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Practice review

Reducing anxiety in elective surgical patients

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Nurses can use communication skills to help reassure patients before surgery


In this article…

  • What good communication is and why it is necessary
  • Verbal and non-verbal communication
  • Communiation tools suitable in nursing
  • Alleviating anxiety



Michael John Pritchard is advanced nurse practitioner for surgery and orthopaedics, Wirral University Teaching Hospitals NHS Foundation Trust.


Pritchard, MJ How effective communication skills can reduce anxiety in elective surgical patients (2010) Nursing Times; 107: 3, early online publication.

Effective communication is the cornerstone of good healthcare yet it can be a difficult skill to master. Poor communication can have serious consequences for patients and cause irreparable damage to the nurse-patient relationship.This article explores how nurses can use communication tools with surgical patients and help relieve anxiety.

Keywords: Anxiety, Communication, Preoperative preparation 

  •  This article has been double-blind peer reviewed


5 key points

1. Use a recognised tool to aid the communication process and identify patient anxieties

2. Anxious patients need reassurance. Listening to their concerns and acknowledging them can reduce anxiety

3. Adapting or changing how you carry out procedures, and allowing a relative or friend to stay with the patient may reduce anxiety

4. Keeping patients informed about what is happening, particularly if there are any delays in treatment, can make them feel less anxious

5. Communication tools should be straightforward, easy to use and flexible


Poor communication with patients can have serious consequences and put lives at risk (Greenberg et al, 2007)It can lead to healthcare professionals being unable to support patients or their families (Mullally, 2000).

Many preoperative patients research their conditions on the internet, and while this can be helpful, they may become confused and anxious. Staff must address these concerns by communicating in a way patients can understand, and providing information so they can make informed decisions.

The ability to put patients at ease and to communicate in a language they understand is vital (Rimer and Kreuter, 2006). Researchers have explored the range of communication skills healthcare professionals can use, such as questioning, listening, summarising and closure (Harrison and Hart, 2006). Others have looked at the use of these skills to obtain information and reduce anxiety, or to ensure continuity of care (Berry, 2007). The most effective way of meeting patients’ needs is to tailor information to the individual (Rimer and Kreuter, 2006).

The relationship between patient and healthcare professional should be based on good communication; failure in this can have serious consequences for patients’ wellbeing (Stevens and Rogers, 2009).

Both verbal and non-verbal communication can convey information about feelings, ideas or knowledge. To understand communication, it is important to identify its three components (Box 1).


Box 1. The three components of communication

  • Verbal messages – the words we choose
  • Paraverbal messages – how we say the words
  • Non-verbal messages – visual stimulation, written word, body language, silence and listening

Source: Baird and Weinberg (1988) 

The five Is for effective communication

1. INTERACT with the patient

2. Establish the INTENTION of the interaction

3. Decide on the INTERVENTION to be used

4. Assess the IMPACT of the intervention

5. Evaluate the IMPLICATIONS of the information obtained and then act accordingly.

Source: Hamilton and Martin (2007)


Verbal communication

Verbal communication uses the spoken word to acknowledge, amplify, confirm or contradict other verbal or non-verbal messages. This also includes the tone and rate of speech which can convey understanding, sympathy, empathy or acknowledgement.

Using technical language may hinder patients’ ability to make informed decisions. Verbal communication that is hurried or delivered in a disinterested tone will also affect how information is perceived by patients. They may feel unable to ask questions, which may have a serious effect on their ability to make informed decisions (Klafta and Roizen, 1996).

Non-verbal communication

Non-verbal communication includes rapport, empathy or body language. Studies by Mehrabian and Wiener (1967) and Mehrabian and Ferris (1967), both concluded that 93% of communication is non-verbal. The importance of this was highlighted by Richmond et al (2001) who found that doctors who showed a high level of non-verbal immediacy, such as sitting forward or smiling, had a positive impact on patient satisfaction, and perception of the quality of medical care received. It also reduced patients’ fears of communication with their doctor.

It is possible to tell when someone is happy, sad or in pain by their appearance, and nurses can use these non-verbal signals when they are assessing and evaluating care. This is a skill they develop as they progress through their careers and gain experience and knowledge (Benner, 1984). Patients see listening as one of the most important parts of communication; nurses sould listen to what patients say so they understand what is actually being asked (Mullally, 2000).

Culture and communication

Thomas et al (2004) suggested cultural attitudes, beliefs and practices not only influence patients, but also healthcare staff. Cooper and Roter (2003) found that patients from ethnic minority groups were more likely to choose physicians from their own ethnic background, and view the quality of healthcare provided by them more favourably.

Consequently, healthcare training has incorporated culture into communication skills education (Spouse et al, 2008).     

Nurses’ communication skills

Researchers have identified areas where good communication is vital, such as care satisfaction and adherence to treatment (Kennedy Sheldon and Ellington, 2008). Tulsky (2005) suggests that patients have individual desires for information, and the only way to find these is to ask them. When concerns are disclosed, distress is reduced and coping abilities are improved (Stanton et al, 2000). However, according to Florin et al (2005), only 50% of patients who expressed concerns had these issues acknowledge by nurses. Wilkinson (1991) suggests nurses are not confident in communicating with patients about their concerns, and Uiterhoeve et al (2008) indicate that nurses avoid responding to them.

Communication tools

Communication tools used for preoperative assessment should be agreed between the medical and nursing staff. They must be simple, straightforward, easy to use and flexible enough to be of clinical value. They include:

  • The Amsterdam Preoperative Anxiety and Information Scale (Moerman et al, 1996);
  • The Hospital Anxiety and Depression Scale (Zigmond and Snaith, 1983);
  • The Visual Analog Scale (Kindler et al, 2000).

These tools can help to identify which part of the surgical procedure the patient is anxious about. If patients have concerns about the anaesthetic, giving them the opportunity to see the anaesthetist before the procedure may reduce their anxiety. Explaining what will happen when they go to theatre, and when they return to the ward can reduce their fear of the unknown.

The five Is framework for effective communication (Box 1) enables nurses to address the concerns in a logical way (Hamilton and Martin, 2007). It can be used to improve clinical practice by using patient feedback to examine practice, and identify common themes.

Patients are routinely admitted on the day of their surgical procedure, so concerns need to be addressed during the patient’s preoperative assessment visit.


How anxiety affects patients undergoing surgery is unique to the individual.

McCabe (2004) suggested that patient-centred communication is the bedrock of a positive nurse-patient relationship.

Nurses have a responsibility to ensure they communicate as effectively as possible with patients and should use any tool available to help improve the communication process.

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