Skill List > Communication with Anxious Patients
Clinical Alert
First acknowledge and take care of the patient's physical and emotional discomfort, but avoid dwelling on physical complaints. Focus on understanding the patient, giving feedback, assisting in problem solving and providing an atmosphere of warmth, caring, and acceptance.

Elsevier Clinical Skills covers the principles of this procedure. You must follow local policies and procedures regarding technique, equipment used and documentation.
Authors:
Based on Mosby Nursing Skills
Adapted by: Chris Brooker BSc MSc SRN SCM RNT
Updated by: Chris Brooker BSc MSc SRN SCM RNT
Last updated: June 2017
Learning Objective
After reading the skill overview, watching the animation, following up some of the references/web sites and completing the self-test quiz you should be ready to be assessed in practice in the skill of communication with an anxious patient.

Introduction

Patients in the healthcare setting often experience anxiety for a variety of reasons. A newly diagnosed illness, separation from loved ones, the threat of investigations or surgical procedures, and expectations of life changes, such as being unable to work, are just a few factors that cause anxiety. How successfully a patient copes with anxiety depends, in part, on previous experiences, the presence of other stressors, the significance of the event causing anxiety and the availability of supportive resources. The nurse can be a support to the patient. The nurse helps to decrease anxiety through effective communication and explanation. ‘Among the most effective and easiest interventions nurses can use to reduce anxiety and stress is to provide useful and understandable information. Patients should know what to expect in relation to illness, recovery and specific interventions (Murphy 2013). The communication methods reviewed in this skill will enable you to help an anxious patient to determine factors causing anxiety and to cope more effectively. There are four stages of anxiety with corresponding behavioural manifestations: mild, moderate, severe, and panic (Box 1).

Box 1 Behavioural manifestations of anxiety: stages of anxiety. (From Perry A G, Potter P A 2010 Clinical Nursing Skills and Techniques, 7th edn. Mosby Elsevier, St Louis.)
 
Mild anxiety
  • Increased auditory and visual perception
  • Increased awareness of relationships
  • Increased alertness
  • Able to problem solve
Moderate anxiety
  • Selective inattention
  • Decreased perceptual field
  • Focus only on relevant information
  • Muscle tension; diaphoresis (profuse perspiration)
Severe anxiety
  • Focus on fragmented details
  • Headache, nausea, dizziness
  • Unable to see connections between details
  • Poor recall
Panic state of anxiety
  • Does not notice surroundings
  • Feeling of terror
  • Unable to cope with any problem

Helping the patient to identify possible sources of anxiety, such as illness, hospitalisation, knowledge deficits, or other known stressors gives them an understanding of anxiety and increases their sense of control. Remember that patients and their family members who are stressed often require repeated explanations.

Cultural considerations

Nurses face challenges when communicating with culturally and linguistically diverse patients. Effective communication between culturally diverse patients and nurses is vital to improving health outcomes. Providing both general and disease-specific information to patients in a culturally sensitive manner improves chronic illness self-management. Conversely, a language barrier prevents the delivery of timely health care, thereby exacerbating (or worsening)  existing health problems and causing new health issues.

The following factors are essential to effectively care for culturally and linguistically diverse patients: (1) use of appropriate linguistic services (e.g., interpreter or bilingual healthcare workers) or other communication strategies; (2) a display of empathy and respect; (3) use of accurate health history taking for diagnostic and treatment purposes and health promotion and teaching; and (4) use of patient-centred communication, including the patient's part in all decision making about their care. It is also helpful to speak plainly. Understand that members of certain cultures use cultural phrases or slang common to their culture and this is not an indication that they do not understand English.

When nurses communicate with patients of diverse cultures, an interpreter is sometimes necessary. When using an interpreter, address the patient and family directly; do not direct questions or comments to the interpreter. Take care to make sure that the patient understands. Speak slowly in normal tones, and avoid overly technical jargon or terms unique to a culture (Box 2). Adopting a flexible, respectful attitude that also communicates interest in the patient bridges any communication barriers that exist because of cultural differences between patient and caregiver.

Not all cultures express anxiety, anger, and depression in the same way as they are expressed in Western culture. Sometimes people present with somatic complaints, such as loss of appetite or poor sleep.
For example, a patient speaks of lack of sleep and appetite but denies the sensation of anxiety.

Box 2 Special approaches to patients who speak different languages. (From Giger J, Davidhizar R 2007 Transcultural Nursing: Assessment and Interventions, 5th edn. Mosby Elsevier, St Louis.)
  • Use a caring tone of voice and facial expression to help alleviate the patient's fears.
  • Speak slowly and distinctly, but not loudly.
  • Use gestures, pictures, and play acting to help the patient understand.
  • Repeat the message in different ways if necessary.
  • Be alert to words the patient seems to understand and use them frequently.
  • Keep messages simple and repeat them frequently.
  • Avoid using medical terms and abbreviations that the patient may not understand.
  • Use an appropriate language dictionary.

Children and anxiety

Children often demonstrate anxiety through physical and behavioural signs but are unable to express anxiety verbally. Some children express anxiety through restless behaviour, physical complaints, or behavioural regression, such as bed wetting. It is vital to note any changes in a child's behaviour that occur during illness or hospitalisation (Hockenberry & Wilson 2015).

Older people and anxiety

Anxiety is one of the most common symptoms seen in older adults. Patients may become fixed in a routine and intent on performing activities a certain way. Anxiety develops as a result of a specific event or a general pattern of change, for example, bereavement or poor health).

Anxiety is sometimes present in long-term care settings, such as a residential home or nursing home and sheltered housing. Manage anxiety based on the patient's presenting behaviour taking into consideration any cognitive or physical impairment.

Psychosocial factors such as anxiety and confusion, lack of mobility, and spatial organisation of long-term care settings are factors that decrease social contact, thus hindering communication with peers and healthcare staff. This leads to further feelings of isolation, boredom, and increased anxiety.

Older adults who are socially isolated and have multiple medical problems are more likely to experience anxiety or low mood. In addition, they are less likely to seek help for these problems.

Care in a person’s home

Anxiety occurs in home care settings. Manage anxiety based on the patient's presenting behaviour taking into consideration any cognitive or physical impairment.

Anticipation of a home care visit may increase a patient's anxiety and lead to exacerbation of symptoms. For this reason, some patients avoid home care visits.

Preparation and safety

  • Are you competent to provide this care? Should you summon an experienced colleague to help?
  • Assess for physical, behavioural, and verbal cues that indicate the patient is anxious, such as dry mouth, sweaty palms, tone of voice, frequent use of call bell, difficulty concentrating, wringing of hands, and statements such as ‘I am scared’.
  • Assess for possible factors causing patient anxiety (e.g., hospitalisation, unknown diagnosis, fatigue, worries about family or job).
  • Assess factors influencing communication with patient (e.g., environment, timing, presence of others, values, experiences, need for personal space because of heightened anxiety).
  • Discuss with the patient and family members (with patient’s permission) the possible causes of the patient's anxiety.
  • Prepare for communication by considering the following: patient goals, time allocation, and resources.
  • Recognise personal level of anxiety and consciously try to remain calm (breathe slowly and deeply). Be aware of nonverbal cues that indicate own anxiety (e.g., body language, posture, cadence of speech).
  • Prepare physical environment: provide a quiet, private, calm area and allow ample personal space.

Procedure

  1. Perform hand hygiene.
  2. Introduce yourself and check the patient’s identity, using the patient's name-band or asking the patient's name, according to local policy.
  3. Provide a brief explanation of the purpose of the interaction to obtain the patient’s consent and cooperation.
  4. Use appropriate nonverbal behaviours and active listening skills, such as staying with the patient at the bedside and maintaining a relaxed posture. Rationale Nonverbal messages to the patient express interest and help to alleviate anxiety.
  5. Use appropriate verbal techniques that are clear and concise to respond to the anxious patient. Use brief statements that acknowledge current feelings and provide direction to the patient, such as ‘I have noticed that you seem anxious. Would you like to rest in your room?’ Rationale Appropriate techniques and statements provide reassurance and prevent further escalation of anxiety.
  6. Help the patient acquire alternative coping strategies, such as progressive relaxation, slow deep-breathing exercises, and visual imagery techniques. Rationale Coping mechanisms provide the foundation for effective communication so that the patient can explore causes of anxiety and steps to alleviate anxious feelings.
  7. Provide necessary comfort measures, such as pain relief. Rationale Pain heightens patients' anxiety.
  8. Perform hand hygiene.

Ongoing care, monitoring and support

  • Observe for continuing presence of physical signs and symptoms or behaviour that reflect anxiety. Rationale Observation determines extent to which planned interaction relieved the patient's anxiety.
  • Ascertain how the patient will cope with anxiety in the future and make decisions about their own care. Rationale – Measures patient's ability to assume more health-promoting behaviour.
  • Evaluate the patient's ability to discuss factors causing anxiety. Rationale – Measures the patient's ability to attend or focus on an area of concern.

Documentation and reporting

  • Document the interaction in the patient's nursing notes and include:
    • cause(s) of the patient's anxiety and any behavioural signs and symptoms, such as sweating
    • how you relieved the patient’s anxiety and their response
    • patient and family education.
  • Speak to a colleague if you have concerns.
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