Understanding and Managing Patient Fear in the Hospital Setting

Understanding and
Managing Patient Fear
in the Hospital Setting
Darien Kadens, PhD, MBA,
Director of Healthcare Research, Sodexo
Lisa Herms, MSc, Research Analyst, Sodexo

2
The information and concepts contained in this document are the proprietary property of Sodexo.
As such, they cannot be reproduced or utilized without permission. ©2015
Few regard being in the hospital as a pleasant
experience. A hospital stay is usually associated with
a dual burden — the unpleasantness of the condition
causing the hospitalization, as well as the discomfort
associated with the state of being in a hospital. Medical
research and increasingly also patient engagement can
help speed and alleviate the first issue. To mitigate the
second concern, hospital staff and administrators can
make valuable contributions.
Health care that is patient-centered is increasingly
acknowledged as an essential foundation to improve not
only patient satisfaction, but also safety and clinical
outcomes. The Affordable Care Act (ACA) repeatedly
refers to patient-centeredness, patient satisfaction,
and patient experience in its provisions, and even when
only the general term “quality measures” is referenced,
patient-centered assessments are often implied1
.
In fact, patient experience is a key criterion of health
care quality, next to patient safety and treatment
effectiveness. Tools such as the HCAHPS (Hospital
Consumer Assessment of Healthcare Providers and
Systems) survey and the Press Ganey survey help
to quantify and evaluate the provision of care from
the patient perspective. With the advance of these
measurement tools, effectively improving patient-
centered care and focusing on patient feedback is no
longer simply the right thing to do, but is becoming a
business imperative. Both ranking — which helps to
determine utilization — and service remuneration are
often linked directly to patient feedback and outcomes.
The public availability of hospitals’ performance scores
has opened hospital care provision to the curiosity
and scrutiny of health care consumers. The Centers
for Medicare & Medicaid Services’ Hospital Inpatient
Value-Based Purchasing (VBP) Program, which seeks
to link the Medicare payment system to observable
quality measures, explicitly relies on HCAHPS scores for
adjusting payments based on a Total Performance Score
(TPS). The TPS is currently comprised of the clinical
process of care domain score (weighted as 20% of the
TPS), the patient experience of care domain (weighted as
30% of the TPS), the outcome domain score (weighted
as 30% of the TPS), and the efficiency domain score
(weighted as 20% of the TPS). More and more private
insurers also rely on patient experience information in
setting their reimbursement levels.
It is therefore vital for a hospital to look toward
enhancing patient experience in a hospital setting. This
is partially shaped by accounting for the fears faced by
patients in hospitals.
1. DEFINING PATIENT FEAR
AND UNDERSTANDING ITS
MANIFESTATION
1.1 Sources of Patient Fear
Most people experience a certain level of fear and
discomfort in a hospital setting, with varying degrees of
severity. This is shaped by either personal experience,
the experience of family or friends, or sometimes simply
media reporting, which most often reports on negative
rather than positive outcomes.
Fear in the hospital setting can stem from several
sources. In a review of academic literature and interviews
with recent patients, results indicate that fear typically
revolves around two aspects: a loss of control and
depersonalization. A hospital is one of the few places
where an individual essentially forfeits control over
every task s(he) normally performs2,3,4
. Restrictions on
personal freedom, mobility and choice, coupled with
perceived objectification from hospital staff, can lead to
a feeling of shame and helplessness.
Fear typically revolves
around two aspects:
a loss of control and
depersonalization.
The Patient Empathy Project has identified the most
common patient fears from a series of patient surveys
covering 1,080 adults and spanning 3.5 years, displayed
in Table 1 below5
. These have also been reaffirmed and
individually examined in other studies6,7,8,9,10,11
, touched
on in patient interviews, and can be seen in media
coverage of hospital incidents.

3
Table 1
The Patient Empathy Project – Top Patient Fears
1. Infection
2. Incompetence
3. Death
4. Cost
5. Medical Mix-Up
6. Needles
7. Rude Doctors and Nurses
8. Germs
9. Diagnosis/Prognosis
10. Communication Issues
11. Loneliness
Source: Patient Empathy Project5
Sometimes, patient fear is straightforward, such as a
fear of needles or blood. However, most of the fears faced
by patients are more fundamental.
A primary concern is the fear of hospital infections
and germs. In an interview with Sodexo, Jane, a new
mother who recently underwent surgery and extensive
chemotherapy for breast cancer, states that the fear
of “getting sicker the longer you stay, because of
secondary infection,” led her to leave the hospital very
shortly after undergoing surgery. Jane believes that this
fear was conveyed to her through media coverage as well
as through her own doctors.
As would be expected, there is significant fear of death
and poor prognosis. This is heightened by a fear of
incompetence and mix-ups. These can be medical mix-
ups, such as foreign objects being left inside a patient
during surgery or an IV port not being removed when
it should be. Mix-ups can also be administrative, such
as the confusion of patient records, or, as the example
of a Calvary hospital shows12
, a mix-up with respect to
the timely delivery of appropriate food to patients with
special dietary requirements.
Hospitalization is associated with two-fold financial cost
— the cost associated with a hospital treatment, as well
as a cost in terms of foregone income that accompanies
days of sickness. Particularly in the United States, where
the medical bill of a hospitalization is often already
unaffordable, patients may significantly fear these costs.

4
Communication, respect, courtesy, and empathy — or
lack thereof — are other key issues. A hospital patient
is in an institution whose bureaucratic structure is
foreign to him or her; patients are subject to directives
of various lines and levels of authority, which sometimes
results in contradictory information and instructions
from members of staff. This leaves the patient
confused and afraid, with no means to determine which
statements are correct. In another interview, John, a
concerned father who had to take his daughter into the
hospital on numerous occasions for seizure episodes,
explained how a lack of communication propagated
further anxiety. Unsure of what ailed his daughter,
hospital staff ran tests with the sole explanation that
“the doctor ordered it.” This lack of communication
then led him to independent researching of medical
terminology and tests, confusing and contradictory
Internet findings, and hence even greater anxiety.
The last fear that the Patient Empathy Project points
out, which is at the same time one of the most
fundamental and pervasive, is the fear of loneliness.
Facing an illness is an isolating experience in and of
itself. John says that he felt isolated by his own design,
because he “didn’t want others to worry about [his] state
of mind,” and Jane states that isolation came from the
mindset that “everybody is living their life… and then
there’s you, who has cancer.” But in a hospital setting,
this isolation is amplified. As she puts it, “being sick, you
are already starting from a place of disconnect, and then
the hospital setting perpetuates that.” Patients are left
alone for much of their hospital stay. There is physical
isolation and boredom, stemming from significant
restrictions placed on patients, safety and visitation
regulations, and potential clinician-imposed immobility
(i.e., confinement to a hospital bed). Yet, in Jane’s words,
“it’s in that loneliness that fear comes in, because all you
can do is worry.”
1.2 Manifestation of Fears
Not every individual will perceive the aforementioned
fears in the same way. Severity will differ from case to
case; some individuals will experience a few fears, while
others may deal with all of them. Having established
the main sources of fear in a hospital, one must look
toward how patients themselves perceive these fears,
and how the fears are manifested in patient attitudes
and behaviors. Patients deal with fear in different ways;
some crave clarity and information to overcome their
fear while others focus on external distractions such as
personal interests or social interactions.
To formalize this, Sodexo has undertaken an in-depth
study on patients, using exhaustive qualitative and
quantitative research methods in both the USA and in
France, and systematically applying factor analysis to
segment patient attitudes. The resulting Behavioral
Segmentation Tool — Personix™ Patients — has been
used to identify 6 “families” of patients, with emphasis on
the behaviors these patients exhibit to cope with the fear
experienced during their hospital stay. The 6 families are
described in greater detail below.
“Being sick, you are already
starting from a place of
disconnect, and then the hospital
setting perpetuates that.”
– Jane, mother and breast cancer survivor
Patients deal with
fear in different ways;
some crave clarity
and information
while others focus on
external distractions.

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6 Patient Families
At any given moment in time in a hospital, Sodexo’s research hypothesizes that patients’ attitudes can be distributed
according to these 6 clusters. These vary depending on whether or not individuals turn to an inner focus or reach out, as
well as whether they deflect or tackle the fear they are facing.
Patients with a self-centric attitude do
not frontally address the fears they are
facing, but rather put them aside in an
effort to concentrate on self-interest. These
individuals try to singularize their hospital
stay, making sure that they get
what they want, in an attempt
to regain some control over their
situation.
Though still deflecting rather than tackling
fear, minglers do so very proactively by
reaching out to others and fostering social
contact. Whereas attention-seekers want
hospital staff to merely listen, minglers are
looking to go a step further and
bond, through mutual interaction.
Worriers do not manage their fear
as directly as acceptors, and require
significantly more support and continuous
reassurance. They rely on rational
explanations, coaxing and regular check-
ups to trigger the recollection
process, reassure them of their
progress, and bring stability.
Attention-seekers, similar to Self-
Centrics, also do not confront their
fears, but rather escape them through
various distractions. They attempt to
break through the depersonalization and
standardized routines, trying to become
the center of attention. Unlike
the Self-Centrics, however, they
seek out human interactions and
emotional support.
Acceptors keep their fear under control
through ensuring that they are correctly
informed of their status and progress at
all times. Oftentimes, they try to actively
engage in their healing process and
adhere by rules and guidelines,
trusting that “doctor knows best.”
Loners withdraw from their surroundings
and value their loneliness and privacy. Out
of fear, these individuals isolate themselves,
which in turn is again a source of fear.
Isolation and fear amplify one another,
and the loner endures through
mere resignation or sometimes
depression.
Though at any point in time most patients fall into one of these 6 clusters, they are not permanent. Patient attitudes
can change throughout the hospital stay, following certain milestones or as a result of specific experiences.

6
1.3 Consequences of Patient Fear
Fear, though a natural response, is generally
acknowledged to be a negative and undesirable
phenomenon. In the hospital setting, fear can be
particularly detrimental for successful treatment and
recovery, producing cognitive, physiological, behavioral
and affective reactions that can severely hinder a speedy
and safe recovery, regardless of the particular fear
source or an individual’s attitude cluster.
A primary consequence of fear is that it can make
the treatment experience worse than it truly is. This
form of catastrophizing has been suggested and
tested by several studies3,13,14,15,16,17
. If patients are
not given enough information about their condition
and communication is lacking, they may experience
the discomfort of the hospital stay and treatment
more intensely, which manifests itself in heightened
adverse physiological responses and reduced powers of
concentration. For example, the white coat syndrome
is a commonly acknowledged phenomenon whereby
patients exhibit a blood pressure level above their
normal range18
. This syndrome is not only dangerous,
but it also may produce inaccurate measures of vital
signs, which are necessary for determining treatment
path and dosage. Another adverse effect of extreme
cases of fear is refusal to seek treatment, even when
highly needed. For example, a fear of hospital superbugs
and infections in the United Kingdom has kept people
out of the hospital who otherwise needed treatment11
.
In another example, fear of isolation may also prevent
some people from seeking treatment, such as in the
case of antibiotic resistance19
or in the choice between
home- and hospital-centered terminal care20,21
.
Fear also has consequences in terms of how it shapes
and influences the interaction between patients and
hospital staff. Some patients become what Taylor3
describes as “good patients;” namely, those who are
passive and compliant. What this passivity may mean,
however, is that patients are in a state of depressed or
anxious helplessness22,23
. This has physiological as well
as sociological consequences. Reports have shown that
fear can “paralyze” patients to the point when they
stop speaking up and do not voice their complaints to
the staff, even for minor aspects of their care, out of
fear of reprimand or being seen as burdensome24
. John
illustrates this point very well when talking about his
interaction with his daughter’s doctors: “I didn’t want to
be that intrusive parent who came across as pushy or
obnoxious. I didn’t want to jeopardize anything for her. I
guess I felt retaliation could come in some way.”
Other patients turn into “bad patients” — those who
exhibit anger in light of the seemingly arbitrary exercise
of control by the hospital. Such a negative attitude can
in turn have adverse effects on relations with hospital
staff, who may be confronted with disappointment,
anger, hatred, or even violence at times. Not only can
this hinder the effective provision of appropriate care,
but it can also negatively impact staff motivation, which
affects quality of care as well as sustainability of the
hospital as a company.
2. RESOLVING PATIENT FEAR
To help prepare patients for fear in hospitals, and
potentially allay their concerns, there is significant
scope for contribution by hospital staff and providers in
the community. The underlying aim of most attempts to
resolve patient fear is to combat communication issues
and loneliness — the key drivers of fear. Three main
areas are vital starting points: staff awareness, patient
involvement, and social support.
Staff awareness, patient
involvement, and social
support are essential for
overcoming patient fear.
To help alleviate patient fears, staff and administration
awareness about these fears is extremely important25
.
Despite the fact that patient fears are intuitively easy to
understand, some studies have shown that these fears
are not always perceived by hospital staff. For example,
Heikkila et al. found that there was a significant
incongruence between perception of fear by patients
and nurse awareness thereof26
. This finding suggests
that it is important to further examine the sources
of patient fears and, perhaps even more importantly,
to spread this knowledge throughout the hospital
staff, to avoid stereotypical views of patient fears,
subconscious belittling of patients, or even unintentional
reinforcement of certain fears.

7
Patient involvement and communication are also key areas where improvements can be made. Physicians and staff
members may not appreciate the necessity of creating a safe environment for open communication, one which
facilitates shared decision-making22,27
. Giving information may be seen as something that is unnecessary, would
simply confuse the patients even more, might cause an (emotional) reaction that could hinder proper care provision,
or at the very least is simply time-consuming. Yet self-care, pre-operative preparation, feelings of control, the
setting of appropriate expectations, and a belief that one can affect one’s own condition can lead to better physical
and psychological states, offsetting many of the pernicious side effects that the traditional loss of control and
depersonalization create.
Social support refers not only to the extent to which friends and family members are allowed to participate and be
on site for the patient, but also to other forms of indirect support, such as through entertainment offers, relaxation
facilities and various amenities designed to bring comfort.
These three areas can be targeted in all stages and aspects of a hospital stay. Actual implementation and solutions
to how fear can be alleviated through these must be shaped and individualized to specific patient needs and behavior
groups, though some general statements are possible.
KEY AREAS FOR IMPROVEMENT TO ALLEVIATE PATIENT FEAR IN HOSPITALS
I M P R O V E S TA F F A W A R E N E S S , P AT I E N T I N V O LV E M E N T & S O C I A L S U P P O R T
ARRIVAL
PROCEDURES
DURING THE HOSPITAL STAY:
AMENITIES & SERVICES
POST-DISCHARGE
COMMUNICATION
AND SUPPORT
Physical Environment
Food Services
Follow-up
Appointments
and Care
Transportation,
Home Maintenance,
and Support during Recovery
Pre-Admission
Communication
Check-In Practices
Media & Entertainment
Relaxation & Support
Family & Visitors
The arrival and discharge processes and facilities must become more humanizing. As patients are either entering or
leaving this new and unique institution of the hospital, they require some form of buffer zone to allow a smooth and
coherent transition.
Right from the beginning, communication between staff and administration must be open, direct and friendly. For
example, the Memorial Hospital and Health System in South Bend, Indiana, has adopted “check boxes” of fears in
the EMR, which allow staff to record and follow up on a specific patient’s fears by pointing them to the appropriate
resources. Along the same lines, acknowledging some of the most common patient fears, Memorial Hospital also banned
the practice of saying “good luck” to patients. Furthermore, staff members were asked to no longer assume that every

8
patient wants a private room but to explicitly ask for
preference for a private or shared room — allowing
the patient to balance privacy against companionship
and make an independent decision. Evidence from The
Patient Empathy Project suggests that these measures
had a positive impact on the hospital’s HCAHPS Score
and hence (by inference) patient experience28
.
Some suggest that hospitals should take a more
concierge-type approach to the hospital stay, focusing
on the delivery of services beyond just health care.
Throughout hospitalization, it is vital to maintain
patient choice wherever possible, encourage constant
and open communication with staff, and provide
opportunities for social interactions when needed. Above
all, there is a need to allow people to create comfort in
their own way.
One element where improvements can be made is
in the physical environment, and particularly the
cleaning of the patients’ surroundings. To combat
patient fear of infection and germs, it is important to
have a visibly clean environment, while acknowledging
that patient perceptions of cleanliness may differ
from that of hospital staff. Regular and noticeable
cleaning and disinfecting, including sites that might
not be typically thought of (i.e., alarm buzzers, patient
consoles, pillows, bed frames, bedside lockers, door
handles) can alleviate patient fears. The same is true
for frequent staff hand washing before and after patient
contact. These steps can be further supported through
public reporting of hospital cleanliness data. Patients
can use these objective measures — when they are
presented appropriately — and reconcile them with the
hospital staff behavior they observe during their stay.
Patients should also be allowed to actively contribute
to the cleanliness and orderliness of their hospital
environments. Hand hygiene products should be within
easy reach, and patients should be given assistance (if
needed) to clean their hands. Other aspects to consider
include the possibility for patients to influence the
scheduling of their cleaning, the color of their sheets/
towels, and the scent of the cleaning supplies to be used
in their rooms.
Another key aspect that can serve as a source of either
anxiety or comfort to patients is the food services
offered during a hospital stay. In attempts to “bring
back a sense of normal,” as Jane puts it, some patients
might appreciate the option to order from a selection
of take-out menus or benefit from 24/7 service. Others
find comfort in knowing that their families left behind at
home are being provided with meals during their stay.
Meals can also be an opportunity for social interaction,
with trays that are in easily transportable formats or the
possibility to have guest trays for visitors and family at
no or little extra charge. To enhance communication and
patient awareness of their care, nutritional information
can be showcased alongside any meals, including
information that highlights the beneficial aspects of the
delivered food and how this contributes to the patient
healing process.
To combat isolation and loneliness, media and
entertainment services are also invaluable tools.
Additionally, opportunities for social support from
sources other than family and friends can help alleviate
fear, such as multi-professional counseling, support from
nurses, patient navigators, or a pre-operative support
group. Studies have found that when the amount of
social support is high, patients experience lower levels of
anxiety and fear9,23,25,29
.
Nevertheless, visitation by friends and family remains
one of the arguably most important aspects of a hospital
stay, and this support can be a powerful way to alleviate
fear. Making visitation easier, more flexible and more
frequent can greatly contribute to patient peace of mind
and anxiety. Some suggest accommodation or food
offers be made available for a few key visitors, to ensure
continuous companionship and support from loved ones
through major stages.
Health care delivery does not end when the patient
leaves the hospital, but rather continues post-discharge.
Furthermore, psychological research has shown that the
“ending” of an experience — here a hospital stay — can
have significant impact on the remembered experience
and retrospective evaluation of the care received. It is
therefore vital to ensure that throughout the discharge
and post-discharge processes, patient fears that may
have been mitigated successfully through various
means during the stay do not come back. To do this,
patients need clear instructions about next steps and, if
possible, the possibility to commit to the next follow-up
appointment right away. Contact information in case of
future questions and anxieties should be made available,
either in terms of contact information for medical staff
or patient and survivor support groups. Some patients
may also benefit from a comfort pack, a schedule or

9
meal plan, or transportation and home maintenance
to help them adjust and return to their normal life.
Tidelands Health in South Carolina was able to reduce
hospital readmissions by 40% in less than six months
and improve patient experience and loyalty scores by
using a concierge-style approach to post-discharge
follow-up and support for patients30
.
All of these solutions must be tailored to specific
patients, based on which behavior group they classify
as at any point in time, and also to the particular stage
and timing each patient is in. Different patients need
different forms of support at different points in time. An
all-round concierge service that takes care of patients’
non-clinical needs can help to alleviate fear and has
been shown to improve patient experience and increase
HCAPHS scores.
SUMMARY
To truly understand and manage patient fear in the
hospital setting, one must acknowledge several aspects
of this fear. As a first step, one must identify the
sources of patient fears, which are multiple and varied.
Arguably more vital to managing patient fear, however,
is understanding how fear is perceived by patients —
how fear manifests itself in patient attitudes. Sodexo’s
Personix™ tool has enabled the clustering of patient
attitudes into six categories, ordered in a matrix along
two scales. While no individual can be entirely assigned
to one of these clusters for the duration of their hospital
stay, acknowledging the presence of these different
attitudinal groups can be a good starting point for
understanding the patient behaviors observed.
Patient fear is widely recognized to be negative — if
not managed properly, it can hinder effective healing,
result in an unnecessarily poorly perceived experience,
and have negative impacts on hospital staff. These
outcomes are vital, and emphasis on patient experience
and patient-centered care will only continue to grow;
thus, hospital staff must look toward mitigating and
alleviating patient fears. In doing so, hospitals must
target solutions not only toward specific fear sources,
but also at different patient attitudes, to ensure that
there are no unintended consequences that could
heighten any adverse phenomena or anxiety.

10
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Personal Interviews with Jane and John (Names are anonymized).

Understanding and Managing Patient Fear in the Hospital Setting

Understanding and Managing Patient Fear in the Hospital Setting

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