ANGER AND AGGRESSSION

Saima Habeeb, P.G Obstetrics and Gynaecological Nursing, Tutor, BGSBU University (J & K)

Anger is an immediate response that arises when we feel threatened

or mistreated. Threats can come in many forms and are not just
physical (such as being assaulted) but also include financial threats
such as losing your job. Feelings of jealousy, guilt and embarrassment
can also be behind anger.
Anger is a natural response that everyone experiences, however when
it gives rise to aggression it becomes a problem. Shouting and physical
violence are ways we release anger that may cause problems with
family, friends and work colleagues.
Aggression arises from an innate drives or occurs as a defense
mechanism and is manifested either by constructive or destructive
acts directly towards self or others. Aggressive people ignore the rights
of other people. They must fight for their own interests and they
expect same from others. An aggressive approach to life may lead to
physical or verbal violence. The aggressive behavior often covers a
basic lack of self confidence. Aggressive people enhance to their self
esteem by overpowering others and thereby providing their superiority.
They try to cover up their insecurities and vulnerabilities by acting
aggressive.

Meaning and Definition:

Anger: Anger is defined as a strong uncomfortable emotional response
to provocation that is unwanted and incongruent with ones values,
beliefs or rights.
Aggression: aggression refers to behavior that is intended to cause
harm or pain.
Human aggression is any behavior directed towards another individual
that is carried out with the proximate intent to cause harm. In addition,
the perpetrator must believe that the behavior will harm the target,
and that the target is motivated to avoid the behavior. (Bushman &
Anderson 2001)

Causes of anger and aggression:

1. Evolution: Our early ancestors would have experienced a great

deal of threat in their lives and their inbuilt response (known as the
‘fight or flight response’) helped keep them safe and alive. This same
inbuilt human response causes the feelings of anger we experience
when we feel under threat today.

2. Society: Men can feel under peer pressure to ‘man-up’, particularly

in male-dominated environments. In addition, society has become
focused on alcohol, which is closely linked to aggression. This is
because alcohol reduces our inhibitions and alters how we perceive
situations.

3. Childhood: People may be more prone to anger problems if they

experienced abuse as a child. This is thought to be because they are
permanently on ‘high alert’ as a result of their past and may react to
perceived threats in a way considered excessive by others. In addition,
if you had an aggressive role model as a child you are more likely to
react to anger in the same way.

4. Specific events: Job loss often triggers anger because it threatens

financial security. Similarly, any other situations which are interpreted
as containing some form of threat or injustice may be result in
aggressive outbursts.

Symptoms of anger and aggression:

We may respond to anger in physical and psychological ways such as

those listed below:
Anger – physical responses: increased heart rate and blood
pressure, sweating, muscle tension, clenched jaw
Anger – psychological responses: feelings of frustration, feelings of
rejection, feelings of mistreatment, hostility towards some people
Aggression: shouting at people (e.g. family, colleagues, strangers,
physical violence (e.g. hitting, punching people or slamming doors),
ignoring or socially excluding others (passive aggression)

Characteristics of aggressive behavior:

 Aggressive behavior is communicated verbally or non verbally

 They may speak loudly and with greater emphasis
 They usually maintain eye contact over a prolonged period of
time so that the other person experiences it as an intrusive
 Gestures may be emphatic and often seem threatening. E.g; they
may point their figure, shake their fists, stamp their feet or make
slashing motion with their hands
 Posture is erect and often aggressive people lean forward slightly
towards the other person. The overall impression is one of power
and dominance.

Types of aggression:

 Instrumental aggression – aggression aimed at obtaining an

object, privilege or space with no deliberate intent to harm
another person.
 Hostile aggression – aggression intended to harm another
person such as hitting, kicking, or threatening to beat up
someone.
 Relational aggression – a form of hostile aggression that does
damage to another’s peer relationship, as in social exclusion or
rumor spreading.

MANAGEMENT OF AGGRESSION:

Aggression is not an inevitable or unalterable form of behavior. On the

contrary, because it stems from a complex interplay between
cognition, situational factors, and personal characteristics, it can be
prevented or reduced through some useful techniques.

1. Punishment: In most societies throughout the world,

punishment – delivery of aversive consequences is a major
technique for reducing aggression. People who engage in such
 behavior receive large fines, are put in prison, and in some
countries are placed in solitary confinement or receive physical
punishment for their aggressive actions.

2. Self regulation: From an evolutionary perspective, aggression

can be viewed as adaptive behavior, at least in some situations.
For instance, competition for desirable mates is often intense,
and one way to win in such contests is through aggression
against potential rivals. On the other hand, living together in
human society often requires restraining aggressive behavior.
Lashing out at others in response to every provocation is not
adaptive and can greatly disrupt social life. For this reason, it is
clear that we possess effective internal mechanism for restraining
anger and overt aggression. Such mechanism are described by
the term self – regulation or self – control and refers to our
capacity to regulate many aspects of own behavior, indulging
aggression.

3. Positive self -talk: another very powerful anger management

technique is to change the inner conversation that you have with
yourself. It is very normal daily occurrence for people to have an
inner dialogue that can either get them more worked up (e.g.; if
he even looks at me the wrong way, I am going to explode’’) or
put them in a calmer frame of mind (e.g.; relax, stay calm, I can
get through this’’). These words we say to ourselves are very
powerful and can definitely influence how we feel and how we
subsequently behave.

4. Forgiveness: give up the desire to punish someone who has

hurt us and seeking, instead, to act in kind, helpful ways towards
 them, may be highly beneficial in many ways, including the
reduction of subsequent aggression.

5. Multisystemic therapy: one approach that appears promising

is Multisystemic therapy. Multisystemic therapy is a family based
approach that first identifies the major factors contributing to the
delinquent and violent behaviors’ of the individual undergoing
treatment. Biological, school, work, peer group, family and
neighbourhood factors are examined. Intervention is then tailored
to fit the individual constellation of contributing factors.
Opportunities to observe and commit further violent and criminal
offenses are severely restricted, whereas prosocial behaviour
opportunities are greatly enhanced and rewarded. Both the long
term success rate and cost benefit ratio of this approach have
greatly exceeded other attempts at treating violent individuals.
General Principles of Management

 The safety of patient, clinician, staff, other patients and potential

intended victims is of most importance while looking after
aggressive patients.

 The doors should be open outwards and not be lockable from inside
or capable of being blocked from inside.

 while working with impulsively aggressive or violent patients in any

setting one must take care to reduce accessibility to patients of
movable objects as well as jewellery and other attire that might
add to the risk of injury during an assault, including neckties,
necklaces, earrings, eyeglasses, lamps and pens.

 Adequate caregiver training and the availability of appropriate

supervision are critical safeguards in the treatment of potentially
dangerous patients.

 The caregiver may choose to present a few key observations in a

calm and firm but respectful manner, putting space between self
and patient; avoiding physical or verbal threats, false promises and
build rapport with client.

 For caregivers treating patients with a high risk for violence

behaviour, training in basic self defence techniques and physical
restraint techniques are useful.
NURSING PROCESS: Nursing Assessment

 A violence assessment tool can help the nurse.

 Establish a therapeutic alliance with the patient.

 Assess patient’s potential for violence.

 Develop a plan of care.

 Implement the plan of care.

 Prevent aggression and violence in the milieu.

 Following the assessment , if the patient is believed to be

potentially violent, the nurse should:

 Implement the appropriate clinical protocol to provide for the

patient and staff safety

 Notify co-workers

 Obtain additional security if needed

 Assess the environment and make necessary changes.

 Notify the physician and assess the need for prn medications.

Nursing Interventions

1.Self awareness

The most valuable resource of a nurse is the ability to assess one’s self
to help others .to ensure the most effective use of self , it is important to
know about personal stress that can interfere in one’s ability to
communicate with patients. Anxiety, angry, tiredness, apathy, personal
work problems etc... from the part of nurse can affect the patient.
Negative countertransferance reactions may lead to non therapeutic
responses on the part of the staff. Ongoing self awareness and
supervision can assist the nurse in ensuring that patient needs rather
than personal needs are satisfied.

2.Patient education

Teaching patients about communication and the appropriate way to

express anger can be one of the most successful interventions in
preventing aggressive behaviour.
Teaching patients that feelings are not right or wrong or good or bad can
allow them to explore feelings that may have been bottled up, ignored or
repressed. The nurse can then work with patients on ways to express
their feelings and evaluate whether the responses they select are
adaptive or mal adaptive.

P4Eatient education plan for appropriate expression of anger

Content
Instructional activities Evaluation
Help the patient Focus on nonverbal Patient demonstrates
identify anger behaviour. an angry body posture
Role plays nonverbal and facial expression.
expression of anger.
Label the feeling using the
patients preferred words

Give permission for Describe situations in which Patient describes a

angry feelings. it is normal to feel angry. situation to which
anger would be an
appropriate response.

Practice the Role play fantasized Patient participates in

expression of situations in which anger is role play and identifies
anger. an appropriate response behaviours associated
with expression of
anger.

Apply the -Help to identify a real -Patient identifies a real

expression of situation that makes the situation that results in
anger to real patient angry. anger.
situation. -Role plays a confrontation -Patient is able to role
with the object of the anger. play expression of
anger.
-Provide a positive feedback
for successful expression of
anger.
Identify alternative -List several ways to express Patient participates in
ways to express anger, with and without
Identifying alternatives
anger confrontation.
and plans when each
-Role plays alternative
might be useful.
behaviours.
-Discuss situations in which
alternatives would be
appropriate

Assertiveness training

 Interpersonal frustration often escalates to aggressive behaviour

because patients have not mastered the assertive behaviours.

 Assertive behaviour is a basic interpersonal skill that includes the

following –

 Communicating directly with another person.

 say no to unreasonable requests

 Being able to state complaints.

 Patients with few assertive skills can learn them by participating in

structured groups and programmes .In these settings patients can
watch demonstrate specific skills and then role play the skills
themselves.
  Staff can provide feedback to patients on appropriateness and
effectiveness on their responses.

 Homework also can be given to these patients to help them

generalise these skills

 Expressing appreciation as appropriate outside the group milieu.

Behavioral strategies: Nursing interventions include applying

principles of behaviour management to aggressive patient.

a) Limit setting

 Limit setting is a non punitive non manipulative act in which patient

is told what behaviour is acceptable and what is not acceptable ,
and the consequences of behaviour unacceptably.

 By explaining the rational for the limit and communicating to the

patient in a calm and respectful manner, potentially aggressive
behaviour can be avoided.

 If nurse communicates in an authoritarian, controlling or

disrespectful way patients respond in an angry, aggressive manner.

 One a limit has been identified; the consequences must take place
if the behaviour occurs. Every staff member must be aware of the
plan and carry out it consistently.

 When limit setting is implemented, the maladaptive behaviour will

not immediately decrease, in fact, briefly increase. This is
 consistent with behavioural principles and testing behaviour.

b). Behavioral contracts

If the patient uses violence to win control and make personal gains, the
nursing care must be planned to eliminate the rewards patient receives
while still allowing the patient to assume as much as control, as
possible.
Once the rewards are understood, nursing care must be planned that
does not reinforce aggressive and violent behaviour. Behavioural
contracts with the patient can be helpful in this regard. E.g. Head injured
patients with low impulse control can be told that staff will take them for
a walk if they can refrain from using profanity for 4 hours.
To be effective contracts require detailed information about:
 Unacceptable behaviours.
 Acceptable behaviours.
 Consequences for breaking the contact.
PREVENTION OF AGGRESSION : Workplace guidelines
 Management commitment and employee involvement
 Work site analysis
 Analyse incidents including the characteristics of assailants and
victims, an account of what happened before and during the
incident, and the relevant details of the situation and its outcome.
 identify jobs or locations with greatest risk of violence and
processes procedures that put employees at risk of assault
including how often and when
 Note high risk factors such as type of clients ,psychiatric conditions,
patients disoriented by drugs, physical risk factors of the building,
isolated locations, areas with previous security problems etc.
  evaluate the effectiveness of existing security measures
CONCLUSION
Anger is a normal human emotion that is crucial for individual’s growth.
When handled appropriately and expressed assertively, anger is a
positive creative force that leads to problem solving and productive
change. When channeled inappropriately and expressed as verbal
aggression or physical aggression, anger is destructive and potentially
life threatening force.
Psychiatric nurses in particular, work with patients who have
inadequate coping
mechanisms for dealing with stress. Patients admitted to an inpatient
psychiatric unit are usually in crisis, so their coping skills are even less
effective. During these times of stress acts of physical aggression or
violence can occur. Also nurses spends more time in the inpatient unit
than any other disciplines, so they are more at risk of being victims of
acts of violence by patients. For these reasons, it is critical that
psychiatric nurses be able
to assess patients at risk for violence and intervene effectively with
patients before,
during and after an aggressive episode.
REFERENCES

1. Townsend M C Psychiatric mental health nursing- concepts of care in

evidece basedd practice. 8th edn. Philadelphia: F.A Dais Company;
2005. Page no,262-271,298.

2. Boyd MA .Psychiatric Nursing Contemporary Practice 2nd edition.

Philadelphia: Lippincott Publications; 2001.

3. Keltner LN, Schwecke L H, Bostrom CE. Psychiatric nursing 4th ed.

Philadelphia: Mosby publications; 1999.

4. Kaplan HI, Sadock BJ. Synopsis of Psychiatry, Behavioral Sciences/

Clinical Psychiatry .9th ed. Hong Kong: William and Wilkinson
Publishers; 1998.

5. Stuart GW, Laria MT. Principles and Practices of Psychiatric Nursing.

IST ed. Philadelphia: Mosby Publishers; 2001.

6. Berk, L. Infants, children, and adolescents 3rd ed. Allyn and acon.
Boston; 1999.

7. Moyer, KE. 1968. Kinds of aggression and their physiological basis.

Communications in Behavioral Biology 2A:65-87.