Anxiety and satisfaction in cataract patients 1 Running head: ANXIETY AND SATISFACTION IN CATARACT PATIENTS. Anxiety and Overall Patient Satisfaction in Cataract Patients: Reducing the Impact of Anxiety

The purpose of this study was to identify the impact of personal and situational factors on anxiety and to evaluate adjustments of care delivery used to reduce the impact of anxiety. Moreover, the influence of anxiety on overall patient satisfaction was investigated. Cataract patients (N = 140) at The Rotterdam Eye Hospital filled out two questionnaires. Correlations, t-tests and multiple regression analysis were used to analyze the data. State anxiety was negatively related with overall patient satisfaction. In the present study it was shown that this negative role of state anxiety can be decreased, by implementing special adjustments of care delivery. Thus, health care organizations are able to decrease anxiety and increase patient satisfaction by adapting organizational processes, using a more patient-centred focus. Anxiety and satisfaction in cataract patients 3 Anxiety and Overall Patient Satisfaction in Cataract Patients: Reducing the Impact of Anxiety by Special Adjustments of Care Delivery. Cataract is one of the most frequently experienced diseases among seniors, but effective therapy is available. Most cataract surgeries are performed in day-care setting and most patients are women (63 percent). Eighty-five percent of the population who underwent cataract surgery is 65 years and older (Staaroperaties in Nederland, 2007). An unpleasant surgery may cause anxiety because of the concern about pain people expect to feel and one can be concerned about the diagnosis and prognosis (Edelmann, 1992). Moreover, anxiety can lead to an increased experience of stress in patients before they undergo cataract surgery (Kim, Cho, Woo, & Kim, 2001). Marback (2007), indicated that 33.3 percent of the patients feared the surgical procedure, 54.0 percent was afraid for visual loss and 12.7 percent was even scared for death during surgery. In general, it has been suggested that there is improvement in technique and knowledge of diseases in health care. However, not much has changed in business and management systems since the 1950s (Kaplan, & Patterson, 2008). Focus on innovations in health care can increase patient satisfaction (McKay, 2008). It is suggested that patient satisfaction is an important goal of healthcare services (Karthikeyan, Dahlmann-Noor, Gupta, & Vivian, 2007). Very little empirical information is available about the influence of anxiety on overall patient satisfaction. In this study, the impact of different determinants of anxiety were investigated as well as the influence of anxiety on patient satisfaction. Moreover, the adjustments of care delivery made by some hospitals to reduce the impact of determinants of anxiety and to increase patient satisfaction were evaluated. The research question is: What are the effects of special adjustments of care delivery to reduce the impact of anxiety and what is the influence of anxiety on overall patient satisfaction of Anxiety and satisfaction in cataract patients 4 patients undergoing cataract surgery? Results of this current study will provide recommendations on how to reduce anxiety within patients that undergo cataract surgery. If anxiety proves to have an influence on overall patient satisfaction, it‟s important to know which determinants of anxiety have a significant influence. This study aims to provide a clear insight into the link between anxiety and patient satisfaction and may provide policymakers with relevant information to further improve organizational processes from patients‟ perspective. The next section of the introduction addresses the definition of anxiety and previous research in this area. Furthermore, the theoretical framework used in the present study will be explained. Moreover, what is known about factors contributing to anxiety reduction, health care innovation and overall patient satisfaction from previous research will be discussed. A last section, which concludes the introduction, addresses how these distinct definitions were integrated to shed light on the role of anxiety in patient satisfaction. Anxiety & Cataract Anxiety is widely used within the psychological literature and can be defined as the tense anticipation of a threatening and vague event; it's a feeling of uneasy suspense (Rachman, 1998). “An adequate theory of anxiety must distinguish conceptually and operationally between anxiety as a transitory state and as a relatively stable personality trait” (Spielberger, 1972, p.38). State anxiety is an emotional state, while trait anxiety indicates individual differences in anxiety proneness (Edelmann, 1992). Trait anxiety can be defined as a relatively enduring individual difference between people in how they perceive the world and respond to it. State anxiety on the other hand can best be described as transitory, because it is caused by threatening stimuli and will last for a limited period. As soon as the threat is removed anxiety will decrease. It is stated that state anxiety is influenced by differences in Anxiety and satisfaction in cataract patients 5 already existing anxiety proneness, better known as trait anxiety (Rachman, 1998). Research has suggested that there is a high correlation between state anxiety and trait anxiety (Nijkamp et al., 2004). Nijkamp et al. (2002a) determined factors that were related to anxiety among patients who needed cataract surgery. These determinants were split into personal and situational factors. Personal factors included (anticipation) of sensations, previous experience and coping strategies. Situational factors were the doctor-patient relationship, patient education, social support, waiting, and the hospital organization. Nijkamp et al. (2002a) developed a model regarding these factors and based their research model on the cognitive appraisal theory of Cohen and Lazarus. Cohen and Lazarus developed a theory in which they made a distinction between primary and secondary appraisals. The primary appraisal process is an individual evaluation about the personal relevance and negative consequences of a threat. On the other hand, the secondary appraisal process is a personal judgment about the person‟s ability to cope with the perceived threat (Cohen & Lazarus, in Nijkamp et al., 2002a). The type of appraisals people make are influenced by personal (e.g. coping strategies) and situational factors (e.g. hospital organization) (Lazarus, in Nijkamp et al., 2002a). From their study, Nijkamp et al. (2002a) concluded that personal factors as well as situational factors were related to anxiety in patients who needed to undergo cataract surgery. In another study, Nijkamp et al. (2004) further examined factors related to induced anxiety in patients undergoing cataract surgery. A model of anxiety related factors, which consisted of personal and situational factors was used. Nijkamp et al. (2004) concluded that gender and trait anxiety correlated significantly with state anxiety. It was indicated that individuals with higher trait anxiety levels and women showed more state anxiety. Furthermore, positive outcome expectancies and social support correlated with state anxiety. Anxiety and satisfaction in cataract patients 6 Level of anxiety was the highest before surgery, after surgery it declined immediately, anxiety was higher again after the postoperative visit. In summary, studies conducted by Nijkamp et al. (2002a, 2004) showed that gender, trait anxiety, outcome expectancy and social support correlated significantly with state anxiety. Furthermore, Nijkamp et al. (2002a, 2004) have shown that it is important to understand personal and situational factors related to anxiety, in order to successfully implement anxiety reducing interventions. The present study was build on the cognitive appraisal theory and the findings by Nijkamp and colleagues (Nijkamp et al. 2002a, 2004). To further extend these previous studies, in the present study possible determinants of state anxiety were added. Furthermore, the relationship between anxiety and overall patient satisfaction was investigated (see Figure 1). The research model will be explained in the last section of the introduction. In the next section, the theoretical framework used for this study will be discussed. Cognitive Appraisal Theory It depends on patients‟ perceptions and emotional reactivity if a stressful situation causes anxiety (Carlson, & Buskist, 1997). The cognitive processes of people (thoughts, attitudes, beliefs, images) should play an important role in whether people experience a situation as stressful (Lazarus, in Lazarus, & Folkman, 1984). Cognitive appraisal can be defined as a process through which a person evaluates whether a potentially stressful situation is relevant to his or her well-being and, if so, in what way (Folkman, Lazarus, Gruen, & DeLongis, 1986b). According to Lazarus and Folkman (1984) cognitive appraisal, or perception, is a two-stage process. In the first stage („primary appraisal‟) a person considers whether the situations is perceived as threatening with regard to the own well-being. For example, is there potential harm or benefit to my health or well-being? If a person judges a situation as threatening, in the second stage („secondary Anxiety and satisfaction in cataract patients 7 appraisal‟) a person assesses the availability of the resources necessary to cope adequately with the stressful situation. Folkman et al. (1986b) indicated that people evaluate different coping strategies such as an attempt to change the situation, accept the situation or seek more information. How much stress or anxiety is experienced depends on the interaction between the interpretation of the situation („primary appraisal‟) and the interpretation of coping possibilities („secondary appraisal‟) (Folkman, Lazarus, Dunkel-Schetter, DeLongis, & Gruen, 1986a). Appraising a situation as primarily threatening leads to more inadequate psychological reactions, such as containing the possibility of harm or loss, than when appraising a situation