Anxiety is a widespread mental health concern affecting up to one-third of the United States population at some point during an individual’s lifetime 21. Individuals with anxiety disorders often have impairments socially, professionally, and in their physical health 20. National healthcare costs for the management of anxiety disorders are estimated at $46.6 billion annually, 75% of the expenses being attributed to anxiety-related morbidity, mortality, and loss of job productivity 11.  The novel coronavirus of the 2019 (COVID-19) pandemic has increased these statistics globally, with 76 million newly diagnosed cases of anxiety disorders since its onset, with a 25% overall increase in the disorders’ prevalence 9. With the increasing rates of anxiety disorders and the associated healthcare burden, a focus on the diagnosis and treatment of anxiety disorders claims new relevance.

Beyond the economic impact of anxiety disorders, the psychosocial impact on the quality of life is another concern. Mood disorders are often a precursor to substance use disorders. The comorbidity of the two disorders is not only predictive of their presence, but also of their severity, with a more severe mood disorder driving a more problematic or potentially fatal subsequent substance use disorder 16. It is believed that up to 90% of individuals who commit suicide have a psychiatric illness, most frequently a mood disorder 23. Suicide remains the tenth leading cause of death in the United States and the second leading cause of death among Americans ages 10-34, claiming over 47,500 American lives annually 5, and claiming over 700,000 deaths annually worldwide 28. As with any disease process and its related mortality and morbidity rates, investigating contributing risk factors is essential.

Anxiety is assessed utilizing evidence-based standardized screening tools. The Generalized Anxiety Disorder-7 (GAD-7) screening tool assesses anxiety levels using subscale areas of anxiety on a 4-point Likert scale of seven items with scoring ranges from 0 to 21, addressing elements of anxiety including nervousness, irritability, worry, restlessness, and fear 19. Other standardized anxiety screening tools include the State-Trait Anxiety Inventory (STAI), the Hospital Anxiety and Depression Scale (HADS), the Anxiety Depression Stress Scale (ADSS) and the Adult Manifest Anxiety Scale (AMAS) 10. The Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5), gives criteria for diagnosing anxiety disorders 1. Symptoms assessed in this catagory include irritability, worry, fear, restlessness, fatigue, and muscle tension, with these symptoms often causing distress in social functioning 1.

Treatment for anxiety often includes psychopharmaceuticals, which can be effective in reducing anxiety symptoms while potentially introducing bothersome side effects, dependence, and compliance issues 3. Given the large population affected by anxiety, and the obstacles involved with psychopharmacology use, Complementary Alternative Medicine (CAM) has gained interest as a treatment for anxiety. CAM includes modalities such as yoga, meditation, mindfulness, and Reiki. Among these, Reiki is less understood and researched for the potential efficacy in the treatment of anxiety.

Reiki is a form of biofield energy healing, aimed to balance the Chi, or universal energy, within the body 2. Reiki was originally developed in Japan in the 20^th century, as a way of clearing negative energy blockages that prevent the natural flow of this healing energy within the body 12. The Reiki practitioner directs energy from the universe to the recipient in areas where energy blockages are sensed, using systematic hand movements above the recipient’s body 27. Energy imbalances within the recipient are cleared and homeostasis of mind, body and soul are restored, creating a sense of well-being 12. The purpose of this study is to explore what is known about Reiki and its efficacy in treating anxiety, and to answer the PICO question: In patients with anxiety (P), how does the administration of Reiki (I), when compared to the administration of sham Reiki or no intervention (C), affect self-assessed anxiety levels (O)?

Hildegard Peplau was revolutionary in the field of psychiatric nursing. She is described in many accounts as the mother of psychiatric nursing 14. Peplau created the interpersonal relations theory, a model of the nurse-patient relationship that unfolds in three basic phases: orientation, working, and resolution 22. Peplau later expanded on this concept by introducing a model of interpersonal relations that replaced the working phase with two delineated phases: identification and exploitation 14. Peplau identified six essential roles of the nurse within the interpersonal relations model: stranger, teacher, resource person, counselor, surrogate, and leader 18. Peplau was the second published nurse theorist, following Florence Nightingale. Nightingale asserts that nursing cannot be led strictly by empirical science, rather the nurse’s therapeutic use of self is essential to promoting patient well-being 14. Peplau’s conceptual framework can be applied to any area of nursing and fits especially well with the model of care for the psychiatric mental health nurse practitioner (PMHNP).

Patients with anxiety are particularly vulnerable. Easily flooded with overwhelming feelings, both emotional and physiological, they are at risk for termination of treatment if the treatment proves to be too stressful. It is the ethical and professional duty of the PMHNP to establish rapport with the patient and create a foundation of trust in the orientation phase of treatment. Incorporation of Reiki into a patient’s treatment plan fits into Peplau’s phases of nurse-patient relations model, with the role of PMHNP in its process spanning from stranger, to resource person to counselor. If the PMHNP is administering the Reiki therapy, the required, extended proximity to the patient demands a level of trust and respect that is best created with adherence to Peplau’s interpersonal relations theory.

A comprehensive, in-depth critique of the included literature was conducted using step-by-step guidelines 8. Key components of the research believability and robustness were assessed per these guidelines.

Ten quantitative studies were included in this research 24713152124252627. These studies were analyzed using step-by-step guidelines for critiquing quantitative research 8.

Elements that influence the believability of the research include the article’s writing style, author’s credentials, report title’s conciseness, and presence and quality of the abstract 8.

The writing style of the included articles was overall of high-quality. Collectively, the writing was concise and well-organized and free from jargon and grammatical errors.

The authors were well-equipped to conduct studies on anxiety and its treatment. The articles were authored by writers with degrees in nursing, philosophy, psychology, or medicine 2713152124252627. With degrees in medicine, nursing, psychology and philosophy, all writers also were credentialed to participate in studies focusing on Reiki and anxiety. They were similarly equipped to ask appropriate research questions relevant to the study focus 8. One author is an undergraduate student whose major is not stated 4.

Elements of a study that influence the robustness of the research include a clearly stated purpose of the study, logical consistency of the flow of the article’s elements, a comprehensive literature review, theoretical framework to ground the study, objectives that reflect the literature review, appropriate sampling of participants, ethical considerations, and solid methodology of the study with discussion of findings and recommendations for future research 8.

Of the ten studies, two were three-arm pilot studies using a Reiki intervention group, a sham Reiki group, and a standard of care (SOC) control group 24. Sham Reiki utilizes a non-certified layperson to mimic the hand movements of a Reiki practitioner while the recipient lies on a therapy table receiving what appears to be a valid Reiki session 24. Four of the ten studies were two-arm studies, with a Reiki intervention group and a SOC group 7152124. The four remaining studies were single-arm studies assessing only Reiki intervention groups 13252627.

Data collection was conducted through written surveys completed by participants, except for one study, which utilized a verbal survey 4.

Standardized anxiety screenings were utilized in seven of the ten studies 271521242527. The State-Trait Anxiety Inventory (STAI) was used to measure anxiety in four of the eight studies 271524. The Hospital Anxiety and Depression Scale (HADS) was used in one of the eight studies 21. The Anxiety, Depression, Stress Scale (ADSS) was used in one of the eight studies 25. The Adult Manifest Anxiety Scale (AMAS) was used in one of the eight studies 27. These evidence-based, standardized instruments for gathering data about anxiety are appropriate for the purpose of the studies 8. The remaining three studies utilized non-standardized questions about anxiety levels, rated on a 10-point or 11-point Likert scale, designed for the purpose of the study 41326.

Utilization of evidence-based, standardized instruments helps to maintain consistency and validity of results 8. The studies utilizing these methods meet this standard. The authors utilizing questionnaires designed for their studies risk known efficacy and substantiality for measurement of the addressed research variables 8.

In each article, all sources of information were accurately referenced at the end of the article 24713152124252627 .

A synthesis of the literature reports the studies’ findings in a cohesive manner, identifying themes that emerged from the sum of the articles. Data are reported with levels of statistical significance of findings 8. The following themes were identified: the effect of Reiki administered in various settings, the effect of Reiki on manifestations of anxiety, Reiki’s interconnectedness with pain and anxiety, and cultural considerations of the implementation of Reiki.

Reiki was found to reduce anxiety levels in all ten studies 24713152124252627. Seven of the studies showed a statistically significant reduction in anxiety scores (p<0.001) 271315252627. The remaining three studies showed reduced scores ranging from a 0.21 to 0.6 average decrease in points, however these reductions in points lacked statistical significance (p>0.05) 42124.

Five of the studies focused on a preoperative/preprocedural setting 27152124. Four of the studies were conducted in outpatient therapeutic settings 4132527. One study was conducted in an inpatient hospital setting 26. In seven studies, Reiki administration was reported to reduce anxiety levels in all settings with statistically significant scores (p<0.001), with STAI scores averaging a reduction of 4.8 to 7.0 points and other scales scores averaging a reduction of 1.9 to 5.25 points2713152521242627. Reiki sessions varied widely in duration with sessions ranging from 15 to 90 minutes in length, and in quantity, with participants receiving a single session to daily sessions for 45 days 271315252627. In the remaining three studies, Reiki administration was found to reduce anxiety levels in each setting, however, with scores that lacked statistical significance 42124. Scores ranged in reduction from 0.21 to 1.2 points 42124. Reiki sessions varied less in this group, ranging in duration from 10 to 20 minutes, with each participant receiving one or two Reiki sessions 42124.

Seven of the ten studies assessed related manifestations of anxiety 241315212627. Three of the studies looked at vital signs in response to Reiki treatment as a physiological demonstration of anxiety 2415. Four of the studies looked at emotional subscales of anxiety, including tension, irritability, jitteriness, nervousness, fatigue, and stress and worry related to social concerns, rating them with standardized scales, such as the Positive and Negative Affect Schedule (PANAS) and the Spiritual Well-Being Scale (SWB) 7132627. The data from these related manifestations of anxiety and emotional subscales of anxiety will be discussed in detail.

Reiki’s effect on perceived pain was assessed in four of the ten studies utilizing a ten-point scale, with ten being the worst pain and zero being an absence of pain 2131526. Findings on Reiki’s effect on pain as it relates to anxiety levels will be discussed further.

Studies involving American patients showed that Reiki provided a statistically significant (p<0.001) reduction in anxiety symptoms 213152627. These studies utilized various screening tools, such as the STAI, AMAS and a 10-point Likert scale with up to 8% reduction in anxiety scores 213152627. Reiki sessions ranged in duration from 15 to 90 minutes 213152627. Italian and Indian patients studied also showed statistically significant (p< 0.001) reduction of anxiety levels, with scores 25% to 50% lower after the administration of Reiki 725. These studies ranged widely in their administration of Reiki, with sessions lasting 15 to 60 minutes, for anywhere from one to 45 sessions 725. Turkish and Brazilian patients did not show similar results with reduction of anxiety scores 2124. Turkish patients did show statistically significant different scores (p< 0.05) between the Reiki administration group and the control group due to increased self-reported anxiety levels of the control SOC group, as reflected with STAI scores decreasing from 40.03- 39.82 in one, 30-minute Reiki session 24. Brazilian patients did show statistically significant improvement in self-reported existential and spiritual well-being after two, 20-minute Reiki sessions, and the authors note that the interpretation of well-being and the absence of anxiety symptoms are filtered through a cultural lens 21. These scores were reduced on average from 2.1 points to 7.9 points on the Spiritual Well-being Scale 21.

The existing literature on Reiki’s effect on anxiety is minimal and does not cover a wide range of study participants. Only two of the studies focused on the effect of Reiki on anxiety for individuals in treatment for an anxiety disorder 2527. It is important that the research answer the question of Reiki’s effectiveness in the treatment of anxiety for those experiencing it on a regular basis: patients with anxiety disorders. Only three of the ten studies indicated that taking anxiolytics or other psychotropic medication for mood was an exclusionary factor for study participation, therefore, a comparison of individuals with and without preexisting anxiety conditions, and with and without psychopharmacological treatment was not conducted 21521.

Five of the ten studies focused on the effect of Reiki on preoperative patients’ anxiety levels, which focused half of the literature on a narrow population 27152124 One study that conducted three or four Reiki sessions per patient, with one session preoperatively and the remaining postoperatively, did not report on the anxiety levels of participants after their first Reiki session preoperatively 2. The scores reported in this study were assessed prior to the first treatment preoperatively, then at discharge after subsequent treatments, when preoperative anxiety is naturally concluded and mood-altering pain medication is likely being given 2. Six of the ten studies utilized only a single Reiki session to assess anxiety levels, as opposed to looking at cumulative effects of the intervention over time 4713152426. Two of the studies utilized convenience sampling at Reiki centers, where the participants were biased towards open mindedness and previous knowledge of Reiki’s potential benefits 413.

Patient satisfaction is indicated in future research implications, as an increase in Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) surveys benefits both the hospitals and the consumers 2. These patient satisfaction scores are public and affect hospital Medicaid and Medicare reimbursement rates 6. For a broader and deeper understanding of Reiki’s potential benefit in the treatment of anxiety, several different settings, diagnoses, and age groups need to be studied 215. Reiki’s benefit on inpatient settings where anxiety levels are commonly high, such as on intensive care units, burn units, and inpatient substance abuse units, would broaden the research and make findings more transferrable 24. Including all age groups in various studies would indicate if the intervention is beneficial across the lifespan 15. Studies need to be conducted in a wide array of settings, both inpatient and outpatient, to show the full potential of Reiki as an intervention for patients receiving primary, secondary and tertiary care 15. Differentiating studies and study participants by whether preexisting anxiety disorders are present, and if anxiolytic or other psychopharmacological treatment is being utilized, is critical in creating studies that identify individuals who would benefit from Reiki treatments for anxiety. These studies need to be conducted over time to explore the potential long-term benefits of Reiki as a treatment for anxiety, utilizing a series of Reiki sessions to explore potential maximum efficacy 13726. Reiki practitioners work at three different skill levels, including level one, level two, and Reiki master. The skill level of the Reiki practitioners in a study should be congruent, ruling out wide variance of the treatment rendered 13.

For the advanced practice registered nurse (APRN), research on Reiki could potentially open the door to a low-cost, safe alternative intervention for treating anxiety across many patient care settings. Identifying means to treat anxiety nonpharmacologically allows the APRN to limit prescribing risks associated with anxiolytics that are controlled substances, such as dependence and diversion. Having CAM modalities offered alongside traditional therapies within the APRN practice increases patient satisfaction 26. Patients report higher levels of satisfaction with their care when they experience their provider as unhurried, present, and compassionate 15. Nurses are trained on a holistic body, mind, and soul model, which is well-tailored to the implementation of a guided energy therapy such as Reiki. Hildegard Peplau’s interpersonal relations theory sets solid theoretical framework for the appropriateness of studying Reiki’s potential benefit for patients of APRNs 22.