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Dealing with patient anxiety: course code C-16352 O/D/CL.

Healthcare research demonstrates that anxiety is related to a reduction in patient attention, recall and compliance. (2,5,6) Furthermore, it creates a barrier to effective patient-practitioner communication (7) and can contribute to wasted healthcare resources due to non-attendance of appointments (8,9) and, in other cases, excessive unnecessary utilisation of healthcare services. (10,11) Recent research has confirmed that there is a significant relationship between patient anxiety and lower levels of satisfaction following eye examinations. (12) Dissatisfied patients are problematic to practice because they make more complaints, (13) costing practices both time and money. Of concern is that up to 25 % of patients attending optometric practice are anxious. (14) In light of this it is helpful for optometrists to be aware of the issues surrounding patient anxiety.


The nature of anxiety

In the early 20th Century, Watson and Morgan (15) presented the original model for classical conditioning. The basic theory is that when an initial neutral and non-anxiety provoking event (unconditioned stimulus) is paired with an aversive experience, then an anxiety response ensues (unconditioned response). Subsequently, this anxiety response becomes associated with the aversive experience, and the unconditioned stimulus then is able to produce the anxiety reaction. However, such theories do not explain why some people are more prone to anxiety than others. This issue was considered by Spielberger (16) who presented a popular conceptual framework whereby he differentiated the concepts of 'trait' and 'state' anxiety. It is a more complicated model than simple conditioning; rather it involves integration between anxiety proneness (trait anxiety), past learning and memory, and sensory and cognitive feedback (Figure 1). This is now a widely accepted theory forming the basis of many studies measuring anxiety. (17)

Within Spielberger's anxiety model, trait anxiety is described as a stable personality trait, whereas, state anxiety is a transient experience caused by a specific perceived threat. Threats within healthcare are subjective and determined by the patient's thoughts and expectations. If a patient determines that a situation will lead to personal negative outcomes, this will be identified as a 'threat'. Considering that eyesight is the most valued sense, (18) any perceived threat is likely to result in anxiety. For example, discomfort of clinical procedures, detection of eye disease and adapting to spectacles have all been identified as patient concerns. (14,19-21) The 'threats' perceived by patients may vary between individuals, but all will result in anxiety.

Which patients are more likely to be anxious?

Understanding which patients attending for an eye examination are more likely to be anxious can help optometrists identify those who may be more at risk of poor attention, recall and compliance. Recently, a study sought to identify which factors predict patient state anxiety levels in optometric practice. (22) A total of 366 patients were asked to complete a questionnaire prior to their eye examination. The questionnaire measured state anxiety, trait anxiety and outcome expectancies. Interestingly, the results of the study showed that age, gender, duration since last eye exam and the reason for appointment were not related to high anxiety levels. This suggests that optometrists cannot assume that anxiety is reserved for one 'type' of patient eg, elderly people. Rather, trait anxiety, expecting 'bad news' and being a non-spectacle wearer were all independent predictors of increased state anxiety (Table 1). How these findings apply to clinical practice is summarised in the following sections.

High anxiety personality types

Trait anxiety is a stable personality trait which is normally distributed within the population. (17) However, there are also smaller groups of people within the population who have lower and higher than average trait anxiety levels. Therefore, the finding that trait anxiety predicts state anxiety, suggests that there will always be a group of patients who attend for eye examinations with high levels of anxiety.

Patients who expect 'bad news'

It is well reported within other areas of healthcare that the expectancy of receiving bad news is a cause of patient anxiety. (23,24) Furthermore, the expectation of 'bad news' can stop patients initially articulating their concerns. (7) Most optometrists have probably experienced this in practice eg, a patient who had revealed no concerns at the start of the examination wants reassurance after a fundus examination that they 'don't have a cataract'. This is a common patient anxiety which is driven by a fear of 'going blind'. Indeed, the levels of anxiety associated with losing sight should not be underestimated. This is demonstrated by the high levels of anxiety and depression recorded in patients with low vision. (25) However, optometrists should be aware that the definition of 'bad news' will be unique to each patient and is not only related to detection of pathology eg, identification of a colour vision deficiency may be insignificant to some individuals, but devastating for an aspiring pilot. This highlights the importance of developing good communication and rapport with each patient in order to elicit patient priorities and concerns.

Patients who don't wear spectacles

Patients who do not wear spectacles are more likely to be anxious. One reason for this could be that spectacle wearers are more familiar with the optometric experience and as such are more relaxed. However, a further explanation may be that patients perceive wearing spectacles as a 'threat'. Anecdotal reports suggest that patients are concerned about adaption to spectacle wear and the possible changes to personal appearance. (14,19,21) This reiterates the importance of identifying and addressing patient concerns as a mechanism to reduce patient anxiety.

When are patients anxious during the consultation?

In addition to understanding which patients attending practice are most likely to be anxious, it is also helpful for the optometrist to know if there are any specific events during the consultation that patients find particularly stressful.

To date, only two studies have investigated patient anxiety during routine eye examinations and contact lens fitting. (26,27) Both studies measured changes in skin conductance (Figure 2), to assess arousal, which is the physiological correlate of anxiety. It is based upon the principle that sweat ducts fill, producing a more conductive path through the skin when a person is aroused (the same principle as a lie detector test). (27)


The results of the first study indicated that patient anxiety levels are not constant during eye examinations. However, the specific parts of the eye examination that make people anxious were difficult to identify for various reasons (including a small sample of patients and a variety of "reasons for visit" for the eye examination). In a following study, skin conductance was measured on a larger group (35 patients) attending practice for an initial contact lens fit ie, a specific type of examination/"reason for visit". (26) This clearly revealed that anxiety levels are significantly raised at four points of the consultation: history and symptoms, contact lens insertion, contact lens removal and patient advice (Figure 3).

Anxiety during 'communicative interaction'

Communicative interaction relates to two specific periods during the consultation: during history and symptoms-taking and when offering advice at the end of the consultation. For a patient, dialogue with a 'professional' can be an anxiety-provoking situation, causing some people to feel embarrassed or silly (social anxiety). (28,29) Often, the desire to make a good impression further fuels anxiety. (30,31) When the optometrist gives advice to the patient, there can again be heightened arousal due to social anxiety.

However, the heightened anxiety during dialogue with the optometrist may also reveal a more fundamental patient concern. Namely that patients place substantial value upon good communication with the optometrist. This is a well-recognised patient concern within medicine. In that context, when patients do not feel understood by the practitioner, feel out of control, or do not have their questions answered, they are less satisfied with the consultation. (32,33) Communication between patients and practitioners is a dynamic and complex process. Considering this, perhaps it is not surprising that patients show heightened states of anxiety during these points of the consultation.

These findings are clinically significant as there is an increased risk of poor patient attention and recall of what the optometrist has said. (2,6) For this reason optometrists should not assume that the patient will remember key information explained to them during the consultation.

Anxiety during contact lens insertion and removal

Patient anxiety levels increase when the optometrist tells a patient "I am now going to select a contact lens and place it into your eye". (26) It is well understood that the expectation of pain evokes an anxiety response. (34) However, it is interesting that this heightened state of anxiety is not maintained upon insertion (or removal) of a second contact lens. (26) This may be because experiencing the event once gave the patients a more accurate "expectancy", resulting in a reduction of anxiety. Many patients avoid trying contact lenses because they are anxious about having a contact lens in their eye. (3) However, these results indicate that after the patient has experienced the event once, they are less anxious about having the second contact lens inserted.

How to minimise patient anxiety

Identifying potentially anxious patients is important and allows optometrists to modify their routine to help the patient relax. This will help minimise the negative effects of anxiety eg, poor attention and recall. Communication style and provision of written information are perhaps two of the most effective methods to manage anxiety.


Communicate effectively

In order to reduce patient anxiety, it is essential that the practitioner identifies the specific 'threat' or concern perceived by the patient. Once this has been elicited the optometrist can communicate information in a clear and realistic way to the patient and there is an increased potential for clinical success. (38)

At the close of the consultation, the patient-centred strategy involves the practitioner initiating a discussion with the patient to involve them in the decision making. Patients who feel that they have been involved in their management are often more likely to comply with advice. The discussion also allows the practitioner to check patient understanding and hence avoid poor compliance.

Provide written information

It may be beneficial for optometrists to consider providing written materials and repeating advice to patients, which are techniques used in medical practice to improve clinical success. (39,40) Written information can help reduce anxiety by creating accurate expectancies. For example, after identifying the misconceptions about wearing contact lenses, the optometrist could provide written information to be taken away. This allows the patient to read and think about trying contact lenses in a more relaxed environment.

Written information can also be used to assist with patient recall. This is especially useful when discussing pathology. Optometrists should never assume that the patient will remember what they have been told during an examination, especially if the patient is anxious. Providing a leaflet or simply writing the condition on a piece of paper is a simple way to ensure the patient remembers and understands what has been discussed.


This article has shown how anxiety is a feature of every optometric practice. Seeking to understand and explore patient concerns will assist in improving outcomes, satisfaction and compliance.

About the author

Dr Helen Court is an optometrist and lecturer at Cardiff University. Her research interests include patient-practitioner communication, anxiety and low vision. The author acknowledges Cardiff University and Bausch & Lomb who co-funded the research.


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Module questions

PLEASE NOTE There is only one correct answer. All CET is now FREE. Enter online. Please complete online by midnight on June 17 2011--You will be unable to submit exams after this date--answers to the module will be published on CET points for these exams will be uploaded to Vantage on June 27 2011.

Course code: C-16352 O/D/CL

1. Which of the following has been associated with anxiety?

a) Increased patient satisfaction

b) Increased patient compliance

c) Decreased patient recall

d) All of the above

2. Which of the following statements is TRUE?

a) State anxiety is a stable personality trait

b) Anxiety theories suggest that past experiences and conditioning are responsible for trait anxiety levels

c) State anxiety is related to anxiety proneness, sensory and cognitive feedback

d) Every patient has the same trait anxiety level

3. Why might a patient be anxious when talking to an optometrist?

a) They want to create a 'good impression'

b) They want to maintain control over the conversation

c) They want to be understood

d) All of the above

4. Skin conductance recordings show that patients experience heightened levels of anxiety:

a) When the practitioner removes a contact lens

b) When the practitioner touches the eye

c) During all clinical procedures

d) All of the above

5. Which of the following communication techniques have been shown to help reduce anxiety?

a) Using a practitioner-centred consultation style

b) Using 'we' rather than 'I' (plural pronouns)

c) Using closed questions

d) Speaking quietly

6. Which of the following statements about the provision of written information to anxious patients is FALSE?

a) It is useful for addressing contact lens misconceptions

b) It should always be presented in leaflet format

c) It helps modify outcome expectancies

d) It can assist with patient recall and compliance
Table 1

Multiple linear regression results for the predictors of state
anxiety in optometric practice (* significant at p=0.05) (reproduced
from Court et al. (22))

                    B          SE     [beta]         p

Trait anxiety     0.278      0.046          0.354    0.000 *
Patient/         -0.260      0.150         -0.101     0.085

Possible         -0.331      0.121         -0.145    0.007 *
(bad news)

Patient/         -0.095      0.150         -0.036     0.529

Physical         -0.074      0.155         -0.024     0.633

Perceived        -0.121      0.204         -0.032     0.555

Spectacle         0.373      0.148          0.122    0.012 *

Routine           0.210      0.213          0.087     0.325

Problem           0.044      0.239          0.016     0.853

Emergency        -0.526      0.366         -0.083     0.152
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Author:Court, Helen
Publication:Optometry Today
Geographic Code:4EUUK
Date:May 20, 2011
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