Stress in medicine: Strategies for caregivers, patients, clinicians—Promoting better outcomes with stress and anxiety reduction

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The traditional paradigm for cardiac care has emphasized the use of technology to treat disease. Our focus on technologies such as echocardiography, advanced imaging instrumentation, and cardiac catheterization mirrors the preoccupation of society as a whole with technologic advances.

Attention has only recently been given to the patient’s emotional experience and how this might relate to outcomes, recovery, and healing. An expanded paradigm of cardiac care incorporates pain relief, emotional support, spiritual healing, and a caring environment. These elements of patient-centered care aim to relieve stress and anxiety in order to achieve a better clinical outcome.


The importance of patient-centered care is illustrated by the results of a 2007 survey in which 41% of patients cited elements of the patient experience as factors that most influenced their choice of hospital.1 Accepted wisdom on patient choice has historically centered on medical factors such as clinical reputation, physician recommendations, and hospital location, each of which was cited by 18% to 21% of the patients surveyed. Elements of the patient experience cited in the study include stress-reducing factors such as the appearance of the room, ease of scheduling, an environment that supports family needs, convenience and comfort of common areas, on-time performance, and simple registration procedures.

Székely et al2 found in a 4-year followup study that high levels of preoperative anxiety predicted greater mortality and cardiovascular morbidity following cardiac surgery. In a study by Tully et al,3 preoperative anxiety was also predictive of hospital readmission following cardiac surgery. Preoperative stress and anxiety are reliable predictors of postoperative distress.4

The variety and relative efficacy of interventions to reduce stress and anxiety are not well studied. Voss et al5 showed that cardiac surgery patients who were played soothing music experienced significantly reduced anxiety, pain, pain distress, and length of hospital stay. One Cleveland Clinic study of massage therapy, however, was unable to demonstrate a statistically significant therapeutic benefit, despite patient satisfaction with the therapy.6


Identifying patients who exhibit significant preoperative stress and providing, as part of an expanded cardiac care paradigm, emotional care both pre- and postoperatively may ameliorate clinical outcomes. As such, the Heart and Vascular Institute at the Cleveland Clinic formed a healing services division, based on the concept that healing is more than simply physical recovery from a particular procedure. The division’s mission statement is: “To enhance the patient experience by promoting healing through a comprehensive set of coordinated services addressing the holistic needs of the patient.”

A healing services menu is offered to each patient (Table). Referral for these services can come from the patient, family, physicians, or nurses. Of the first 898 patients admitted for heart surgery who were offered healing services on the third or fourth postoperative day, 582 chose one or more of the services (average, 2.7 interventions; total interventions, 1,514), most frequently spiritual or holistic nursing care. Ninety-three percent of these patients felt the services were helpful, and 90% said that they would recommend them to others. A personal connection between the patient and family and caregivers fosters feelings of a healing partnership that lessens stress and anxiety.

At the Cleveland Clinic, healing services are now integrated with standard services to enhance the cardiac care paradigm. Our standard medical services focus on areas of communication and pain control, both of which affect anxiety and stress. The need for enhanced communication is significant: 75% of patients admitted to a Chicago hospital were unable to name a single doctor assigned to their care, and of the remaining 25%, only 40% of responders were correct.7

It is worth noting that communicating more information to a patient is not necessarily better. Patients given detailed preoperative information about their disease and the potential complications of their cardiac surgery had levels of preoperative, perioperative, and postoperative stress, anxiety, and depression similar to those who received routine medical information.8,9 On the other hand, patients desire information about their postoperative plan of care while they are experiencing it, and value communication with physicians, nurses, healing services personnel, and other caregivers when it is presented in a calm and forthright manner. Communications should emphasize that the entire clinical team is there to help the patient get better.


Pain control is an aspect of care that was long ignored. The goal of the pain control task force at the Cleveland Clinic is the development of effective, efficient, and compassionate pain management.

The fifth vital sign, one that escapes the electronic medical record, can be addressed by this question: “How are you feeling?” Treating pain will reduce stress and anxiety. Before surgery, pain management priorities are discussed with patients, and at each daily encounter the goal is to set, refine, and exceed expectations for pain control through discussion and frequent pain assessments.

Reducing anxiety and stress is the goal of both standard care services and healing services, resulting in more satisfied patients with better clinical outcomes.


Bobbi is a 78-year-old woman who was initially recovering well following cardiac surgery, including valve surgery, but had to return to the intensive care unit, which is difficult for patients. She was subsequently returned to the floor but was reluctant to walk and progressed slowly, despite normal electrocardiogram, radiographs, and blood panel results. We discovered that her husband was in hospice care in another state, causing Bobbi anxiety as she expressed concern over being her husband’s caregiver while being weakened physically herself. She was fearful of moving forward and her recovery stalled.

The primary care nurse referred her to the healing services team. The healing services team provided support for her anxiety and stress, and reviewed options for managing her husband’s care. She participated in Reiki, spiritual support, and social work services. During her admission her husband died, so the team provided appropriate support.

When asked about her experience upon leavingthe hospital, Bobbi did not mention her surgeon or the success of her heart valve procedure, but commented instead on the healing services team that enabled her to get through the experience.

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