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Does Exposure to Nature in a Pain Clinic Waiting Room Influence Patient’s Anxiety, Pain Ratings, or Perception of Their Healthcare Experience?

12 February 2018


Chronic Pain

More than one hundred million Americans suffer from chronic pain – pain characterized as lasting over 6 months (Boyles, 2011). It is estimated by the Institute of Medicine that the cost of chronic pain across the categories of productivity loss and medical treatment is around 600 billion dollars every year (Steglitz, Buscemi, & Ferguson, 2012). Although our understanding of pain and how it should be treated by specialists is still developing, there has been a shift towards treating pain in a more holistic and interdisciplinary manner (Boyles, 2011). For example, other alternative treatments for chronic pain that are commonly explored are acupuncture, massage, herbal supplements, exercise, chiropractic manipulation, supplements and vitamins, therapy, stress-reduction techniques, yoga, hypnosis, biofeedback, and music therapy among others (Volkow & McLellan, 2016). Analgesics, otherwise known throughout the literature as painkillers, do not treat pain effectively by themselves, and more comprehensive treatments have begun to include pain management, coping strategies, and preventative measures (Narita et al., 2006). One experience that patients with pain often experience is comorbid anxiety. Managing stress and anxiety levels in patients with chronic pain can bolster a patient’s ability to function in their day to day lives.

Pain is a complex phenomenon that most everyone experiences, humans and animals alike. Pain is an attention-demanding sensory process (Rochais, Fureix, Lesimple, & Hausberger, 2016). When we are in pain, our attention gravitates towards the pain, the cause of pain, and what to do to reduce or expel the pain. Pain pulls us inwards, away from our external environment and can make it challenging to nearly impossible to maintain awareness of any other type of information. The increased focus on pain can result in catastrophizing and in higher levels of anxiety and depression, thus deteriorating one’s quality of life (Asmundson & Norton, 1995). In a study of patients suffering from chronic pain by Kremer et al. (2013), catastrophizing pain was associated with pain intensity, distress, and functional disability. The experience of stress can influence pain through the activation of the sympathetic nervous system, which in turn can exacerbate underlying pain, eventually forming a repetitive cycle. Patients with chronic pain have been linked with increased significant psychiatric morbidities, specifically to mood and anxiety disorders (Knaster, Karlsson, Estlander, & Kalso, 2012), and an increasing body of literature has demonstrated the strong relationship between stress, anxiety, and pain.

The complexities within the population of those individuals experiencing chronic pain pose a challenge for researchers who aim to discover methods for clinicians to use in their efforts to provide therapeutic relief. Researchers should be mindful of the possibility of participant overstimulation, as many may not be able to tolerate it well. For instance, fast tempo music provided in a waiting room may serve well for the general population, however, this may be for an individual with chronic pain. Similar to the variation in pain sensitivity, Asmundson and Norton (1995) differentiate varying levels of anxiety sensitivity and how this influences perception and management of pain. They found that those with high anxiety sensitivity were more negatively impacted by their experience with pain, exhibited more cognitive disruption, experienced more anxiety in response to pain, had greater fears of their pain, and reported an increased negative affect than did the average and low sensitivity to anxiety groups. Additionally, the high anxiety sensitivity patients reported significantly greater use of analgesic medications to manage their pain. These findings suggest that the chronic pain population may have a lower threshold for feeling overstimulated as compared to the general population; this may result in significantly more negative experiences of both pain and affect. Advancing our understanding of factors that exacerbate or relieve the experience of chronic pain can strengthen our ability to provide appropriate treatment modalities, including preventative care (Asmundson & Norton, 1995). It has been suggested that detection and management of anxiety within pain treatment settings should be mandatory in an effort to provide comprehensive care (McWilliams, Cox, & Enns, 2003). Given the diverse presentation and experience of anxiety, as well as the role it plays in avoidance behaviors, appropriate assessment strategies are required.


Patients often have stressful experiences in hospitals or doctor’s offices (Wilson-Barnett, 1979; Gordon, Sheppard, & Anaf, 2010). This stress is often a result of the patient’s reason for the visit, which may be diagnostic or procedural in nature, depending on whether they feel ill or have an injury. The anxiety a patient might experience, specifically within healthcare settings, can be categorized as short-term state anxiety (unlike longer-term trait anxiety), and is caused by the arousal of the autonomic nervous system (Shuldham, Cunningham, Hiscock, & Luscombe, 1995). Patients can experience fear, uncertainty, and anxiety that can complicate their health and recovery (Beukeboom, Langeveld, & Tanja-Dijkstra, 2012). In addition, patient’s anxieties can have adverse impacts on their cognitive ability, can cause mental and physical discomfort, and can trigger avoidance (Vaughn, Wichowski, & Bosworth, 2007). More importantly, this anxiety has been shown to further complicate the symptoms a patient is already experiencing and has been associated with increased blood pressure, heart rate, and respiratory rate (Haun, Mainous, & Looney, 2001). Possible explanations of patient anxiety experienced prior to reaching the waiting room or while waiting to be seen may include: (a) thoughts about the unfamiliar environment, (b) loss of independence and sense of control, (c) separation from friends and family, (d) lack of information, financial stress, (e) problems with pain and medications, (f) or threat of severe illness or death (Arneill & Devlin, 2002).

Though the most commonly reported psychiatric disorder in chronic pain is depression (Surah, Baranidharan, & Morley, 2014), there is a paucity of research between the relationship of anxiety and chronic pain, warranting further investigation within this arena. When pain is invasive, persistent, and intertwined with stress and anxiety, quality of life and self-efficacy can suffer the effects of pain permeate into the patient’s overall physical health, psychological wellbeing, social relationships, and personal expectations and goals. Pain can also complicate their ability to carry out daily tasks and routines, and can be economically burdensome (Carlson, 2014). It is common among those who suffer from chronic pain conditions to avoid pain-related activities that may induce or exacerbate pain and anxiety associated with their pain (Yamaguchi, Nicholson Perry, & Hines, 2014). This avoidance can lead to a diminished sense of control, increase beliefs that certain activities will cause pain, and result in additional anxiety-related pain. According to the fear-avoidance model of pain, anxiety towards pain and avoidant behaviors are major contributors to the chronic pain experience (Engel, Schwartz, Jensen, & Johnson, 2000; Vlaeyen, & Linton, 2000). The perception of pain seems to play a critical role in reinforcing avoidant behaviors, leading to inactivity, social withdrawal, and the exacerbation of chronic pain.

Waiting Rooms and Anxiety

The physical attributes of waiting rooms may also contribute to stress, as it has been shown to increase patient anxiety (Yu, Chojniak, Borba, Girão, & Lourenço, 2010). The period spent within the waiting room provides patients with ample time to ruminate about a multitude of concerns and worst-case scenarios (Beukeboomet et al., 2012). For those who are faced with medical conditions and additional life stressors, the effects of waiting can be exacerbated. Positive distractions within the waiting environment may have the ability to shift a patient’s focus away from their own status and towards something else, thus improving their affective state (Nanda et al., 2012). The waiting room is the first impression of a healthcare facility that patients receive. It is common for this first impression to be generalized to the way in which the patient perceives the doctors, nurses, and staff (Arneill & Devlin, 2002). If the environment communicates that it was designed with the patient in mind, it is more likely that the patient will have a positive experience with the healthcare process and will maintain an overall increased satisfaction level with their healthcare experience (Arneill & Devlin, 2002; Bournes & Mitchell, 2002).

The time spent in the waiting room is a robust determinant of overall patient satisfaction (Pruyn & Smidts, 1998). The way in which patients perceive situations plays a large role in this. One study found that the physical attractiveness of a waiting room not only decreased patient’s anxiety levels, but also influenced their perception of quality of care to a greater degree than the actual waiting time (Becker & Douglass, 2008). Zakay (1989) also found that elements within the waiting room environment affected the patient’s internal clock by diverting their attention away from the passage of time. The implication of how the wait time corresponds to patient’s overall satisfaction should be considered in healthcare facilities where patients are spending a bulk of their time within the waiting room, which is often more time than they spend with their provider.

Current research suggests that anxiety should be targeted in chronic pain treatment settings; therefore, incorporating nature elements within a chronic pain waiting room may generate positive influences on the overall healthcare experience, in addition to the patient’s perception and experience of their pain. Targeting the treatment of anxiety within the waiting room can be considered part of the comprehensive care of chronic pain. Baldwin (2012) highlights the importance of such research investigating the effects of creating a comfortable and relaxing experience for patients within hospital settings, since such investigations promote cost-effective strategies that can be implemented across a variety of healthcare settings, from large hospitals to smaller clinics. Beukeboom et al. (2012) state that aesthetic enhancements in these settings can provide unobtrusive and inexpensive stress and anxiety management methods for patients and staff alike. It is possible that elements of nature within the waiting room could result in decreased levels of anxiety and may aid patients in mediating their pain experience.


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