Journal of Psychosocial Nursing and Mental Health Services

CNE Article Supplemental Data

Degree of Anger During Anger-Generating Situations Among Psychiatric Staff Nurses: Association Between Nurses' Attitudes Toward Service Users' Aggression and Confidence in Intervening in Aggressive Situations

Seiji Shimosato, PhD, RN; Aimi Kinoshita, MSN, RN, PHN

Abstract

Some situations require psychiatric staff nurses to respond to service users' negativity or aggression. As a result, psychiatric staff nurses may experience anger. The current study examined how anger levels of psychiatric staff nurses triggered by anger-generating situations by service users affected nurses' confidence and attitudes. A questionnaire survey was administered among 386 psychiatric staff nurses. The questionnaire surveyed anger levels in anger-generating situations, aggressiveness, nurses' attitudes toward aggression, and self-efficacy of intervening in aggressive situations. Path analysis revealed differences between male and female nurses. Male nurses' anger in response to physical aggression was mild when they were confident in handling aggression. Furthermore, female nurses who had high confidence in intervening in an aggressive situation had low anger levels. Confidence in intervening in aggressive situations appeared to dissipate anger and ease nurses during aggressive interactions. [Journal of Psychosocial Nursing and Mental Health Services, 56(9), 51–59.]

Abstract

Some situations require psychiatric staff nurses to respond to service users' negativity or aggression. As a result, psychiatric staff nurses may experience anger. The current study examined how anger levels of psychiatric staff nurses triggered by anger-generating situations by service users affected nurses' confidence and attitudes. A questionnaire survey was administered among 386 psychiatric staff nurses. The questionnaire surveyed anger levels in anger-generating situations, aggressiveness, nurses' attitudes toward aggression, and self-efficacy of intervening in aggressive situations. Path analysis revealed differences between male and female nurses. Male nurses' anger in response to physical aggression was mild when they were confident in handling aggression. Furthermore, female nurses who had high confidence in intervening in an aggressive situation had low anger levels. Confidence in intervening in aggressive situations appeared to dissipate anger and ease nurses during aggressive interactions. [Journal of Psychosocial Nursing and Mental Health Services, 56(9), 51–59.]

Numerous studies have reported the frequency with which nurses in clinical psychiatric settings are subjected to verbal abuse or violence (Foster, Bowers, & Nijman, 2007); however, these problems occur in departments other than psychiatry and are observed worldwide (Needham, Abderhalden, Halfens, Fischer, & Dassen, 2005). However, violence of service users in psychiatric wards may be triggered by their mental state, resulting in increased aggression, or by their frustration from undergoing forced treatments. In particular, isolation from the community and restrained freedom are long-known risk factors of violence (Moylan & Cullinan, 2011). Many service users live with hallucinatory/paranoid state–induced fear, confusion, and distress because of being placed in highly controlled environments after involuntary admission. For such service users, violence is a means of self-defense in this fearful context. Nurses should not respond to aggression by attempting to eliminate it, but rather by providing supportive person-centered care (National Institute for Health and Care Excellence [NICE], 2015). However, managing aggressiveness is difficult. Nurses may be frightened by particularly intense expressions of anger or physically aggressive behavior, which may instigate feelings of anger and resentment.

Emotions such as anger and fear may make nurses respond in inappropriate ways (Bimenyimana, Poggenpoel, Myburgh, & van Niekerk, 2009). Anger plays an important role in aggressiveness, as it is one of the three facets of aggression (Ando et al., 1999). In Russel's circumplex model of affect, anger is a highly considered dimension of arousal and unpleasantness (Matsuda et al., 2013) and can easily lead to aggressive behavior. For example, when a nurse experiences anger that is triggered by a service user, he/she may respond with indirect aggression, such as making a sarcastic remark, or with malicious behaviors toward the service user. Furthermore, these retributive actions may result in risks for abuse.

Shibuya and Takahashi (2014) schematized relative factors in the process of anger expression in psychiatric staff nurses using covariance structure analysis. This model describes how a lack of social support makes occupational stress more likely to stimulate anger responses and increases the risk of aggressive behavior. In addition, the model mentions that the number of years of experience has a more remarkable effect on male nurses than female nurses, and male nurses are more likely to resort to physically aggressive behaviors. Shibuya and Takahashi (2014) also grouped stress in psychiatric staff nurses into two categories, namely stress related to personal relationships and restraining work environments and stress related to job responsibilities. Challenges such as managing hallucinations, delusions, verbal abuse, and violence during patient interactions were categorized under the latter category. As such, aggressive behaviors exhibited by service users are perhaps the most prominent anger-generating factors for psychiatric staff nurses.

Emotional control exemplified by anger management toward nurses is proposed to manage anger triggered by aggressive behaviors of service users (Eslamian, Fard, Tavakol, & Yazdani, 2010). Another well-known effective approach is the aggression management training program (AMP), which was established in the 1970s in western countries (Farrell & Cubit, 2005). Since then, many programs have been developed based on the AMP, invoking intrapersonal changes in nurses, such as attitudinal changes and increased confidence to manage aggressive behaviors of service users (Farrell & Cubit, 2005). The first original AMP in Japan, the Comprehensive Violence Prevention and Protection Program (CVPPP), was developed in 2005 (Certification Committee for CVPPP, 2005). Rice, Harris, Varney, and Quinsey (1989) reported that the AMP aimed to reduce violence by being non-restrictive, non-authoritarian, and non-provocative. Indeed, a negative attitude toward aggressive behaviors of service users would incite being provocative and authoritarian. Confidence is an important skill for intervention, as it is an essential attribute of intervening during a patient's aggressive behavior and helps in intervening without developing negative attitudes toward the aggressive behaviors of service users.

However, there are insufficient data to demonstrate how anger levels of nurses in response to provocations of service users affect self-efficacy in intervening in violence or the attitudes toward aggressive behaviors of service users. Nakahira, Moyle, Creedy, and Hitomi (2009) reported that managers have more positive attitudes toward aggressiveness; however, aggressive behaviors of service users are typically handled by nonmanagerial, male staff nurses. Researching staff nurses' anger and its effect and examining differences between staff nurses with regard to their sex are highly important, as these individuals are frontline staff who intervene during these situations. Thus, the current study aimed to examine the associations among factors such as anger triggered by service users, individuals' aggressiveness, self-efficacy in intervening in aggressive behaviors of service users, and psychiatric staff nurses' attitudes, including differences between sexes.

Aggression and violence have many definitions. In the current study, violence was defined as extreme physical aggressive behaviors. Aggression was defined as “any verbal, nonverbal, or physical behavior that is threatening or physical behavior that actually does harm,” according to Nijman, Merckelbach, Evers, Palmstierna, and Campo (2002, p. 392). The definition includes aggression toward oneself; however, in the current study, it was restricted to aggression toward other individuals.

Conceptual Framework

The current study's hypothesis is shown in Figure 1. Anger is triggered in nurses during anger-generating situations with service users, but the degree of anger varies depending on the aggressiveness of the individual. Staff nurses' degree of anger may be associated with their years of experience and their own aggressiveness. A difference exists between male and female nurses. When nurses have high confidence in intervening in violence, they do not become angry and are able to demonstrate positive, rather than negative, attitudes toward the aggressive behaviors of service users.

Predicted model of factors associated with degree of anger generated by patients' behavior.

Figure 1.

Predicted model of factors associated with degree of anger generated by patients' behavior.

Method

Participants

A questionnaire survey was administered to participants of 25 workshop sessions for medical safety in 2016 hosted by 16 national and local government hospitals nationwide. Participants were widely recruited so that they represented all regions of Japan. Workshop participants' characteristics such as experience, position, and affiliation varied, but the group comprised a notably high ratio of male psychiatric staff nurses. Other professionals, such as physicians, psychiatric social workers, and occupational therapists who worked at psychiatric departments or children's group homes, were also included, although they were proportionately few in number. Participants of particular interest for the current study were staff nurses in non-managerial positions at psychiatric departments, because they were most likely to have frequent experience with direct care. The proportion of males in general as well as male psychiatric staff nurses who responded to the surveys was low, which was similar to approximately 25% in a previous study (Shibuya & Takahashi, 2014). In the current study, participants of the aforementioned workshops were selected to increase the overall number of male staff nurse participants because they were most likely to intervene in situations that involved aggressive behaviors. Consent to participate in the survey was obtained after explaining the nature of the study in writing.

Survey Details

The original survey included sex and age as basic demographic data, years of experience, and employment affiliation. Participants were asked about the intensity of a nurse's anger in response to service users' behaviors that triggered anger, nurse's self-efficacy in intervening in violence, nurse's attitude toward the aggressive behaviors of service users, and aggressiveness of nurses.

Levels of Nurses' Anger in Response to Anger-Generating Situations by Service Users. Nagasawa and Saito (2011) assessed associations between factors that generate anger and personality traits among university students using factors for expression of negative emotions as those that generate anger. The authors examined a two-factor structure of expressing negative emotions, namely factors of intentional harm, such as “threatening in a loud voice” and “taunting with belittling remarks,” and those of expressing discontent, such as “verbalizing discontent toward the person” or “telling the person that his/her action caused an inconvenience” (Nagasawa & Saito, 2011, p. 64). Because factors of intentional harm denote behaviors intended to harm, such as threatening, they are understood to have an aggressive side. In the current study, the authors referred to the factors described by Nagasawa and Saito (2011), namely factors of expressing negative emotions, and added physically aggressive behaviors, such as “hitting the nurse” or “kicking the nurse,” to create a questionnaire (16 items). Participants were asked to evaluate these items using a 7-point Likert scale, where 1 denoted strongly disagree and 7 denoted strongly agree.

Self-Efficacy in Intervening in Aggressive Behavior. This segment surveyed self-efficacy in intervening in violence based on a previous study (McGowan, Wynaden, Harding, Yassine, & Parker, 1999) and comprised eight items that asked participants to assess whether they had confidence in verbal or physical intervention, such as “How much confidence do you have in making a psychological intervention with a highly aggressive service user?” Participants indicated their responses by choosing from “I have no confidence” (1 = least confident) to “I have confidence” (6 = very confident). All eight items were totaled, with higher scores indicating greater confidence.

Nurses' Attitudes Toward Aggressive Behaviors of Service Users. Participants' attitudes toward aggressive behaviors were evaluated according to studies by Noda, Sato, and Sugiyama (2014) and Nakahira et al. (2009) after obtaining permission to use the Attitude Toward Aggression Scale (ATAS). Participants responded using a Likert-type scale by selecting answers between strongly disagree (1 point) and strongly agree (5 points) regarding the attitudes of nurses toward aggressive behaviors of service users. Compared with Nakahira et al.'s (2009) three-factor structure of negative, positive, and communicative, Noda et al. (2014) noted that a negative and positive two-factor structure subscale was more appropriate. Considering that the current survey was conducted in Japan, a two-factor structure was hypothesized. Participants responded to all 18 items using a scale of 1 (strongly disagree) to 5 (strongly agree). All subcategory scores were totaled, with higher scores indicating stronger tendencies in each of those attitudes.

Aggressiveness of Nurses. The Japanese version of the Buss–Perry Aggression Questionnaire (BAQ) (Ando et al., 1999) was used to assess nurses' aggressiveness. The BAQ is a self-report measure of aggression that is used worldwide. The BAQ has four subscales: anger, hostility, verbal aggression, and physical aggression. In the Japanese version, when translated literally, the subscale anger means “short-temperedness.” Therefore, the term short-temperedness was used in the current study to avoid confusion with anger-generated situations. Participants responded whether they strongly disagreed (1 point) or strongly agreed (5 points) using four subscales of physical aggression, short-temperedness, hostility, and verbal aggression. Total points were added in each sub-scale after flipping the responses for inverted questions. Finally, responses to the complete questionnaire were calculated to determine overall aggressiveness, with higher scores representing less introspective individuals who are more prone to interpersonal aggressive behavior and less likely to choose problem-solving alternatives.

Procedure

A written description of the study, consent form, and questionnaire were distributed to workshop participants. An oral description was also provided. The survey was voluntary, with no penalty for refusing participation. The survey was anonymous, and the questionnaire could not be retrieved once submitted. Questionnaires were manually retrieved, and data were entered into a computer for statistical processing.

Statistical Analysis

SPSS 21.0 and Amos 21.0 were used for statistical analysis. After determining descriptive statistics of the surveyed items, principal component analysis was performed on the anger levels to identify factor structures. Furthermore, the differences between sexes for each factor were analyzed using t test. Pearson correlation coefficient was used to assess correlations between factors, and path analysis was used to examine the causal associations.

Ethical Considerations

The study was approved by the ethics review board of the authors' affiliated research institutions. The voluntary nature of participation and right to withdraw at any time without penalties was explained in writing. The survey took 5 minutes to complete and would not involve psychological distress. Participant consent was obtained in writing. After data were collected, statistical processing was performed using a computer with no external connections, and the paper surveys were destroyed once data entry was completed.

Results

Participants

Data were collected from 544 workshop participants with different professional backgrounds. For the purpose of the current study analysis, data were extracted for 386 staff nurses. All questionnaires with missing data, overlapping data, or illegible responses for age, sex, years of experience, and employer characteristics or surveyed parameters were excluded from analysis. A total of 313 respondents (213 men, 100 women) were included in the analysis. Mean participant age 35.2 years (SD = 8 years), and mean years of experience was 8.2 years (SD = 6.2 years) (Table 1).

Participant Characteristics

Table 1:

Participant Characteristics

Level of Nurses' Anger According to Anger-Generating Factors: Factor Analysis

A factor analysis of 16 anger-generating factors was performed using principal factor method and Promax rotation. Two factors with eigenvalues ≥1 (first factor: 8.05, second factor: 1.81) were extracted. The overall interpretability was 65.7%. The first factor included verbal and nonverbal aggressive behaviors, such as sarcastic remarks, glaring, and taunting, and actions such as refusal; these behaviors and actions were collectively termed nonverbal factors of anger. The second factor indicated physically aggressive behaviors such as hitting or biting and was termed anger generated by physically aggressive behaviors (Table 2). The reliability of all items was high, with a Cronbach's alpha of 0.939.

Factor Analysis of the Degree of Anger During Anger-Generating Situations (N = 313)

Table 2:

Factor Analysis of the Degree of Anger During Anger-Generating Situations (N = 313)

Table 3 shows scores regarding self-efficacy in intervening in aggressive behaviors, nurses' positive and negative factors on the ATAS, subcategories of the BAQ, and anger-generating situations. A sex-related difference was detected. Self-efficacy was significantly higher in male staff nurses than female staff nurses, as male nurses had more confidence intervening in aggressive behaviors (t = 4.49; p < 0.001). Among the measures of aggression, physical aggression in the BAQ was significantly higher in male staff nurses than female staff nurses (t = 2.85; p = 0.004).

Scores for Each Item by Sex

Table 3:

Scores for Each Item by Sex

Correlations Among Items

Table A (available in the online version of this article) shows the Pearson correlation coefficients for each item. A positive correlation was found between age and years of experience for both sexes, but in female staff nurses, a weak negative correlation was found between age and anger generated by non-physical factors (r[98] = −0.270; p = 0.006). In other words, the older the nurse, the lower the level of anger generated by non-physical factors. In female staff nurses, a weak negative correlation between age and anger generated by physical aggression was found (r[98] = −0.214; p = 0.033).

CorrelationsCorrelations

Table A:

Correlations

A weak positive correlation was found in “self-efficacy in intervening in aggressiveness” in both sexes. In addition, the higher the number of years of experience, the higher the confidence level (male staff nurses: r[211] = 0.206, p = 0.003; female staff nurses, r[98] = 0.282, p = 0.004). Moreover, higher confidence levels in male staff nurses were associated with lower anger levels when subjected to physical aggression (r[211] = −0.291; p < 0.0001). In male staff nurses, higher confidence levels were associated with higher verbal aggression in the BAQ (r[211] = 0.262; p < 0.0001). In contrast, in female staff nurses, higher confidence levels were associated with lower levels of anger generated by non-physical factors (r[98] = −0.232; p = 0.020).

In contrast to aggressiveness in female staff nurses, for whom a positive correlation was found among all sub-categories of short-temperedness, hostility, physical aggression, and verbal aggression, no correlation was found among verbal aggression and other sub-categories in male staff nurses.

In terms of nurses' positive attitudes toward service users' aggression, a mild negative correlation with negative attitudes was found in male staff nurses (r[211] = −0.289; p < 0.0001). When negative attitudes decreased, positive attitudes tended to increase. However, this correlation was not found in female staff nurses.

With regard to nurses' negative attitudes toward service users' aggression, a positive correlation was found with anger generated by non-physical factors in both sexes, and higher anger levels were associated with the tendency to have negative attitudes (males, r[211] = 0.310, p < 0.0001; females, r[98] = 0.375, p < 0.0001). Moreover, a correlation was found with the levels of anger generated by physical aggression in both sexes (males, r[211] = 0.253, p < 0.0001; females, r[98] = 0.409, p < 0.0001), and a more negative attitude was associated with a higher likelihood to experience anger more intensely when subjected to physical aggression.

In terms of the levels of anger generated by non-physical factors and aggressiveness, the correlation was highest with short-temperedness in male staff nurses (r[211] = 0.375; p < 0.0001), and there was also a positive correlation with overall aggressiveness (r[211] = 0.283; p < 0.0001). In female staff nurses, a mild correlation was noted for short-temperedness in the BAQ (r[98] = 0.291; p = 0.003), overall aggressiveness (r[98] = 0.299; p = 0.031), and other hostility factors (r[98] = 0.269; p = 0.007).

Anger generated by physical aggression mildly correlated with short-temperedness (r[211] = 0.260; p < 0.0001) in male staff nurses, but there was no correlation with aggressiveness in female staff nurses.

Path Analysis: Effects Between Items by Sex

The effects of each factor were predicted based on the correlation coefficients of each factor and path analysis was performed for both sexes. Path analysis is a statistical method using covariance structure analysis developed by multiple regression analysis. Path analysis forces the researcher to make explicit causal assumptions in the model, provides a graphical method for representing the pattern of causal assumptions, and provides tests for the significance or non-significance of hypothesized paths.

Trials, such as changing the input factors or direction of the arrow, were performed to confirm that all path coefficients (β) were significant; the χ2 value, which indicated the appropriateness of the model, was not significant, and the comparative fit index (CFI) was >0.95, root mean square error of approximation (RMSEA) was ≤0.08, and Akaike's information criterion (AIC) became smaller (Garson, 2015).

For male staff nurses, the most appropriate model was established as shown in Figure 2A. The goodness of fit of this model was highest if the parameters were as follows: χ2 = 12.573, df = 20, p = 0.895, CFI = 1.000, RMSEA = 0.000, and AIC = 44.57. In this path diagram, the confidence level in handling aggressiveness among male staff nurses had low interpretability (R2 = 0.11), but the level was affected by experience (β = 0.21, p = 0.001) and BAQ verbal aggressiveness (β = 0.27, p < 0.001). Thus, confidence appeared to attenuate anger generated by physical aggression (β = −0.27, p < 0.001). In other words, anger generated by physical aggression decreased as confidence increased. Moreover, anger generated by physical aggression influenced anger generated by non-physical factors (β = 0.52, p < 0.001), which influenced negative attitudes (β = 0.31, p < 0.001). When negative attitudes decreased, positive attitudes increased (β = −0.29, p < 0.001).

Path analysis for (a) males (χ2 = 12.573; df = 20; p = 0.895; comparative fit index [CFI] = 1.000; root mean square error of approximation [RMSEA] = 0.000; Akaike's information criterion [AIC] = 44.57) and (b) females (df = 13; p = 0.35; CFI = 0.991; RMSEA = 0.032; AIC = 44.34).Note. e1 to e6 are error values. Numbers adjacent to arrows indicate standardized regression weights (path coefficients), and numbers on upper right corners of squares represent the squared multiple correlation.*p < 0.05; **p < 0.01.

Figure 2.

Path analysis for (a) males (χ2 = 12.573; df = 20; p = 0.895; comparative fit index [CFI] = 1.000; root mean square error of approximation [RMSEA] = 0.000; Akaike's information criterion [AIC] = 44.57) and (b) females (df = 13; p = 0.35; CFI = 0.991; RMSEA = 0.032; AIC = 44.34).

Note. e1 to e6 are error values. Numbers adjacent to arrows indicate standardized regression weights (path coefficients), and numbers on upper right corners of squares represent the squared multiple correlation.

*p < 0.05; **p < 0.01.

For female staff nurses, the most appropriate model was established as shown in Figure 2B.

Self-efficacy in intervening in aggressiveness decreased anger generated by non-physical factors (β = −0.20, p = 0.012) and reduced negative attitudes toward aggressiveness (β = −0.19, p = 0.029). Considering the interpretability of the effects of age on years of experience in female staff nurses (β = 0.56, p < 0.001), there was no such effect in male staff nurses. In addition, anger generated by non-physical factors affected anger generated by physical aggression (β = 0.71, p < 0.001), which influenced negative attitudes toward aggressive behaviors (β = 0.40, p < 0.001). Positive attitudes were not shown in this model. In female staff nurses, anger generated by non-physical factors was affected by age (β = −0.23, p < 0.001). Female staff nurses' aggressiveness in the BAQ affected not only short-temperedness and verbal aggression, but also overall aggressiveness.

Discussion

The current study targeted psychiatric staff nurses, particularly those who provided direct care. Mean age of participants was 35.2 years, and mean years of experience was 8.2 years. In Japan, nurses in this age group are at a stage in their career when they take on leadership roles; therefore, the results of this study are assumed to be an accurate reflection of the anger responses that arose in their real-life interactions with service users. A positive correlation was found between age and years of experience in both male (r = 0.617) and female (r = 0.558) staff nurses. The slightly lower correlation found in female staff nurses may be due to the fact that these individuals are more likely to temporarily leave the workforce for reasons such as having and raising children, which affects their years of experience.

Differences in Anger-Generating Factors by Sex

In the current study, for anger-generating factors, physically aggressive behaviors were added to Nagasawa and Saito's (2011) factors for expressing negative emotions. The results of the factor analysis revealed that there were two types of anger: one generated by physically aggressive behaviors and the other by non-physical factors. Non-physical factors were direct verbal aggression, including shouting, demanding unfeasible requests, and rejecting the nurse's advice or instructions. Regardless of whether the aggression was verbal or nonverbal, negative or commanding tones in addition to aggressive factors provoked anger. Because there were no differences in scores between sexes, the results indicated that all nurses experienced anger similarly when faced with work-related anger-generating factors in psychiatric settings.

Weak negative correlations were found between age and non-physical factors and age and anger generated by physical aggression in female staff nurses in the current study. However, there was no correlation between aggressiveness and age. Nonetheless, in female staff nurses, short-temperedness as an individual personality trait does not change with age; changes are only observed in response to anger triggered by service users. As female nurses age, they may more easily understand a patient's position. Therefore, it is possible that aggressiveness itself in female staff nurses does not change, and nurses can potentially respond without experiencing much anger triggered by service users. If nurses understand why patients get angry, nurses may not have feelings of anger. Training based on interpersonal dynamics, such as Interpersonal Dynamics Consultation, in which members of multidisciplinary teams meet and share experiences (Reiss & Kirtchuk, 2009), can be effective for understanding patients' aspects and reducing anger toward them.

Self-Efficacy and Aggression

Self-efficacy in intervening in aggression was significantly lower in female staff nurses than male staff nurses, suggesting their lack of confidence in managing aggressive behaviors. In general, aggressive service users are often directly handled by male staff nurses. Therefore, this difference may have been affected by the lack of experience in intervening among female staff nurses.

Years of experience affected self-efficacy in male and female staff nurses. More opportunities to intervene in aggressive situations may naturally increase confidence. However, confidence in intervening in aggressive behaviors itself is an important factor for successful intervention; thus, confidence is important independent of experience. Intrapersonal changes in confidence have been observed in AMPs (Farrell & Cubit, 2005), and these programs should be more actively offered to female staff nurses to enhance their confidence in managing aggressive behaviors.

Attitudes Toward Aggression

Negative attitudes toward aggressive behaviors using ATAS for male staff nurses were negatively correlated with positive attitudes, and attenuating negative attitudes increased positive attitudes, whereas in female staff nurses, there was no correlation. This finding suggests that the negative attitudes of male staff nurses increased as positive attitudes decreased because of experiencing a direct impact from engaging in intervention during aggressive situations of service users. On the other hand, negative attitudes of female staff nurses to aggressive behaviors of service users did not inversely translate to decreasing their positive attitudes because their positive and negative attitudes were influenced by other factors.

Inter-Factor Effects in Path Analysis

Different models were established for male and female staff nurses in terms of self-efficacy in intervening in aggressive behaviors and attitudes toward aggression. In male staff nurses, anger generated by physically aggressive behaviors decreased as confidence levels in intervening in aggressive behaviors increased, which also affected their anger generated by non-physical factors. Because anger was minimized, attitudes toward aggressive behaviors shifted from negative to positive.

In male staff nurses, higher anger levels, provoked through actual encounters with aggressive service users, may become a risk factor that accelerates nurses' own aggressive behaviors toward service users. Undergoing training to build skills and confidence to handle aggressive situations appeared to be more important than simply adapting through repeated experience. Furthermore, it is important to educate health care staff on person-centered care. Shibuya and Takahashi (2014) reported that male psychiatric staff nurses were more likely to receive occupational support than their female counterparts. Because the current study did not assess the types of occupational support male staff nurses received, it is unclear whether the support influenced their ability to handle aggressive situations. However, other support systems, such as service user–staff support and support among colleagues, may also play a role. Thus, a cooperative relationship and mutual support will enhance safe ward culture (Schalast, Redies, Collins, Stacey, & Howells, 2008). Further investigations are warranted in this respect.

In contrast to male staff nurses, anger generated by non-physical factors decreased in female staff nurses as confidence for intervening in aggressive behaviors increased, and confidence directly decreased negative attitudes. When the level of anger generated by non-physical factors was high, anger generated by physically aggressive behaviors also increased, which as a result reinforced negative attitudes. Unlike in male staff nurses, confidence in intervening decreased anger generated by non-physical factors in female staff nurses and reduced negative attitudes toward the aggressive behaviors of service users. Therefore, verbal skills training, such as verbal de-escalation (NICE, 2015), may be effective for decreasing anger in staff nurses.

The current authors deduced that this situation was caused by the fact that female staff nurses had fewer occasions to engage in direct physical intervention. The forms of aggression female staff nurses encountered were more often verbal than physical (e.g., being shouted at, spoken to in commanding tones, rejection). These verbal aggressive behaviors probably had more effect on female staff nurses owing to the frequency of and their familiarity with the events.

Positive attitudes toward aggressive behaviors did not appear in the path diagram for female staff nurses, most likely reflecting the effects of other factors, and warrants further investigation.

The current study examined anger, aggressiveness, attitudes, and confidence. Aggressiveness was studied as an individual factor. Because individuals with rumination (Anestis, Anestis, Selby, & Joiner, 2009) are more likely to develop aggressive behaviors, further studies are needed to examine the factors that contribute to individual aggressiveness.

Limitations of the current study included lack of measures to assess participants' personality traits as individual characteristics, which warrants further investigation of these aspects in future studies.

Conclusion

The current study investigated factors associated with service users generating anger in psychiatric staff nurses, particularly those who were involved in direct care, and two types of factors were identified: anger generated by non-physical factors and anger generated by physical aggression. The effects of anger were also examined in terms of individual nurses' aggressiveness, self-efficacy in intervening in aggressive behaviors, and nurses' attitudes toward aggressive behaviors of service users.

The results demonstrated differences between male and female staff nurses. In male staff nurses, higher confidence toward managing aggression reduced anger generated by physical aggression, which subsequently decreased negative attitudes. In female staff nurses, confidence in intervening in aggressive behaviors was higher when non-physical anger was lower, and negative attitudes also decreased.

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Participant Characteristics

VariableMean (SD)
Males (n = 213)Females (n = 100)Total (N = 313)
Age (years)34.5 (7.1)36.6 (9.3)35.2 (8)
Years of experience7.8 (5.5)9 (7.3)8.2 (6.2)

Factor Analysis of the Degree of Anger During Anger-Generating Situations (N = 313)

ItemScore (Mean, SD)Factor 1Factor 2
Taunting the nurse with belittling remarks3.96 (1.54)0.8050.022
Insulting the nurse to his/her face3.87 (1.59)0.7120.164
Glaring3.43 (1.47)0.821−0.045
Verbalizing discontent at the nurse3.57 (1.46)0.775−0.014
Shouting3.94 (1.45)0.6280.213
Demanding unfeasible requests3.93 (1.58)0.7260.044
Threatening in a loud voice4.02 (1.61)0.5730.277
Accusing the nurse of offensive actions3.28 (1.41)0.776−0.076
Sarcastic remarks3.63 (1.49)0.727−0.017
Rejecting the nurse's advice or instructions3.19 (1.32)0.776−0.117
Ignoring the nurse3.22 (1.45)0.705−0.051
Accusing the nurse of not working3.46 (1.61)0.5960.025
Throwing objects at the nurse4.63 (1.68)0.0430.897
Attempted to hit or kick the nurse4.61 (1.63)0.0570.877
Spitting at the nurse4.82 (1.70)−0.0790.920
Biting the nurse4.49 (1.85)−0.0990.861
Eigenvalue8.051.81
Cumulative interpretability (%)65.7

Scores for Each Item by Sex

Item (Score Range)Mean (SD)t Testp Value
Total (N = 313)Male (n = 213)Female (n =100)
Efficacy (8 to 48)22.33 (6.07)23.36 (6.08)20.15 (5.47)4.49<0.001
ATAS
  Positive attitude (5 to 25)16.79 (2.45)16.76 (2.44)16.86 (2.48)−0.350.727
  Negative attitude (13 to 65)42.75 (7.39)42.84 (7.10)42.57 (7.99)0.290.767
BAQ
  Short-temperedness (5 to 25)13.72 (3.93)13.67 (3.85)13.83 (4.11)−0.330.740
  Hostility (6 to 30)15.83 (3.09)15.67 (3.23)16.16 (2.76)−1.310.192
  Physical aggression (6 to 30)14.51 (3.63)14.91 (3.60)13.67 (3.57)2.850.004
  Verbal aggression (5 to 25)14.11 (2.75)13.95 (2.69)14.46 (2.87)−1.540.125
  Total aggression (22 to 110)58.18 (8.19)58.20 (7.91)58.12 (8.78)0.080.934
Anger-Generating Situation
  Non-physical factors (12 to 84)42.78 (13.83)42.16 (13.34)44.09 (14.80)−1.150.251
  Physical aggressive behavior (4 to 84)18.50 (6.39)18.62 (6.31)18.24 (6.57)0.490.625

Correlations

AgeExperienceEfficacyPositive attitudeNegative attitudeShort-temperednessHostilityP.aggressionV.aggressionT.aggressionNon-physicalPhysical
Age1.0000.617**0.103−0.040−0.0530.0100.026−0.003−0.103−0.021−.135*−0.102
Experience0.558**1.0000.206**−0.0130.0480.0850.145*0.021−0.0180.1040.023−0.030
Efficacy0.0790.282**1.0000.003−0.076−0.081−0.030−0.0180.262**0.029−0.156*−0.291**
Positive attitude0.025−0.076−0.1451.000−0.289**0.061−0.005−0.0900.035−0.001−0.069−0.072
Negative attitude−0.150−0.136−0.199*−0.0851.0000.157*0.0900.056−0.0400.1250.310**0.253**
Short-temperedness−0.139−0.048−0.0960.0650.1171.0000.290**0.280**0.0520.750**0.375**0.260**
Hostility−0.071−0.106−0.1530.0680.1430.343**1.0000.058−0.0560.556**0.151*0.001
P. aggression0.004−0.119−0.0090.1110.0020.308**0.250*1.0000.0410.629**0.1320.112
V. aggression−0.077−0.1080.104−0.028−0.0160.217*0.1860.0911.0000.361**−0.062−0.042
T. aggression−0.111−0.139−0.0620.0880.0950.772**0.637**0.659**0.523**1.0000.283**0.164*
Non-physical−0.270**−0.117−0.232*0.0270.375**0.291**0.269**0.216*−0.0280.299**1.0000.582**
Physical−0.214*−0.014−0.010−0.0380.409**−0.2140.0720.151−0.1440.1180.714**1.000
Authors

Dr. Shimosato is Professor and Ms. Kinoshita is Research Assistant, School of Health Sciences, Department of Community and Mental Health Nursing, Shinshu University, Matsumoto City, Nagano Prefecture, Japan.

The authors have disclosed no potential conflicts of interest, financial or otherwise. This study was a part of the research project funded by Grant-in-Aid for Scientific Research in Japan.

Address correspondence to Seiji Shimosato, PhD, RN, Professor, School of Health Sciences, Department of Community and Mental Health Nursing, Shinshu University, 3-1-1 Asahi, Matsumoto City, Nagano Prefecture, Japan; e-mail: sshimos@shinshu-u.ac.jp.

Received: November 14, 2017
Accepted: February 09, 2018
Posted Online: April 19, 2018

10.3928/02793695-20180322-02

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