Anger management The purpose of this reflective report is to look at the nature and management of anger

University Degree Subjects allied to Medicine

RAD 214 Reflective Report 0405481

The purpose of this reflective report is to look at the nature and management of anger using a Firewall model adapted from Novaco’s Model for Anger Arousal (Feindler and Ecton, 1986), which can be found in Appendix A and the communication event described in Appendix B.

Anger has been of interest to researchers for a long time. For many years they have tried to study and observe anger, but it is not an easy task as it involves complex emotions such as thoughts, feelings, behaviour and according to Averill’s J.R. 1983 it is based on uniquely individual characteristics. No two patients or health care providers will respond and express anger in the same way. Some people will respond and express anger in order to get to the thoughts and feelings, others respond and express feelings and thoughts to get to the anger. These emotions are natural reactions and no matter how the individual perceives anger the body is always prepared to fight or flight (Gamham, P. 2001). Hence, depending on the previous experiences dealing with anger, the person will either attack (physically, verbally or by shutting away) or will run (for example out of a door, to look for a help). In both cases the brain releases hormones and chemicals to give a rush of energy, the heart rate increases, blood pressure rises, and levels of adrenaline and noradrenalin are heightened.

However, anger is not a disorder or medical condition. According to the Concise Oxford Dictionary (2004) anger is an “extreme displeasure” which can lead to “instinctive feeling as opposed to reason”. Unfortunately the definition above fails to convey the effects of anger both on a person who is angry and on anyone who receives the anger or witnesses it as a passive observer. The effects of anger can be harmful and negative, such as loosing self-efficacy, self esteem, self-image, or it can be rewarding and positive, leading to becoming assertive, expressing tension, energising and helping to feel in control (Novaco, R.W. 1976). Positive experience prepares health care providers to think rationally, analyse and take responsibility for the actions. Nevertheless, anger is one of the most difficult emotions for people to recognize in themselves, express to others and deal with it appropriately and has become a problem in an acute healthcare environment (Winstanley, S. and Whittington, R. 2004).

Anybody can become angry, but nobody can make the individual become angry. In any situation the person has the power to choose and the ability to get in touch with their own thoughts, feelings and to deal with them; either by rejecting anger and harming others or accepting and respecting others and yourself. The best way to do deal with anger is to prevent it occurring in the first place. This means getting to know the triggers that cause anger, recognising changes in emotional status that evoke angry feelings, defusing them at the point of difficulty or before it becomes dangerous (Clark, C. et al. 2005). The triggers provoking anger can be emotions such as frustration, hurt, annoyance, disappointment, harassment, fear and others (Faupel, A. et al. 1998). These triggers are like signals telling the body that is time to get angry and they are all important because once it has been activated it occurs automatically, inevitably and generates negative emotions even before the person has time to think about what was happened or what to do about it (Berkowitz, L. 1993).

This is evident in the communication event described in Appendix B. The main trigger in this communication event is not being able to proceed with the chest x-ray examination due to the patient leaving his request card at home. This caused anger arousal in the patient, because his needs and expectations had not been met (not being able to have a chest x-ray), which lead to frustration, disappointment. The student misinterpreted the patient’s anger and caused the student to believe that his/her care was undervalued or he/she was not appreciated. The unexpected anger that was shown by the patient (raised tone of voice) created a state of arousal for the student. This arousal was experienced as a physical response (the colour of the face changed, breathing became more rapid, adrenaline levels rose) and emotional response (feelings of fear and threat). Nevertheless the student should have supported the patient and not responded angrily. It is important to remember that people say things in the heat of stressful situations that they would not normally say (Arnold, E. and Underman, B.G. 2003). The comment about the student being awkward may be directed at her purely because she was the person available at the time when the patient got angry. However it can be difficult for the student to be pleasant when being criticised and verbally attacked, but it is vital to stay calm and respond to the patient in a professionally appropriate manner, thus reducing the anger. Unfortunately, the student appeared to lack the skills of how to interact with angry patients and this apparent lack of skills can be another trigger for anger.

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The key triggers of anger, in the communication event described in Appendix B, have been overlooked and underestimated. This includes the dismissive attitude by the student towards the patient, lack of empathy for patient-centred care and lack of experience in dealing with angry patients. The angry outburst of the student could be avoided by a patient-centred approach that respects individual demands and determines in meeting individual needs (Payne, S. and Walker, J. 1996). If the needs of the patient have not been met this may affect the perceptions of care and feelings of wellbeing (McCabe 2004). Feeling unwell, unhappy about health, physical problems, health system, or the health care provider with whom the patient is in contact are enough to make individuals irritable, which may mean they are more likely to become angry (Lyon, B. 2000, McCauley, J. and Tarpley, M. 2004). The largest determinant in meeting an individuals needs is the quality of the relationship between the patient and the health care provider (Deeny, P. and McCrea, H. 1991), but it does not appear that a beneficial relationship had been established in the communication event described in appendix B. Rather than mirroring the patient’s angry response, the student needed to stand back and reflect critically on the type of relationship she was developing with the patient and use professional skills and intuition to identify potential triggers that can precipitate angry reactions. The situation could easily have been predicted and prevented.

There are often opportunities to stop anger developing into an outburst. By understanding and identifying the common sources and early warning signs of anger the health care provider would be more likely to make the right decision of how to respond effectively to angry patients (Faupel, A et al.). The student, in the communication event described in Appendix B, had noticed some of the warning signs of the patient’s behaviour (twitching arms, raised tone of voice), but failed to take any actions to prevent the anger developing further. Instead of trying to pause and reflect on what may be behind the anger the student responded to patients actions in a defensive way (face colour changed, breathing became more rapid and adrenaline levels rose). This supports the research done by Levenson, R.W. et al.1992 which outlines that expressing an emotion can result in feeling an emotion. In both cases the patient and the student expressed anger, which lead to produce the experience of anger. It happened automatically even before the patient and the student had time to think about what had happened. The brain released hormones and chemicals, which changed the ability to focus on the situation and how it could be avoided or what it could be done. To maintain a control of a tense situation is always desirable, but it can be difficult to achieve.

Maintaining control of a situation is always desirable and can be achieved by changing the way the individual thinks and reacts to a situation. By changing how the individual thinks it is possible to change how the individual feels. This gives more time for the individual to choose how he/she will behave. If the student, in the communication event described in Appendix B, would think that it was an unfortunate accident and the patient called her awkward because he felt frustrated and disappointed for forgetting the card the entire event might be prevented.

To manage anger situations involves making choices about the best action plan (Bandura 1982). The common responses to anger are withdrawing, distancing, or leaving the situation (Tavris, C. 1989). Leaving the room, when the event becomes unmanageable and threatening, is considered to be the most effective action to take to prevent further harm, calm the feelings, to think more rationally, to regain the professional look, and to decide what to do next (Smith, E.M. and Hart, G. 1994). Remaining calm and thinking before acting is usually more helpful in controlling anger. This leads to support the contentions made by Tavris (1989), Wilting (1990) that controlling anger expression is very important for maintaining interpersonal relationships and a professional look. Components of professionalism include empathetic engagement, responsiveness to individual needs and effective communication (Barondess, J. 2003).

There is evidence to indicate that patients view communication as an issue that is central to their care and feelings of wellbeing (McCabe, C. 2004). This supports Faupel, A. et al 1998 who states that patients’ get angry due to failure in communication – either because the other person has not treated him right or because the person has not been able to communicate in any other way apart from getting angry. Often angry patients will not be receptive to information that they are given and can distort the message they hear, so the clearer the message that is given to the patient the less room there is for misinterpretation (Bundy, C. 2001). Therefore effective communication between the emotionally distressed, angry patient and the health care provider requires extra effort to ensure that the patient accurately perceived what has been communicated (Lockyear, P.L.B. 2004).

The student, in the communication event described in Appendix B, appeared to be lacking in communication skills and attention to physical and emotional needs of the patient and failed to appreciate the patients’ uniqueness, which was a trigger to the arousal of the patient’s anger.

The first communication mistake student made was when she greeted the patient without introducing herself. Just by saying “Good afternoon, Mr X, I am Y, the student radiographer” is more than an example of good manners and shows respect, concern and allows the patient to choose how he wishes to be addressed (Dans, P.E. 1993). The patient was emotionally distressed (lost his wife), unwell (pneumonia) and upset (forgetting the card), which may mean he was more likely to become angry (Lyon, B. 2000, McCauley, J. and Tarpley, M. 2004) and by talking to the patient impersonally the student diminished the self esteem of the patient and raised feelings of anger. It would be much better if the student could sit the patient down and try to handle anger by remaining calm and communicating honestly, openly and by hearing what the patient is saying, understanding his position and trying to attain an acceptable solution of how the problem can be solved. Clear, distinct speech, good eye contact and speaking face-to-face would help the patient to feel that he has full attention and concern from the student. Some reassurance from the student that she is doing what she can to resolve the problem might prevent any outburst of anger, or provide a better relationship which would help with the situation.

Anger is common feature of everyday life and occurs in nearly everyone, several times a week (Averill, J.R. 1983). It is an essential part of human being, which involves complex emotions such as thoughts, feelings and behaviour. Dealing, understanding and recording these emotions can help to reach the goals, solve problems, improve communication and even protect the health, such as high blood pressure or heart disease (Smith, W.T. et al. 2004). Therefore it is important that the health care providers are educated and supported with how to express, manage and deal with anger and angry patients effectively. In doing so the health care providers will be able to maintain control of anger situations, which will arise quite often in the environment of health care.

APPENDIX A

The Firework Model. Adapted from Novaco’s model for anger arousal by Feindler, E. and Ecton, R. in Adolescent anger control: cognitive behavioural techniques.

Trigger – it is an event that stimulates individual’s thoughts, feelings, behaviour which leads to anger. It is a stage at which patient/health care provider perceives an event as threatening.

The fuse (signs of anger) – is the mind reacting to a particular event and depends on individual differences how long/short is going to be.

The explosion – is the body’s response to an event and may lead to anger being expressed. There are external and internal hat contribute to the explosion. The external factor the person may or may not have control over. The internal factors can be controlled.

APPENDIX B

One Friday afternoon, during my second year placement, the radiography department I was working in was quiet with no patients waiting to be x-rayed. The radiographers, after a hard and busy day, sat down and started talking about what they were going to do at weekend. Whilst they were talking an elderly male out-patient arrived. Because I was not involved in the weekend planning conversation I went to the patient, who looked pale and breathless, and greeted him:

“Hello. How can I help you?”

The patient looked breathless and it took at least a minute or two to answer me back. At first the patient apologised for not been able to answer to my greeting before and told me it was due to his earlier illness – pneumonia, which made him very poorly and short of breath, but after the antibiotic treatment he feels much better. Now that he feels better the doctor wants him to have another chest x-ray to make sure that the antibiotics cured the pneumonia.

I asked the patient for the request card that his doctor should have given him but he told me that he had forgotten the card and left it at home. I explained carefully to the patient that without the request card it would be not possible to carry out the chest x-ray. It is the request card that gives unambiguously information about the patients name, address, date of birth and provides with a clinical details why the examination needs to be done (the requested examination should correlate with the clinical history). The chest x-ray involves radiation dose and before it is carried out the justification should be made of whether this is going to be beneficial to the patient (Risk versus Benefit) and provide more information for the doctor, such as whether the treatment is working or whether the illness is gone. The request card should also be sign by the doctor or someone who is referring for the examination, which makes part of the justification. Without the request card with the patient details, clinical indications and referees signature the examination can not be carried out.

After the explanation of why the examination could not be carried out I noticed that the patient suddenly changed: he started twitching his arms and he had raised the tone of his voice. The patient still could not understand why I could not help him: it is not the end of the working day, nobody else was waiting to be x-rayed and I am suppose to help him not be awkward towards him.

His words about being awkward to him really upset me. I could feel the colour of my face was turning from its normal pink colour to red, I got sweaty, my breathing became more rapid and my adrenaline levels rose to the point that I just wanted to shout: “Listen, I am here to help you - not to be awkward by refusing to carry the chest x-ray”.

So it was at this point that I decided to excuse myself and leave the waiting area to calm down and decide what I was going to do next. I decided to go back to the radiographers and ask for their advice. I told them what happened, what I had done and that I needed somebody’s help to deal with the situation. One of the senior radiographers told me to go back to the patient and tell him again that we cannot help him without the request card. I asked the senior radiographer to come with me and explain to the patient why the chest examination cannot be carried out. The senior radiographer did not look happy about it but agreed to come with me.

When the senior radiographer and myself went back - the patient seemed to be much calmer. The reasons why we were unable to carry out a chest x-ray examination without a request card was explained again, but this time with the solutions how we might be able to help him. The patient was offered to ring home and ask someone to bring the card for him, but this was not possible as he lived on his own after his wife died from breast cancer. Then the senior radiographer asked the patient if he knew the name of the doctor that sent him for the chest x-ray. The patient remembered the doctor’s name, but it was not useful to us, because when we tried to ring the doctor’s surgery there was no answer.

When the solutions attempt to solve the problem did not give us a satisfactory result it was decided that we could not do anything else to help him apart from asking him to come back another day when it was convenient for him to do so. The patient was not happy about it and left the x-ray department distressed and angry.

When patient left than I started to think why did it happen as it happened? Maybe it was something that I overlooked; maybe it was something that has been there for a while and the patient tried to tell me. Only then I realised why the patient got angry and what he was angry about. I was at fault, by getting angry I lost the ability to think clearly and I forgot that the patient also has feelings, wants and needs.

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