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American Journal of Critical Care. 2004;13: 146-152
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Assessment of Anxiety in Intensive Care Patients By Using the Faces Anxiety Scale

By Sharon McKinley, RN, PhD, Jane Stein-Parbury, RN, MEd, PhD, Afsaneh Chehelnabi, BMed and Judy Lovas, BA, MSc. From University of Technology Sydney (SM, JS-P, AC, JL) and Royal North Shore Hospital (SM, AC, JL), Sydney, New South Wales, Australia.


   Abstract
Top
 Abstract
Methods
 Results
 Discussion
 References
 
• Background Anxiety is difficult to detect in patients receiving mechanical ventilation because clinical signs are confounded and patients often cannot respond to validated anxiety measures. Most patients can respond to the single-item Faces Anxiety Scale.

• Objectives To assess the validity of the Faces Anxiety Scale, the frequency and severity of state anxiety, and correlates of anxiety in intensive care patients.

• Methods A research assistant made a single clinical judgment of anxiety in the range of 1 to 10 on the basis of patients’ nonverbal responses (ie, nods) to 9 questions about mood and their physical and behavioral signs. Patients then responded to the Faces Anxiety Scale. Demographic, clinical, and pharmacological data were obtained from the patients’ charts.

• Results Mean age of the 106 patients was 61 years; 62% were men. Admission diagnoses were cardiovascular in 26% of patients, respiratory in 26%, trauma in 18%, neurological in 12%, gastrointestinal in 12%, and other in 6%. At the time of anxiety assessment, 89% were receiving mechanical ventilation. The correlation between patients’ self-reports of anxiety on the Anxiety Faces Scale and the research assistant’s assessments was 0.64 (P < .001). Some anxiety was reported by 85% of patients (mean level 2.9; SD 1.2). Anxiety levels were lower in patients who had recently received sedatives or opioids but were not related to heart rate or blood pressure.

• Conclusions The Faces Anxiety Scale is a valid means of measuring anxiety in intensive care patients. Anxiety is common in these patients and is often moderate to severe.

Critically ill patients often report that they experienced psychological distress, including anxiety and fear, during treatment in an intensive care unit (ICU).1 Often these reports were obtained from patients after discharge from the ICU,1–3 but increasingly investigators are seeking to learn about patients’ anxiety levels during critical illness in observational studies4–6 and experimental intervention studies.7,8 To promote comfort, which is a clinically meaningful outcome in its own right,9 clinical practitioners seek to avert and alleviate anxiety and fear in patients during ICU treatment. In addition, evidence indicates that these emotions are associated with physiological responses, such as changes in autonomic tone,10 increased myocardial workload,11 increased coagulability,12 and reduced immune response,10 that may interfere with patients’ recovery. These responses are the likely mediators of the increased morbidity and mortality that occur in more anxious critically ill patients.13,14 Thus, detection and reduction of anxiety in critically ill patients are important clinical goals for ICU staff.

Anxiety can be assessed by objective observation of physiological and behavioral signs such as heart rate, blood pressure, muscle tension, facial expression, and restlessness; by measurement of cortisol and catecholamine levels, which are increased during the stress response; or by patients’ self-reports of the extent to which the patients are feeling anxious, tense, or fearful.15 Objective signs and biochemical measures of stress are difficult to interpret and may be unreliable in critically ill patients because the signs and values may be the result of physiological stressors, psychological stressors, or both.16 Therefore, research into anxiety associated with critical illness usually relies on patients’ self-reports of anxiety levels. However, this approach presents other difficulties. Critically ill patients are often limited in responding to validated anxiety scales that involve cognitive effort the patients cannot sustain and verbal responses they cannot make because of tracheal intubation.7,17

Several investigators4–8 described the use of self-reports of anxiety measures in critically ill patients. Desbiens et al4 used 2 simple questions about the frequency and severity of anxiety and other symptoms; the choices of answers ranged from "not at all" to "all the time" for frequency and from "not at all severe" to "extremely severe" for severity. Patients in the study were very ill and at high risk of death, but many were not interviewed about their symptoms because of intubation or other impediments to communication. Therefore, the usefulness of interviews in which those questions are used in intubated ICU patients is untested. Rincon et al5 used the Hospital Anxiety and Depression Scale18 to assess anxiety in 96 patients in critical care units in a private hospital in Central America. However, all the patients were able to communicate verbally and had low severity of illness scores and so were not representative of the general ICU population. Nelson et al6 used a modification of the Edmonton Symptom Assessment System,19 which was designed for patients receiving palliative care, to study the symptom experience of cancer patients receiving intensive care. With the modified scale, 7 symptoms, including anxiety, were assessed by using a 4-point numeric rating scale (none to severe), and 50% of patients were able to self-report. Three quarters of the patients were receiving mechanical ventilation at the time of admission to the ICU, suggesting that many intubated patients were able to respond to the anxiety numeric rating scale. However, the construct validity of analog scales has been questioned because respondents must transform subjective experience into the abstract expression of the experience represented by the scale,20 a task likely to be difficult for critically ill patients with limited cognitive capacity.

In 2 intervention studies7,8 with ventilator-dependent patients, the 6-item version of the Spielberger State Anxiety scale was used, the English language version21 in one and a Chinese language version22 in the other. In both studies, patients were alert and able to communicate by holding up fingers in response to questions and did not themselves complete the instruments. The internal consistency coefficient alphas were .67 and .72, which are less than the .82 reported originally for the 6-item Spielberger scale.21 Although this brief scale was minimally difficult for critically ill patients to respond to, Chlan7 remained concerned about its validity for this population and recommended further work to develop an anxiety self-report measure suitable for ICU patients receiving mechanical ventilation.

Obtaining valid and reliable measures of anxiety in ICU patients is important because of the effect of anxiety on patients’ comfort and recovery. Each of the measures used in previous studies has practical or theoretical limitations for its use with ICU patients. Therefore, the Faces Anxiety Scale was developed for assessing anxiety in critically ill ICU patients, many of whom cannot respond to existing validated measures of anxiety.17 The Faces Anxiety Scale is a single-item scale with 5 possible responses, ranging from a neutral face to a face showing extreme fear, and is scored from 1 to 5. More ICU patients were able to respond to the Faces scale than to a 6-item anxiety scale or a numeric analog anxiety scale, and it had good properties of continuous measurement (ordinal and interval properties).17

In this article, we report on the criterion validity of the Faces scale and the frequency and severity of state anxiety in a sample of ICU patients. Criterion validity requires that a scale perform well in relation to another measure that is widely used in the field and accepted as valid.23 For assessment of state anxiety, we would use the state anxiety component of the Spielberger State-Trait Anxiety Inventory24 as the criterion reference for comparison in a study population who could readily respond to the scale. However, the 20-item Spielberger State scale would not be accessible for many of the population for whom the Faces Anxiety Scale was developed. Even 6-item anxiety scales are somewhat difficult for ICU patients to complete.7,17 Therefore, in consultation with a liaison psychiatrist, we elected to use clinical judgment of patients’ anxiety levels as the standard against which to assess the validity of the new scale.


Because ICU patients are often nonverbal, use of currently available anxiety measures is difficult.

 

The specific aims of this research were to assess the validity of the Faces Anxiety Scale in ICU patients, assess the frequency and severity of state anxiety in ICU patients, and explore correlates of anxiety in ICU patients.


   Methods
Top
 Abstract
 Methods
Results
 Discussion
 References
 
Criterion validity of the Faces scale was assessed in relation to the clinical judgment of patients’ anxiety by a trained research assistant (interviewer) and was based on clinical signs of anxiety and patients’ non-verbal responses to a set of standard interview questions. The use of clinical judgment is widely regarded as a valid means of assessing anxiety and other psychological states.25–27 The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), interview schedules are often used to diagnose psychiatric disorders via structured clinical interview,28 and the structured clinical interview is regarded by some investigators as the gold standard against which other assessment methods are judged.25,29 However the DSM-IV interview requires sustained cognitive involvement by patients, and alternative clinical interview techniques have been used for medical inpatients with cognitive limitations.29 Clarke et al27 questioned the construct validity of DSM-IV diagnoses in patients hospitalized with physical illness and found that the usefulness of the diagnoses was limited. Further, the purpose of our study was to assess psychological distress rather than to diagnose a psychiatric disorder, so we selected alternative structured clinical interview techniques. The trained interviewer first questioned each patient and made a judgment of the patient’s anxiety level, and then the patient was asked to respond to the Faces Anxiety Scale. Clinical and demographic data were obtained from the patients’ records.

Patients and Setting
Patients were in 1 of 3 ICUs, general, cardiothoracic, or neurosurgical, of Royal North Shore Hospital, a large tertiary referral hospital, or in the combined intensive care and coronary care unit of Hornsby Hospital, a suburban district hospital, in Sydney, Australia. The study was approved by the human research ethics committees of both hospitals and the University of Technology Sydney. A total of 86% of the patients in the sample were recruited in the general ICU of Royal North Shore Hospital; 9% were recruited in the neurosurgical unit at Royal North Shore, and the remaining 5% in the cardiovascular unit at Royal North Shore or the unit at Hornsby Hospital. The majority of patients therefore were being nursed in open-plan 6-bed rooms. All units allowed 2 visitors per patient at most times during a 24-hour period. The usual staffing ratio of the study ICUs was 1 registered nurse per patient.

Eligible patients were any patients in an ICU who could interact even intermittently in order to respond to questions about their feelings and emotions, opened their eyes in response to hearing their name or spontaneously or were awake, understood English, and had sufficient corrected vision to see the Faces scale. We also sought patients who had a tracheal tube in place for mechanical ventilation or were receiving noninvasive positive-pressure ventilation. Patients were resting when approached and asked to participate in the study and were not engaged in other activities. A total of 109 patients agreed to participate, and subjective anxiety scores in response to the Faces scale were obtained from 106 patients; each patient was included only once.

Materials and Procedure
Daily checks were made in the ICUs for patients eligible for the study. For each patient deemed eligible, the registered nurse caring for the patient was approached and asked if the nurse agreed to having the patient asked to participate in the study and also if the nurse was willing to help. At a time convenient for the nurse, the patient was read the information statement approved by the ethics committees and asked if he or she wished to participate in the study. If the patient gave nonverbal agreement to participate, the clinical interview commenced.

The questions that the interviewer asked the patient were the 9 questions in the anxiety scale of the Profile of Mood States.30 This instrument is a valid self-report measure, but in this study, the nonverbal response of the patient to the short questions of the Profile of Mood States anxiety subscale were used as the main basis for the clinical judgment by the interviewer of the patient’s level of anxiety. The patient was asked each question, for example, do you feel tense, do you feel panicky, do you feel relaxed? Patients indicated yes or no by nodding or shaking their head or using thumbs-up or thumbs-down hand signals. If a patient indicated yes, the interviewer then asked if the feeling was a little bit, so-so, or very much, using hand gestures to accompany each response. The patient indicated how much of the feeling he or she had by responding to the closest answer, which was recorded as 1, 2, or 3. The interviewer observed the patient for clinical signs of anxiety in consultation with the nurse caring for the patient in order to place the observations in the context of the patient’s recent clinical appearance. Signs included facial expression, ability to maintain eye contact, ability to concentrate, shaking hands, and sighing. Considering mainly the patient’s responses to the questions, but also any recent clinical signs consistent with anxiety, the interviewer then rated her clinical judgment of the patient’s anxiety level in the range of 1 to 10. The patient was then shown the Faces Anxiety Scale on an 11 x 42-cm (4.3 x 16.5-in) card and asked to point to the face that showed how the patient felt that time. If a patient was anxious at the time of interview, the patient’s nurse determined the source of the anxiety and addressed it with usual practices, such as providing information and explanations.

Demographic and clinical data were recorded on a standard form. The clinical data included respiratory status, heart rate, blood pressure, diagnosis, major problems, impending and recent procedures, and drug therapy in the past 24 hours, such as sedatives, opioids, corticosteroids, and anticonvulsants, that could affect mental state. In addition, a record was made of the score on the Acute Physiology and Chronic Health Evaluation II31 at the time, and a score, based on the scoring system reported by Cullen et al,32 was calculated for the number and intensity of interventions being received by the patient. The intervention scoring system was updated to reflect current Australian intensive care practices and incorporate factors such as patients’ obesity and isolation nursing.33

Data Analysis
The data were summarized by using descriptive statistics. The distributions of the anxiety scores were visually checked by using histograms. The relationship between the interviewer’s clinical judgment of patients’ anxiety and the patients’ self-reports on the Faces Anxiety Scale was assessed by using the Pearson correlation coefficient. Relationships between anxiety scores and clinical and demographic characteristics were assessed by using {chi}2 analysis and the Pearson correlation coefficient.


   Results
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 Abstract
 Methods
 Results
Discussion
 References
 
Clinical and demographic characteristics of the patients are presented in Table 1Go. Patients were mostly men (61%); mean age was 61 years (range 17–86 years). Approximately half (52%) of the patients had cardiovascular or respiratory diagnoses at the time of admission to the ICU. Most (95%) had an endotracheal or tracheostomy tube in place, and 89% were being treated with mechanical ventilation at the time of data collection. Scores on the Acute Physiology and Chronic Health Evaluation II at the time of data collection ranged from 2 to 23 and were in the low range on average; intervention scores ranged from 19 to 56 and were moderate on average. The 3 patients who initially agreed to participate in the study but subsequently did not respond to the Faces scale either changed their minds or were too tired to respond. Only 8% of patients had family members present at the time of data collection.


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  		Table 1 Clinical and demographic characteristics of the sample

 
Anxiety scores were moderately high (Table 2Go). Most patients reported some anxiety and were judged to be anxious on the basis of the clinical interview. Approximately two thirds of patients had moderate to severe anxiety. The anxiety scores from both the clinical judgment and the Faces scale were normally distributed. The correlation between clinical judgment of anxiety and patients’ self-report on the Faces scale was 0.64 (P < .001).


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  		Table 2 Anxiety scores and levels

 

Clinically judged anxiety levels correlated with results on the Faces Anxiety Scale.

 

Two thirds of the patients (67%) had received some sedative or opioid drugs in the preceding 24 hours (Table 3). A total of 40 patients had received a single agent; the single agents used most often were morphine (n = 19 patients, 18%), propofol (n = 7, 7%), and midazolam (n = 6, 6%). Morphine was given in combination with a sedative to 30 patients (28%): with midazolam in 19 (18%), with propofol in 9 (8%), and with diazepam in 2 (2%). Patients were categorized as recently sedated if they were receiving sedatives, major tranquilizers, or opioids at the time of data collection or if they had received the drugs within a defined period before data collection (Table 4Go). The defined periods were 4 hours for diazepam and midazolam, 30 minutes for propofol, 24 hours for haloperidol, and current infusion for morphine and fentanyl.


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  		Table 4 Sedative and opioid drugs recently administered before data collection*

 
Anxiety scores were split at the median value of 3 into low or moderate to severe anxiety. A {chi}2 test was conducted to assess any relationship between recent receipt of sedatives and anxiety. Of the 45 patients categorized as recently sedated, 55% had anxiety levels of 1 to 2, and 35% had anxiety levels of 3 to 5; of the remaining 61 patients, 45% had anxiety levels of 1 to 2 and 66% had anxiety levels of 3 to 5 ({chi}2 = 4.3, P = .04). However, of the 64 patients reporting anxiety levels of 3 to 5, 66% had not been recently sedated. We found no relationships between anxiety levels and receipt of adrenergic agonists (48% of patients), ß-blockers (5% of patients), or corticosteroids (15% of patients)

Pearson correlation indicated no relationship between anxiety levels and mean arterial pressure (r = 0.053) or between anxiety levels and heart rate (r = 0.013) at the time of interview. Similarly, we found no relationships between anxiety scores and sex, age, diagnosis, ventilation status, intervention scores, and scores on the Acute Physiology and Chronic Health Evaluation II.


Two thirds of patients had moderate to severe anxiety, and 34% of them had recently been sedated.

 


   Discussion
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 Abstract
 Methods
 Results
 Discussion
References
 
An essential step in establishing the acceptability of a new psychometric measure is to show that it performs well in relation to an already accepted measure of the construct, in this instance, state anxiety. The patients in our study, for whom a new measure of state anxiety is considered necessary,7 would have been quite limited in responding to even short validated state anxiety scales or the DSM-IV interview schedules used to diagnose anxiety disorders.28 Therefore, the new Faces Anxiety Scale was assessed in relation to a structured clinical assessment of anxiety by a trained interviewer, based mainly on the patients’ nonverbal responses to the short questions from the Profile of Mood States anxiety subscale.30 The correlation between the objective clinical judgment of the interviewer and the patients’ self-reports of anxiety on the Faces scale is well within the recommended range of 0.4 to 0.8 for criterion validity.23 Thus, in addition to the evidence that the Faces Anxiety Scale is accessible by sick, nonverbal ICU patients, and that it has good continuous measurement properties,17 the results indicate that the Faces scale is a valid measure of state anxiety and that it elicits normally distributed scores in this population of patients.


The Faces Anxiety Scale is useful in ICU patients and is a valid measure of anxiety.

 

As Streiner and Norman23 discuss, it is not known in this situation how much measurement error or lack of reliability each of the measures contributes to lower correlations between measures of the same construct. The possibility that the accepted measure or gold standard has yielded data with measurement error is equal to the possibility that the new measure being validated has error. Global self-rating anxiety scales are sensitive, and brief scales are considered adequate.34

The frequency and levels of anxiety in our patients, most of whom were receiving mechanical ventilation, are comparable to the frequency and levels reported in other studies6–8 of patients receiving mechanical ventilation. Anxiety is often experienced by patients receiving ventilatory assistance and is often moderate to severe. Although this fact is well known from retrospective,1–3 and now prospective, studies, anxiety continues to be a problem for patients. Anxiety is difficult to address and manage clinically because its detection is difficult in many patients receiving intensive care. An easily administered, self-report measure of anxiety suitable for routine clinical use has not been available. Critical care nurses rate the assessment of anxiety in their patients as very important but often rely on behavioral and physiological manifestations to diagnose it, manifestations that may not be apparent until long after the onset of subjective feelings of anxiety.35 The unreliability of these manifestations in critically ill patients is reinforced by our results; we found no relationships between self-reported anxiety and physiological and other clinical factors. Further, physiological responses at times of stress may differ greatly between different persons.34 The Faces Anxiety Scale appears to be a promising means of obtaining self-reports of state anxiety from ventilator-dependent patients for routine clinical purposes, as well as for research into interventions to reduce anxiety.

As would be expected in patients receiving mechanical ventilation, many of our patients had received sedative and/or opioid drugs in the 24 hours preceding data collection, and several had received a major tranquilizer. Similarly, many had received agents that could be affecting sedation and anxiety levels at the time of data collection, although patients who were included were sufficiently alert and responsive to participate in the short interview despite the drugs they were receiving. The proportion of patients receiving such drugs is similar to those reported in some other studies7,8 of patients receiving mechanical ventilation. The drugs used are largely consistent with those recommended for analgesia, sedation, and agitation in adult ICU patients,36 except that parenteral lorazepam is not available in Australia and continuous infusion midazolam is therefore used when prolonged administration of a benzodiazepine is required. The finding that recent administration of sedating drugs was associated with lower anxiety levels is reassuring, but the proportion of patients reporting moderate to severe anxiety who had not recently received sedatives or opioids is of concern. This finding further underlines the difficulty of detecting anxiety in ICU patients and reinforces the need for simple self-report measures for routine clinical assessment of anxiety.

Much research has shown that relatively simple, nonpharmacological interventions that can be implemented by clinical nurses do reduce anxiety in acute and critical care patients. In a review of studies published from the 1950s to the 1970s, Mumford et al37 concluded that a range of modest, psychologically based interventions reduced length of stay and improved other comfort and recovery outcomes in patients who had had surgery or a myocardial infarction. The interventions were intended to provide information or emotional support to patients and were carried out by a range of healthcare clinicians, including nurses. More recent studies have shown benefits, including reduction of anxiety, from the use of music in critically ill patients who were not ventilator dependent38–40 and in those who were.7,8 A brief foot massage reduced heart rate, blood pressure, and respiratory rate in critical care patients.41 Provision of information including specific sensory information, in addition to procedural information, was effective in reducing anxiety and stress in several populations of patients.42,43 Specific information, including the sensations that would be felt, was beneficial during mechanical ventilation in adult postoperative cardiac surgical patients.44,45 Increasingly, evidence exists that some of these straightforward interventions should be considered for adoption into routine critical care nursing practice because they improve patients’ comfort. However, investigations are needed to determine whether such interventions are powerful enough to be effective in countering the general demands of the physical and psychological stressors experienced by the more heterogeneous general ICU patients16 and the possible influence that psychological distress has on physical recovery.10–12


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  		Table 3 Sedative and opioid drugs therapy in the 24 hours before data collection

 

   ACKNOWLEDGMENTS
 
We thank the nursing staff of the study intensive care units for their cooperation and assistance; Dr Christopher Tennant, professor of psychiatry, for advice on selection of the criterion method of assessing anxiety; and Dr Richard Lee, senior staff specialist, intensive care unit, for assistance in interpreting the pharmacological data. This work was performed at the Royal North Shore and Hornsby hospitals in the Northern Sydney Area Health Service. Funding was provided by a University of Technology Sydney research grant.

To purchase reprints, contact The InnoVision Group, 101 Columbia, Aliso Viejo, CA 92656. Phone, (800) 809-2273 or (949) 362-2050 (ext 532); fax, (949) 362-2049; e-mail, reprints{at}aacn.org.


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