (2021). Where Do Models for Change management, Improvement and Implementation meet? a Systematic Review of the Applications of Change Management Models in Healthcare.
_Journal of Healthcare Leadership_,
_13_(2), 85–108. https://doi.org/10.2147/JHL.S289176
Magnon, V., Dutheil, F., & Vallet, G. T. (2021). Benefits from one session of deep and slow breathing on vagal tone and anxiety in young and older adults.
_Scientific Reports_,
_11_(1). https://doi.org/10.1038/s41598-021-98736-9
National Institute of Mental Health. (2024).
_Any Anxiety Disorder_. Www.nimh.nih.gov; National Institute of Mental Health. https://www.nimh.nih.gov/health/statistics/any-anxiety-disorder
Terlizzi, E. P., & Zablotsky, B. (2024). Symptoms of Anxiety and Depression Among Adults: United States, 2019 and 2022.
_National Health Statistics Reports_,
_213_, CS353885. https://doi.org/10.15620/cdc/64018
U.S Census Bureau. (2025).
_QuickFacts: Miami-Dade County, Florida_. Census Bureau QuickFacts; United States Census Bureau. https://www.census.gov/quickfacts/fact/table/miamidadecountyflorida/BZA115223