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

- non-personalizing anger

- lacking understanding

- holistic understanding

losing emotional control

- taking charge of own anger

Diminished self-efficacy

Maintained self-efficacy

I
I

I
DISCONNECTING
<=

Strategies reusing self-efficacy

- shielding, taking Ume out
- transfemng t>lame rehearsing
- seeking peer support smoothing

644

=>

CONNECTING

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

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-

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

. South and G. Hart

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

believed the state of illness gave patients the n ^ t to be

angry One nurse explained

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'

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 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

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

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

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

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

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

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

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

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'

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

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
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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
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