The Royal Marsden Hospital Manual of Clinical Nursing Procedures - Lisa Dougherty [157]
Crucially you will also need to explore what stops people from acting and what changes might cause them to act. If you consider the patient is at risk, explain to them that you need to refer them for further support.
Inform and involve the consultant and psychological support services. Suicidal thoughts do not mean that people are at risk but you do need to establish what the risk is.
Assessing suicidal risk needs to be simple (Billings 2004, R5).
When patients do feel anger, they may feel too depleted by experiences of disease and treatment to express it (Bowes et al. 2002).
For some people, anger may be the least distressing emotion to display. Sometimes helplessness, sadness and loss are far harder to explore and show to others. Anger therefore can be a way of controlling intimacy and disclosure, but it can escalate to threatening, abusive or violent behaviour.
Evidence-based approaches
Prevention is the most effective method of managing anger; that is, diffusing stressful or difficult interactions before they become a crisis. There are situations encountered within practice where challenging or difficult behaviour can be seen to be related to underlying stress and difficulty in a person’s situation. Anger, aggression and violence may have ‘biological, psychological, social and environmental roots’ (Krug 2002, p.25). People frequently get angry when they feel they are not being heard or when their control of a situation and self-esteem are compromised. Many health professionals are unfortunately renowned for failing to acknowledge patients as people and this can stimulate an angry and arguably legitimate behavioural response. Institutional pressures can influence healthcare professionals to act in controlling ways and may contribute to patients’ angry responses (Gudjonsson et al. 2004). Patients are often undergoing procedures that threaten them and they may consequently feel vulnerable and react aggressively as a result. Another source of anger can be when personal beliefs in the form of rules are broken by others. We therefore need to strive to be aware of individual and cultural values and work with them to avoid frustration and upset.
People also can become angry when they feel that they have not been communicated with honestly or are misled about treatments and their outcomes. To prevent people’s frustration escalating into anger or worse, health professionals need to ensure that they are communicating with people openly, honestly and frequently.
Some patients may appear or sound aggressive when they are not intending to be and the nurse must therefore use good judgement to clarify their behaviour in these instances. Nurses need to be aware of their own boundaries and capabilities when dealing with challenging or abusive situations.
Threats, uncertainty and disempowerment may predispose people to anger and living with and being treated for any serious condition can be sufficiently threatening and disempowering, for example those affected by cancer (Faulkner and Maguire 1994).
It is frequently possible to engage with and manage some of the underlying features without endangering anyone. People who are behaving aggressively probably do not normally act that way and may apologize when helped.
Talking down or de-escalation of situations where someone is being non-compliant can be achieved with careful assessment of the situation and skilful communication. NICE (2005) clinical guidelines on managing disturbed and violent behaviour recommend remaining calm when approaching someone and offering them choices. It is acknowledged, however, that there is little research indicating the correct procedure to follow.
Box 5.10 lists signs indicating that people may be angry. It is necessary to engage people sensitively and carefully to attempt to help them whilst maintaining a safe environment for all.
Box 5.10 Warning signs that a patient is angry
Tense angry facial signs, restlessness and increased volume of speech.
Prolonged eye contact and a refusal to communicate.
Unclear