The Human Side of Fear
By Nancy Hassett Dahm, RN, BSN

We are health care professionals well trained in our chosen fields. We view medical procedures as a necessary tool to diagnose and treat the many ailments and diseases that afflict the body. We are task-oriented in our approach to achieving the most effective and accurate outcome - a technically perfect procedure.

However, while we recognize that patients are the subjects for procedures, do we really consider the psychological factor of fear when delivering patient care? After all, we do this every day, perhaps many times a day. This is what we do. We are professionals who accomplish our tasks with professionalism and acumen. Is the consideration of patients' fears significant enough to address when a patient is having a "simple" procedure? Ask yourself for whom is the procedure "simple", the health care professional or the patient? Read on. This is one person's experience. Mine. This is the human side of fear.

I don't want to be here. I just want to go home. I can see him looking at me. Is it even me he wants? No. Not this time, but soon. It's cold in here. Sounds are louder, clanky, and almost with an echo, not soft and serene .

The screaming is what I remember the most. I remember seeing the syringe coming at me every time, without mercy. The nun in black said if I didn't stop screaming, she would pad the walls and not let me see my mother. Then she stuck me deep in my little behind and the pain was searing like a burning poker. It was always the same, every four hours around the clock for months. I was five years old, and not old enough to understand that the penicillin was necessary in order to save my life. What I did perceive was that I was being tortured, and the women in black had no mercy for my fear, just angry words of retribution. When the injections were finally no longer necessary, the woman in black came in with the syringe. She laughed as she said to my mother "I'm just going to pretend to give this to her." "You will not", my mother said, as she grabbed the syringe from her hand. Since then, I was always afraid of having things done to me, even if it was for my own good.

I am an adult now, and understand the reasons and rationales for doing a colonoscopy. I'm a nurse, so of course I understand, but it doesn't get any easier. Not by a long shot. It wasn't my fault. The physician seemed nice enough and I trusted his skill. But then at the turn of the descending colon, his hands began to shake as he visibly struggled to advance the scope against the resistance of adhesions. I remember the screaming. I couldn't contain the pain. He yelled "Stop it! Everyone will hear you!" The doors flung open and voices were raised saying "What's going on in here? We can hear you in the next room."

I wouldn't go back for another colonoscopy for seven years. I just couldn't. It was mostly fear that kept me away. It is fear that I fight each and every time I go for an invasive procedure even though I know it is for my own good.

He is looking at me, and coming my way. With one sweeping motion there is a loud swish of the rings as they clash in one disharmonious ring. "Mrs.Dahm? We're going to start an IV now, then we'll bring you in. I understand you'll be put to sleep during the procedure." ( Wait a minute. They shoot horses don't they? They put animals to sleep to put them out of their misery. What if I don't wake up? What if something goes wrong? What if they find something bad?) I just want to go home. But I can't.

Fear. It is a powerful emotion. It is fear that keeps us away from the colonoscopy, endoscopy, and a host of other recommended procedures that could save our lives. You can't just say to yourself get over it, or grow up and expect that your attitude will change. Fear is a product of past experiences and perceptions. Fear is a consciously recognized danger or threat. Some procedures, in my view, are recognized threats. They are foreign to our everyday experiences and, for the patient, there is a total loss of control while being "processed" for and during the procedure. It is essential, therefore, that we recognize that fear is a factor that influences not only patient decisions to undergo procedures, but outcomes as well. If a patient perceives the threat as harmful to their safety and security, they may not elect to have the procedure. That is the outcome. If however, we investigate a patient's fear factor, we can diminish the perception of the threat, and make the experience more palatable or even pleasant. The outcome will change. The patient will return for the needed follow-up examinations.

It is prudent to assume that all people are fearful not only of procedures, but also the environment in which they take place. The starkness of steel, linoleum floors, and the emergency medical equipment hanging above bedside tables are hardly conducive to warm and fuzzy feelings of safety and security. A "scary" environment can trigger the perception of a threat. Not everyone will show fear in an overt manner. On the contrary, many people are good at hiding their feelings, including me. I can appear to be very calm on the surface. My foray into the surreal world of fear takes place mainly in my mind. The feelings of fear can be outwardly subtle but there are ways to detect the signs and symptoms. Observe your patients for these signs and symptoms. This is essential in order that they also experience "a technically perfect procedure." They may exhibit one, a few, or all of the following: Your intervention is needed.

• Rapid pulse • Elevated blood pressure • Repetitive dry cough or clearing of the throat • Rapid eye movements • Unusually talkative • Unusually quiet • Forgetfulness • Frequent urination • Nervous laughter • Frequent questions • Unable to lie still in holding area • Complaints of feeling too cold • Nausea • Fidgetiness • Hard swallowing • Cold extremities

There are many things health care professionals can do to help patients cope with fear. While you may think that joking with patients is good for "breaking the ice", it really doesnŐt always help. What will help is a calm, reassuring manner, and using your skills for anticipatory planning. Come right out and address the issue of fear with your patients. Simply ask them if they are feeling fearful. Question them. Talk to them. Tell them exactly what is going to take place, before it takes place. Be as specific as possible. Information is powerful and it can alleviate much of their fear. There should not be any surprises for the patient. Addressing fear with your patient shows respect, caring, and advocacy.

I would suggest that every hospital, ambulatory center, endoscopy suite, etc. formulate a patient questionnaire regarding patient fears prior to the patient undergoing a procedure. It should be a scale rated system that includes the patient's past history of experiences with procedures. It is my professional opinion that if we investigate and incorporate the fear factor in our delivery of patient care, we will see an increase in positive patient outcomes.

©2003 All rights reserved. Nancy Hassett Dahm, RN, BSN, is the author of the internationally acclaimed book, Mind, Body, and Soul; A Guide to living with Cancer. Visit her website at www.cancerbook.com.

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