Aggression is any form of behaviour used with the intention to harm or injure another person (Health Services Advisory Committee 1997). This includes acts carried out with the intent to cause physical harm, directed either outwardly towards others or inwardly at the individual (self-mutilation). They range from verbal or emotional acts to serious physical harm (Shepherd 1994). This includes antisocial behaviour, for example lack of respect towards others; physical or verbal aggression where the intent is to injure; and assault with the intent being to cause the other person harm.

Bibby (1995) defined health-related aggressive actions as those occurring when a health worker feels threatened or abused or is assaulted by a member of the public during the course of their duties. Similarly the Counter Fraud and Security Management Service, a special health authority within the NHS who have overall responsibility for the management of violence and aggression within the healthcare sector, define aggression as: ‘the intentional application of force to the person, without lawful justification, resulting in physical injury or personal discomfort’ (CFSMS 2006).

These definitions however, fail to take into account unintentional violence resulting from illness or injury, or where a patient’s mental capacity is impaired. Whatever definition of aggression is used, it should have meaning for those involved, and show recognition of the problem encountered as part of their work. Promoting the issue of violence and aggression within the healthcare setting is as important as defining it, if not more so.

Nurses frequently deal with people who are in desperate need of attention and care, which they may, through ill-health, age or other circumstances, be unable to provide for themselves. They work with people across the whole of society, in circumstances that may be difficult and demanding, and often work long and unsociable hours. Patients may be anxious and worried about coming into hospital and what might happen to them. Some may be predisposed towards violence and aggression as a means of coping. Likewise, it may be that their relatives or friends express frustration or distress through aggression. While these factors do not excuse aggression, it is understandable why nurses and those that they care for occasionally come into conflict. It is important to recognize at this point that aggression is very rarely purposeless. People are aggressive either because they want something to happen or because they want something to stop happening. In clinical settings, aggression and violence may be used by patients as a way of getting what they want. Violent acts may be used to force change or to gain control. Rewards from violence include attention from staff and status and prestige among the patient group. For example, the patient who behaves violently is observed more frequently and has more opportunities to discuss concerns with their doctor and nursing staff. Despite this nurses are often expected to face their assailants and even to continue to provide and care for them following an attack. This situation is likely to test the nurse’s ability to cope with the psychological consequences of threats and assaults even further, and the cycle can become self-perpetuating.

Aggressive actions can also originate from colleagues. Many tensions can occur within work teams and in healthy organizational cultures; those tensions can be a valuable force for initiating change. Psychological violence is often perpetrated through repeated behaviour, of a type which may alone be relatively minor but which cumulatively can become a very serious form of violence. Although a single incident can suffice, psychological violence often consists of repeated, unwelcome, unreciprocated and imposed actions, which may have a devastating effect on their target. This is typical in bullying and harassment. Bullying turns to harassment when it is targeted repeatedly toward the same person or staff group and the chosen target is to some extent defenceless in the face of the perpetrator.

Bullying is a real problem within the health service, causing many staff to take sickness absence or early retirement and to leave the service altogether. Most organizations now have polices and procedures for dealing with bullying and harassment that outline what is and what is not acceptable behaviour. Penalties for transgression can result in dismissal. However, proving someone has been a bully is difficult, particularly if it has been done in a covert way.

The Evolve 12.1 resource provides further information on bullying in the workplace.

It would be wrong to rely solely on policies and procedures to protect the individual from aggression. One possible way of combating aggression such as bullying is to develop skills of assertiveness (RCN 2005). It is suggested that those people who are singled out for bullying and harassment are those that lack the ability to stand up for themselves and their rights. Linsley (2006) suggests that assertiveness is about the individual standing up for their rights in such a way as not to violate the rights of others. Being assertive can help the individual to develop a belief and confidence in herself or himself. The more that individuals stand up for their rights and act in a manner that is respectful of themselves and others, the higher their self-esteem. Assertiveness consequently can help a person to develop their self-confidence so that they can address threatening situations effectively.

Two neurotransmitters, noradrenaline (norepinephrine) and serotonin, have been the prime focus of studies into aggression. Low serum concentrations of serotonin and high serum noradrenaline concentrations have been found in aggressive individuals (Hollin 1992). Unfortunately, though, a simple cause and effect relationship between these neurotransmitters and aggression has not in fact been found. So, while they do not cause aggression on their own, they may contribute to the severity of the aggressive episode (McElliskem 2004) (Fig. 12.1).

Most research into hormones and the aggressive response has concerned the sex hormones. These are thought to act at two levels:

Owens & Ashcroft (1985) were among the first to note how the male sex hormone, androgen, influenced aggressive responses. They discussed how castrated rats became less aggressive – probably due to their removed androgen supply – and how monkeys with high serum androgen concentrations were associated with higher levels of aggressive responses. The problem is that it is difficult to replicate these findings in human subjects. Although it can be shown that males are more involved in violent and sexual crimes and that male delinquency is associated with the onset of puberty (Beresford et al 2006), attributing such behaviour to high androgen levels has not been proven in human subjects.

One other area of hormonal influence on aggressive behaviour is the role of hormones in the menstrual cycle (Hines & Kimberly 2003). This was promoted by women attributing violent or aggressive actions to the premenstrual stage of their menstrual cycle. Again problems establishing a definite causal linkage is the major issue and as yet this has not been established.

Whilst the exact amount of influence that genetics have on aggressive behaviour is still questioned, studies on animals have shown that a tendency towards aggression is at least partly inherited. The main problem with biological research into aggressive behaviour is that it is difficult to separate factors like genetic make-up from the complex variables that make up human individuals.

Freud’s model of the person comprised a bipolar model (Frankl 1990):

The assumption behind this theory is that two primitive forces, the life and death instincts, oppose each other in our subconscious, and this incongruence is the origin of aggression. Freud asserted that this is a process void of thought patterns and is driven entirely by our instincts. This model would seem to have a crucial flaw, however; having defined the general aims of the life and death instincts, Freud failed to determine their source.

The frustration–aggression hypothesis was first set out in the 1930s by Dollard et al (1939). It proposes that aggression, rather than occurring spontaneously, is a response to the frustration of some goal-directed behaviour by an outside source. Goals may include such basic needs as food, water, sleep, sex, love and recognition. Contributions to frustration–aggression research further established that an environmental stimulus must produce not just frustration but anger in order for aggression to follow (e.g. Berkowitz, 1990 and Geen, 2001), and that the anger can be the result of stimuli other than frustrating situations, such as verbal abuse (Cohen et al 1998). Anger will always lead to aggression, however, as anger can be displayed in a number of ways and conversely act as a motivator and medium for positive change (Berkowitz 2001).

Social learning theory focuses on aggression as a learned behaviour. It analyses the roles of models (a behaviour displayed by another) in the acquisition of aggressive behaviour (e.g. Anderson and Dill, 2000, Freedman, 2002 and Akert et al., 2005).

Social learning has three principal components:

Children learn many social skills through this process. It involves being attentive to the following: remembering, imitating and being rewarded by people, television, books and magazines (Bushman 1998). Reducing restraints on aggressive behaviour through modelling thus can in turn reduce the inhibitions against behaving aggressively by leading a person to believe that this is a typical or permissible way of solving problems or attaining goals, and in turn, distort their views about conflict resolution (Bushman, 1995, Bushman, 1998 and Geen, 2001).

While anger frequently precedes violent behaviour, it is important to recognize that anger does not always lead to violence. Anger is a negative emotion that arises when there is a threat or delay in achieving a goal, or a conflict between goals. It signals that something is wrong in oneself, in others, or in one’s relationship(s) with others and the three possible targets of a person’s anger are others, impersonal objects/life conditions, or oneself.

Sometimes it may be therapeutic to legitimize anger, perhaps if the standard of healthcare falls below what the individual expects. In fact, many people believe that anger is healthy and necessary. Hollinworth et al (2005) suggest that it is a common experience to become angry, and that expressing anger is a normal process. It is not the anger that is legitimate and right, but the stress that underlies the anger. Expressing anger is also a mechanism for enhancing self-respect, and a constructive action that can lead to correcting a perceived wrong.

Aggression takes many different forms. Physical aggression inflicts harm through deed or act, whereas verbal aggression creates harm through words. Aggression can also be expressed directly or indirectly (Kaukiainen et al 2001). Direct means of aggression take place in face-to-face situations, whereas indirect aggression is delivered via the negative reactions of others (Buss 1995). Often, indirect aggression is a kind of social manipulation, like spreading malicious rumours about the target person or trying to persuade others not to associate with him or her. Bullying and harassment are two types of aggression commonly found in the workplace (Royal College of Nursing 2001) which encompass this type of behaviour. Not only are such behaviours upsetting for those directly involved, but also for those who witness and have to deal with it.

If the point has been reached where an aggressive act is imminent, then the assault cycle is entered (Fig. 12.2). Using this model helps to identify how the aggression has occurred and the type of intervention that would be most appropriate.