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Reducing Patient Anxiety in Healthcare

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Contact Hours: 3

This educational activity is credited for 3 contact hours at completion of the activity.

Course Purpose

The purpose of this course is to provide healthcare professionals with a brief overview of patient anxiety, its known physiological factors, its contributing factors, and strategies and nursing considerations that healthcare professionals can adopt to reduce the detrimental effects of this condition and ensure optimal health outcomes.

Overview

Anxiety, in general, refers to a multifaceted emotional state characterized by feelings of unease, worry, and apprehension, often accompanied by physiological manifestations such as increased heart rate, sweating, and restlessness. While it is a common human experience, it becomes clinically significant when it interferes with daily functioning. This course defines patient anxiety, its known physiological factors, and its contributing factors. This course also highlights specific strategies and nursing considerations that healthcare professionals can adopt to reduce the detrimental effects of this condition and ensure optimal health outcomes.

Course Objectives

Upon completion of this course, the learner will be able to:

  • Define anxiety and its emotional and physiological responses.
  • Recognize factors that increase patient anxiety in healthcare.
  • Understand how patient anxiety can cause barriers to healthcare.
  • Identify strategies to reduce patient anxiety.
  • Review nursing considerations when caring for a patient with anxiety.

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This activity has been planned and implemented in accordance with the policies of FastCEForLess.com.

Disclosures

Fast CE For Less, Inc and its authors have no disclosures. There is no commercial support.

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Definitions
AmygdalaA small part of your brain that processes emotions, memories, and learning. 
AnxietyAn abnormal and overwhelming sense of apprehension and fear often marked by physical signs (such as tension, sweating, and increased pulse rate), by doubt concerning the reality and nature of the threat, and by self-doubt about one’s capacity to cope with it.
BenzodiazepinesMedications that slow down your brain and nervous system, making them helpful for treating anxiety, insomnia, seizures, and other conditions.
Gamma-Aminobutyric Acid (GABA)A neurotransmitter that slows down brain activity and reduces stress, anxiety, and fear. 
Generalized Anxiety DisorderA condition with exaggerated tension, worrying, and nervousness about daily life events.
NeuronalRelating to neurons, the nerve cells that transmit information in the body.
Neurotransmitters Signaling molecule secreted by a neuron to affect another cell across a synapse.
NorepinephrineA neurotransmitter and a hormone that plays a key role in the body’s “fight-or-flight” response.
Prefrontal Cortex Located at the front of the frontal lobe and affects behavior, personality, and ability to plan.
SerotoninA neurotransmitter and hormone that influences mood, sleep, digestion, and other body functions. 
Serotonin Reuptake Inhibitors (SSRIs)A type of antidepressant that have been shown to increase levels of serotonin in the brain.
Introduction

Anxiety, in general, refers to a multifaceted emotional state characterized by feelings of unease, worry, and apprehension, often accompanied by physiological manifestations such as increased heart rate, sweating, and restlessness. While it is a common human experience, it becomes clinically significant when it interferes with daily functioning.1 Patient anxiety specifically denotes anxiety experienced within a medical or healthcare context. This type of anxiety arises due to several factors, not just those related to illness and related medical procedures. It is also exacerbated by the healthcare environment itself and personal factors. Patients often exhibit heightened anxiety when faced with medical uncertainty, invasive procedures, fear of the unknown, or concerns about their health outcomes.2

Certain demographics are more susceptible to experiencing patient anxiety, such as those with pre-existing mental health conditions or generalized anxiety disorder.1 Also, those undergoing serious medical procedures, those diagnosed with severe illnesses, children, and the elderly often have increased vulnerability and heightened anxiety within healthcare settings from the stressors associated with their health conditions and the unfamiliar hospital environment.3 Distinguishing patient anxiety from normal anxiety involves considering the situational triggers and the impact on an individual’s well-being. While both involve worry and apprehension, patient anxiety is often more focused on health-related concerns.1 This course defines patient anxiety, its known physiological factors, and its contributing factors. This course also highlights specific strategies and nursing considerations that healthcare professionals can adopt to reduce the detrimental effects of this condition and ensure optimal health outcomes.

Define Anxiety

In medical terms, anxiety is a complex emotional and physiological response involving the interaction of various brain regions, neurotransmitters, and hormonal systems. At its core, anxiety involves the intricate interplay of neurotransmitters such as serotonin, norepinephrine, and gamma-aminobutyric acid (GABA) within certain brain structures, including the amygdala and prefrontal cortex.1 The following describes how these components can manifest anxiety in the presence of stressors.

  • Serotonin
    • Also known as a “feel-good” neurotransmitter, influences mood, such as happiness and calmness. Low serotonin levels are associated with a higher risk of anxiety disorders. Medications like selective serotonin reuptake inhibitors (SSRIs) aim to increase serotonin levels and are commonly used to treat anxiety.4
  • Norepinephrine
    • Another neurotransmitter that involves the body’s stress response. It plays a role in increasing arousal, alertness, and vigilance when a person feels threatened. In the context of anxiety, excessive or dysregulated norepinephrine levels can contribute to heightened states of arousal and anxiety.5
  • Gamma-Aminobutyric Acid (GABA)
    • A regulator neurotransmitter that aids in the inhibition of neuron excitability in the brain. Low GABA levels or impaired GABA function can lead to increased neuronal excitability, potentially contributing to the development of anxiety. Medications like benzodiazepines work on the GABA system to reduce anxiety.6
  • Amygdala
    • An almond-shaped structure within the brain that processes emotions, particularly fear and stress response. In the context of anxiety, an overactive or hypersensitive amygdala can contribute to exaggerated responses to perceived threats or stressors, amplifying feelings of anxiety.7
  • Prefrontal Cortex
    • A brain region involved in decision-making, problem-solving, and regulating emotions. It is responsible for exerting top-down control over emotional responses generated by the amygdala. Disruptions in the prefrontal cortex’s function can lead to difficulties in regulating emotional responses, contributing to the persistence of anxiety.8

Imbalances in these neurotransmitters and disruptions in the function of brain structures result in both the onset and perpetuation of anxiety. In the context of patient anxiety, these physiological effects are often intricately tied to the fear of health-related concerns, from potential diagnoses and medical procedures to the uncertainty surrounding the outcome of medical conditions. In addition, past firsthand experiences in medical settings or those of close family and friends can contribute to the development and persistence of patient anxiety.1,2,4,5

Factors that Increase Patient Anxiety in Healthcare

Given the multifaceted nature of patient anxiety, healthcare professionals must understand the psychological, social, and environmental elements of a patient’s anxiety to address their concerns adequately. Common concerns that can cause patient anxiety include:

  • Lack of communication of plan for care
  • Lack of understating medical terminology
  • Speaking foreign languages
  • Unfamiliar surroundings
  • Having to rely on strangers for care
  • Concerns for costs
  • Being alone or away from family
  • Losing employment

Lack of Communication of Plan for Care

A lack of communication in the plan for patient care to the patient is a significant contributor to heightened patient anxiety in several ways. The absence of a clear and comprehensible communication channel results in a lack of clarity for patients. Without a concise and transparent understanding of their treatment course, patients grapple with uncertainty regarding their condition, prognosis, and subsequent steps in their care journey. This ambiguity fosters a sense of unease and apprehension, augmenting anxiety levels.9

Inadequate communication prevents patients from actively engaging in decisions concerning their health, ultimately diminishing their sense of control and autonomy. This emotional burden is compounded by the potential fear of the unknown. The gravity of their health condition or inability to mentally prepare for upcoming medical interventions heightens levels of anxiety. Communication issues also undermine the establishment of trust between patients and healthcare providers. This failure not only diminishes faith in the healthcare system but also sows doubts regarding the competence of the medical professionals providing care.10

Lack of Understating Medical Terminology

The specialized nature of medical terminology creates an unfamiliar jargon for patients, hindering patients’ grasp of their medical conditions. This, in turn, creates a significant communication barrier between healthcare providers and patients. Not only are patients confused, but they are unable to ask relevant questions, express concerns, or make informed decisions, thereby impeding their autonomy in healthcare decisions. This lack of understanding amplifies the emotional distress experienced by patients. The inability to grasp the intricacies of their health conditions and the nuances of medical discussions heightens feelings of uncertainty and fear. Also, the misinterpretation of medical terms poses risks to patient safety. Patients may misunderstand instructions or medication regimens, leading to non-adherence or incorrect application of healthcare recommendations, potentially compromising their well-being.11

Speaking Foreign Languages

When patients communicate in a language a healthcare professional does not understand fluently, it hampers the transmission of vital medical information. This impedes accurate diagnosis, appropriate treatment, and a comprehensive understanding of the patient’s medical history, symptoms, and concerns. Even when interpreters or translation services are utilized to close the communication gap, there is still the risk of inaccuracies being introduced while crucial information is relayed. The nuances of medical terminology, cultural context, and patient narratives may be distorted in translation, potentially leading to misunderstandings between the patient and the healthcare provider.12

The language barrier further hinders the establishment of rapport between patients and healthcare professionals. The inability to converse in a shared language limits the formation of a strong patient-provider bond, hindering the development of trust and empathy. This can adversely impact the patient’s comfort, confidence in the care provided, and willingness to disclose critical health information. Without anyone in the healthcare setting who understands them, patients can often feel isolated and vulnerable, unable to express themselves or comprehend the information being conveyed fully. During critical healthcare decisions or in emergencies, this can substantially heighten patient anxiety.12

Unfamiliar Surroundings

Being in an unfamiliar environment can evoke feelings of isolation, fear, and anxiety for several reasons. Typically, it starts with disorientation as hospitals, clinics, or medical facilities can be complex, maze-like environments for individuals not accustomed to them. This lack of familiarity may lead to heightened confusion and stress as patients try to navigate not just the unfamiliar physical space but also the protocols for getting help. This disorientation also exacerbates the feeling of powerlessness, particularly in situations of illness or injury. Patients may experience a loss of autonomy and self-efficacy when they are in an environment they do not understand or cannot navigate easily. This sense of disempowerment can amplify feelings of vulnerability. This in turn, hinders the development of comfort and establishing a trusting relationship with healthcare providers. Patients may be less forthcoming with their concerns or health information and more interested in leaving the unfamiliar premises as soon as possible.10

Having to Rely on Strangers for Care

The need to depend on strangers for care can lead to a sense of vulnerability because it requires entrusting one’s well-being to someone with whom there is no prior relationship. This can be unsettling and emotionally distressing. Additionally, the absence of familiarity with caregivers can hinder effective communication. Patients may experience a sense of alienation or emotional detachment, which can significantly impact their overall experience and emotional state during their healthcare journey. They may not be able to openly express their concerns, ask questions, or engage in discussions about their health. Another aspect of relying on a stranger for care is concerns about the quality and reliability of care the unknown healthcare professional can provide. Patients may start to question the competency of the healthcare professional and their ability to understand their specific needs, adding to their overall stress and anxiety.13

Concerns for Costs

The financial burden related to healthcare expenses can greatly heighten patient anxiety. Not only is there uncertainty associated with the total costs involved, but there is also the fear of not being able to afford the necessary medical care. This anxiety can be particularly pronounced in situations where individuals lack adequate insurance coverage or face unexpected healthcare needs, such as emergencies or chronic conditions requiring ongoing care. The fear of incurring substantial medical debt or the inability to cover treatment expenses can significantly impact a patient’s mental and emotional state, leading to increased anxiety.

Another concern is the lack of control over healthcare costs. The lack of transparency in pricing and the potential for unforeseen or hidden healthcare expenses limits a patient’s ability to plan or budget for healthcare needs. This lack of predictability and control over financial aspects of care can magnify feelings of uncertainty. This financial strain can also lead to a sense of helplessness and despair. Patients may feel overcome by the prospect of managing healthcare expenses, leading to a constant state of worry, which can inhibit their ability to focus on their health or engage effectively with their healthcare providers.14

Being Alone or Away from Family

Family members often play a pivotal role in providing emotional support, empathy, and a sense of security. When individuals are alone or away from their family, they no longer feel the safety of that support network and experience a loss of security. In periods of vulnerability, this absence can intensify feelings of loneliness and isolation. In a healthcare setting, these feelings become amplified as individuals also face the uncertainty, discomfort, and stress of an illness or medical procedure. The absence of family or familiar faces can also impact decision-making and participation in healthcare discussions. Family members often assist in understanding and processing medical information, advocating for the patient’s needs, and providing a sense of continuity and familiarity. Their absence can make decision-making more challenging, potentially leading to increased anxiety due to uncertainty or the feeling of not being adequately supported.16

Losing Employment

The loss of employment often brings about financial uncertainty, which can significantly contribute to heightened anxiety. Individuals may worry about their ability to afford healthcare, especially if their insurance coverage is tied to their employment. The fear of not being able to cover medical expenses, especially during a time of need, can lead to increased stress. Suppose the loss of employment does result in the loss of health insurance. In that case, it creates significant concerns about access to healthcare services, particularly if individuals face ongoing health issues or require consistent medical care. The fear of being unable to afford necessary treatments, medications, or even basic healthcare visits can contribute to heightened anxiety levels.17

The psychological impact of losing employment goes beyond financial concerns. Employment loss can also result in a loss of identity and social connections, which can contribute to feelings of isolation and stress. It can also impact an individual’s sense of control and stability. This lack of structure, particularly when dealing with a health concern, can significantly increase anxiety levels. 17

How Patient Anxiety Causes Barriers to Healthcare

Patient anxiety can create significant barriers to healthcare. Most concerning is how it manifests in fears so distressing that individuals either delay or completely avoid seeking medical attention, even going into a state of denial about their health conditions. However, this avoidance can result in an even higher risk of unfavorable outcomes, especially if individuals continue to wait until symptoms become severe. This may result in an emergency with more complicated health issues and necessitating urgent, costly interventions.17

For patients who do seek healthcare, patient anxiety may lead to difficulties effectively conveying symptoms, concerns, or medical history to their healthcare providers. This can lead to misunderstandings or an incomplete exchange of crucial information, potentially compromising the accuracy of diagnoses and treatment plans. Then, when it comes to treatment, the patient may feel overwhelmed by the potential side effects, the complexity of the treatment regimen, or the fear of the unknown. This can result in non-compliance with medications, follow-up appointments, or recommended lifestyle changes, hindering the effectiveness of treatment and leading to poorer health outcomes. In cases where anxiety is the primary concern, the anxiety itself can hinder access to mental health services. The fear of judgment, stigma, or the anticipation of addressing their anxiety issues can deter individuals from seeking the necessary mental health support, perpetuating the cycle of anxiety, and hindering recovery.18

How to Reduce Patient Anxiety

While treatment approaches like those for treating general anxiety are available for reducing patient anxiety, there are also several strategies healthcare professionals can adopt to reduce patient anxiety without solely relying on pharmacological interventions or psychotherapy. These strategies address the numerous factors that contribute to heightened stress and distress within the healthcare environment by creating a more patient-centric, supportive, and anxiety-reducing setting, as explained below.18,20,21

  • Communication can be improved by conveying transparent information about treatment plans, diagnoses, and procedures in a manner accessible to patients. Healthcare professionals can encourage open dialogue and offer regular updates to patients to ease their anxiety. This approach not only ensures patients comprehend their care but also diminishes uncertainty, fostering a sense of control. This approach also builds trust between patients and healthcare providers.10,19,20
  • To tackle the lack of understanding of medical terminology, healthcare professionals should focus on using simple terms, visual aids, and patient-friendly literature to explain complex jargon. Providing such accessible information empowers patients to navigate their healthcare with confidence and understanding. Visual aids and simplified explanations help bridge the gap between technical language and patient comprehension for a clearer understanding of their conditions and treatments. Addressing this lack of understanding not only diminishes anxiety but also cultivates a more informed and engaged patient population within healthcare settings.11, 19,20, ,21
  • To overcome foreign language barriers, healthcare facilities should invest in language interpretation services that offer multilingual resources. Having proficient interpreters and translated materials can close communication gaps and ease patient anxiety related to language barriers. Healthcare providers who have a diverse patient population or see that their service area has another prevalent language, such as Spanish, can also improve their understanding and fluency. While learning another language may be time-consuming, it can help in building camaraderie and enhance patient interaction, greatly reducing a patient’s stress levels.12, 20, ,21
  • Creating a welcoming ambiance can address the anxiety from unfamiliar surroundings. Whether that is done through calming aesthetics, clear signage, or familiar elements, such considerations can promote a sense of ease. Incorporating familiar cues and a more inviting atmosphere not only improves patient comfort but also cultivates a reassuring environment, fostering a positive experience within medical facilities.20, ,21
  • To mitigate the discomfort of relying on unfamiliar caregivers, healthcare organizations should prioritize a compassionate and supportive environment. Healthcare professionals should focus on establishing empathetic connections with patients as they discuss their health to diminish the feeling of talking to a stranger. Building a strong rapport and offering empathetic care nurtures a trustworthy relationship and eases the anxiety associated with relying on unfamiliar caregivers. This approach not only enhances patient comfort, but also ensures a more personalized care experience.13,19, 20, 21
  • To alleviate anxiety stemming from healthcare costs, healthcare facilities should offer financial counseling and transparent pricing details. Providing comprehensive information about expenses, available support programs, and financial aid resources can significantly reduce uncertainty and anxiety related to healthcare costs. This guidance on available financial assistance helps patients feel more informed and empowered, minimizing the stress and anxiety associated with unpredictable healthcare expenses.14, 21
  • To address the anxiety resulting from being alone or separated from family in healthcare settings, it is vital to encourage the presence of a support system. Healthcare facilities can facilitate this by offering flexible visiting hours, allowing for remote communication for families, and organizing support groups. These measures aim to reduce feelings of isolation and anxiety.15, 20, 21

To ease the anxiety deriving from job loss, healthcare facilities should offer support resources such as information about social services and financial aid programs. They can also provide counseling for job loss-related anxiety in the facility to assist individuals in coping with unemployment stress.17

Nursing Considerations

When addressing patient anxiety, nurses should adopt a multifaceted approach that addresses emotional as well as social concerns. They should prioritize empathetic communication, actively engaging with patients to understand their key concerns and fears and provide clear and compassionate explanations to ease stress. Patient education is a key element, and nurses can play a vital role in ensuring patients comprehend the various aspects of their care, from procedures to expected outcomes. By empowering patients with information, nurses can reduce their anxiety.20,21

Nurses can also help create a comforting, familiar environment, by maintaining the healthcare spaces in terms of cleanliness and organization and strategically incorporating soothing elements. This may involve the use of calming colors, soft or natural lighting, personal belongings, and recognizable décor to cultivate a serene ambiance. Additionally, ensuring clear signage is present can help patients easily navigate pathways, reducing any feelings of disorientation. By paying attention to these intricate details, nurses can create a space that minimizes environmental triggers for anxiety.21,22,23

For patients who arrive alone, nurses can guide them through decision-making by providing comprehensive information at each step. By clarifying the available choices, discussing risks and benefits, and answering questions, they can help empower patients to reach a decision more confidently. In addition, nurses can offer empathetic support, becoming a support that respects the patient’s autonomy and collaborates to help them understand their care plan. 21,22,23 Moreover, nurses can integrate relaxation techniques to reduce patient anxiety. By guiding individuals through deep breathing exercises, mindfulness practices, progressive muscle relaxation, and guided imagery, they can help patients alleviate stress and tension, promoting a sense of calm while in the healthcare facility. Continual assessment is also critical so that nurses can adapt care as needed, providing ongoing support to address fluctuations in anxiety levels. 21,22,23

Conclusion

Patient anxiety is a complex condition. While understanding the neural underpinnings of anxiety aids in comprehending its physiological manifestation, it is critical to understand the external aggravators that can intensify patient anxiety, such as medical uncertainties, complicated jargon, unfamiliar environments, communication barriers, lack of support, and financial concerns. The repercussions of heightened anxiety are vast, impacting patient well-being and healthcare access. From delays in seeking medical attention to hindering communication and treatment adherence, patient anxiety presents significant barriers. However, healthcare providers can adopt effective strategies that focus on transparency, language accessibility, familiarity, and empathetic patient-centric care to alleviate patient anxiety without the immediate need for pharmacological interventions. Nursing considerations play a vital role in addressing patient anxiety, including compassionate communication and educational support, and the integration of relaxation techniques. Each recommendation can help foster a serene and supportive healthcare environment. These measures collectively aim to reduce patient anxiety, ensuring a more informed, empowered, and comforted patient experience within the healthcare setting.

References
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  2. Weiss, R., Vittinghoff, E., Fang, M., Cimino, J., Chasteen, K., Arnold, R., Auerbach, A., & Anderson, W. (2017). Associations of Physician Empathy with Patient Anxiety and Ratings of Communication in Hospital Admission Encounters. Journal of Hospital Medicine, 12(10), 805–810. https://doi.org/10.12788/jhm.2828
  3. Wilson, C. J., Mitchelson, A. J., Tzeng, T. H., El-Othmani, M. M., Saleh, J., Vasdev, S., LaMontagne, H. J., & Saleh, K. J. (2016). Caring for the surgically anxious patient: a review of the interventions and a guide to optimizing surgical outcomes. The American Journal of Surgery, 212(1), 151–159. https://doi.org/10.1016/j.amjsurg.2015.03.023
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  6. Schür, R. R., Draisma, W. R., Wijnen, J. P., Boks, M. P., Koevoets, J. C., Joëls, M., Klomp, D. W., Kahn, R. S., & Vinkers, C. H. (2016). Brain GABA levels across psychiatric disorders: A systematic literature review and meta‐analysis of 1H‐MRS studies. Human Brain Mapping, 37(9), 3337-3352. https://doi.org/10.1002/hbm.23244
  7. Rajmohan, V., & Mohandas, E. (2007). The limbic system. Indian Journal of Psychiatry, 49(2), 132-139. https://doi.org/10.4103/0019-5545.33264
  8. Gonsalvez, I., Lee, I., Öngür, D., Seidman, L. J., Schmahmann, J. D., Eack, S. M., Keshavan, M. S., Pascual-Leone, A., & Halko, M. A. (2019). Breakdown of Functional Connectivity in Cerebellar-Prefrontal Network Underlies Negative Symptoms in Schizophrenia. The American Journal of Psychiatry, 176(7), 512. https://doi.org/10.1176/appi.ajp.2018.18040429
  9. Alacadag, M., & Cilingir, D. (2018). Presurgery Anxiety and Day Surgery Patients’ Need for Information. Journal of PeriAnesthesia Nursing, 33(5), 658-668. https://doi.org/10.1016/j.jopan.2017.06.125
  10. Thu, H. (., Stutzman, S. E., Supnet, C., & Olson, D. M. (2015). Factors Associated With Increased Anxiety in the MRI Waiting Room. Journal of Radiology Nursing, 34(3), 170-174. https://doi.org/10.1016/j.jradnu.2015.04.009
  11. Derevianchenko, N., Lytovska, O., Diurba, D., & Leshchyna, I. (2018). IMPACT OF MEDICAL TERMINOLOGY ON PATIENTS’ COMPREHENSION OF HEALTHCARE. Georgian Medical News, 284, 159–163. https://pubmed.ncbi.nlm.nih.gov/30618411
  12. Shamsi, H. A., Almutairi, A. G., Mashrafi, S. A., & Kalbani, T. A. (2020). Implications of Language Barriers for Healthcare: A Systematic Review. Oman Medical Journal, 35(2), e122. https://doi.org/10.5001/omj.2020.40
  13. Lebel, S., Mutsaers, B., Tomei, C., Leclair, C. S., Jones, G., Petricone-Westwood, D., Rutkowski, N., Ta, V., Trudel, G., Laflamme, S. Z., Lavigne, A., & Dinkel, A. (2020). Health anxiety and illness-related fears across diverse chronic illnesses: A systematic review on conceptualization, measurement, prevalence, course, and correlates. PLoS ONE, 15(7). https://doi.org/10.1371/journal.pone.0234124
  14. Health care costs are associated with depressive and anxiety disorders in primary care. (1995). American Journal of Psychiatry, 152(3), 352–357. https://doi.org/10.1176/ajp.152.3.352
  15. Contino, C., Das, M., & Bosmans, W. G. (2020). Anxiety and depression symptoms, and lack of emotional support among the general population before and during the COVID-19 pandemic. A prospective national study on prevalence and risk factors. Journal of Affective Disorders, 277, 540-548. https://doi.org/10.1016/j.jad.2020.08.026
  16. Harris, M. F., Harris, E., & Shortus, T. D. (2010). How do we manage patients who become unemployed? Medical Journal of Australia, 192(2), 98–101. https://doi.org/10.5694/j.1326-5377.2010.tb03429.x
  17. Ye, J., Shim, R., & Rust, G. (2012). Health Care Avoidance among People with Serious Psychological Distress: Analyses of 2007 Health Information National Trends Survey. Journal of Health Care for the Poor and Underserved, 23(4), 1620. https://doi.org/10.1353/hpu.2012.0189
  18. Waumans, R. C., Muntingh, A. D. T., Draisma, S., Huijbregts, K. M., van Balkom, A. J. L. M., & Batelaan, N. M. (2022). Barriers and facilitators for treatment-seeking in adults with a depressive or anxiety disorder in a Western-European health care setting: a qualitative study. BMC Psychiatry, 22(1). https://doi.org/10.1186/s12888-022-03806-5
  19. Legg, A. M., Andrews, S. E., Huynh, H., Ghane, A., Tabuenca, A., & Sweeny, K. (2015). Patients’ anxiety and hope: Predictors and adherence intentions in an acute care context. Health Expectations : An International Journal of Public Participation in Health Care and Health Policy, 18(6), 3034-3043. https://doi.org/10.1111/hex.12288
  20. Stubbe, D. E. (2016). Alleviating Anxiety: Optimizing Communication with the Anxious Patient. Focus: Journal of Lifelong Learning in Psychiatry, 15(2), 182-184. https://doi.org/10.1176/appi.focus.20170001
  21. Weisfeld, C. C., Turner, J. A., Dunleavy, K., Ko, A., Bowen, J. I., Roelk, B., Eissa, R., Benfield, E., & Robertson, K. (2021). Dealing with Anxious Patients: A Systematic Review of the Literature on Nonpharmaceutical Interventions to Reduce Anxiety in Patients Undergoing Medical or Dental Procedures. The Journal of Alternative and Complementary Medicine, 27(9), 717–726. https://doi.org/10.1089/acm.2020.0504
  22. Hardavella, G., Aamli-Gaagnat, A., Frille, A., Saad, N., Niculescu, A., & Powell, P. (2017). Top tips to deal with challenging situations: Doctor–patient interactions. Breathe, 13(2), 129-135. https://doi.org/10.1183/20734735.006616
  23. Yamamoto-Mitani, N., Noguchi-Watanabe, M., & Fukahori, H. (2016). Caring for Clients and Families with Anxiety: Home Care Nurses’ Practice Narratives. Global Qualitative Nursing Research, 3. https://doi.org/10.1177/2333393616665503
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