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

Nurses' responses to patient anger: from disconnecting to connecting

MarthaE Smith MNRN
Assistant Director, Yarmouth School of Nursing, Yarmouth, Nova Scotia

and Geraldme Hart MSN RN

Associate Professor, Dalhousie University, School of Nursing, Halifax, Nova Scotia, Canada

Accepted for publication 14 January 1994

SMITH ME &HARTG (1994) Journal of Advanced Nursmg 20, 643-651 Nurses' 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 the recipients of patient anger The data were collected by interviewing nine female registered nurses m two hospitals in south-western Nova Scotia The participants were asked to discuss their feelings and responses to an intense encounter writh an angry patient Anger was defined as a multi-dimensional concept with negative cogitations The concept of self-efficacy emerged as the major area of concern for the participants The findings suggest that when the threat to self was high, nurses managed anger situations by disconnecting from the angry patient Low or controllable threats were generally managed by connecting with the angry patient

PURPOSE OF THE STUDY

METHODOLOGY

The purpose of this study was to explore how female Grounded theory, developed hy Glaser & Strauss (1967), nurses define anger and to explore female nurses' percep- was chosen as the most appropnate research design tions of their responses as recipients of patient anger, because ofthe lack of existing theory to explain and predict including the meanings and feelings they relate to these how nurses define and respond to patient anger This approach, used in a nursing context, is a particularly responses Accordmg to Duldt (1982), nurses have a 50-50 chance useful research method to generate knowledge m a field of encountermg angry expressions from other health care of study where limited mformation is known (Stem 1980, workers and patients, and from patients' families, dunng Chenitz & Swanson 1986) the course of a work week Due to its powerful force, The qualitative research design of grounded theory is expressed and unexpressed anger can be very upsettmg to both a theory and a highly systematic method of collectmg, both the angry person and the recipient AveriU's (1982) organizing and analysing data The information was colstudies suggest that the actual response is hased on lected hy mtervievsrmg participants usmg an open ended umquely mdividual charactenstics, such as past expen- question format The participants were asked at>out their ences, level of frustration, perceived threat, level of self- expenences with anger, hoth m the nursing context and confidence and the presence of other emotions personal context, in order to study the sociai and psychoSeveral conceptual and theoretical frameworks exist on logical phenomena afifecting their tjehaviour The ultimate anger, however, these frameworks have not been validated purpose was to generate a theory which descnhes, explains for use m nursing No known studies could he found which or predicts this Ijehavioux m the nursing context The initial mterviews were analysed to form tentative exammed the apphcation of these theones to the nurses' codes and categones which guided subsequent data response as a recipient of patient anger
643

ME Smith and G Hart collection Using constant comparative analysis, concepts were prepared at tbe diploma level except for one eventually emerged encompassing the behavioural pro- baccalaureate cesses used by nurses when encountering angry patients Several measures were taken to enhance reliability and FINDINGS AND ANALYSIS validity of this qualitative study (Younge & Stewin 1988) To ensure accuracy, only nurses who could recall at least Encountermg intensely angry patients symbolized a potenone fairly recent encounter with an angry patient were tially tbreatenmg event for all nurses m tbe study interviewed Participants were chosen from different set- However, tbe intensity of tbe expenence vaned accordmg tings to broaden tbe context and enricb tbe data Tbey to tbe individual mterpretation given to tbe patient's anger were allowed to descnbe tbeir own reality m tbeir own and to tbe nurse's appraised ability to manage tbe words to minimize researcber mfiuence Tbe interviews situabon were taped and transcribed verbatim to ensure accuracy Tbe core vanable emerging from tbe data was managing Participants were nine female registered nurses wbo vol- anger tbreats, and tbis descnbes bow female nurses unteered from two small community hospitals m Nova felt and responded as tbe recipients of intense patient Scotia, Ganada Tbey ranged m age from 20 to 45 years anger (see Figure 1) Managing anger tbreats involved and bad practised for between 1 5 and 21 years, mainly m minimizing tbe threat of tbe patient's anger to one's overall medical-surgical settings m tbeir local communities All sense of well-bemg Managing tbe threat was viewed as

Figure 1 Managing anger threats by 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

Maintained self-efficacy

I I

I
DISCONNECTING <=

=>

CONNECTING

Strategies reusing self-efficacy - shielding, taking Ume out - transfemng t>lame rehearsing - seeking peer support smoothing

644

Nurses' respoases to patumt anga process related and contained vanous stages and turning points within one interaction sequence and over tune Gaining mastery in managing angry patient situations was difficult The nurses in this study noted that encounteni^ angry patients was generally uncommon m their settings The experience of confronting angry patients tended to throw nurses off-balance by its unexpected nature and because of the multiple ways patients expressed their anger Managing anger Managing anger situations involved making choices about the best course of action based on the level of perceived self-efficacy (Bandura 1982) For most nurses, encountering angry patients tended to cause emotional arousal which interfered with their cognitive ability to process the patient's angry message and to respond m a professional manner Only when self-efficacy was perceived as adequate for that given situation did nurses tend to move towards helping the angry patient (connecting) If selfefficacy was appraised as low, nurses tended to move away from the angry patient (disconnecting) Thus, the way nurses lmtially appraised and managed anger threats fell into two basic patterns disconnecting and connecting The categories were not static, dichotomous states but rather on a continuum The two patterns will be described and analysed separately Following this, the factors that lead to nurses moving from one pattern to the other will be described and analysed m terms of the core variable of how nurses 'mmage' patient anger In this study, the incidence of connecting with the angry patient was the least common of the two patterns The ability to connect seemed to be contingent on such factors as experience, interpretation of the patient's angry message and the nurse's emotional response to being a recipient of certain types of anger Thus, the pnmary focus of this paper will be to describe the process of disconnecting This will be followed by a description of the contrasts m the connecting pattern petency or personal integrity The threat intensified as the nurse recognized her feelings interfered vnth her abihty to immediately manage the situation Thus, the threat mcluded not only what the angry patient said or did but. more importantly, the threat arose from the nurse's feelmgs of madequacy or lowered self-efficacy

RESPONSES LOWERING NURSES' SELF-EFFICACY

Specific attnbutes of angry messages and the angry patient, and the nurses own cogmtive and emotional responses to patient anger, tended to diminish the nurse's perceived level of self-efficacy Common responses to anger perceived as threatening were to personahze the angry message, to lack understanding and to lose emotional control

Personalizing angry messages

Examples of angry statements or t)ehaviours considered as personal mcluded insults, 'she would call us names call us "whores" and other very bad names and I felt very degraded, and sarcasm, a patient replied to the nurse's question, 'Are you alleigic to any medication?' with 'Yes, I'm allergic to pain', stated m a very 'nasty tone'' For another nurse, the mcident mvolved casting doubt on the nurse's credibility, 'I was giving out medications and being questioned continuously by this male patient' The tone or mtensity of angry messages increased the personalizmg effect of the event As one nurse stated, 'it was the way she said it' Terms descnbmg the tone included bemg sarcastic, belligerent, degrading auid loud Thus, anger was felt to be inappropriate when it was directed at the nurse's mt^nty Certain attnbutes of angry patients increased the perception of a threat to the nurse's mtegnty Threatening patients were defined as mentally alert, often more well than ill, and challenging the nurse's control of patient care Labels given to describe this cat^ory of patients were 'difficult', 'uncooperative', 'ungrateful', 'disrespectful', 'unappreciative' and 'demandmg' Negative labelling of certain types of patients is comparable to Podrasky & Sexton's (1988) findings that nurses tend to respond to difficult patients with emger and frustration Less threatening angry patients tended to be the confused and the very ill Confused angry patients were seen as the mam typie of patient presenting a threat to the nurse's physical well-being, however, nurses were clear m pointing out that confused patients were more frustrating than threatening even when acting aggressively towards the nurse One nurse claimed that she could accept their aggressive behaviour b>ecause, 'you don't know how much they really know they are being that way' Seriously lU patients were given a wider scope of acceptable modes for anger expression The nurses generally
645

THE DISCONNECTING PATTERN

Disconnecting is presented first for two reasons it was the most common initial reaction to being the recipient of a patient's anger, and all the nurses m the study revealed gomg through a disconnectmg process at some pomt m their nursing career Thus, the predominant movement on the continuum seemed to he from disconnectmg to connecting Disconnecting describes the lack of ability to associate mentally, emotionally and physically with the angry patient A disconnecting response occurred when the patient's anger was appraised as a threatening event and personalized to mean an attack on the nurse's level of com-

. South and G. Hart believed the state of illness gave patients the n ^ t to be angry One nurse explained totally off guard', 'I was shocked and set back', and 'you are at a lc^s' Shock was expenenced as a physical and emotional You are more sympathetic the patient is sick' You don't get so response One nurse descnhed her physical response as angry or hurt by It It's hke it's theu' excuse they are allowed feehng 'sweaty, fiustered, red in the face I know I turned to be angry, they are having a bad tune* blood red I can remember my heart pounding' Another The legitimization of angry behaviour from senously ill nurse said she remembered feeling 'hyper' Like, you know, patients and the dimmished mental capacity of certam your adrenaline gets going and your heart starts beatmg patients helped nurses to intellectually explain the faster' patient's behaviour and comments as separate from the Feelmgs of fear and anxiety seemed to make the situation nurse's self-worth That is, they could explain to them- overwhelming and beyond the scope of their appraised selves that these patients could not control their behav- ahihty One nurse declared iour, thus decreasing the nurse's perception of a self-threat
When you are in that situation, even if you could thmk of it now, when you're there your level of stress is going higher and the things don't come or pop into your head like they should

Lacking understanding Canng for the threatenmg tjrpe of angry patient seemed to alter the nurses's ahihty to understand the patient's reahty and was met with resentment hy some nurses One nurse stated, 'he was here for us to serve him and to do what he wanted when he could fully well have heen home', indicating that this type of patient did not belong m the acute care settmg When these patients questioned different aspects of their care or refused care, some nurses felt friistrated, threatened and angry A possible explanation for these feelmgs is that the nurse's self-worth m the acute care setting is closely tied to controlling the physical aspects of care Interestmgly, all the nurses supported the patient's nght to express anger and helieved that anger expression had some positive outcomes This lends support to Rothenhurg's (1971) Novaco's (1976) and Avenll's (1982) contentions that anger has positive functions However, most nurses placed conditions on the appropnateness of certain anger expression modes over others One nurse stated, 'they can talk to me about it, they can even raise their voice as long as they talk about it and if it's not at me' Another nurse stated, 'they certamly have the nght hut don't take it out on the nurse'

Feeling attacked
Emotional arousal was enhanced when the event was mterpreted as a personal attack Most of the nurses' interpretations of the patient's anger contained 'at me' phrases, mdicating they felt personally attacked Examples included 'she just blew up at me', 'she was throwmg orders at me', and 'she wanted to get at me' Feelmg attacked interfered with the ability to respond and seemed to be related to feelmg shocked and off-balanced

Feehng blame
An outcome of feelmg attacked was to also feel a sense of hlame or guilt Assuming some personal responsihihty for the patient's anger tended to make the situation more threatenmg One nurse stated, 'it [my confidence] just went totally down because I didn't understand what I had done' Another nurse wondered, 'maybe it was something I overlooked, mayhe it is something that has heen there for a while and she was trymg to tell me' Assuming blame seemed to anse from the nurses' interpretation of the situation as their stones contamed no evidence of validating the cause of the anger with the patient

Losing emotional control

The attnbutes of the patient's angry message seemed to affect the degree and types of emobonal arousal expenenced by nurses when encountermg angry patients According to Bandura (1982), the higher the emotional arousal, the lower the perceived level of self-efficacy In this study, the participants reported a wide range of emotional arousal and loss of personal control

Feeling powerless
Feelmg shocked, uncertam, attacked, and at fault all increased feelmgs of powerlessness The degree of powerlessness was apparent m statements mdicatmg that this tj^e of situation was beyond the scope of the nurse's abihty and role responsibilities One claimed, 'we're not psychiatnsts, we're just nurses'' Another nurse bielieved, 'except for psych nurses, noliody knows and nohody feels able to cope with what they might hear and then what do you say'' Powerlessness also arose frism the realization that the profession had not prepared them with acceptable options Feelings of fear, uncertamty and powerlessness seemed to he related to a struggle between two opposing beliefs on the one hand, as mdividuals, nurses believed that they

Feeling shocked
The unexpected nature ofthe patient's anger created a state of shock and confusion of var5ang degrees and a sense of hemg off-balance A vanety of words were used to descnhe this state of confusion and imbalance, such as 'it took me
646

Nurses' responses to pahent aagw should be able to protect themselv^ against unjust anger attacks, on the other hand, as 'good nurses', they should be able to control their emotions and help patients who are angry even when they perceived the anger was directed at them Feeling angry The feelmg of anger was the most common outcome of bemg the recipient of certain types of patient anger and seemed to arise as an automatic response to feelmg threatened and powerless Nurses seemed to become angry when they felt unfairly treated, unjustly accused, blocked m task completion, and when they expenenced fear, anxiety and frustration related to feelings of mefficacy Many of the nurses who disconnected seemed to fear the power of their own anger and the possible negative outcomes if this anger went unchecked In Campbell & Muncer's (1987) study of women's social talk about anger, they found that women frequently made reference to fearmg the power of their own anger and the damage anger expression would have on the relationship Inherent in this belief, and in the findmgs of the nurses who disconnected, IS that these women held negative beliefs about their own anger expression Hiding anger All nurses who disconnected admitted to feelings of anger Their struggle involved holdmg back their own anger and maintaining a 'professional' standard of conduct One nurse professed, 'I've never, never talked or screamed back at 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 outside the work setting The common fear seemed to be that this propensity for anger expression might surface and cause damage to the nurse's image and the nurse-patient relationship One nurse descnbed the difference for her
At home, you feel different If you don't think you deserved it, you can react differently because you can get mad at each other at work, you have to be able to behave more professionally I think you treat the patient as the important person and you don't do anything to upset them you have to be careful because you don't v\rant to hurt their feelings so sometimes you put up vnth a bit more than you would with your family

you feel good for a minute, that's all It makes the situation worse and they don't want you near them' NURSES' STRATEGIES FOR MINIMIZING SELF-EFFICACY THREATS To mmimize anger threats and to raise the level of perceived self-efficacy, the nurses m the disconnecting pattern used such nurse-focused strategies as shielding, taking timeout, transferring blame, seeking peer support, rehearsmg and returning to smooth over the anger All these strategies are seen to promote disconnectii^ from the angry patient and tend to mvolve measures to reheve the nurse's own stress These findmgs lend support to duck's (1981) study mdicating that nurses most often respond to angry patient situations by protecting themselves rather than assisting the patient to reduce stress Shielding Shieldmg strategies were initial attempts to protect the nurse from the perceived harm and to conceal the nurse's emotional arousal and diminished self-efficacy Shielding strategies tended, however, to aggravate the situation and led to a complete breakdown in communication In all cases, the underlying reason for the patient's anger was not addressed by the nurses who responded by disconnecting Specially significant strategies were keeping cool and defending Keeping cool was a strategy used to give the impression that the nurse was not feeling angry nor affected by the patient's anger Keeping cool seemed to be a highly valued and important component of maintaining professional composure as most of the nurses seemed to stnve for achievement of this unaffected state To protect self-esteem, most nurses who emotionally disconnected from the angry patient resorted to some form of defensive or protective strategy Learning to defend oneself agamst an angry patient was seen by some as important for survival m the profession One nurse believed that not standing up for yourself lowered self-esteem She descnbed her feelings when she stood up to a patient who was angry and rude to her 'It made me feel good' Because I didn't feel like always the one that was at blame, at fault And I didn't feel guilty' These findmgs lend support to the energizing functions of anger as identified by Novaco (1976) However, Gibb (1982) contends that defensive behaviour tends to create defensive postures in others Taking timeout Timeout was descnbed as a 'cooling off penod' or a 'calming down tune' and accounts for the penod of time the nurse physically disconnected from the patient The mam reasons nurses gave for leaving mcluded a need to escape
647

Showing anger Allowing oneself to make an angry response seemed to provide a temporary protective shield around the nurse's eroding self-esteem However, showing anger had a paradoxical effect on self-efficacy and self-esteem Nurses who became angry in order to get through a threatening situation, tended to expenence shame and guilt for 'losmg their cool' and thus expenenced frirther erosion to thenself-esteem As one nurse declared, showing ai^er 'makes

Smith and G Hart the patient's anger, to prevent further harm to the nurse's self-esteem, to seek a safe environment for releasu^ emotional tension, to sort out and deal with the nurse's feelings and to seek emotional support Thus, leaving was considered the most effective action to take when the situation became unmanageable and more threatening Most nurses descnbed a common pattern m leaving the situation One nurse declared, 'I usually walk away and then after a while I think about what I have done and then you have to go back and correct it' Another nurse replied, 'I didn't know how to handle it so I just sort of walked out of the room' Withdrawing, distancing or leaving the situation is a common response to anger and is referred to hy many authors and researchers (Moritz 1978, Flaskemd et al 1979, Duldt 1982, Lemer 1985, Tavris, 1989) However, leaving an angry patient may instill feelings of guilt and failure in some, as nurses are 'supposed' to help patients deal with angry feelings TVansferring blame A common strategy for minimizing anger threats to self was transferring blame Blaming involved finding an external cause for feelings of low self-efficacy According to Shaver's (1985) theory on the attnbution of blame, 'negative events demand explanation, a demand frequently satisfied by finding someone who is answerable for the occurrence' In this study, blaming involved blaming the patient, blaming the workplace and blaming the nursing profession, and IS closely related to the feelings of anger and powerlessness described previously Blaming offered a social explanation for why the event had become unmanageable One nurse stated, 'I don't know if they have a nght to come out and blow up at me They should have discussed it before it got to the point of full blown anger' Blammg the workplace weis related to the lack of time available for managing angry patients and to different aspects of the setting which increased the likelihood of nurses being the recipients of misplaced anger One nurse stated, 'It's kind of hard to deal with because we are so busy 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 One nurse declared It's usually when they are mad at the doctor for something he is doing and they won't say an5rthing to him but they will say it all to us and there is really nothing we can do Some nurses blamed the nursing profession for inadequate preparation to deal with the reality of the workplace and for instilling high expectations and values without giving them the necessary skills to achieve or uphold these
648

expectations Discovering that they actually did get angry with certain t3rpes of patients left some nurses feeling very viilnerable and devalued One nurse said
You are not taught how to deal with it [anger] I think you just have to take it and ignore it and you are supposed to act professional I had a job to do and I had to ignore myself, my feelings had no part in it, only hers'

Seeking peer support

Some nurses expenenced an immediate need to seek peer support upon leaving the situation One nurse recalled, 'I just wanted to go say to another nurse, "I've got to tell you what happened"'' Talking to others had positive consequences such as helping to relieve feelings of guilt and self-blame One nurse explained, 'it made me feel a little bit better about myself And that I was not the guilty one, that it probably could have happened to anyone'

Rehearsing
A strategy for preparing to return to the angry patient was rehearsing Most claimed that time away from the patient helped to calm their feelings, to think more rationally, to regain their professional composure, and to decide on a different approach Also, most nurses believed timeout had allowed the patient to calm down as well, thus returning tended to be a less threatening event compeired with their previous interaction Nurses described how they mcreased their feelings of self-efficacy by mentally preparing themselves for the next encounter One nurse Sud, 'I'm always going through little speeches I'll run through different points that I want to bring up in my head before going into the room'

Returning to smooth
Smoothing was also a strategy to connect at some level with the patient Discussion of the angry mcident was seen by most nurses as potentially harmful to the relationship and to the nurse's self-esteem Smoothing was seen to decrease the probability of the patient's anger returning with the same intensity One nurse descnbed how she presented herself as a 'nice nurse' to win over a very angry patient You try to do anything to make them feel better to offset the anger such as something nice You tell them they look nice, take them to the bathroom or give them a back rub or do something to make them feel that, 'Gee, she is trying to be nice to me' Many beheved that avoidmg the anger topic was the best approach for repairing the distance between them One nurse recalled her approach to smoothmg 'I walked in as

Nurses' response to patent anger

if nothmg had ever happened and started asking her how she felt' Avoiding the anger topic is opposite to Avenll's (1982) findmgs that women often talk over the anger mcident with the instigator, suggesting that perhaps something IS occumng in the cluucal setting to prevent this outcome These findings may suggest that mterpersonal relationships between patients and nurses may not be as close as the nursing hterature implies Feelmg cool towards the angry patient lends support to Duldt's (1982) findings that nurses, more than non-nurses, report becoming cool, distant and mistrustful and tend to engage m alienating behaviours towards the angry person From the nurses' perspective, smoothing tended to he a very effective strategy for regaining control of the relationship and was deemed successful if anger did not enter the relationship again Discussion of the anger was not necessary for closure ofthe incident, in fact, the opposite would seem true Only one nurse disclosed talking to the patient about the anger This outcome occurred when the patient apologized first to the nurse Smoothing sometimes had negative consequences for nurses, whether the tactics worked in suppressing the immediate anger threat or not Over time, smoothing tended to be very stressful to maintain Maintaining situational control tended to have a paradoxical effect on the ability to preserve self-esteem and to feel efficacious Instead of the patient showing anger, nurses often became angry when they felt forced to resort to this method One nurse stated, 'I feel like a maid just so that they don't get angry'' THE CONNECTING PATTERN According to this study, connecting seemed to occur as nurses geuned more experience with anger in general and learned through expenence that taking charge of one's own angry feelmgs and responses was more rewarding and less stressful than showing anger or letting anger control them Connecting means the abihty to associate mentally, physically and emotionally with the angry patient A connecting response tended to occur when the patient's anger was appraised as somewhat threatening hut manageable Although all the nurses m this study descnbed encounters with intensely angry patients, the stories of three of the most expenenced nurses contained elements of how they were leaming to master the threat of being the recipient of intense anger Nurses' strategies for niin<"i":ing anger threats The nurses m the connectmg group descnbed nurse and patient focused strategies for minimizing anger threats ind raismg self-efficacy Nurse-focused strategies mcluded non-personahzing anger and takmg charge of one's own anger

Non-personalizing anger
The nurses m the connecting group tended to shift their thinkmg to look for the underlying cause of the patient's anger rather than blaming the angry patient This did not mean anger sitiiations were easy to manage hut, with time and expenence, they learned not to take the patient's anger as a personal attack One nurse stated, 'Now, I tend to be more expenenced and I realize that maybe the patient is angry most likely not at me as a person, it's just the situation also you become more tolerant' By learning not to personalize the patient's anger nurses were hetter able to take charge of their own reactions as the recipient and thus were able to raise their level of perceived self-efficacy Holistic understanding of patient situation Connectmg also involved using patient focused strategies for minimizing anger threats to the patient's reality These strategies included detecting early signs of anger, explaining to prevent patient anxiety, and explonng feelings Experienced nurses were more likely to use their observation skills and their past experiences to recognize subtle changes in the patient's behaviour One nurse drew on her past expenences with cancer patients to recognize the potential for anger m a quiet, withdrawn cancer patient and took measures to intervene before the anger became overt Encouraging patients to talk atwut angry feelings depended, in part, on the degree of trust established between the nurse and the patient One nurse descnhed how a patient assessed her before disclosing that his anger was related to a delayed cancer diagnosis She stated, 'he just sort of looked at me as if he was asking himself, "Can I trust her''" ' Civing the patient a lead was viewed as important for facilitating open communication 'When I asked him how he felt about it [cancer], that's when it sort of started I gave him the opening and he took advantage of i t ' McKay et al (1986) noted a similar relationship between nurse empathy and patient trust and selfdisclosure

Taking charge of own anger

When connecting nurses expenenced feelings of frustration or anger in response to patient anger, taking charge methods, such as 'taking a deep breath and looking at something different for the moment' were usually effective One nurse claimed that feeling anger with patients was rare but if it occurred, 'I usually start countmg and leave the room and it only takes me a minute or two and I calm down and go hack' According to Tavns (1989), the classic 'count to ten' advice has survived for centimes and still remains an effective self-control strategy Under certain conditions, some nurses took charge of their anger by desensitizing self Common descnptive terms denoting this type of strategy included, 'letbng it
649

M Smith and G Hart slide', 'letting it fly over my should', 'don't let it bother me', and 'letting it pass' These findmgs lend support to the contentions made by Lemer (1985), Spielberger et al (1988), Tavns (1989) and Wilting (1990) that controlhng anger expression, or m this case, takmg charge of one's own anger, is very important for mamtaining lnterpiersonal relationships, raising self-efficacy, and promoting piersonal well-being All the nurses m the connecting group reported that their ability to handle patient anger had improved with experience and some in the disconnecting group observed that more expenenced nurses seemed to have learned to handle patient anger more easily and effectively than they did There seemed to be a t)elief in both groups that more effective responses to patient anger, or mcreased selfefficacy, could be developed by nurses over time given a supportive professional environment DISCUSSION The findmgs of this study suggest that anger is a multidimensional and complex concept However, commonalities were noted in the type of expressions identified as 'anger' by the participants, such as the tone and mtensity These findings are similar to those found by Avenll (1982) and referred to by Lemer (1985) and Tavris (1989) as common mdicators of anger m others The type of patient expressmg anger and causing degrees of anger m the nurse recipient were also similar, suggesting that certain charactenstics of patients may provoke anger in the recipient This lends support to Podrasky & Sexton's (1988) findings that nurses tend to react to 'difficult' patients with anger and frustration Tavris (1989) recogmzes that some people are more difficult to deal with and devotes several pages m her book to contending with 'the difficult person' The significance to nursing is findmg out if the characteristics of difficult persons vary by the context The type of emotions aroused by being the recipient of patient anger were also similar, however, the degree of emotional arousal and the method chosen to manage these emotions varied among the participants How nurses managed being the recipients of patient anger demonstrates the multi-dimensionahty of anger Meaning The meaning given to the patient's anger exposed the nurse's implicit theory about anger and its expression Nurses who interpreted the anger as a personal attack tended to view the function of the patient's anger differently from nurses who mterpreted the anger as the patient's expression of fear and anxiety However, it should be noted that both the connecting and disconnectmg nurses tended to view the pabent's expression of
650

anger negatively For the comiectmg nurses, anger was seen as an emotion which could have negative repercussions for the patient, that is, by expressmg anger to the nurses, they nsked bemg labelled and treated as the 'difficult' patient Nurses who disconnected mterpreted the patient's angry message as a personal mtegnty attack, therefore definmg the situation as negative The findmgs of this study mdicate, as Spielberger et al (1988) and Tavns (1989) suggest, that the context is a major determinant to how people respond as the recipients of anger The nurses' stones mdicated that their response to anger as a spouse, parent, lover or friend was very different to their response as a 'nurse' Professional sociahzation had taught them that 'good nurses' do not get angry at patients or, if they do, they are 'supposed' to withhold their anger expression Some nurses were t)etter eqmpped to negotiate the bndge t)etween the 'pnvate' response and the 'professional' response, leading to minimal confhct For others, their pnvate response spilled over into their professional domain, causmg feelings of guilt, shame, fear, anxiety and anger Tune and experience emerged as important factors in learning successful management of anger m the professional context A trend In comparing how nurses managed anger m different contexts, an interesting trend was noted In the personal context, sitting down and talking about the issue leading to the anger was very important, thus supporting Avenll's (1982) findings that women usually talk over the incident with the other party However, talking about the mcident with the angry patient was often avoided in the professional context This study indicated that nurses often do not know how to respond m a manner which upholds their perceptions of the expectations of the nursmg profession, therefore, disconnecting and smoothmg were the predommant responses References
Avenll J R (1982) Anger and Aggression An Essay on Emotion Springer-Verlag, New York. Bandura A (1982) Self-efBcacy mechanism m human agency American Psychologist 37, 122-147 Campbell A & Muncer S (1987) Models of anger and aggression m the social talk of women and men Journal for the Theory of Social Behaviour 17, 489-511 Caiemtz W C & Swanson J M (1986) From Practice to Grounded Theory Quahtative Research m Nursing Addison-Wesley, Menlo Park, California Duldt B (1982) Helping nurses to cope with the anger-dismay syndrome Nursing Outlook 30, 168-174 Flaskemd J H, Halloran E J, Lund M & Zetterland J (1979) Avoidance and distancing a descriptive view of nursmg Nursing Forum 18, 158-174

Nurses' responses to patient anfsr

GibbJ (1982) Defensive coimnumcation The Jaumal of Nursing Admuustratian 12(4), 14-17 Glaser B & Strauss A. (1967) The Discovery of Ground Theory Aldine, Chicago Gluck M (1981) Learning a therapeutic verbal response to anger Joumal of Psychiatnc Nursing and Mental Health Services 19(3), 9-12 Lemer H G (1985) The Dance af Anger Harper & Row, New York McKay R., Hughes J & Carver E (1986) Nurse empathy and pabent salf-disclosures m nurse-patient interactions Proceedings afthe Westem European Nurse Researchers Conference, Helsmh, Finland 2, 96-106 Montz D (1978) Understanding anger Amencan Jaumal af Nursing 78, 81-83 Novaco R (1976) The functions and r^ulaUon of the arousal of ai^er Amencan Jaumal of Psychiatry 133, 1124-1128 Podrasky D & Sexton D (1988) Nurses' reacUons to difficult patients Image 20,16-21 Rothenhuig A (1971) On anger Amencan foumal of Psychiatry 128,454-460 Shaver K.G {\^i)TheAttnbution of Blame Causality, Responsibility and Blameworthmess Spnn^t^Varlag, New Ywk. Spialberger C, Krasner S & Soloman E (1988) Hie expenence, expression and control of anger In Health Psychology Individual Differences and Stress (Jamsse M P ed ), SiwingeTVerl^, New York. StemPN (1980) Grounded theory m^odology its uses and processes linage 12(1), 20-23 Tavns C (1989) Anger The Misunderstood Emation Simon & Schuster, New York Wilting J (1990) Nurses, Colleagues, and PaUents Achieving Congenial Interpersonal Relatianships University of Alberta PTess, Alberta Younge O &StewmL (1988) Reliability and validity misnomers for qualitative research Canadian foumal af Nursing Research 20, 61-66

651