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Summary: Objective: The study aims to assess anxiety levels of patients in an x-ray room and to explore the influence of an audiovisual intervention on patient experience taking individual differences in need for control and active coping style into account. It is well known that anxiety has a negative effect on clinical outcomes and overall patient experience. Method: Patients were assigned to one of four conditions. Depending on the condition they were assigned to, they received an audiovisual intervention, information about the intervention and the opportunity to choose an audiovisual theme. Anxiety, willingness to recommend the hospital, satisfaction, need for control and active coping were measured. Results: A total of 149 participants completed the study. Anxiety levels were low. Patients were most likely to recommend the hospital when they received the audiovisual intervention and information about it. Patients with a low active coping style were less satisfied and this effect was reversed by providing an audiovisual intervention. Conclusion: The present study reveals that providing an audiovisual intervention and information about it increased patient satisfaction in a digital x-ray environment.
Keywords: Anxiety, patient satisfaction, patient experience, digital x-ray.
Citation: Klaming L, Van der Zwaag M, Van Minde D, Geraedts H. The influence of an audiovisual intervention on patient experience in a digital x-ray room. J Participat Med. 2013 Sept 11; 5:e36.
Published: September 11, 2013.
Competing Interests: The authors have declared that no competing interests exist.


A visit to a hospital can be a stressful experience for patients and can induce feelings of anxiety. Anxiety can be caused by a multitude of factors, including unfamiliar surroundings and noises as well as the feeling of loss of control and dependence on strangers. Besides these factors, perceived or actual risk of the medical procedure as well as uncertainty about the diagnosis and prognosis may provoke anxiety.[1] It is well known that anxiety has a negative effect on treatment adherence and recovery time following a procedure. Moreover, anxiety may interfere with the medical staff workflow by increasing medication need and procedure time and may compromise diagnostic quality (eg, due to an increase in motion artifacts in magnetic resonance imaging [MRI]).[2][3][4][5][6] Since various studies have revealed the profound effects of hospital environment on anxiety, satisfaction and clinical outcomes [7][8][9][10][11] more attention is being paid to the patient experience when a new hospital is designed. Numerous studies have demonstrated that an improved hospital design has a beneficial effect on anxiety reduction, satisfaction, clinical outcomes and workflow.[3][7][8][9][11][12][13][14][15][16] The present study was conducted to explore anxiety levels of patients in the X-Ray department of a hospital and to investigate the influence of an audiovisual intervention on patient experience (ie, anxiety and satisfaction) in this setting taking individual differences in coping style into account.

Factors Influencing Patient Experience

The presentation of audiovisual stimuli during a medical examination, can reduce anxiety and consequently enhance the overall patient experience. Miller and colleagues [9] found that presenting burn patients with visual and auditory stimuli decreased pain, stress and anxiety. In another study, an audiovisual nature distraction was found to reduce discomfort and distress in female chemotherapy patients.[11] In an experimental set-up, Tse et al [14] demonstrated that providing a video of a natural scenery during pain infliction significantly increased pain threshold and pain tolerance. An audiovisual intervention is believed to reduce anxiety because it distracts attention away from unpleasant stimuli and symptoms, requiring relatively little effort from the patient.[9][11] Research has shown that a combination of auditory and visual distraction has more benefit than either used alone.[3][17] In addition to decreasing anxiety, audiovisual distraction was found to increase patient satisfaction.[3][17]

Another important factor with regard to anxiety in a hospital environment is an individual’s need for control. Need for control is a psychological construct that consists of two facets: behavioral involvement and need for information.[18][19][20] Need for behavioral involvement refers to having direct influence on the medical procedure. Need for information refers to receiving information about the procedure, which seems to play an important role in preparing for a medical procedure.[21][22][23][24][25] Numerous studies have demonstrated that people prefer participation in the health care process and that providing information to patients prior to a medical examination reduces anxiety.[26][27][28][29][30][31]

Control does not always have a positive effect. Besides an individual’s preference for participation and information, his level of active coping plays an important role in determining how he will deal with a stressful situation.[32][33][34][35] Generally, people who have an active coping style tend to directly address a situation in an attempt to influence the stressor.[32][33][34][35] Passive coping refers to not taking any action, but giving responsibility to an outside source.[33][35] In a medical context, an active coping style was found to be associated with positive outcomes, eg less anxiety and depressive symptoms, and a passive coping style with negative outcomes.[35][36][37][38] Someone with an active coping style is more likely to have a preference for behavioral involvement and information and will, therefore, experience less anxiety if he receives a high level of control. In contrast, providing control to an individual with a passive coping style may have a negative effect.[20][22][39][40]

Taken together, anxiety can be decreased by means of environmental factors such as an audiovisual distraction as described above, as well as by providing patients with control taking individual differences in need for control and active coping style into account.


Little is known about the anxiety experienced during a diagnostic x-ray procedure. Research has found that interventional radiological procedures, which involve x-ray but are more invasive than diagnostic X-Ray procedures, induce moderate to high levels of anxiety.[4][41] Anxiety may be associated with certain aspects of a diagnostic x-ray procedure; eg, the perceived radiation risk, uncertainty about the diagnosis, unfamiliar surroundings, noises, and loss of control.

In addition to identifying anxiety levels of patients undergoing an x-ray procedure, the study aims to explore whether an audiovisual intervention reduces anxiety and increases satisfaction in this environment taking individual differences in need for control and active coping style into account.



The study took place in the Jeroen Bosch Hospital in Den Bosch, the Netherlands. This hospital has four digital x-ray rooms, two of which are equipped with an audiovisual intervention developed by Philips Healthcare. This system is based on distraction of patients using a combination of dynamic colored ambient lighting, video projections, and sound.

The study was conducted on 4 consecutive days; ie, 1 day for each condition. Participants were assigned to one of the following four conditions based on the day their examination was scheduled: (1) patients did not receive the audiovisual intervention (control condition), (2) patients received the audiovisual intervention (AVI), (3) patients received the audiovisual intervention and received information about it (AVI + info), and (4) patients received the audiovisual intervention, information about it, and were offered a choice of the audiovisual theme (AVI + info + choice).

Four themes were provided to participants in conditions 2, 3, and 4. All themes show nature imagery, which is well known to help reduce anxiety.[12][15] For each theme, the music was quiet and slow in order to be experienced as relaxing and it matched the theme of the video. In conditions 2 and 3, a theme was randomly chosen by the researcher, making sure that each of the four themes was presented to an equal number of participants. Patients in condition 4 could choose among the four themes.


State anxiety, need for control, active coping, and satisfaction with the hospital were measured.

State anxiety.
State anxiety was measured by means of the shortened eight-item version of the State Anxiety Inventory (STAI-S).[7][42][43][44] State anxiety refers to the intensity of anxiety experienced in reaction to a specific event, in this case the diagnostic x-ray procedure. The scores on the eight-item version were converted to the 20-item version to enable comparison to other studies; hence, scores can range between 20 and 80 with higher scores indicating a higher level of state anxiety. In addition to assessing state anxiety before and after the diagnostic procedure, patients were asked to indicate on a seven-point Likert scale how nervous they were (1) with regard to the procedure and (2) with regard to the diagnosis.

Need for control.
Need for control was measured by the Krantz Health Opinion Survey (KHOS).[18] The behavioral involvement scale consists of nine items that measure to what degree a person actively seeks to exert control in a medical environment. The information scale consists of seven items that measure to what degree an individual wants to be informed about medical decisions.[18] A seven-point Likert scale ranging from 1 (totally disagree) to 7 (totally agree) was chosen, rather than the original dichotomous response. This is in line with previous studies that have used other response formats.[19][20] Higher scores indicate a higher need for behavioral involvement and information respectively.

Active coping.
Coping style was measured with six items of the active coping dimension of the Utrecht Coping List (UCL) [32]. This dimension measures to what degree an individual tries to disentangle a situation and actively looks for solutions to a problem. Participants rated each item on a four-point Likert scale ranging from “rarely or never” to “very often.” Higher scores indicate a higher level of active coping.

Satisfaction was measured by asking patients to indicate how willing they were to recommend the hospital to a friend or colleague, which is known as Net Promoter Score (NPS). The NPS was scored on an 11-point Likert scale ranging from 0 (not at all likely) to 10 (extremely likely).[45] The percentage of detractors was subtracted from the percentage of promoters to get an overall NPS. The NPS is typically used in marketing research to get an indication of customer loyalty. The scores are divided into three categories, the really satisfied (ie, the promoters, score 9-10), the passively satisfied (ie, the fence sitters, score 7-8), and the unsatisfied (ie, the detractors, score 0-6), because this clustering turned out to provide the best prediction of customer behavior.[45]


All participants provided informed consent prior to the study. Before the x-ray, state anxiety was measured with the STAI-S and patients were asked to indicate how nervous they were with regard to the procedure and the diagnosis. Patients assigned to the control condition were then accompanied to an x-ray room without colored light, video projection, or music. Patients assigned to the experimental conditions were accompanied to an x-ray room with the audiovisual intervention and were given the following information: “The diagnostic x-ray room has colored light, a video projection, and music.” This information was provided to make patients aware of the presence of the audiovisual intervention. Patients in condition 4 received the following additional information: “There are a number of different themes from which you can choose. Please indicate which theme you would like to have in the x-ray room.” When patients returned from the diagnostic x-ray room, they completed the STAI-S, the active coping questions from the UCL and the NPS. Participants in conditions 2, 3, and 4 also completed the KHOS.


In total, 165 patients participated in this study. Sixteen (9.7%) participants failed to complete more than 50% of the questionnaires and were therefore excluded resulting in a total sample of 149 participants (76 men, 72 women (information about gender was missing for one person)). The mean age of participants was 54.6 years (SD=14.7 years). As expected, there was no difference in initial STAI-S scores between the four conditions (F(3, 129)=.66, p=.58).

Table 1. N, mean age (SD) and initial STAI-S scores of participants across four conditions.


As can be seen in Table 1, the STAI-S scores were relatively low in all four conditions; ie, lower than clinically relevant anxiety scores, which are scores of 40 or higher,[43][46] and lower than in patients undergoing an interventional radiologic procedure.[4] This finding demonstrates that patients who undergo a diagnostic x-ray examination are typically not very anxious. The vast majority of the patients (N=129 (90.8%)) indicated that they were not nervous at all with regard to the procedure and most patients (N=80 (56.3%)) indicated that they were not nervous at all with regard to the diagnosis. Participants who had indicated that they were nervous with regard to the diagnosis (N=19 (13.4%)) had higher STAI-S scores (M=47.5, SD=11.1). It therefore seems that a diagnostic x-ray procedure does typically not induce high levels of anxiety, and in cases where it does, this seems to be due to anxiety associated with the diagnosis rather than the procedure itself.

A repeated-measures ANOVA with time (before, after) as within-subject factor and condition and gender (male, female) as between subject factors (N=124) did not reveal a main effect for time, indicating that STAI-S scores did not significantly decrease (F(1,124)=.41, p=.52). No significant difference in anxiety reduction between the four conditions was found (F(3,124)=1.14., p=.33). The results showed a trend for gender, in that female patients had higher anxiety levels than male patients (F(1,124)=3.89, p=.051).

Table 2. Mean and SD of STAI-S scores across the four conditions for N=124.

For the subsequent analyses, STAI delta was calculated by subtracting the STAI-S before score from the STAI-S after score for each participant. An ANCOVA with condition (2 (N=25), 3 (N=20), 4 (N=18)) as fixed factor, KHOS-I and KHOS-B as covariates and STAI delta as dependent variable did not reveal a main effect for condition (F(2,58)=.75, p=.48). Neither need for information (F(1,58)=.18, p=.67) nor need for behavioral involvement (F(1,58)=.26, p=.61) were significantly related to STAI delta. Hence, there is no difference between conditions with regard to anxiety reduction after controlling for need for control.

An ANCOVA with condition (1 (N=36), 2 (N=26), 3 (N=23), 4 (N=25)) as fixed factor, active coping as covariate and STAI delta as dependent variable did not reveal a significant main effect for condition (F(3,105)=.6, p=.62). Active coping was unrelated to STAI delta (F(1,105)=2.12, p=.15). Hence, there is no difference between conditions with regard to anxiety reduction after controlling for active coping.


The NPS of the four conditions were: control condition: 0% (N=43), condition 2: 27% (N=37), condition 3: 46.9% (N=32), condition 4: 5.6% (N=36). Figure 1 illustrates the NPS percentages of the four conditions: detractors (score 0-6), fence sitters (score 7-8) and promoters (score 9-10).

A one-way ANOVA with the raw NPS data revealed a significant effect for condition (F(3,147)=3.1, p<.05). Posthoc tests revealed a significant difference in mean NPS between condition 3 (M=8.4 (SD=1.4)) and condition 4 (M=7.1 (SD=2.5)). Patients were more likely to recommend the hospital if they received the audiovisual intervention and information about it than when they also received choice of an audiovisual theme. This finding suggests that providing an audiovisual intervention and information about the intervention increases satisfaction, but only if patients do not have to choose an audiovisual theme. Figure 1. Percentage of promoters, fence sitters and detractors in the four conditions.

An ANCOVA with condition (2 (N=30), 3 (N=23), 4 (N=25)) as fixed factor, need for information, and behavioral involvement as covariates and raw NPS as dependent variable did not reveal a significant main effect for condition (F(2,73)=1.9, p=.16). None of the covariates was significantly related to NPS (KHOS-I: F(1,73)=.02, p=.9, KHOS-B: F(1,73)=.05, p=.83). When comparing the condition with no information (condition 2, N=30) to the conditions with information (conditions 3 and 4, N=48), a significant interaction effect was found (F(1,76)=4.87, p<.05). The NPS was equally high in both conditions (no information condition: M=7.8 (SD=1.8), and information conditions: M=7.7 (SD=2.2)). However, when looking at the effect of need for information on NPS, a difference between the two conditions was found, although the difference failed to reach significance. In the no information condition, patients with a high need for information gave lower NPS (F(1,29)=3.02, p=.09), whereas in the information condition, patients with a higher need for information gave higher NPS (F(1,47)=2.8, p=.1). This finding suggests that congruency between need for information and providing information has a beneficial effect on NPS. To explore the effect of active coping on the NPS in the distinct experimental conditions, an ANCOVA was conducted with condition (1 (N=41), 2 (N=32), 3 (N=25), 4 (N=33)) as fixed factor, active coping as covariate and raw NPS as dependent variable. A significant interaction effect was found (F(3,123)=3.37, p<.05). When looking at the distinct conditions separately, active coping was only found to be related to NPS in condition 1 (F(1,39)=18.39, p<.001). Patients who did not get an audiovisual intervention were less likely to recommend the hospital if they had a low active coping style. Active coping was unrelated to NPS for patients who did get an audiovisual intervention. Based on this finding, it seems that providing an audiovisual intervention eliminates the negative effect of low active coping on the NPS.

Discussion and Conclusion

The present study provides insight into the experience of patients undergoing a diagnostic x-ray examination. In this context, patients experience relatively low levels of anxiety. This finding is not surprising given that this medical procedure is typically short, not invasive and well understood by most patients. Patients who had higher levels of anxiety were also more nervous with regard to the diagnosis and, therefore, it seems that higher levels of anxiety are due to the diagnosis rather than the procedure itself.

The second aim of the study was to explore the influence of an audiovisual intervention on anxiety and satisfaction in a diagnostic x-ray scenario. Since patients in this specific hospital environment had low anxiety levels, the audiovisual intervention aimed at decreasing anxiety had relatively little effect. But this is not necessarily the case for other hospital environments, such as MRI procedures and PET uptake, where patients are typically more anxious and, therefore show a reduction in anxiety when offered an audiovisual intervention.[7] More research on the effect of an audiovisual intervention in medical environments in which anxiety plays a more predominant role seems beneficial.

With regard to satisfaction, differences between the conditions were found. Most importantly, patients who received the audiovisual intervention and information about it were most likely to recommend the hospital. Providing patients with an audiovisual intervention increased the NPS from 0% to 27%. Providing information about the intervention further increased the NPS to 46.9%. We attribute this increase to patients being consciously aware that the hospital is taking extra measures to enhance their experience. In contrast to our expectations, offering choice of an audiovisual theme reduced the NPS to 5.6%, which is only marginally higher than in the control condition. Choosing a theme may, therefore, be seen as something that requires effort, but the benefit is not clear. It will be interesting to see whether choice of an audiovisual theme increases satisfaction in a medical environment where anxiety levels are higher.

Another important finding is that patients with a low active coping style gave lower NPS when they did not receive an audiovisual intervention, whereas low active coping was not related to NPS when patients received the intervention. This finding suggests that providing an audiovisual intervention can undo the negative effect of a low active coping style on satisfaction.

Identifying ways to improve patient experience is necessary to reduce discomfort and consequently improve clinical outcomes and workflow. Taken together, the present study demonstrated that anxiety levels of patients undergoing an x-ray procedure are relatively low. Satisfaction can be increased when providing patients with an audiovisual intervention and information about the intervention.


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Copyright: © 2013 Laura Klaming, Marjolein Van der Zwaag, Daisy Van Minde, Harm Geraedts. Published here under license by The Journal of Participatory Medicine. Copyright for this article is retained by the author, with first publication rights granted to the Journal of Participatory Medicine. All journal content, except where otherwise noted, is licensed under a Creative Commons Attribution 3.0 License. By virtue of their appearance in this open-access journal, articles are free to use, with proper attribution, in educational and other non-commercial settings.