Characteristics of Patients who Experience Fear During Hospitalization

The purpose of this study is to describe individuals likely to experience fear, apprehension, or anxiety during hospitalization. Supporting literature has much to say about intervening once these feelings occur, but little on the description or characteristics of patients exhibiting these feelings during hospitalization. The intent of this exploration is to allow nurses to identify these patients sooner and prevent unnecessary stress and delays in care. Theoretical Framework When a patient experiences fear, they respond through the stress response cycle commonly observed as delays in wound healing and immunosuppression when feelings are prolonged. Identifying individuals likely to experience fear can prevent these negative consequences as well as allow for positive outcomes from hospitalization.  The parent study was a quantitative analysis of patient perceptions and satisfaction of the nursing bedside handoff. A questionnaire was utilized to measure various factors including the presence of fear. Secondary analysis was completed to explore the characteristics of patients who reported fear, apprehension, or anxiety. The data was evaluated for significant relationships between reported fear and patient demographics through descriptive statistical analysis.  The findings have shown that Caucasian individuals over the age of 60 are significantly less likely to experience fear, apprehension, or anxiety during EXPLORING FEAR DURING HOSPITALIZATION 3 hospitalization No other demographic data was found to have a significant relationship to the experience of fear, apprehension, or anxiety during hospitalization.  Additional literature paired with these findings point to generational values and characteristics as contributing factors. Supporting literature also demonstrates that patient's perception of safety may play a role in lessening these feelings.  Characteristics of Patients who Experience Fear During Hospitalization The experiences of fear, apprehension, and anxiety are some of humanity's most basic emotions (Halter, 2014) Depending on the situation and stimulating factors, any individual can experience these feelings in varying capacities. According to the North American Nursing Diagnosis Association (NANDA) fear is defined as "the response to a perceived threat that is consciously recognized as a danger," and anxiety is defined as "a feeling of apprehension caused by anticipated danger accompanied by the autonomic response whose source is often unknown to the individual," (Wiley, 2014, pg. 323 and 336) Additionally Taber's Cyclopedic Medial Dictionary (2009) defines apprehension as, "awareness of the meaning and significance of a particular sensory stimulus as modified by one's own experiences, knowledge, thoughts, and emotions." On a physiological level, these responses to perceived danger similarly affect patients. The body reacts to these feelings through activation of the stress response cycle (Lewis, Dirksen, Heitkemper, Bucher, 2014) When activation of this response is prolonged, suppression of the immune system can result and lead to a worsened health status (Seyle, 1950) However when a patient experiences lower intensities of these feelings, the body is less inhibited and in some cases, is supported by the stress response and able to heal more effectively (Salleh, 2008;Selye, 1950) Much research has been done to develop interventions that alleviate these feelings of fear, apprehension, and anxiety. Even though these interventions have shown to be effective, gaining the knowledge of who is more likely to experience fear, apprehension, or anxiety during hospitalization may be beneficial. If nurses can identify susceptible patients sooner, proper interventions can be initiated earlier, and may enable the alleviation of the elicited EXPLORING FEAR DURING HOSPITALIZATION 5 stress response. This early identification may increase quality of care delivered by fending off the negative effects of a prolonged stress response as well as guiding the patient toward quicker recovery than otherwise expected. The aim of this study is to explore the factors predisposing individuals to experiencing fear, apprehension or anxiety during their hospitalization.  One way nurses can effectively prevent patients from experiencing feelings of fear, apprehension, and anxiety during hospitalization is to enhance their perception of safety. When patients do not feel safe during their hospitalization they are more likely to experience fear, apprehension, and anxiety because their compromised condition can be seen as a danger. Factors shown to inhibit a patient from feeling safe during hospitalization include discrepancies in nursing care and communication, patient's perceived loss of control, unmet psychosocial needs, and lack of a good support system (Wassenaar, Schouten, Schoonhoven, 2014) As nurses work to lessen factors inhibiting patients' perception of safety, they will begin to enable patients to feel less fearful, apprehensive, or anxious during hospitalization (Wassenaar et al. 2014) In a subsequent study, patients who underwent colonoscopy were more likely to be anxious and fearful about the procedure if they had never had one before or were unaware of what the procedure would involve (Rollbusch, Mikocka Walus, Andrews, 2014) This too demonstrates that a deficit in patient knowledge (and potentially a deficit in communication between the care team and the patient) may augment a patient's experience of fear, apprehension, and anxiety during hospitalization. When the psychosocial needs of patients in an intensive care unit were evaluated,  6 it was observed that these needs were met when the participants felt safe (Hupcey, 2000) Specifically, the study ascertained that patients' perception of safety hinged on their ability to regain control, understand their care, establish trusting relationships between themselves and the staff, and maintain hope throughout hospitalization. It was observed that when patients felt a loss of control during periods of confusion or when their needs for information and understanding their treatment were unmet, they not only felt unsafe, but some began to refuse treatment and fight with staff. These behaviors were identified not only as feelings of fear, apprehension, and anxiety which could lead to physiologic delays in healing through activation of the body's stress response, but also as potential situations that could lead to delays in evidence based hospital therapy. Others have explored why patients suffering from end stage diseases would withhold information of a worsening condition or choose to delay seeking medical care in these circumstances. Findings suggested that patients perform these types of behaviors because of their overwhelming desire not to return to the hospital and the underpinning fear of getting worse (Lowey, Norton, Quinn, Quill, 2014) These patients explained that during their previous hospitalizations they had experienced many losses including the loss of control over their health, independence, and functional ability. Further, they rationalized that by exercising control over when they reported their symptoms or sought medical care they could regain some of that previously lost control, even if it meant a worsened health outcome. Just as in the previous studies discussed, here too, the patients who experienced fear, apprehension, and anxiety were hindered in the healing process in a multitude of dimensions. These patients may be hastening their own demise as a result of their fear of getting worse. Lowey, Norton, Quinn, and Quill, (2014) bring to light just EXPLORING FEAR DURING HOSPITALIZATION 7 how important it is for nurses and other health care providers to identify patients at risk for experiencing fear, apprehension, and anxiety during hospitalization. When the health care team can establish a patient's perception of safety, many detrimental consequences can be avoided. When patients determine that they are well taken care of and that their needs are met, they not only are more likely to feel safe, but they are also more likely to divulge feelings of fear, apprehension, or anxiety (Lasiter, 2011) Participants in a study regarding perceptions of safety acknowledged that if their call light went unanswered they would feel very unsafe. Additionally it was observed that when the nurses were within a safe proximity, took initiative, and demonstrated generous oversight in their care, participants were more likely to identify their specific fears. Here too the patient's trust in the care team was key to reducing fear, apprehension, and anxiety during hospitalization. The current literature supports the need for patients to feel safe within a healthcare setting to promote effective healing. The literature also brings to light how patient expectations influence the perception of safety as well as the consequences both physiologically and psychosocially when these needs are not met. However there is much to be learned about what factors specifically influence a patient's experience of fear, apprehension, and anxiety during hospitalization. If it is known that patient perception of control, good communication between the patient and medical staff, and understanding of the situation can deter feelings of fear, what sorts of factors influence a patient to experience these feelings in the first place? There is little known about how an individual's demographics such as education, age, gender, ethnicity, or other factors EXPLORING FEAR DURING HOSPITALIZATION 8 influence the experience of fear, apprehension, and anxiety during hospitalization. The purpose of this secondary analysis is to explore what some of these factors may be as well as to better equip nurses to identify patients at higher risk of experiencing fear, appr