Key learning points:
– Nurses are increasingly likely to encounter angry patients in clinical settings
– Being able to recognise the signs that a patients’ anger might be escalating is important for comfort, safety and security
– Having the tools to diffuse anger before it escalates is essential
It is a commonly held belief that we are getting angrier as a nation; indeed, in 2008 the Mental Health Organisation launched a report called Boiling Point1 in which 64% of respondents claimed that people in general are getting angrier. The findings of this research make sobering reading; more than a quarter of people in the UK worry about how angry they sometimes feel, with one in ten of us admitting that we have trouble controlling our own anger. In fact, these self-report findings might be an underestimate, since the same study also showed that almost a third of people polled (32%) say they have a close friend or family member who has trouble controlling their anger. Clearly we are better at recognising it in others than in ourselves.
All of this means that nurses and nursing practitioners are increasingly likely to come across angry patients, so having the tools to manage this anger is important for today’s practitioner.
Why might patients get angry?
Via the anger management courses I deliver to nurses, doctors and other health professionals in the NHS across the UK, I have come up with a fairly comprehensive list of the reasons practitioners give for why patients might get angry (see Box 1). Some of these mean that patients are angry before you even get to see them, and many also reflect the high stress that patients are under. There are probably other reasons but Box 1 shows how widespread a problem patient anger can be. Many of these causes fit within a finite number of themes such as perceived injustice, thwarted goals, raised expectations or simply stress and anxiety. Raised expectations are produced partly by the 'customer/patient' charter culture that has mushroomed over the past decade. This is a charter for our 'rights' and leads us to have high expectations that we receive superlative service in all aspects of our life. When, as is inevitable, reality falls short of these expectations, we feel that we have the right to get angry about it. At the same time we have become more demanding as a nation, we are also living a more frenetic and frantic pace of life, which means our stress levels are raised. In 2012, hospital admissions in England for stress rose by 7% in 12 months2 and –according to the Mental Health Foundation – 59% of British adults say their life is more stressful than it was five years ago.3 In fact, almost half (47%) of all respondents revealed that they feel stressed every single day.3 This raised stress means that our tolerance for things going wrong is dramatically reduced. Nearly half of respondents in one survey claimed that being stressed led them to feeling irritable and short-tempered.3 Anger can also cause stress as they share similar patterns of physiological arousal too.
Signs and symptoms of the angry patient
While most of the time it will be obvious when a patient is annoyed, it is important to be alert to signs and symptoms that the anger might be escalating. No health practitioner enjoys dealing with angry patients – it is stressful and upsetting – but we should be mindful that patients, like anyone else, are entitled to get angry at times. It is how that anger is expressed that is key and preventing anger intensifying into fury, rage or aggression is paramount. Here are some red flags to watch out for when dealing with irate patients:
– Changes in body language –Most people would recognise a clenched fist as a sign of anger, but the key here is to watch for changes in body language rather than specific pointers. A patient who was previously very fidgety and suddenly becomes calm should raise as much alarm as the one who starts jabbing their finger or slamming their fist on the desk. Other signs that anger is escalating include a flushed face, trembling, sweating, exaggerated movements of their arms, clenched teeth and rapid breathing or breathlessness.
– Aggressive language –this includes the frequent use of accusation (you acted negligently), 'I' statements (I am very angry), use of threats (if you don’t do this I will…), the use of forceful words like must, should, will, ought etc (you will sort this out), opinions delivered as facts (this practice is the worse one in the area), and use of sarcasm or mockery.
– Signs of irrationality –very angry people often lose sight of reason and thus seem unable to comply with sensible requests or suggestions. If the patient seems not to be listening or unwilling to accept reasonable suggestions to solve the problem, then this could be a sign that their rage has taken them over the edge.
– A lack of other options –another possible precursor to rage is when a patient feels that they have nowhere else to go with their complaint. If they feel that there are no options left they may well be unable to control their fury as they have little left to lose.
– Perceived lack of sympathy with their situation –everyone wants to feel valued and understood, and patients who start to voice concerns in this direction (no one here seems to understand why I am so upset) should signify red flags with regards to possible escalation of anger.
How to manage patient anger
The key to managing patient anger in a clinical setting is to try to disrupt the anger response early on. It is easier to prevent someone flying into a rage than it is to diffuse that rage once it is there (especially given that very angry or emotional people are often beyond reason). Here are some useful techniques:
– Acknowledge that you understand both the problem and the emotion –it is often important to the patient that you recognise not just what has happened, but how it makes them feel. For example; "I understand that the appointment letter got lost in the post and that this might have made you feel that we don’t care about you" is far more effective than "yes, the letter clearly got lost in the post, that’s all."
– Be human –nurses and other health professionals must, for their own protection and for that of the patient, adopt some professional aloofness at times, but it is also important to show humanity when dealing with emotional patients. Show empathy, understanding and concern as a human.
– Show that you are doing all you can to help –patients get angry when they feel that the practitioner isn’t showing the level of care and concern that they feel is warranted. Things do go wrong but perceived lack of care and understanding from the nurse (often caused by time pressures) can exacerbate the situation.
– Appear to be on their side –related to the above, an angry patient can be calmed quite quickly by a nurse who appears
to be fighting with them rather than against them. It is hard
to remain angry with someone who seems to be working hard for you.
– Acknowledge imperfections of diagnosis, investigations, and treatment –the NHS is far from perfect and things do go wrong. Sometimes defensiveness on behalf of the nurse can inflame the fury whereas acknowledging the mistake can diffuse it. If appropriate, apologise – and if not appropriate, at least acknowledge the emotions that have arisen.
– Be assertive –diffusing anger is not the same as giving in to the demands of furious or aggressive patients. Sometimes patients demand things that are not in anyone’s interest to have, such as prescriptions or tests. It is important to remain assertive about this while trying to diffuse the anger (for example, "You might feel that we are not letting you have this treatment because we don’t care, but there are risks associated with having the treatment that we don’t feel are warranted…").
– Change the environment –if the patient’s anger is escalating, consider moving to an alterative space or room. This will allow them this opportunity to take a few moments to regroup while you settle somewhere else and it is harder to continue to be very angry when thinking about the logistics of moving (collecting bags, coats etc). A change of environment can also break the anger cycle that becomes associated with the place the anger started. Make sure, however, that you don’t relocate to a secluded area if you feel at risk.
– Make notes –this can have both the effect of convincing the patient that you are taking their concerns seriously (rather than dismissing them) and also that you are taking down evidence which might encourage some restraint on their part.
– Leave the situation –if all else fails and you feel in any way threatened, don’t be afraid to leave or summon support. This is especially important if you are dealing with psychotic or mentally ill patients who are volatile and unable to respond to your attempts at de-escalation.
In addition to the advice above, there are also some things that you should never do with an angry patient. Don’t use patronising language or tell them to "calm down"; this immediately puts you in parent mode and them in child mode, which is likely to cause them to act like a petulant, hot-tempered children rather than a calm, rational adult. Similarly, avoid saying things like: “You’re not going to get anywhere by shouting,” which is a parent-like command (though you could request that they lower their voice because it is disturbing other patients – this is an adult-like request). Avoid dead-end statements ("there is nothing more to be done"), aggressive hand actions (pointing, jabbing fingers) and confrontational posture (hands on hips or arms folded etc), and this will also help prevent the conflict from escalating.
The chronically angry or stressed patient
Some of the patients that you encounter may need more long-term interventions for their anger and stress. Such patients might be those who present with complaints that are caused or exacerbated by stress or chronic anger (eg, irritable bowel syndrome (IBS) or palpitations), those who fear that their anger may be, or indeed has been, a danger to themselves and others or those who have been urged to seek help by people around them (such as spouses or work colleagues). These patients might be seeking help because they either express anger inappropriately (eg, aggressively) and/or experience it too often (they get angry at the slightest provocation) and, as explained earlier, this is often tied in with high stress levels.
Given that there is likely to be some reluctance to seek help (only 6% of people consider visiting a GP or a medical professional for their stress-related issues3), when they do they should be treated with sensitivity and thoughtfulness. It is essential that their concerns are taken seriously. The range of options include NHS websites, self-help books, self-help programmes, Improving Access to Psychological Therapies (IAPT), community mental health nurses, counsellors, therapists (private or NHS), or group management programmes run either by the NHS if you are fortunate (and sadly, these are few and far between) or by some other agencies (private or voluntary sector). Some of these will need referral via the GP. Selecting between these options depends on the severity of the presenting problem and on the willingness of the patient to change. Suggesting self-help books to a patient who is at risk to others or themselves, for example, would be inappropriate (referral to specialist anger management input would be best there), But equally, trying to enrol a patient (who has lost their temper once in a clinic), into a six-week anger control programme might be just as inappropriate, especially if they are not receptive to the idea that they have a problem.
Nurses are increasingly likely to encounter angry and/or stressed patients in the clinical setting and it is essential that they have the skills to diffuse anger before it escalates.
It is important to recognise the signs of an angry patient and to select from the range of techniques that can be effective in disrupting the anger response.
Northumberland, Tyne and Wear NHS Foundation Trust’s self-help anger guide – ntw.nhs.uk/pic/leaflets/Controlling%20Anger%20A4%202015.pdf
NHS Newcastle and North Tyneside Community Health’s six week anger programme –
Mann S, Manage Your Anger. Hodder and Stoughton, 2013.
Newcastle Psychological Services. newcastlehealthyminds.nhs.uk/downloads/
HelpGuide.Org – helpguide.org/articles/stress/stress-management.htm
1. Richardson C, Halliwell E. Boiling Point: Problem anger and what we can do about it. Mental Health Foundation, 2008. angermanage.co.uk/pdfs/boilingpoint.pdf (accessed 29 February 2016).
2. NHS Choices. Sharp rise in hospital admissions for stress – 'recession to blame'.
nhs.uk/news/2012/09September/Pages/rise-in-hospital-admissions-for-stress.aspx (accessed 29 February 2016).
3. Mental Health Foundation. mentalhealth.org.uk/our-news/news-archive/2013-news-archive/130108-stress/ (accessed 29 February 2016).
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