Nurse Response to Patient Anger

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oumal of Advanced Nursmg,1994,20,643-651

Nurses' responses to patient anger: fromdisconnecting to connectingMarthaE Smith MNRNAssistant Director, Yarmouth Schoo l of Nursing, Yarmouth, Nova Scotia

nd G era ldm e H ar t MSN RNssociate Professor, Dalhousie U niversity, School ofNursing, Halifax, Nova Scotia,anada

ccepted for publication 14 January 1994

SMITH ME &HARTG (1994) Journal of Advanced Nursmg 2 0, 643-651Nurses' responses to patient anger, from disconnecting to connecting

Caring for angry patients can be a threatening experience Grounded theory

research was used to explore female nurses' reactions and feelings as therecipients of patient anger The data were collected by interviewing nine femaleregistered nurses m two hospitals in south-western Nova Scotia Theparticipants were asked to discuss their feelings and responses to an intenseencounter writh an angry patient Anger was defined as a multi-dimensionalconcept with negative cogitations The concept of self-efficacy emerged as themajor area of concern for the participants The findings suggest that when thethreat to self was high, nurses managed anger situations by disconnecting fromthe angry patient Low or controllable threats were generally managed byconnecting with the angry patient

URPOSE OF THE STUDY

he purpose of this study was to explore how femaleurses define angerand to explore female nurse s' percep-ons of their responses as recipients of patient anger,cluding the meanings and feelings they relate to thesesponsesAccordmg to Duldt (1982), nurses havea 50-50 chanceencountermg angry expressions from other health care

orkers and patients, and from patients' families, dunng

e course of a work week Due to its powerful force,pressed and unexp ressed anger can be very upsettmgtoth the angry person and the recipient AveriU's (1982)

udies suggest that the actual response is hased onmquely mdividual charactenstics, suchas past expen-ces, level of frustration, perceived threat, levelof self-nfidence and the presence of other emotionsSeveral conceptualand theoretical framew orks existonger, however, these framew orks have not been validatedr use m nursing No known studies couldhe found whichammed the apphcation of these theones to the nurses 'sponse as a recipient of patient anger

M E T H O D O L O G Y

Grounded theory, developedhy Glaser & Strauss (1967),was chosen as the most appropnate research designbecause ofthe lack of existing theory to explain and predicthow nurses define and respond to patient anger Thisapproach, used in a nursing context, is a particularlyuseful research method to generate knowledge m a fieldof study w here limited mformationis known (Stem 1980,Chenitz & Swanson 1986)

The qualitative research designof grounded theory isboth a theory and a highly systematic method of collectmg,organizing and analysing data The information was col-lected hy mtervievsrmg participants usmgan open endedquestion format The participants were asked at>out theirexpenences with anger, hothm the nursing contextandpersonal context,in order to study the sociai and psycho-logical phe no me na afifecting their tjehaviour The u ltimatepurpos e was to generatea theory which descnhe s, explainsor predicts this Ijehaviouxm the nursing context

The initial mterviews were analysedto form tentativecodes and categones which guided subsequent data

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collection Using constant comparative analysis, conceptseventually emerged encompassing the behavioural pro-cesses used by nurses when encountering angry patients

Several measures were taken to enhance reliability andvalidity of this qualitative study (Younge& Stewin 1988)To ensure accuracy, only nurses who could recall at leastone fairly recent encounter with an angry patient wereinterview ed Participa nts were chosen from different set-tings to broaden tbe context and enricb tbe data Tbeywere allowed to descnbe tbeir own reality m tbeir ownwords to minim ize researcber mfiuence Tbe interviewswere taped and transcribed verbatim to ensure accuracy

Participants were nine female registered nurse s wb o vol-unteered from two small community hospitals m NovaScotia, Ganada Tbey ranged m age from 20 to 45 yearsand bad practised for between 1 5 and 21 years, mainly mmedical-surgical settings m tbeir local comm unities All

were prepared at tbe diploma level except forbaccalaureate

FINDINGS AND ANALYSIS

Encountermg intensely angry patients sym bolized a ptially tbreatenmg event for all nurses m tbe sHowever, tbe intensity of tbe expenence vaned accoto tbe individu al m terpretation given to tbe patien t's and to tbe nurse's appraised ability to managesituabon

Tbe core vanable emerging from tbe data was m ananger tbreats, and tbis descnbes bow female nufelt and responded as tbe recipients of intense paanger (see Figure 1) Managing anger tb reats invominim izing tbe threat of tbe patient's anger to one's ovsense of well-bemg Managing tbe threat was viewe

Figure 1 Managing anger threatsby raising self-efficacy

Encountenng angry patients

I

Appraising situation

More threatening event Less threatening event

- personalizing anger

- lacking understanding

losing emotional control

- non-personalizing anger

- holistic understanding

- taking charge of own anger

Diminished self-efficacy

I

DISCONNECTING< =

Maintained self-efficacy

I

I

= >

I

CONNECTING

Strategies reusing self-efficacy

- shielding, taking Ume out

- transfemng t>lame rehearsing

- seeking peer support smoothing

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Nurses' respoases to patumt anga

rocess related and contained vanous stages and turningoints within one interaction sequence and over tuneGaining mastery in managing angry patient situationsas difficult The nurs es in this study noted that encoun-ni^ angry patients was generally uncommon m their

ettings The exp erience of confronting angry patientsnded to throw nurses off-balance by its unexpected

ature and because of the multiple ways patients

xpressed their anger

Managing anger

Managing anger situations involved making choices aboute best course of action based on the level of perceivedlf-efficacy (Band ura 1982) For mo st nurses, encoun-ring angry patients tended to cause emotional arousalhich interfered w ith their cognitive ability to process theatient's angry message and to respond m a professionalanner On ly w hen self-efficacy w as perceived as

dequate for that given situation did nurses tend to move

wards helping the angry patient (connecting) Ifself-ficacy w as appra ised as low, nurses tended to move awayom the angry patien t (disconnecting) Thu s, the wayurses lmtially appraised and managed anger threats fellto two basic patterns disconnec ting and connectingThe categories were not static, dichotomous states butther on a con tinuu m The two patterns will be described

nd analysed separately Following this, the factors thatad to nurses moving from one pattern to the other will described and analysed m terms of the core variable of

ow nurses 'mmage' patient angerIn this study , the incidenc e of connecting w ith the angrytient was the least common of the two patterns Theility to connect seem ed to be contingent on such factorsexperience, interp retation of the patie nt's angry messaged the nurse's emotional response to being a recipient ofrtain types of anger Thu s, the pnm ary focus of thisper will be to describe the process of disconnecting Thisll be followed by a description of the contrasts m thennecting pattern

HE DISCONNECTING PATTERN

sconnecting is presented first for two reasons it was theost common initial reaction to being the recipient of atient's anger, and all the nurses m the study revealedmg through a disconnectmg process at some pomt meir nursing career Thu s, the predominant movement one continuum seemed to he from disconnectmg tonnectingDisconnecting describes the lack of ability to associateentally, emotionally and physically with the angrytient A disconnecting response occurred when thetient's anger was appraised as a threatening event andrsonalized to m ean an attack on the nurse 's level of com-

petency or personal integrity The threat intensified asthenurse recognized her feelings interfered vn th her abih ty toimm ediately manage the situation Th us, the threatmcluded not only what the angry patient said or did but.more importantly, the threat arose from the nurse 's feelmgsof madequacy or lowered self-efficacy

RESPONSES LOWERING NURSES'SELF-EFFICACY

Specific attn butes of angry messages and the angry patien t,and the nurses own cogmtive and emotional responses topatient anger, tended to diminish the nurse's perceivedlevel of self-efficacy Com mon resp onses to anger per-ceived as threatening were to personahze the angry mess-age, to lack understanding and to lose emotional control

Personalizing angry m essages

Examples of angry statemen ts or t)ehaviours considered aspersonal mcluded insults, 'she would call us names callus "whores" and other very bad names and I felt verydegraded, and sarcasm, a patient replied to the nurse'squestion, 'Are you alleigic to any medication?' with 'Yes,I'm allergic to pain', stated m a very 'nasty ton e'' Foranother nurse, the mc ident m volved casting doubt on thenurse 's credibility, 'I was giving out medication s and beingquestioned continuously by this male patient'

The tone or mtensity of angry messages increased thepersonalizmg effect of the event As one nurse stated, 'itwas the way she said it' Terms descnbm g the toneincluded bemg sarcastic, belligerent, degrading auid loudThus, anger was felt to be inappropriate when it wasdirected at the nurse's m t^ n ty

Certain attnbute s of angry patients increased th e percep -tion of a threat to the nurs e's mte gnty Threatenin gpatients were defined as mentally alert, often more wellthan ill, and challenging the nurse 's control of patien t careLabels given to describe this cat^ory of patients were'difficult', 'uncooperative', 'ungrateful', 'disrespectful','unap precia tive' and 'dem and mg ' Negative labelling ofcertain types of patients is comparable to Podrasky &Sexton's (1988) findings that nurses tend to respond to

difficult patients with emger and frustrationLess threatening angry patients tended to be the con-fused an d the very ill Confused angry patients were seenas the mam typie of patient presenting a threat to thenurse's physical well-being, however, nurses were clear mpointing out that confused patients were more frustratingthan threatening even when acting aggressively towardsthe nurse One nurse claimed that she could accept theiraggressive behaviour b>ecause, 'you don 't kno w h ow m uchthey really know they are being that way'

Seriously lU patients w ere given a wider scope of accept-able mo des for anger expression The nur ses generally

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believed the state of illness gave patients the n ^ t to beangry One nurse explained

You are more sympathetic the patient is sick' You don't get soangry or hurt by It It's hke it's theu' excuse they are allowedto be angry, they are having a bad tune*

The legitimization of angry behaviour from senously illpatients and the dimmished mental capacity of certam

patients helped nurses to intellectually explain thepatient's behaviour and comments as separate from thenurs e's self-worth That is, they could explain to them-selves that these patients could not control their behav-iour, thus decreasing the nur se's perce ption of a self-threat

Lacking understanding

Canng for the threatenmg tjrpe of angry patient seem ed toalter the nurses's ahihty to understand the patient's reahtyand was met with resentment hy some nurses One nursestated, 'he was here for us to serve him and to do what hewanted when he could fully well have heen home', indi-cating that this type of patient did not belong m the acutecare settmg Whe n these patients questioned differentaspe cts of their care or refused care, som e nurs es felt friis-trated, threatened and angry A possible explanation forthese feelmgs is that the nurse's self-worth m the acutecare setting is closely tied to controlling the physicalaspects of care

Interestmgly, all the nurses supported the patient's nghtto express anger and helieved that anger expressionhad some positive outcomes This lends supp ort toRothenhurg's (1971) Novaco's (1976) and Avenll's (1982)conten tions that anger has positive functions However,most nurses placed conditions on the appropnateness ofcertain anger expression mo des over others One nurs estated, 'they can talk to me about it, they can even raisetheir voice as long as they talk about it and if it's not atm e' Another nurse stated, 'they certamly have the nghthut don't take it out on the nurse'

Losing emo tional control

The attnbutes of the patient's angry message seemed to

affect the degree and types of emobonal arousal expen-enced by nurses when encountermg angry patientsAccording to Bandura (1982), the higher the emotionalarous al, the lower the perceiv ed level of self-efficacy Inthis study, the participants reported a wide range ofemotional arousal and loss of personal control

Feeling shockedThe unexp ected natu re ofthe p atien t's anger created a stateof shock and confusion of var5ang degrees and a sense ofhemg off-balance A vanety of word s were used to descn hethis state of confusion and imbalanc e, such as 'it took me

totally off guard', 'I was shocked and set back', and are at a lc^s'

Shock was expenenced as a physical and emotiresponse One nurse descnhed her physical responfeehng 'swea ty, fiustered, red in the face I know I tublood red I can remember my heart pou nding ' Anonurs e said she remembered feeling 'hy per ' Like, you kyour adrenaline gets going and your heart starts be

faster'Feelmgs of fear and an xiety seemed to make the situ

overwhelming and beyond the scope of their appraahihty One nurse declared

Whe n you are in that situation, even if you could thm k of itwhe n you're there your level of stress is going higher and things don't come or pop into your head like they should

Feeling attackedEmotional arousal was enhanced when the event mterpreted as a personal attack Most of the nu

interpretations of the patient's anger contained 'atphra ses, md icating they felt persona lly attacked Examincluded 'she just blew up at me', 'she was throwmg oat me ', and 'she wanted to get at me' Feelmg attainterfered with the ability to respond and seemed trelated to feelmg shocked and off-balanced

Feehng blameAn outcome of feelmg attacked w as to also feel a senhlame or guilt Assum ing some personal respo nsihihtthe patient's anger tended to make the situation mthreatenm g One nurse stated, 'it [my confidence] just totally dow n because I didn't un derstand w hatI had donAnother nurse wondered, 'maybe it was something I olooked, mayhe it is something that has heen there fwhile and she was trymg to tell me ' Assuming blseemed to anse from the nurses' interpretation of the ation as their stones contamed no evidence of validathe cause of the anger with the patient

Feeling powerlessFeelmg shocked, uncertam, attacked, and at faultincreased feelmgs of pow erlessness The degree of po

lessness was apparent m statements mdicatmg thattj^e of situation was beyond the scope of the nuabihty and role respons ibilities One claimed, 'we 'repsy chia tnsts, we're just nu rse s'' Ano ther nurse bielie'except for psych nurses, noliody knows and nohody able to cope with wha t they might hear and then whayou say' '

Powerlessness also arose frism the realization thaprofession had not prepared them with acceptable optFeelings of fear, uncertamty and powerlessness seemehe related to a struggle between tw o opposing beliefsthe one hand, as mdividuals, nurses believed that

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Nurses' responses to pahent aagw

should be able to protect themselv^ against unjust angerattacks, on the other hand, as 'good nurses', they shouldbe able to control their emotions and help patients whoare angry even wh en they perceived the anger was directedat them

Feeling angryThe feelmg of anger was the most common outcome of

bemg the recipient of certain types of patient anger andeemed to arise as an autom atic response to feelmg threat-

ened and po werless Nurses seemed to become angry whenhey felt unfairly treated, unjustly accused, blocked m task

completion, and when they expenenced fear, anxiety andrustration related to feelings of mefficacy

Many of the nurses who disconnected seemed to fearhe power of their own anger and the possible negative

outcomes if this anger wen t unchecke d In Campbell &Muncer's (1987) study of women's social talk about anger,hey found that women frequently made reference to fear-

mg the power of their own anger and the damage angerxpression wou ld have on the relationship Inherent inhis belief, and in the findmgs of the nurses who discon-ected, IS that the se wo men held n egative beliefs aboutheir own anger exp ression

Hiding angerAll nurses wh o disco nnected adm itted to feelings of angerTheir struggle involved holdmg back their own anger andmain taining a 'professional' standard of cond uct One

urse professed, 'I've never, never talked or screamed backt a patient, but I felt like it, a good many times''

The common factor, with the exception of one nurse,was that all admitted to freely expressing their anger out-ide the work setting The comm on fear seemed to be thathis propensity for anger expression might surface andause damage to the nurse's image and the nurse-patientelations hip One nu rse descn bed the difference for her

t hom e, you feel different If you do n't think you deserved it,ou can react differently because you can get mad at each othert work , you have to be able to behave more professionally Ihink you treat the patient as the important person an d you don'to anythin g to upse t them you have to be careful because youon't v\rant to hurt their feelings so sometimes you put up vnth at more than you would with your family

howing angerllowing oneself to make an angry response seemed torovide a temporary protective shield around the nurse'sroding self-esteem How ever, showing anger had a para-ox ical effect on self-efficacy and self-esteem Nurses whoecame angry in order to get through a threatening situ-ion, tended to expenence shame and guilt for 'losmg

heir cool' and thus expenenced frirther erosion to then-elf-esteem As one nurse declared, showing ai^e r 'makes

you feel good for a m inu te, that's all It mak es the situatio nworse and they don't want you near them'

N U R S E S ' S T R AT E G I E S F O R M I N I M I Z I N GSELF-EFFICACY THREATS

To mmimize anger threats and to raise the level of per-ceived self-efficacy, the nurses m the disconnecting pat-

tern used such nu rse-focused strategies as shieldin g, takingtimeout, transferring blam e, seeking peer sup port, rehears-mg and returning to smooth over the anger All these stra-tegies are seen to promote disconnectii^ from the angrypatient and tend to mvolve measures to reheve the nu rse'sown stress These findmgs lend support to d u c k 's (1981)study mdicating that nurses most often respond to angrypatient situations by protecting themselves rather thanassisting the patient to reduce stress

Shielding

Shieldmg strategies were initial attempts to protect thenurse from the perceived harm and to conceal the n urse'semotional arousal and dimin ished self-efficacy Shieldingstrategies tended, however, to aggravate the situation andled to a complete breakdown in com mun ication In allcases, the underlying reason for the patient's anger wasnot addressed by the nurses who responded bydisconnecting

Specially significant strategies were keeping cool anddefending Keeping cool was a strategy used to give theimpression that the nurse was not feeling angry nor affec-

ted by the patie nt's anger Keeping cool seemed to be ahighly valued and important component of maintainingprofessional composure as most of the nurses seemed tostnve for achievement of this unaffected state

To protect self-esteem, most nurses wh o emotion ally dis-connected from the angry patient resorted to some form ofdefensive or protective strategy Learning to defend oneselfagamst an angry patient was seen by some as importantfor survival m the profession One nurse believed thatnot standing up for yourself lowered self-esteem Shedescnbed her feelings w hen she stood up to a patient whowas angry and ru de to her 'It mad e me feel goo d' Because

I didn 't feel like always the on e that was at blam e, at faultAnd I didn't feel guilty' These findmgs lend sup port tothe energizing functions of anger as identified by Novaco(1976) How ever, Gibb (1982) con tends that defensivebehaviour tends to create defensive postures in others

Taking timeout

Timeout was desc nbed as a 'cooling off p eno d' or a 'calm-ing down tune' and accounts for the penod of time thenurse physically disconnected from the patient The mamreasons nurses gave for leaving mc luded a need to escape

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the patient's anger, to prevent further harm to the nurse'sself-esteem, to seek a safe environment for releasu^emotional tension, to sort out and deal with the nurse'sfeelings and to seek emotional sup port Th us, leaving wasconsidered the most effective action to take whe n th e situ-ation became unmanageable and more threatening

Most nurses descnbed a common pattern m leaving thesituation One nurse declared, 'I usually walk away and

then after a while I think about w hat I have do ne and thenyou have to go back and correct it' Another nu rse replied ,'I did n't kn ow h ow to han dle it so I just sort of walked o utof the room'

Withdrawing, distancing or leaving the situation is acommon response to anger and is referred to hy manyauthors and researchers (Moritz 1978, Flaskemdet al1979, Duldt 1982, Lemer 198 5, Tavris, 1989) How ever,leaving an angry patient may instill feelings of guilt andfailure in some, as nurses are 'supposed' to help patientsdeal with angry feelings

TVansferring bla m e

A common strategy for minimizing anger threats to selfwas transferring blam e Blaming involved finding an exter-na l cau se for feelings of low self-efficacy Ac cord ing toShaver's (1985) theory on the attnbution of blame, 'nega-tive events demand explanation, a demand frequentlysatisfied by finding someone who is answerable for theoccurrence'

In this study, blaming involved blaming the patient,blaming the workplace and blaming the nursing pro-fession, and IS closely related to the feelings of anger an dpowerlessness described previously Blaming offered asocial explanation for why the event had become unman-ageable One nurse stated, 'I don't know if they have angh t to come out and blow up at me They should havediscussed it before it got to the point of full blown anger'

Blammg the workplace weis related to the lack of timeavailable for managing angry patients and to differentaspects of the setting which increased the likelihood ofnurses being the recipients of misplaced anger One nu rsestated, 'It's kind of hard to deal with because we are sobusy the workload' We don't have time' It's hard to

find time when you have 28 patients to set up and feed''Many nurses who disconnected viewed themselves as

'scapegoats' for patient anger meant for the doctor Onenurse declared

It's usually when they are mad at the doctor for something he isdoing and they won't say an5rthing to him but they will say it allto us and there is really nothing we can do

Some nurses blamed the nursing profession for inad-equate preparation to deal with the reality of the workplaceand for instilling high expectations and values withoutgiving them the necessary skills to achieve or upho ld the se

expectations Discovering that they actually did get with certain t3rpes of patie nts left some n urs es feelingviilnerable and devalued One nurse said

You are not taught how to deal with it [anger] I think you juhave to take it and ignore it and you are supposed to act prfessional I had a job to do and I had to ignore myself,feelings had no part in it, only hers'

Seeking peer support

Some nurses expenence d an imm ediate need to seeksupp ort upon leaving the situation One nurse recalljust wan ted to go say to another nurs e, "I've got to telwhat happened" ' '

Talking to others had positive consequences suchelp ing to relieve feelings of guilt and self-blame nurse explained, 'it made me feel a little bit better amyself And th at I was not the guilty one, that it procould have happened to anyone'

Rehearsing

A strategy for preparing to return to the angry patientrehearsing Most claimed that time away from the pahelped to calm their feelings, to think more rationallregain their professional composure, and to decide different app roach Also, most nurses believed timhad allowed the patient to calm down as well, returning tended to be a less threatening event compwith their previous interaction

Nurses described how they mcreased their feelingself-efficacy by mentally preparing themselves for theencounter One nurseSud, 'I 'm alw ays going through lspeeches I'll run through different points that I wabring up in my head before going into the room'

Returning to smooth

Smoothing was also a strategy to connect at some with the patient Discussion of the angry mcide nt wasby most nurses as potentially harmful to the relationand to the nurse 's self-esteem Smoothing was see

decrease the probability of the patient's anger returwith the same intensity One nurse descnbe d how shesented herself as a 'nice nurse' to win over a very apatient

You try to do anything to make them feel betterto offset the ansuch as something nice You tell them they look nice, take to the bathroom or give thema back rub or do something to mthem feel that, 'Gee, she is trying to be n ice to me '

Many behev ed that avoidm g the anger topic was theapproa ch for repairing the distance betwee n them nurse recalled her approa ch to smoo thmg 'I walked i

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if nothm g had ever happened and started asking her ho wshe felt' Avo iding the anger topicis opposite to Avenll's(1982) findmgs that women often talk over the anger mci-dent with th e instigator, suggesting that perhap s somethingIS occumng in the cluu cal setting to prevent this outcomeThese findings may suggest that mterpersonal relation-ships between patientsand nurses may not be as close asthe nursing hterature im plies Feelmg cool towardsthe

angry patient lends support to Duldt's (1982) findings thatnurses, more than non-nurses, report becoming cool,dis-tant and mistrustful and tend to engage m alienatingbehaviours towards the angry person

From the nurses' perspective, smoothing tendedto he avery effective strategy for regaining control of the relation-ship and w as deemed successfulif anger did not enter therelationship again Discussionof the anger was not neces-sary for closure ofthe incident,in fact, the opposite w ouldseem true Only one nur se disclosed talking to the patientabout the anger This outcome occurred whenthe patientapologized first to the nurse

Smoothing sometimes had negative consequences fornurses, whether the tactics worked in suppressing theimmediate anger threat or not Over time, smoothingtended to be very stressful to maintain Maintaining situ-ational control tended to have a paradoxical effect on theability to preserve self-esteem and to feel efficaciousInstead of the patient showing anger, nurses often becameangry when they felt forced to resort to this method Onenurse stated, 'I feel like a maid just so that they don'tget ang ry''

T HE C O N N E C T I N G PAT T E R N

According to this study, connecting seemed to occur asnurses geuned more experience with angerin generalandlearned throu gh expen ence that taking charge of one's ownangry feelmgs and responses was more rewarding and lessstressful tha n sho wing anger or letting anger control them

Connecting means the abihty to associate mentally,physically and emotionally with the angry patient A con-necting response tended to occur when the patient's angerwas appraised as somewhat threatening hut manageableAlthough all the nursesm this study descnbed encounters

with intensely angry patients,the stories of three of themost expenenced nurses contained elementsof how theywere leaming to master the threat of being the recipient ofntense anger

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slide', 'letting it fly over my should', 'don't let it botherme ', and 'letting it pas s' These findmgs lend sup port tothe contentions made by Lemer (1985), Spielbergeret al(1988), Tavns (1989) and Wilting (1990) that controlhnganger expression, or m this case, takmg charge of one'sown anger, is very important for mamtaining lnterpiersonalrelatio nsh ips, raising self-efficacy, and p rom oting piersonalwell-being

All the nurses m the connecting group reported thattheir ability to handle patient anger had improved withexperience and some in the disconnecting group observedthat more expenenced nurses seemed to have learned tohand le patient anger more easily and effectively than theydid There seemed to be a t)elief in both groups that mo reeffective responses to patient anger, or mcreasedself-efficacy, could be developed by nurses over time given asupportive professional environment

D I S C U S S I O N

The findmgs of this study suggest that anger is a multi-dimens ional and complex conce pt However, comm onali-ties were noted in the type of expressions identified as'anger' by the participants, such as the tone and mtensityThese findings are similar to those found by Ave nll (1982)and referred to by Lemer (1985) and Tavris (1989) ascommon mdicators of anger m others

The type of patient exp ressmg anger and causing degreesof anger m the n urse recip ient w ere also similar, suggestingthat certain charactenstics of patients may provoke angerin the recipient This lend s support to Podrasky& Sexton's(1988) findings that nurses tend to react to 'difficult'patie nts with anger an d frustration Tavris (1989) recog-mze s that some people are more difficult to deal with anddevotes several pages m her book to contending with 'thedifficult pers on ' The significance to nurs ing is findmg outif the characteristics of difficult persons vary by thecontext

The type of emotions aroused by being the recipient ofpatient anger were also similar, however, the degree ofemotional arousal and the method chosen to manage theseemotions varied among the participants How nurses man-aged being the recipients of patient anger de mon strates the

multi-dimensionahty of anger

Meaning

The meaning given to the patient's anger exposed thenurse's implicit theory about anger and its expressionNurses who interpreted the anger as a personal attacktended to view the function of the patient's anger differ-ently from nurses who mterpreted the anger as thepatient's exp ression of fear and anxiety However, itshould be noted that both the connecting and discon-nectmg nurses tended to view the p aben t's expression of

anger negatively For the comiectmg nurs es, angerseen as an emotion which could have negative rcussions for the patient, that is, by expressmg anger tnurses, they nsked bemg labelled and treated as'difficult' patient Nurses wh o disconn ected m terpthe patient's angry message as a personal mtegnty atherefore definmg the situation as negative

The findmgs of this study mdicate, as Spielberger

(1988) and Ta vn s (1989) suggest, that the conte xt is a mdeterminant to how people respond as the recipienanger The nurses' stones md icated that their responanger as a spouse, pa rent, lover or friend was very diffto their respon se as a 'nurs e' Professional sociahzhad taught them that 'good nurses' do not get angpatients or, if they do, they are 'supposed' to withtheir anger expression Some nurses were t)etter eqmto negotiate the bndge t)etween the 'pnvate' responsethe 'professional' respon se, leading to minimal conFor others, their pnvate response spilled over into professional dom ain, causmg feelings ofguilt, shame, fe

anxiety and anger Tun e and experience emergedimportant factors in learning successful managemenanger m the professional context

A trend

In comparing how nurses m anaged anger m different texts, an interesting trend was noted In the persona l text, sitting down and talking about the issue leadinthe anger was very important, thus supporting Ave(1982) findings that women usually talk over the inciwith the other party However, talking about the mc iwith the angry patient was often avoided in the pfessional context This study indicated that nurses odo not know how to respond m a manner which uphtheir perceptions of the expectations of the nursmg fession, therefore, disconnecting and smoothmg werepredommant responses

References

Avenll J R (1982) Anger and Aggression An E ssay on E motiSpringer-Verlag, New York.

Bandura A (1982) Self-efBcacy m echanism m hum an agencyAmerican Psychologist37, 122-147

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Nurse Response to Patient Anger