According to Victoroff, anger is a primal—and not always logical—human emotion (Victoroff, 2009). It can range from mild annoyance to intense fury and rage. Aggression may be appropriate or self-protective as in protecting oneself, one’s family, or another individual who is being bullied. If, however, it is characterized by initiating hostilities directed at others, it can be a hostile reaction that occurs when the individual loses control over anger, which can result in physical or verbal destruction that can harm oneself or others.

Violence does not always have anger at its origin, but is “an unjust, unwarranted, or unlawful display of force in order to inflict harm upon, or violate” and is a term that is associated with physical and or mental assault. Bullying is a form of violence and occurs in all professions. Unfortunately, it occurs in the health care system all too frequently. In the health care workplace, bullying has become a destructive force and is often referred to as the “silent epidemic.” Lateral bullying refers to bullying among those of equal status (e.g., nurse-on-nurse violence). Bullying occurs between persons with different levels of authority (e.g., supervisor to staff.). Bullying creates a toxic environment for all staff involved.

Control of anger, aggression, and violence in the health care setting is a top priority. Fortunately, patients most often exhibit some signs of increasing anxiety before it escalates to destructive levels. Some patients are more prone toward angry and aggressive behaviors than others. Individuals who might at times be at risk for violent behaviors are those who abuse substances or have poor coping skills; are psychotic or have antisocial, borderline, or narcissistic traits; or suffer from cognitive disorders, paranoia, or mania.

Ideally, the most useful nursing interventions would be instituted during these initial phases, before a patient’s anger starts to escalate out of control. An understanding of the kinds of situations and patient attributes that might make a patient predisposed to angry and aggressive behaviors is important for nurses. Assessment skills guiding the nurse to signals of escalating anger and aggression are vital.

Accurate assessment and intervention during the early stages of escalating anger are the best prevention of violent or aggressive behavior, which in most instances is the physical attempt to take control. However, there are times when anger has already escalated, and the threat of violence is imminent. At this time, different intervention strategies are needed; an entirely different set of guidelines is warranted when a patient threatens to become physically violent.

No nurse need ever accept or tolerate anger or aggression. Preventive measures are required for the safety of the nurse as well as the patient.

The following sections offer nursing guidelines for assessing (1) anger and potential aggression when a patient is angry and verbally abusive and (2) interventions when a patient’s anger has escalated to physical abuse and staff intervention is required, sometimes in the form of restraints or seclusion. Hospital protocols that follow legal and ethical guidelines should always be followed when restraining or secluding patients.

There are psychopharmacological agents that have been found useful for angry and aggressive patients as well. Guidelines for working with angry and aggressive patients follow the least restrictive means of helping a patient gain control. Least restrictive usually starts with verbal restraints, then chemical restraints, and finally physical restraints/seclusion.

• Paranoia

• Alcohol/drug ingestion

• Certain patients with mania or agitated depression

• Personality disorder patients prone to rage, violence, or impulse dyscontrol (antisocial, borderline, and narcissistic)

• Oppositional defiant disorder or conduct disorder

• Patients experiencing command hallucinations

• Any patient with psychotic features (hallucinations, delusions, illusions)

• Patients with a cognitive disorder (e.g., dementia or delirium)

• Patients known to have intermittent explosive disorder (e.g., domestic violence)

• Certain medical conditions (e.g., chronic illness or loss of body function) can strain a person’s coping abilities and lead to uncharacteristic anger

• Black & Andreasen (2011) suggests asking the following three questions:

2. Have you ever seriously injured another person?

3. What is the most violent thing you have ever done?

• Increasing anxiety and tension: clenched jaw or fist, rigid posture, fixed or tense facial expression, mumbling to self, shortness of breath, sweating, rapid pulse

• Verbal abuse (e.g., uses profanity, is argumentative, makes intrusive demands)

• Loud voice, change of pitch, or very soft voice, forcing others to strain to hear

• Changes in level of consciousness (e.g., confusion, disorientation, memory impairment)

• Intense eye contact or avoidance of eye contact

• Recent acts of violence, including property violence

• Stony silence

• Alcohol or drug intoxication

• Carrying a weapon or object that might be used as a weapon (e.g., fork, knife, rock)

• Milieu conducive to violence:

• Inexperienced staff

• Provocative/controlling staff

• Poor limit setting

• Arbitrarily taking away privileges

2. Assess patient for risk for violence:

• Does patient have a plan?

• Does patient have the availability or means to carry out a plan?

• Consider demographics: sex (male), age (14 to 24), socioeconomic status (low), and support systems (few).

4. Assess self for defensive response or taking patient’s anger personally, which may accelerate the anger cycle. For example, are you:

• Avoiding the patient?

• Suppressing or denying either your own or the patient’s anger?

5. Assess your level of comfort in the situation and the prudence of enlisting other staff to work with you to deal with a potentially explosive situation.

People who commit acts of aggression and violence often lack conflict-resolution skills and resort to more primitive and physical ways of acting and responding. Many believe that a lack of assertiveness or problem-solving skills is an area of dysfunction in violent people. Teaching patients new coping skills and effective behavioral alternatives to manage their anger is helpful for many patients and is a primary prevention intervention. Many practitioners use psychoeducational and cognitive-behavioral approaches for people with anger, violence, and abuse-control problems. Some of the focus in therapy is directed toward the following:

• Enhancing the patient’s ability to identify and manage the attitudes and emotions associated with violent behaviors

• Decreasing social isolation and providing a supportive milieu for change

• Decreasing hostile-dependent relationships when they exist

• Developing nonviolent and constructive conflict resolution skills

Ineffective Coping is an appropriate nursing diagnosis for patients who have angry and aggressive responses to stressful, frustrating, or threatening situations. When a patient’s anxiety and anger escalate to levels at which there is a threat of harm to self or others, Risk for Other-Directed Violence is more appropriate and necessitates an entirely different set of interventions. During this time, talking-down skills are employed. If psychopharmacology or chemical restraints are ineffective, restraint or seclusion of an aggressive patient might be warranted.

Nurses are better prepared when they are familiar with the medications that can be effective during an episode of acute aggression or violence. Again, the least restrictive intervention is usually used first: (1) interpersonal (verbal), then (2) chemical (psychopharmacology), and finally (3) physical restraint or seclusion.

The following text discusses two nursing diagnoses: one for intervention with patients who are angry and hostile, and a second for intervention with those whose anger has escalated to threat of violence toward self or others. Guidelines are given for restraint procedures, and appropriate pharmacological agents for acute anger and aggression are noted.

2. Set limits at the outset:

• Use the indirect approach if the patient is not confused or psychotic (e.g., “You have a choice. You can take this medication and go into the interview room [or hallway] and talk, or you can sit in the seclusion room until you feel less anxious.”).