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Chapter 16
Anger/Aggression Management
Copyright © 2014. F.A. Davis Company
Introduction
• Anger need not be a negative expression.
• Anger is a normal human emotion that, when
handled appropriately and expressed
assertively, can provide an individual with a
positive force to solve problems and make
decisions concerning life situations.
• Anger becomes a problem when it is not
expressed, and when it is expressed
aggressively.
Copyright © 2014. F.A. Davis Company
Definitions
• Anger: an emotional state that varies in
intensity from mild irritation to intense fury
and rage.
—Anger causes physiological changes (e.g.,
increased heart rate, blood pressure, and levels of
biogenic amines).
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Definitions (cont.)
• Anger is:
– Not a primary emotion; learned
– Typically experienced as an automatic inner
response to hurt, frustration, or fear
– A physiological arousal, instilling feelings of power
and generating preparedness
– Significantly different from aggression
– Capable of being under personal control
• Anger has positive and negative functions.
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Definitions (cont.)
1. A client has not received what was expected for
lunch and directs an angry verbal outburst at the
nurse. Which is an accurate description of this
display of emotion?
A. Anger is a primary emotion that is
automatically experienced.
B. Anger is a psychological arousal.
C. The expression of anger can come under
personal control.
D. The expression of anger and aggression are
closely related.
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Definitions (cont.)
• Correct answer: C
– The expression of anger can come under personal
control and is a learned behavior.
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Definitions (cont.)
• Aggression
– Is one way that individuals express anger
– Is a behavior that is intended to threaten or injure
the victim’s security or self-esteem
– Can cause damage with
words, fists, or weapons,
but it is virtually always
designed to punish
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Predisposing Factors to Anger and
Aggression
Modeling
• Role modeling is one of the strongest forms of
learning.
• Role models can be positive or negative.
• Earliest role models are the primary
caregivers.
• As the child matures, role models can be
celebrities or any other influential individual
in the child’s life.
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Predisposing Factors to Anger and
Aggression (cont.)
Operant Conditioning
• Operant conditioning occurs when a specific
behavior is positively or negatively reinforced.
– A positive reinforcement is a response to the
specific behavior that is pleasurable or produces
the desired results.
– A negative reinforcement is a response to the
specific behavior that prevents an undesirable
result from occurring.
• Anger and aggression can be learned through
operant conditioning.
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Predisposing Factors to Anger and
Aggression (cont.)
Neurophysiological Disorders
• Several disorders of, or conditions within, the
brain have been implicated in episodic
aggression and violent behavior. They include:
– Temporal or frontal lobe epilepsy
– Brain tumors
– Brain trauma
– Encephalitis
Copyright © 2014. F.A. Davis Company
Predisposing Factors to Anger and
Aggression (cont.)
2. After repeated requests for a client to unpack and
get settled on the psychiatric unit, the client states,
“I have no intention of unpacking and staying on this
unit.” To avoid a confrontation, the nurse unpacks
the client’s belongings. Which nursing behavior is
exemplified?
A.
B.
C.
D.
Positive role modeling
Negative operant conditioning
Assertiveness
Aggressiveness
Copyright © 2014. F.A. Davis Company
Predisposing Factors to Anger and
Aggression (cont.)
• Correct answer: B
– This situation illustrates negative operant
conditioning. The client’s negative behavior has been
reinforced and rewarded by the nurse’s action of
unpacking for the client.
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Predisposing Factors to Anger and
Aggression (cont.)
Biochemical Factors
• Aggressive behavior may have some
correlation to alterations in brain chemicals.
These include:
– Hormonal dysfunction associated with
hyperthyroidism
– Alterations in the neurotransmitters epinephrine,
norepinephrine, dopamine, acetylcholine, and
serotonin; these chemicals may play a role in
facilitation or inhibition of aggression
Copyright © 2014. F.A. Davis Company
Predisposing Factors to Anger and
Aggression (cont.)
Socioeconomic Factors
• High rates of violence exist within the
subculture of poverty in the United States.
• Poverty is thought to encourage aggression
because of the associated deprivation,
disruption of families, and unemployment.
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Predisposing Factors to Anger and
Aggression (cont.)
Environmental Factors
• Several environmental factors have been associated
with an increase in aggressive behavior. They include:
– Physical crowding of people
– Discomfort associated with a moderate increase in
environmental temperature
– Use of alcohol and some other drugs, particularly cocaine,
amphetamines, hallucinogens, and anabolic steroids
– Availability of firearms
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The Nursing Process: Assessment
• Anger can be identified by a cluster of
characteristics that include:
– Frowning
– Clenched fists
– Low-pitched words forced through clenched
teeth
– Yelling and shouting
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The Nursing Process: Assessment
(cont.)
• Characteristics of Anger (cont.)
– Intense or no eye contact
– Easily offended
– Defensive
– Passive-aggressive
– Emotional overcontrol and flushed face
– Intense discomfort
– Tension
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The Nursing Process: Assessment
(cont.)
• Aggression can be identified by a cluster of
characteristics that include:
– Pacing
– Restlessness
– Tense face and body
– Verbal or physical threats
– Threats of homicide or suicide
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The Nursing Process: Assessment
(cont.)
• Characteristics of Aggression (cont.)
– Loud voice, shouting, use of obscenities
– Argumentative
– Increased agitation
– Overreaction to environmental stimuli
– Panic anxiety leading to misinterpretation of the
environment
– Disturbed thought processes
– Suspiciousness
– Disproportionate anger
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The Nursing Process: Assessment
(cont.)
• Assessing Risk Factors
– Prevention is the key issue in the management of
aggressive or violent behavior.
– Three factors are important considerations in
identifying extent of risks:
• Past history of violence
• Client diagnosis
• Current behavior
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The Nursing Process: Assessment
(cont.)
• Assessing Risk Factors (cont.)
—Past history of violence
• Considered the most widely recognized risk
factor for violence in a treatment setting.
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The Nursing Process: Assessment
(cont.)
• Assessing Risk Factors (cont.)
—Client diagnosis
• The most common client diagnoses associated with
violence include:
—Substance use disorders
—Schizophrenia
—Major depression
—Bipolar disorder
—Neurocognitive disorders
—Antisocial, borderline, and intermittent
explosive personality disorders
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The Nursing Process: Assessment
(cont.)
• Assessing Risk Factors (cont.)
—Current behavior
• Certain behaviors are predictive of impending violence
and have been termed the “prodromal syndrome.”
They include:
—Rigid posture
—Clenched fists and jaws
—Grim, defiant affect
—Talking in a rapid, raised voice
—Arguing and demanding
—Using profanity and threatening verbalizations
—Agitation and pacing
—Pounding and slamming
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The Nursing Process: Assessment
(cont.)
• Nursing diagnoses for inappropriate
expression of anger or for aggressive behavior
include:
– Complicated grieving (if anger is related to a loss)
– Ineffective coping
– Risk for self-directed or other-directed violence
• Outcome behaviors are identified as criteria
for evaluation.
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The Nursing Process:
Planning/Implementation
•
•
•
•
•
•
•
•
•
•
Remain calm.
Set verbal limits on behavior.
Keep a diary of anger.
Avoid touching the client.
Help determine source of anger.
Ignore derogatory remarks.
Help find alternative ways of releasing tension.
Role model.
Observe for escalation of anger.
When behaviors are observed, first ensure that
sufficient staff is available.
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The Nursing Process:
Planning/Implementation (cont.)
3. An angry client states to the nurse, “You red- headed
skinny witch. You can’t tell me what to do.” Which
appropriate intervention would the nurse implement
during this outburst?
A. Reprimand the client for poor judgment and
derogatory remarks.
B. Respond to angry expressions with matching
verbalizations.
C. Offer support by the use of empathy and therapeutic
touch.
D. Ignore initial derogatory remarks.
Copyright © 2014. F.A. Davis Company
The Nursing Process:
Planning/Implementation (cont.)
• Correct answer: D
– During expressions of anger and aggression, ignoring
initial derogatory remarks can be an appropriate
nursing intervention. Lack of feedback often
extinguishes an undesirable behavior.
Copyright © 2014. F.A. Davis Company
The Nursing Process:
Planning/Implementation (cont.)
• Techniques for dealing with aggression
include:
–
–
–
–
–
–
–
–
Talking down
Physical outlets
Medications
Call for assistance
Restraints
Observation and documentation
Ongoing assessment
Staff debriefing
Copyright © 2014. F.A. Davis Company