Nightingale et al. identified rapid practitioner decision-making on first meeting the client that enabled a range of anxiety-reducing strategies to be implemented (Fig. 12.2) [9]. Practitioners employ various strategies to produce quality diagnostic images whilst demonstrating empathy and professionalism. These include facilitating a degree of client empowerment by encouraging the clients to comment on the level of compression force themselves, or at least advising when the level is uncomfortable [8, 9].

Clarke and Iphofen offered an individual patient perspective which identified that being encouraged to say ‘stop’ during a procedure was very empowering [17], and indeed Bruyninckx et al. also stressed that this very act of speaking out could reduce perceived pain levels [18]. However some clients may insist on stopping the application of compression force when it is insufficient for acceptable image quality, thus giving the practitioner a dilemma. How the practitioner addresses this dilemma will have implications for either image quality, client experience, or both, and these difficult practitioner-client interactions are found to be influenced to some extent by the values and behaviours of the individual practitioner, and indeed the culture of the wider screening unit. Murphy et al. identified within some mammography screening units what they described as ‘tribal’ cultural influences upon mammography practitioners where [compression] practice was not necessarily supported by an evidence base but more associated with local social factors [8]. They recognised that the mammography practitioner-client interaction was a paradox of humanistic caring against the demands of imaging technologies, presenting difficult challenges and decisions for individual practitioners [8]. Therefore from the study of Murphy et al. it is reasonable to suggest that the client experience may differ from one practitioner to another, and between different screening units [8].

Although the application of compression force appears to provoke anxiety in lots of women, several studies have identified other causes of anxieties as being very significant in the overall client experience. This includes issues associated with privacy, dignity, the process itself and understandably the implications of finding breast cancer [5, 6]. Murphy et al. found that practitioners identified overt differences in behaviour and anxiety levels between clients attending screening for the first time (prevalent screen) and those attending for follow up screening (incident screen), and this prompted different practitioner responses [8]. First attenders were often extremely anxious and a more detailed explanation was required, often including a demonstration of the equipment. Repeat attenders were often influenced by a prior ‘poor’ experience, requiring a degree of gentle persuasion by the practitioners [8, 9]. In some cases ‘white lies’ (harmless mistruths told in the belief it will benefit the client) about new and improved equipment were told to reassure clients that the discomfort they previously experienced will be reduced [8].

Following breast screening a client may be recalled for a repeat mammography examination (technical recall) because the images are deemed to be non-diagnostic. UK practitioners should record no more than 3 % technical recalls with a target of 2 % [1]. Technical recalls use additional resources, result in additional radiation dose, and are inconvenient for the client, increasing their anxiety about the potential diagnosis.

Some clients, however, are referred to a breast clinic for additional investigations because an abnormality is suspected, and these include both symptomatic clients and screening assessment clients. There is inevitably a high degree of anxiety about potential findings for both client groups. Symptomatic clients will have identified a physical sign of breast disease (e.g. breast lump, nipple discharge) which their doctor considers requires urgent referral. While this will clearly be worrying for the symptomatic client, breast screening clients subsequently recalled to a breast assessment clinic are likely to experience an additional feeling of ‘shock’ (see also Chap.​ 7) [26]. Assessment clinic appointment letters which arrive unexpectedly have been criticised by low income ethnic minority women in one American study as being difficult to understand [27]. In the UK, there may be a delay of several days between informing the client of the need for their breast clinic appointment and the date of the actual appointment. In other countries the delay can be longer. These few days of delay may be filled with worry for the client, their friends and relatives; while some studies report that support from significant others is comforting, it does not diminish the women’s anxiety [28]. The quality of the invitation letter and information leaflet are very significant in this pre-attendance period; personal contact by telephone from a health professional has also been found to be very beneficial in this early ‘waiting’ stage [28].

It is understandable that clients referred to a breast clinic will have anxiety related to the potential diagnosis of breast cancer. As this is the most common female cancer in Western civilisations, with a 1 in 8 lifetime risk of women developing the disease [29], it is highly likely that many women will have been in some way ‘affected’ by the disease, either through friends or relatives with the condition. Clients with a strong family history of the disease across several generations may experience heightened anxiety that is disproportionate to the actual risk factors [30] because they may be unaware of significant improvements in early diagnosis, treatment options and survival in recent years. Severe worry has been identified as a barrier to mammography use in higher risk women, but this is also found in normal risk populations [31]. There is once again a vital role for accurate verbal and written communication of appropriate information with clients. Nevertheless the degree of anxiety experienced by clients could be extremely high on entering the clinic, since they have had several days to consider the potential outcomes.