Anger: The Mismanaged Emotion

Sandra P. Thomas

Disclosures

Dermatology Nursing. 2003;15(4) 

In This Article

Anger in Health Care Settings

Patient Anger

Patient and family complaints have been increasing since the ill-conceived staff downsizing and restructuring of the mid-1990s (Shindul-Rothschild, Berry, & Long-Middleton, 1996). When too few nurses are spread too thin, dealing with high-acuity patients and worried families, patients' anger is often vented to their nurses. The anger can be generated by their feelings of vulnerability and powerlessness as they grapple with depersonalized institutional routines, intrusive procedures, and the receipt of bad news about diagnosis, disability, and prognosis. Additional precipitants of patients' anger include (a) unrealistic expectations that their nurse will be a saintly angel of mercy (Muff, 1982), (b) lack of attention to their physical or psychological needs (Shattell, 2002), and (c) failure of health care personnel to recognize their wholeness and uniqueness (Plaas, 2002). Of course, men and women bring with them into health care settings their habitual anger cognitions and styles of managing anger. Based on the above-cited research findings, it is logical to expect that men may become angered by loss of control, inefficiency of the system, and/or lack of staff professionalism, while women may feel both angry and hurt if they perceive staff as uncaring and/or unwilling to take time to listen to them and form a relationship.

Unfortunately, a nurse's response to a patient's anger is often a defensive one that actually fuels more anger. A patient who is in pain, waiting for an analgesic injection, does not want an explanation ("we're short of help; there are other people ahead of you waiting for a shot"); instead, the patient wants reassurance that something will be done ("I'm really sorry that you've had to wait; I will take care of it right now"). Of course there are patients whose demands seem endless, creating aversion in their caregivers. A classic article by Groves (1978) provides advice for dealing with several types of difficult patients, including those he calls the "dependent clingers" and the "entitled demanders." What nurses must understand is that underneath the angry demands are deep fears of abandonment. While negative feelings toward such patients are understandable, and limits should be set ("I will return to check on you in 15 minutes; please don't call again in the interim unless it is an emergency"), the ultimate solution is giving consistent care that alleviates their fear.

Smith and Hart (1994) conducted a study to examine how medical-surgical nurses managed angry patient situations. When patient anger was perceived as a personal attack, nurses tended to disconnect. They did not understand the patient's reality. As their own anger arose, they feared its power and they sought to hide it. They tried strategies such as taking a timeout, transferring blame, seeking peer support, and "returning to smooth," which meant repairing the relationship with the patient. The "smoothing" did not involve talking with the patient about the anger incident, simply acting as though nothing had happened -- a less-than-ideal resolution. A better outcome was achieved by three of Smith and Hart's study participants, who were able to remain connected with the patient, analyze the anger, and not take it personally. According to the previously cited research of Thomas and colleagues, many people are ashamed after an anger outburst; it logically follows that they may welcome a nurse taking the initiative to clear the air and restore the patient-nurse relationship. Thomas (1998) offers a number of strategies for decreasing patient anger (see Table 1 ).

There is always a possibility that a patient's or family member's anger could escalate to violence. It is vitally important to be alert for clenched fists, pacing, and other signs that an individual is becoming increasingly agitated and potentially assaultive. Threats should be taken seriously and communicated to security personnel promptly. Nurses and other health care workers are at high risk for workplace violence because of their extended periods of direct contact with patients and families during very stressful circumstances and their vulnerability when working in small numbers or alone (for example, on night shifts) (Anderson, 2002). Particularly at risk for violence are younger, less-experienced staff and student nurses (Echternacht, 1999). Prior victimization is also a risk factor. In a recent study by Anderson (2002), nurses who had experienced childhood or adult abuse reported that they experienced more workplace violence events than nurses who had no history of abuse.

Roberts (1991) conducted a study of female nurses who had been assaulted by patients. All of the nurses reported long-term consequences for their job performance. Particularly distressing was management's blaming them for the assault. They found themselves labeled as "the nurse who got hit." Management seldom supported prosecution of the attacker, and nurses were reluctant to proceed with legal action on their own. Coping strategies of the nurses were mainly avoidant: minimizing, denying, and forgetting about the assault. The traumatic experiences of these nurses indicate that a great deal needs to be done not only to reduce the violence itself but also its damaging sequelae. All nurses need training in assessing angry individuals and in violence prevention tactics. Violence Prevention Guidelines have been issued by the Occupational Safety and Health Administration. At this writing, it is not known how many health care facilities are in compliance with these guidelines.

Physician Anger

Another manifestation of dysfunctional anger in health care settings is the oft-reported verbal abuse of nurses by physicians. Physician-perpetrated abuse was more common in Anderson's (2002) study than abusive acts by patients. In a study by Manderino and Berkey (1995), 90% of a sample of staff nurses said they experienced verbal abuse by physicians during the past year.

Participants in the author's studies of female and male RNs (Brooks et al., 1996; Smith et al., 1996) reported disrespectful treatment, criticism, attacks, tirades, and baseless accusations from physicians. Their own words powerfully depict what they experienced. Nurses said that they were "lambasted," "thrashed," "picked on," "belittled," and "lectured." Typical was the following report by a male nurse who had been accused by a physician of something he had not done:

"He thrashed me verbally in front of my peers...I thought, I just can't take this professional abuse...very frustrating to not be able to prove that I hadn't done it...feeling helpless and not being able to defend...not being able to resolve it" (Brooks, 1996, p. 13).

At the moment of such an angry attack by a physician, the nurse's feelings of helplessness are understandable. The attack is often unexpected as well as unfair. But nurses must learn to cope effectively with physician temper tantrums, not only to preserve their own self-esteem but also to prevent adverse consequences for patient care. Researchers found that when doctors acquire a reputation for tantrums, nurses hesitate to call them about a patient or make suggestions about the patient's care (Diaz & McMillin, 1991). Suggestions about how to deal with verbal abuse are listed in Table 2 .

Anger of Nurses at Each Other

One of the most disturbing aspects of the research data on nurses' anger was the vehemence of their anger at each other. Words taken verbatim from the interview transcripts illustrate how nurses wound each other with words: "faultfinding," "bickering," "backbiting," "needling," "snapping," and "cutting" (Brooks et al., 1996; Smith et al., 1996). More subtle manifestations included damaging gossip, nonverbal signals, and chilly silence. These hurtful behaviors are manifestations of a phenomenon called horizontal violence or horizontal hostility (Muff, 1982). Horizontal hostility is a characteristic of oppressed groups who fight among each other because they cannot vent anger at those in power; in the case of nurses, those in power include physicians, supervisors, and administrators. Despite many notable advances in the nursing profession, the majority of nurses still work in hospitals or other facilities with a hierarchical system, where there are one or more levels of personnel above them. There are even hierarchies within nursing itself, based on degrees, certifications, or nursing specialty. For example, in the study by Smith et al. (1996), critical care nursing was viewed as a higher status specialty than maternal-child or psychiatric nursing. Study participants related this hierarchical ordering to the amount of technology employed in patient care.

Some believe that horizontal hostility occurs in nursing because nurses are predominantly women, "trained from birth to be passive-aggressive," as one nurse described it (Smith et al., 1996, p. 28). It is true that nursing traditionally has been viewed as "women's work," devalued in a patriarchal culture just as women themselves have been. It is also true that passive-aggressive behaviors are evident in other female-dominated occupations. But it became clear in the study of male RNs that they too made disparaging remarks about colleagues and experienced verbal attacks from supervisors and co-workers. Horizontal hostility does not occur just because most nurses are women; it occurs because all nurses -- male and female -- have been oppressed. While some authors exhort nurses to develop a positive professional identity (Roberts, 2000) or make a personal declaration "I elect not to be oppressed" (Kritek, 1999), these measures alone will not suffice because oppressive conditions continue to exist.

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