Analysis

Anxious and agitated: how to help a nervous patient

Using communication skills to understand and diminish your patients’ fears about treatment

Using communication skills to understand and diminish your patients fears about treatment, a procedure or attending a consultation

  • Anxiety about treatment is common and can affect care as many as one in ten people in the UK may have a fear of injections and needles
  • How you interact with a patient including how you respond in stressful situations can affect their outcomes and experience of care
  • Tips for putting people at ease in the clinical environment, as well as dealing with parents worried about their childrens care

Nervousness shows itself in many ways, but however it presents in your patient, it can disrupt the therapeutic relationship.

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Using communication skills to understand and diminish your patients’ fears about treatment, a procedure or attending a consultation

  • Anxiety about treatment is common and can affect care – as many as one in ten people in the UK may have a fear of injections and needles
  • How you interact with a patient – including how you respond in stressful situations – can affect their outcomes and experience of care
  • Tips for putting people at ease in the clinical environment, as well as dealing with parents worried about their children’s care
Picture: iStock

Nervousness shows itself in many ways, but however it presents in your patient, it can disrupt the therapeutic relationship.

Anxious patients may be distracted, uncommunicative, possibly hostile. They may be unreceptive to offers of help, information and support.

Anxiety can alter a patient’s experience of care

The consequences can be damaging. For example, the person may not understand what lies ahead, the consent they give may be uninformed, and the trust that sits at the heart of the nurse-patient alliance may be damaged or absent.

Certain procedures may elicit more anxiety than others. The charity Anxiety UK suggests that up to 10% of the UK population may have a phobia about injections and needles.

So what can you do to diminish a patient’s anxiety and thereby optimise their healthcare experience?

We’ve spoken to nursing experts for advice on strategies that may help with patients who are anxious or nervous.

Learn to recognise different signs of anxiety

You might think anxiety shows itself in a particular way because that’s how it affects you. But in others it may be different, says senior lecturer in simulated learning and clinical skills Emily Marron, of Kingston and St George’s University, London.

‘Anxiety presents in many, many forms – from outbursts of anger, raised voices or crying to uncharacteristic silence. So it’s important to recognise the behavioural changes or strategies that people are using to regulate it.’

Look for physical signs and symptoms too – dry mouth, increased heart rate and shaking or trembling, for example.

Understand where anxiety comes from

The amygdala is a small, almond-shaped part of the brain that helps us process memories and decision-making, and generates emotional responses such as anger, fear and anxiety.

In young children, it helps them distinguish what is threatening in their world, says independent health services consultant Bob Price, author of an RCNi continuing professional development article on managing patients’ anxiety.

‘Why is this relevant to understanding anxiety? I think we begin to tackle anxiety when we understand the associations people make with events,’ he says.

While not advocating on-the-spot psychotherapy – ‘no nurse has time for that’ – Mr Price says that helping the patient to see why they fear something is often a starting point for countering their anxiety.

‘Rationalism – cold fact – doesn’t work as teaching until we understand what exercises the patient’s mind.

‘The affected individual cannot understand rationally why they fear something unless they recount a past event or episode. So that might help you as a rationale for unpicking fears.’

Understanding where a patient’s fear comes from – perhaps a childhood event – can help them to deal with it in a different way Picture: iStock

How you respond in stressful situations plays a part

How’s your emotional intelligence? How do you respond in challenging circumstances? Can you manage your own emotions and recognise how they affect other people?

‘If you have some understanding of how you function in stressful situations you can work on those skills,’ says Ms Marron. That’s a key part of the simulated learning she undertakes with nursing students.

10%

Up to 10% of the UK population may have a phobia about injections and needles Source: Anxiety UK

‘We put them into those stressful situations and that enables us to say, “Your initial response was this – now think about that”.’

In a conversation, the tone set by one person is usually followed by the other person, she says.

‘For example, anger is usually met with anger. But if you can remain calm, calmness normally comes from them. There’s reciprocation of that tone.

Practical interventions that can help calm nerves

Moving from theoretical to practical interventions, Ms Marron says knowledge is usually reassuring for anxious patients.

‘So when they’re coming in for an appointment, make sure they have some information.’

‘We tend to minimise things. I’m a great believer in telling someone the worst that could happen is that you’re going to feel a sharp pain or that some people can experience difficulty with this procedure’

Kim Moore, senior lecturer in mental health and learning disability nursing, Birmingham City University

And be sure to tailor that information. Many hospitals and clinics now use short, animated films to explain processes and procedures, she says. One doctor she worked with drew explanatory pictures for the children he was treating.

Don’t hold back on detail. If a patient needs to get undressed before a procedure, tell them whether they can keep their underwear on rather than leave them wondering.

‘Preparing people is key,’ Ms Marron says.

Introduce yourself to the patient

It may sound obvious, but this step is sometimes neglected, says Birmingham City University senior lecturer in mental health and learning disability nursing Kim Moore.

‘It’s amazing how often it doesn’t happen.’

She adds: ‘Talk to the person, keep your voice calm, maintain eye contact.

‘Ask constantly if they’re okay. It can start out really well but then you forget to check that they’re still okay and you find you’ve lost them about 20 stages ago.’

Assess and adjust the clinical environment

Some aspects of a hospital or clinic environment may be fixed and beyond your control but make sure the care setting is as calming as it can be, says Ms Marron.

Natural elements can help. A couple of pot plants may make a difference, so can scents and smells that calm. Music or a television in a waiting area may divert patients’ attention from concerns about what lies ahead.

Drink facilities – within restrictions imposed as a result of COVID-19 – can be helpful for patients whose anxiety causes a dry mouth and throat.

Consider the environment your patients experience Picture: iStock

Explain what the patient can expect

If fear of the unknown is at the heart of the patient’s nervousness, step-by-step explanation of what will follow can be reassuring. But, says Ms Moore, be sure to pitch it right for the individual’s comprehension.

‘You’ve got to be able to gauge the knowledge and understanding of the person in front of you – and it is very variable. You have to talk to them in a way that makes them feel at ease, comfortable.’

Be honest about possible pain or discomfort

Explain – and don’t gloss over – the likelihood of pain or discomfort, Ms Moore suggests.

‘We tend to minimise things,’ she says. ‘I’m a great believer in telling someone the worst that could happen is that you’re going to feel a sharp pain or that some people can experience difficulty with this procedure.’

You’re not saying it will happen, only that it might.

And if you’re asked something you don’t know the answer to, don’t pretend you do. Instead, try to find out.

People know when they’re having the wool pulled over their eyes ‘and it sets their teeth on edge’, says Ms Moore. ‘It doesn’t inspire confidence.’

Honesty, by contrast, is usually appreciated.

Take your time in patient interactions

1 in 25

parents had postponed their preschool-age child’s vaccination due to their child's fear of medical appointments

Source: University of Michigan

Fear of contracting the coronavirus has increased many people’s anxiety about attending hospitals or surgeries.

And, with COVID-19 restrictions, when they do attend it is likely to be alone. This means they will have no one to check with later whether they have understood correctly what a nurse or doctor said during a consultation.

‘You don’t have that support you would normally have,’ Ms Moore says. ‘Someone who can ask the questions you’re too befuddled to think about.’

She concedes that asking nurses to slow things down when they have little enough time anyway is ‘very, very tricky’.

‘But it doesn’t have to be a 15-minute intervention. It can be 20 or 25 minutes.’

Be mindful of the parent or carer’s feelings

While adult patients may be unable to bring a family member with them to an appointment as the pandemic continues, of course parents can still accompany their children.

In these circumstances, keep in mind that children often pick up on the behaviour of their parent, says Ms Moore.

‘If the parent or responsible adult is extremely nervous, the child is going to be nervous too. People mimic those they trust.’

Picture: iStock

Does that mean the nurse should first address the parent’s unease?

‘I think you’ve got to take both on,’ she says. ‘If the adult is very nervous and the child is picking up on that, you want to calm the anxiety of the parent as well as that of the child.’

A 2018 University of Michigan study involving 726 parents of preschool children found one in 25 parents had postponed a vaccine due to their child’s fear of visiting the doctor.

Some one in five respondents said it was hard to concentrate on what the doctor or nurse was saying because their young child was so upset.

Distraction techniques work well with children, says Ms Marron. ‘We use a lot of that in paediatrics. They watch Peppa Pig while we do the injection.’

And while meditation techniques and guided imagery tend to be more applicable in adult care, they can help address children’s anxiety as well.

A study published in 2019 showed that guided imagery could help reduce preoperative anxiety in children as well as postoperative pain.

Practise active listening as part of patient communication

In the end, says Ms Marron, reducing a patient’s anxiety comes down to one core nursing skill: effective communication.

‘And the biggest thing around communication is active listening.’

Which is much more than ‘just listening’, she says.

‘Someone responding to your emotions suddenly starts to bring change in you because the nurse is listening to what you’re saying about those emotions’

Emily Marron, senior lecturer in simulated learning and clinical skills, Kingston and St George’s University, London

‘There’s normally content and emotion to everything people say. Active listening is about listening to the content but more often it’s responding to the emotion rather than what the person has said.

‘This notion of someone responding to your emotions suddenly starts to bring change in you because the nurse is listening to what you’re saying about those emotions.’

1 in 5

survey respondents said it was hard to concentrate on what the doctor or nurse was saying during a consultation because their young child was so upset

Source: University of Michigan

Active listening requires focus on the part of the nurse. Body language is important and the cues you give off should demonstrate not that you necessarily agree with the patient but that you are interested in what’s being said.

‘You’re giving them a voice,’ Ms Marron says. ‘And quite often as nurses we listen in order to respond – we’re already thinking about what our next response will be and then something’s missed along the way.’

The risk then is that the nurse slips into what Ms Marron calls ‘advice mode’.

‘We think we must provide a solution and there’s not always a solution. If you listen to someone’s point of view, their feelings, what’s challenging for them – with the person saying those things aloud – it can bring change.

‘Sometimes they don’t need your advice or solutions.’


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