For several years, hospital staff in a Pathways to Excellence–designated small community hospital have struggled to remain competitive with larger urban hospitals located less than an hour away. Evaluating the patient experience during hospitalization can be an important part of identifying ways to improve care. The clinical nurse specialist (CNS) plays an important role in improving the patient experience, as evidenced by the CNS competencies in the nurses and nursing practice sphere of influence.
The Beryl Institute defines the patient experience as “the sum of all interactions, shaped by an organization’s culture, that influence patient perceptions, across the continuum of care.”1 Trends in patient satisfaction, an expression of the patient experience, for the hospital between 2008 and 2014 showed that the patients’ experience improved modestly.2 Following a review of 18 sources from 2000 to 2014 that defined patient experience, no commonly accepted definition of patient experience was found to exist, but 3 consistent themes were identified: “active patient and family partnership, the integral need for patient-centeredness, and an acknowledgement of the broad and integrated nature of the experience overall.”1(p8)
A 2017 Korean study examined the relationship between nurse staffing and the effects of perceived missed care on the patient experience. Their results showed that perceived inadequate nurse staffing with reports of missed care positively correlated with lower scores for questions evaluating the patient experience.3
Patients who were admitted to Magnet-designated hospitals had a better patient experience than those patients who are not according to a 2016 secondary analysis of 2010 Hospital Consumer Assessment of Healthcare Providers and Systems scores. The retrospective, observational, cross-sectional design of the study limited researchers from determining causality.4
A 2015 European study reviewed data collected from 74 hospitals in 2011 about the patient experience and patient-perceived discharge preparation. They found that there was no association between hospital-wide quality management strategies or patient care strategies and the patient experience.5 A 2014 study from the United Kingdom summarized key issues about the patient experience, finding that patient experience scores differed between populations. The authors recommended adjusting patient experience scores based on population characteristics.6
Gender differences in patients’ experiences for patients admitted to a medical-surgical unit were identified from questions on the Hospital Consumer Assessment of Healthcare Providers and Systems in a 2012 study. Findings showed that women generally had worse patient experiences that men, particularly women who were older, sicker, more educated, and Caucasian. Communication and responsiveness from nursing staff were cited as ways to improve the patient experience for women.7
Following a review of literature from other industries in 2012, researchers developed a framework for optimizing the patient experience by acknowledging the physical and emotional components of it. Three improvement elements were suggested to improve the patient experience: providing personalized medicine, partnering with patients through the continuum of care, and engaging staff.8
Integrating patients into the care team by encouraging them to become active participants in nursing shift report could help to improve the patient experience. It is a simple way to create a therapeutic relationship with patients and personalize care. Nine recent studies about nursing bedside report (NBR) have been published in the past 5 years.
Nursing Bedside Report
An Australian systematic review of patient participation in NBR was conducted using mixed methods and presented in a 2018 article. Two reviewers appraised 21 research and quality improvement data. Identified nurse barriers to NBR were confidentiality breaches, sharing sensitive information, and fear of increased time for nursing report during shift change. Four common roles for patients were identified—contributing during NBR, asking questions, expressing concerns, and adding missed information.9
A 2017 study measured 55 nurses’ perceptions of the benefits and issues with NBR. Although nurses thought NBR was more stressful, they believed it increased nurses’ accountability and patient safety and involved patients in their care.10
A 2017 study from Australia compared nurses’ and patients’ preferences with NBR. Both groups preferred NBR. Patients believed participation created stronger communication with nurses. Having a family member present and having only 2 nurses rather than an entire team involved in NBR were considered important to patients. Nurses did not think having a family member present was important.11
Grounded theory was used in a 2016 study that focused on describing how NBR could keep patients safe. Nurses believed the primary reason for NBR was to tell the patient’s story. They cited 3 advantages to NBR: early patient assessment, direct patient visualization, and prevention of passing incorrect information about the patient.12
Patient and nurse outcomes from a blended process of recorded and NBR were assessed in a 2014 quasi-experimental study. Patients thought the blended process resulting in better nurse-to-nurse communication, more involvement in the NBR and their care, and identification of whom their nurses were going to be. Nurses noted a decrease in patient falls at shift change, an increase in nurse accountability, greater patient involvement in their care, and improved patient safety with NBR.13
Patients’ views of NBR were identified in a 2014 study, which used directed content analysis. Three themes emerged—creating a personal connection space, keeping patients up to date on their care, and varying patient preferences about their level of engagement.14
A systematic review conducted in 2013 found most organizations use a blended report with some information written or a private nurse-to-nurse report plus a brief NBR. Patient advantages identified in the review included a better informed and involved patient, an improved nurse-patient relationship, increased patient satisfaction, decreased falls, improved patient safety, and less time spent discharging patients. Disadvantages included increased patient anxiety, lack of privacy, repetitive information, and lack of patient understanding of medical terms.15
A 2013 study of NBR using Lewin’s change theory identified barriers including confidentiality issues, discussion in front of the patient, fear of change, technology issues, what to do with visitors, and staff issues with participation. Although the authors believed that NBR can improve handover communication and patient safety, they recognized the need for mentoring, coaching, and counseling for staff as NBR is implemented.16
The Agency for Healthcare Research and Quality published an NBR implementation handbook in 2013. They noted the NBR goal was to ensure safe handoffs by involving patients and families in the process. Improved patient safety and quality, enhanced patient experience, increased nurse and physician satisfaction, and better nurse time management and accountability were identified as outcomes of NBR. Recommended steps to implement NBR were use of a multidisciplinary team to identify improvement areas, development of an NBR strategy, and NBR implementation and evaluation.17
Anxiety is a well-documented stressor in hospitalized patients to the extent that it was identified on the initial list of nursing diagnoses by the North American Nursing Diagnosis Association. Recent studies on generalized anxiety during hospitalization are absent, but several addressing anxiety related to diagnosis have been published.
A 2017 study compared depression and anxiety between hospitalized oncological and nononcological patients. They found a high prevalence of anxiety and depressive symptoms in both groups. There was no difference in symptoms between groups, although oncology patients exhibited greater psychological distress.18
In a 2016 study, researchers performed a principle-based concept analysis about complementary therapy use in the perioperative period to decrease anxiety, finding little research about it. They stated that anxiety relief is critical in healthcare and recommended further study using complementary therapies.19
Researchers evaluated stress intensity and anxiety level in cardiac patients before surgery in a 2016 study. Of the multiple variables assessed, only gender was statistically significant in stress about surgery and illness. Women showed higher levels of stress and anxiety.20
A 2018 European study evaluated the effect of psychological factors in patients with heart failure. They discovered that frailty, anxiety, cognitive impairment, and depression were significant predictors of outcomes for both initial and recurrent hospitalizations. They stressed the need for further research in this area.21
None of the reported studies addressed having patients actively participate in NBR. Nor did any of the studies link patient anxiety with NBR. Comparing patient anxiety with active patient participation in NBR will add to the body of knowledge about both concepts.
This descriptive, observational study explored the patient experience for 2 groups of patients admitted to the hospital’s 2 medical-surgical units: the intervention group who actively participated in NBR and the control group who did not. Because hospitalization has long been associated with increased anxiety in patients, which could affect the patient experience, the researchers chose to assess the level of patient anxiety in addition to evaluating the patient experience. The research question for this study was: Does including hospitalized patients as active participants in morning and evening NBR decrease their anxiety and improve their perceptions of their patient experiences during hospitalization?
Institutional review board approval of the study was obtained before data collection began. Nurses on both units received in-service education about the study. All patients admitted to the 2 medical-surgical units during the data collection period were asked if they wished to participate in the study. A convenience sample was composed of patients who consented to participate. They were alternately assigned to either the control or intervention group.
The study objectives were to (1) measure baseline anxiety in patients on admission to the hospital using the Beck Anxiety Inventory (BAI), (2) describe patient self-reported anxiety and patient experiences during hospitalization from journal entries, and (3) evaluate the written opinions in their journals by the intervention group about participating in NBR.
This mixed-methods study included the collection of quantitative and qualitative data. Three data collection tools were used: an investigator-designed demographic data tool, a valid and reliable tool measuring baseline anxiety (BAI), and daily journaling by patients about their anxiety and patient experience. The investigator-designed demographic data tool completed on admission collected limited information (age by decade, gender, ethnicity/race, educational level, hospital unit, payment category, primary admitting diagnosis, and comorbidities). Payment category was included because many patients admitted to the hospital lack adequate insurance coverage resulting in large hospital bills, which might result in an increase in their anxiety.
Beck Anxiety Inventory
Baseline anxiety levels were assessed on admission using the BAI, a 21-item, multiple-choice, self-reporting tool that assesses anxiety in adults and adolescents.22 Reliability for the BAI has been assessed using internal consistency, item analysis, and test-retest. Internal consistency using Cronbach α’s were .92 and .94 in the 2 studies that tested it. Item analysis of corrected item-total correlations (using Bonferroni adjustments) ranged from 0.30 to 0.71 and were significant beyond the .05 level in a 1-tailed test. Correlation of test-retest scores for adults who were tested at baseline and then retested after 1 week was 0.75.23
Validity of the BAI has been assessed using content validity, concurrent validity, construct validity, discriminant validity, and factorial validity. Content validity was assessed by comparing the BAI’s content to the symptom criteria in the Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Revised. Findings showed the BAI comprised symptoms considered to represent anxiety. Concurrent validity was assessed by comparing the BAI to other commonly accepted self-reported and clinically rated anxiety tools. Correlation scores ranged from 0.47 to 0.54 when compared with the other anxiety rating tools. Construct validity was assessed by testing the BAI and 11 tools that measured self-reported and clinical ratings of depression. Findings showed correlations ranged from 0.15 to 0.61. Discriminant validity was assessed using stepwise discriminant-function analysis, which showed BAI scores that were controlled for gender and age differentiated the type of anxiety disorder. Factorial validity was assessed using principal-factor analysis with a promax rotation. Findings showed the BAI reflected self-reports of 4 clusters: neurophysiological, subjective, panic, and autonomic symptoms.23
Content analysis was used to analyze the subjects’ journal entries. Content analysis includes several strategies used to analyze text. It involves a systematic process used to code and categorize texts to describe the content.24 Following data collection, the lead researcher transcribed all of the written entries into a text document. Each of the study questions was used to collate data from the journals. Once all of the data had been transcribed, the lead researcher reread all of the text under each question and listed broad concepts identified therein. After the third reading of the text, the lead researcher identified and documented themes. The coresearcher was then asked to read the text and identify themes contained within it. The 2 researchers then discussed their themes. Once agreement was reached about the themes, the data were analyzed, and all examples of the themes within the text were identified by both researchers. The themes were then compared with previously published themes about the patient experience for similarities and differences.
In this study, each subject was given a pen and a spiral-bound journal with questions about their experience and were asked to complete those questions daily during hospitalization. Journals were used to assess patients’ perceptions about their hospitalization. All patients completed the following questions:
- How did your anxiety change during hospitalization?
- What could the nursing staff have done to alleviate any anxiety that you had?
- How do you feel about the quality of care your received?
- How would you describe the nurses who cared for you?
Patients in the intervention group additionally were asked to complete a fifth question on their opinions about participating in nursing shift reports (5. Please provide your opinions about participating in nursing shift reports).
The texts of daily journal entries were transcribed and analyzed using content analysis. Content analysis is defined as a research technique used to analyze inferences from texts that are valid and can be replicated, which has 3 distinguishing characteristics: (1) it is a method that is empirically grounded using an exploratory process that can predict or infer intent, (2) it rises above traditional symbols, contents, and intents, and (3) it has been developed over time into a unique methodology.24
Quantitative Results From the BAI and Demographic Data Tool
A total of 73 patients completed the demographic data tool and the BAI. Thirty-five of those patients were in the intervention group, and 38 were in the control group. Patients were mostly female (67.1%), Caucasian (89%), and high school or college graduates (84.9%) and covered by some type of insurance (92.1%). Age was aggregated into decades. Patients selected the decade that included their actual age. Ages ranged from the 20s through the 80s. The vast majority of patients (72.6%) were between the ages of 50 and 79 years. Most patients were admitted to the third floor medical-surgical unit (69.9%), which is primarily a surgical unit.
The leading admitting diagnosis was elective joint replacement surgery from osteoarthritis or repetitive injury. Figure 1 provides a graph of the primary diagnoses. There were 171 comorbidities listed for patients, ranging from 0 to 8 per subject. The most frequently cited comorbidity was hypertension. Figure 2 provides a graph of the comorbidities.
There was no statistically significance difference in baseline anxiety scores between patients in the intervention and control groups (t = 0.475, P = .636). The BAI identifies 4 levels of anxiety and places patients into each level based on their total score. The highest group percentage of patients (37%) fell into the minimal anxiety level, but the majority of patients (64%) of patients had more than minimal anxiety. The Table 1 contains the numbers and percentages of patients in each level.
Beck Anxiety Inventory scores between age decades, gender, ethnicity, payment category, and medical or surgical admitting diagnosis were examined. Groups were unequal in all analyses, but means in all decades showed mild or greater anxiety. Results showed that those patients in their 20s had the lowest BAI mean score (9.50), whereas patients in their 30s had the highest showing severe anxiety (mean score, 28.11). Means for patients in all other decades showed mild anxiety. Women had higher mean anxiety levels (16.40) than men (11.24). Caucasian patients had higher mean anxiety levels (15.09) than African Americans (12.00) and Hispanic (12.20) patients. Only 1 area showed statistically significant differences in anxiety levels—whether patients were admitted for surgical procedures or with medical diagnoses. Patients with medical diagnoses had higher levels of anxiety (t = −2.507, P = .015).
Although all 73 patients were willing to complete the BAI and demographic data tool, only 55 (75.3%) were willing to journal. All patients provided information to 4 of the 5 questions on a daily basis. Those in the intervention group provided answers to the fifth question about participating in NBR.
Responses to the question about changes in anxiety revealed varying levels of anxiety on admission, but showed that anxiety levels often changed during hospitalization in both the intervention and control groups. Many subjects had improvements in their anxiety when they began to feel better. Anxiety levels trended down in subjects participating in NBR. Comments from some of the subjects in the intervention group included the following: “I calmed down quite a bit”; “I have not had much anxiety”; “My blood pressure has come down”; “It changed quite a bit. I was put at ease and my anxiety lowered”; “From bad to super!”; “Anxiety free!” Subjects in the control group showed more stable levels of anxiety during hospitalization. Comments from some of those subjects included the following: “It (anxiety level) did not change”; “No change in anxiety.”
Major areas that impeded a decrease in anxiety identified by patients were as follows:
- Unforeseen complications: “I did have the wound from surgery start to bleed a little during the afternoon physical therapy. They put a pressure dressing on it to stop the bleeding, a little anxiety if it doesn’t stop bleeding”; “I spoke with (the doctor) and upon checking my heart he noticed I have several PVCs. I still have anxiety about having PVCs during this 24-hour period.”
- Uncertainty: “When I first got here, my anxiety was through the roof, not knowing what was wrong with me made my anxiety higher”; “My anxiety level went up severely with the lack of knowledge about the tests, eg, what time, how long”; “…I was worried about my bill getting paid and if my insurance would pay for most. Then I got so overwhelmed that I started to cry…”; “From entering the ER and not knowing what was wrong with me, I was very nervous and overwhelmed.”
- Lack of information: “Poor communication on diagnosis. Much less (anxiety) after more communication with staff about my condition and treatment”; “(The doctor) perhaps needs to have more open communication. He ordered TSH but needs to explain the results—follow up with patients when he orders blood work.”
In response to the question about what nurses could have done to alleviate anxiety, many patients felt nurses relieved their anxiety well and did not have any other suggestions. Other patients had suggestions about what nurses could have done. The area frequently cited was better communication about care: “Explain things while they care for me, spend more time listening, provide me with what is important to me, follow through with what you say. Bath time—narrate what my care is”; “Education about my new medicine that patients are going to add to their daily living should be explained”; “Explain more the first day”; “Do shift change in my room so I understand the plan for my care.”
Almost all patients reported positive comments about the quality of care based on a caring environment and teamwork, but some negative comments about the caring environment were also expressed. Patients made that determination based on the following:
- A caring environment: Positive comments included “They are prompt to answer calls or asking if I need anything and would bring it quickly”; “Very good—meals modified for me and I appreciated it. Blood pressure issues addressed quickly and doctor notified. Extra care for skin issues from monitor pad sites—tape allergy”; “Quick response on pain meds and anything I needed.” Negative comments included “I do not think they round as often as they are supposed to. It seemed like they only come when it was time for medicine or to take vitals”; “The doctors have barely spoken to me, so I had to find out through the nurses what was going on with me.”
- Teamwork: “Senior and administrative staff were very helpful in arranging a transfer to a rehab hospital coordinating a rather complex task into a good plan for a good outcome, and they have my thanks for that. It is obvious to see where the concepts of teamwork began at the hospital”; “I never heard a negative word out of anybody toward anyone. You don’t get that everywhere. They all seem to get along and care about one another.”
When asked how they would describe the nurses who cared for them, most patients had positive comments. Two areas identified by patients were as follows:
- The nurses’ relationship with patients: “Amazing, every nurse had an amazing attitude. They have been very helpful in communicating all things along the way”; “They made me feel like we’ve known each other for years”; “They were professional, courteous, kind, understanding—made me feel like family.”
- The nurses’ response to their needs: “When I’ve needed help, pain medication or anything else they have been very prompt in taking care of me”; “When my meds were changed, they printed out the information about it for me”; “Let me take a shower with someone in the room the whole time for my safety.”
The intervention group was included in morning and evening bedside report. All but one of the comments were positive: “Having them discuss your case in front of you relieves any doubt you are hearing everything and they didn’t forget something”; “Excellent—asked if there was anything I wanted to add or anything missing”; “I served in the military and learned that this kind of action, we called them pass-downs and after-action reports [that] not only serve the practical reason of dotting i’s and crossing t’s, involving the patient is empowering and in my opinion is critical to a team approach. Some call it investing in people, and I feel that is one of the best investments any business can make. Great tool all tying together, a good way to start a new shift running forward rather than backwards or sideways”; “At each staff change, all parties were at my bedside, and all the facts about my case were talked about and included me; it gave me a chance to add something and ask questions if needed”; “I think it’s great. You can have a voice and stay informed on what’s going on.” The negative comment was: “I wasn’t particularly fond of it. I’m not sure what the purpose of them is. I feel like with any shift change the employees should discuss the happenings of the exiting shift, to inform the oncoming shift. That to me doesn’t really apply to us patients or shouldn’t.”
Several themes that improved the patient experience when patients participated in NBR emerged from the literature review. They were patients’ perceptions of care,3,13 patient characteristics,6,7 patient engagement,9,12,13 communication,10–12 teamwork,8,13 improved patient safety,9,11,13 and discharge preparation.5,13 In this study, several of the themes mirrored previous findings. Themes that emerged were patients’ perceptions of care, patient engagement, communication, and teamwork.
Qualitative data from the journals also supported increased patient satisfaction with NBR. Patients also noted that they felt included as part of the care team. Although this study did not collect data from nurses, anecdotal information showed that adoption of NBR and satisfaction with it varied among nurses. There were no sentinel events or medication errors reported during the study, supporting the theme of improved patient safety with NBR.
Although journaling showed excellent insight into patients’ feelings about their anxiety and their patient experience, journaling seemed to be a burden to some patients. This may have been partially due to the age of the patients (mean decade age, 5.64). However, journaling allowed patients to express their thoughts, something they might be hesitant to do orally. The hospital leaders are looking for a way to continue some form of journaling. As technology continues to be added to the bedside, verbal journaling might be a better option for future studies.
Findings from this study support that patients do experience anxiety when admitted to the hospital. Including patients in morning and evening NBR can decrease patients’ anxiety and improve their engagement and satisfaction with care. But talking with patients and relaying accurate, frequent information/education updates also decrease anxiety and increase patient engagement. Responses in journals showed that communication or lack thereof played a significant role in patients’ perceptions of their patient experiences. Journal entries also showed just sitting and talking with patients about their hospital course had a profound impact on their experience.
This study had several limitations. First, the data were collected at only 1 hospital that was a small community hospital. Although all adults admitted into the hospital were asked to participate, the patients were older than expected. This was probably because many patients were admitted for elective joint replacement, which usually occurs in older adults. The gender of the patients was overwhelmingly female, and the ethnicity was overwhelmingly Caucasian, limiting findings to those groups. The convenience sample also limited generalizability of the results.
Based on the results of this study, the nursing management team at the hospital has implemented a plan to decrease anxiety by improving communication with patients, thereby improving their patient experience. Daily leadership rounding has been implemented to identify patients’ problems/issues/misunderstandings. The medical-surgical charge nurses and nurse mangers are expected to round daily to keep patients informed about their hospitalization. The nursing director for the units is a CNS and rounds with other senior nursing administrators as often as possible. The 3 clinical nurse leaders on the units round daily with the physicians to ensure patients understand their plan of care. Nurses on limited duty due to injury have been used as patient engagement nurses. Their role is to sit and talk to patients about their hospital experience. And at the end of each shift, staff nurses caring for patients are encouraged to ask patients if there was anything that happened or that was said that they did not understand and to clarify any discrepancies for the patient. Because level of anxiety can vary among patients, assessing that level on admission may help nurses in developing the plan of care to improve the patient experience.
This study adds a small piece to the accumulating knowledge about the patient experience, particularly about how hospital staff and patients in a small community hospital view communication about their care. Further study is needed to improve the patient experience for all patients. Clinical nurse specialists should be the leaders in this research because improving nurse-sensitive outcomes through the use of evidence-based practice is part of the CNS role.
1. Wolf JA, Marshburn D, LaVela SL. Defining patient experience
. Patient Exper J
2. Papanicolas I, Figueroa JF, Orav EJ, Jha AK. Patient hospital experience improved modestly, but no evidence Medicare incentives promoted meaningful gains. Health Aff
3. Cho SH, Mark BA, Knafl G, Chang EC, Yoon HJ. Relationship between nurse staffing and patients’ experiences, and the mediating effect of missed nursing care. J Nurs Scholarsh
4. Stimpfel AW, Sloane DM, McHugh MD, Aiken LH. Hospitals known for nursing excellence associated with better hospital experience for patients. Health Ser Res
5. Groene O, Arah OA, Klazinga NS, et al. Patient experience
shows little relationship with hospital quality management strategies. PLoS One
6. Ahmed F, Burt J, Roland M. Measuring patient experience
: concepts and methods. Patient
7. Elliott MN, Lehrman MK, Beckett EG, Hambarsoomian K, Giordano LA. Gender differences in patients’ perceptions of inpatient care. Health Serv Res
8. Needham BR. The truth about patient experience
: What we can learn from other industries, and how three Ps can improve health outcomes, strengthen brands, and delight consumers. J Healthc Manag
9. Tobiano G, Bucknall T, Sladdin I, et al. Patient participation in nursing bedside handover: a systematic mixed-methods review. Int J Nurs Stud
10. Small DC. Nurses perceptions of traditional and bedside shift report. Nurs Manage
11. Whitty JA, Spinks J, Bucknall T, Tobiano G, Chaboyer W. Patient and nurse preferences for implementation of bedside handover: do they agree? Findings from a discrete choice experiment. Health Expect
12. Groves PS, Manges KA, Scott-Cawiezell J. Handing off safely at the bedside. Clin Nurs Res
13. Sand-Jecklin K, Sherman J. A quantitative assessment of patient and nurse outcomes of bedside nursing report implementation. J Clin Nurs
14. Sherman J, Sand-Jecklin K, Johnson J. Investigating bedside nursing report: a synthesis of the literature. Medsurg Nurs
15. Jeffs L, Beswick S, Acott A, et al. Patients’ views on bedside nursing handover: creating a space to connect. J Nurs Care Qual
16. Radtke K. Improving patient satisfaction with nursing communication using bedside shift report. 2013; 27(1): 10–25.
17. Agency for Healthcare Research and Quality. Nursing Bedside Shift Report Implementation Handbook. 2013; https://www.ahrq.gov/professionals/systems/hospital/engagingfamilies/strategy3/index.html
. Accessed December 5, 2017.
18. De Fazio P, Cerminara G, Ruberto S, et al. Hospitalization and other risk factors for depressive and anxious symptoms in oncological and non-oncological patients. Psychooncology
19. Jaruzel CB, Kelechi TJ. Relief from anxiety using complementary therapies in the perioperative period: a principle-based concept analysis. Complement Ther Clin Pract
20. Rosiek A, Kornatowski T, Rosiek-Kryszewska A, et al. Evaluation of stress intensity and anxiety level in preoperative period of cardiac patients. Biomed Res Int
21. Sokoreli I, Pauws SC, Steyerberg EW, et al. Prognostic value of psychosocial factors for first and recurrent hospitalizations and mortality in heart failure patients: insights from the OPERA-HF study. Eur J Heart Fail
22. Beck AT, Epstein N, Brown G, Steer RA. An inventory for measuring clinical anxiety: psychometric properties. J Consult Clin Psychol
23. Beck AT, Steer RA. Beck Anxiety Inventory Manual
. Bloomington, MN: Pearson; 1993.
24. Bengtsson M. How to plan and perform a qualitative study using content analysis. NursingPlus Open
2016; 2: 8–14.