Anger Among Health Care Professionals

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It is an uncomfortable emotion that is often suppressed—but potent.

CLINICAL REFLECTIONS

Anger is an uncomfortable emotion, both for the angry person and for the person targeted. Like all uncomfortable emotions, there is a natural tendency to suppress anger. At times, we may not even immediately realize we are angry at something or someone. Experts tells us that suppressed anger can be harmful,1 altering our behavior, disrupting relationships, and causing mental and physical health problems.

Open expression of anger, especially about patients, is generally considered unprofessional and unacceptable for health care professionals (HCPs). It is something rarely talked about, and there is a paucity of scientific literature about anger among HCPs. Yet we know that anger is an unavoidable emotion for HCPs, as it is for any other group of individuals—especially under the kind of difficult, frustrating, and stressful conditions that doctors, nurses, and other HCPs face on a regular basis.

The coronavirus pandemic has been especially difficult for HCPs, with strained resources and surging patient demands increasing the workload to unprecedented degrees and provoking increasing reports of burnout. In an emotionally charged piece in The Washington Post, Megan L. Ranney, MD, MPH, an emergency physician and the academic dean of the School of Public Health at Brown University, recently wrote about the experience of taking care of patients during the omicron variant surge in COVID-19 cases2:

As the severe cases accumulate, the distress among providers does, too. It’s certainly because of the exhaustion of caring for horribly sick COVID patients yet again—especially now that the disease is so preventable. But even more, it’s the moral harm from the other cases, the ones that have nothing to do with COVID except that they’ve been overtaken by the pandemic. It’s knowing that an elderly man was on a stretcher for hours with a broken hip, lying in his own urine, because there was no one to care for him. It’s the patient whose inflamed gallbladder smoldered while they waited. It’s the emotional exhaustion from assuaging the understandable anger of families calling for updates, only to be told that their loved one has not been evaluated yet after many hours in the waiting room.

Two things are important to notice here. First, Ranney notes that “the disease is so preventable now.” This is a reference to the availability of vaccines that substantially reduce the risks for serious illness, hospitalization, and death from COVID-19. Here, the doctor is implying that the cause of the surge of patients is in part due to many of them being unvaccinated. Second, however, notice that Ranney mentions the distress and exhaustion she and her fellow HCPs experience—and the word anger is only explicitly used as expressed by “families,” not by the HCPs themselves. Although it is clear from reading what Ranney is writing that HCPs are angry, it is also clearly difficult to say so publicly.

A critical care nurse, Kathryn Ivey, writing in Scientific American in January, on the other hand, does not shy away from using the word anger in relation to her experience with COVID-193:

The anger of the nurses, myself included, surged along with the patient population. Rage seeped along the halls of the intensive care unit, burned in the quick conversations in the medication supply room, and settled around all of us as we tried to keep our heads above water for yet another push of the pandemic that had turned so many of us into open wounds. I was angry at everything: angry at the systemic failures of the government to act, angry at the individuals who treated COVID as a joke, and angry at the disinformation that ushered in more death.

Although Ivey does not say she is directly angry at any patients, she does express anger at a variety of targets, including “the individuals who treated COVID as a joke.” Later in the piece, she writes, “COVID is a hoax until someone you love is lying motionless in a hospital bed, half dead, being kept alive by an angry nurse, a tired respiratory therapist, and a depressed physician.”3

Anger During the Pandemic

To be sure, anger is increasingly cropping up in the literature about HCPs coping with the pandemic.4-8 In a study of 14,600 HCPs that was conducted early in the pandemic, 15% reported experiencing anger the day before participating in a survey.9 Most of this anger appears to revolve around fears of personal vulnerability to infection and lack of resources to deal with the surges in cases.

Anger At Stressful Work Situations

It is important to note, however, that anger among HCPs is not a new phenomenon and not unique to the current COVID-19 pandemic. There is ample evidence from the literature that doctors, nurses, and other health care professionals can experience angry emotions because of the stressful circumstance their work often entails. An article titled “How to get off the anger-go-round” in American Nurse lists 7 things that can make nurses angry, including “feeling overloaded and overwhelmed” and “feeling powerless or lacking control over the work environment.10

Anger has been reported by a variety of different disciplines in response to stressful situations, including among medical students,11 emergency department nurses dealing with domestic violence presentations,12 and internal medicine residents.13 Nurses experience anger toward patients who self-harm14 and following patient safety incidents.15

HCP Anger in the Behavioral Health Care Setting

There is a long psychoanalytic literature on countertransference reactions that includes consideration of psychotherapists’ anger. This is especially found in the literature on borderline personality disorder. There is surprisingly less literature about this regarding other types of behavioral health interventions and other mental health diagnoses. Psychotherapists do report angry feelings toward clients and regard the training they get in this area as “inadequate.”16 Therapists may be especially likely to feel anger toward borderline patients who express rage.17

Nurses may experience anger when dealing with aggressive patients in the behavioral health setting.18 Nurses’ reported anger was significantly positively correlated with their endorsement of restraint as an approach to managing patient aggression.19 HCP anger can in turn exacerbate patient aggression.20 Among female nurses, low confidence in dealing with aggressive situations was associated with higher levels of anger.21 Mindfulness training has been shown in a limited number of studies to be effective in reducing therapists’ anger.20,22

Anger at Patients with Substance Use Disorders

We know that that HCPs can experience anger when a patient with a substance use disorder (SUD) relapses frequently, although the literature on this area is sparse. One study found that physicians’ attribution of personal responsibility, anger, and fear were associated with “lower regard” for working with patients with SUD.23 That is, anger was among the emotions that reduced the clinicians’ willingness to treat patients with SUD. We might conclude from this lack of literature that anger experienced in relationship to patients with SUD is frequently suppressed by clinicians and therefore is not a subject of discussion or empirical study.

Although the pandemic has clearly exacerbated negative emotions and burnout among doctors, nurses, and other HCPs, these are not new phenomena. Given what we know about the harms of suppressed anger, it may be wise for health care organizations to consider steps to help their HCPs recognize, express, and deal with angry emotions, especially when these are directed at patients. It is understandable that HCPs might feel angry at an unvaccinated individual who requires extensive care for COVID-19; at an angry, demanding patient with a behavioral health condition; or at an individual with SUD during one of multiple relapses.

While anger is understandable under these conditions, it can also interfere with both the HCP’s well-being and with the HCP’s ability to provide optimal care. We recommend:

1. Make clear to HCPs that anger is a normal human emotion that occurs when individuals feel frustrated, threatened, or under chronic stress.
2. Help HCPs express angry feelings in closed, confidential settings.
3. Develop tools and support systems to guide HCPs in recognizing both their angry feelings and how anger can adversely affect their and their patients’ well-being.
4. Support HCPs in working through anger and developing healthy coping strategies.

Dr Gorman is a former medical school professor of psychiatry who currently works as CEO of Franklin Behavioral Health Consultants. He is the author or co-author of more than 300 refereed journal articles and of the book Denying to the Grave: Why We Ignore the Facts That Will Save Us (OUP, 2021). Dr Reist is emeritus professor of psychiatry at UC-Irvine and former chief of mental health at the Long Beach VA Healthcare System. He currently serves as chief medical officer for Prairie Health, which is focused on bringing evidence-based treatments for mental illness to primary care settings. Dr Aamar has a decade of behavioral health clinical experience working with multidisciplinary health care teams in primary and specialty treatment, where she implemented clinical protocols to address social and relational barriers of care. She is currently the senior clinical effectiveness consultant at Relias for behavioral and population health, bringing her clinical and operational knowledge of integrated care, clinical research, and behavioral health care to support client use of population performance data to improve clinical performance and patient health outcomes. Dr Steiner is the former commissioner of mental health in the state of Illinois, currently working for Relias Learning Inc. She has acted as a consultant in the field of organizational development to community mental health and domestic violence agencies, and she teaches in human development and counseling at the University of Illinois at Springfield.

References
1. Men and anger management. WebMD. 2020. Accessed March 25, 2022. https://www.webmd.com/men/guide/anger-management#:~:text=What%20Are%20the%20Dangers%20of,a%20variety%20of%20physical%20problems

2. Ranney ML. We’re used to stress in the ER. But omicron has made our jobs impossible. The Washington Post. January 21, 2022. Accessed March 25, 2022. https://www.washingtonpost.com/outlook/2022/01/21/omicron-er-doctor-stress/

3. Ivey K. Nurses struggle through a new COVID wave with rage and compassion. Scientific American. January 11, 2022. Accessed March 25, 2022. https://www.scientificamerican.com/article/nurses-struggle-through-a-new-covid-wave-with-rage-and-compassion/

4. Mellins CA, Mayer LES, Glasofer DR, et al. Supporting the well-being of health care providers during the COVID-19 pandemic: the CopeColumbia responseGen Hosp Psychiatry. 2020;67:62-69.

5. Gloster AT, Zacharia M, Karekla M. Psychological aid for frontline healthcare workersClin Neuropsychiatry. 2020;17(4):253-254.

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8. Di Mattei VE, Perego G, Milano F, et al. The "Healthcare Workers' Wellbeing (Benessere Operatori)" project: a picture of the mental health conditions of Italian healthcare workers during the first wave of the COVID-19 pandemicInt J Environ Res Public Health. 2021;18(10):5267.

9. Forrest CB, Xu H, Thomas LE, et al. Impact of the early phase of the COVID-19 pandemic on US healthcare workers: results from the HERO RegistryJ Gen Intern Med. 2021;36(5):1319-1326.

10. Boertje J. How to get off the anger-go-around. American Nurse. May 11, 2015. Accessed March 25, 2022. https://www.myamericannurse.com/get-anger-go-round/

11. Doulougeri K, Panagopoulou E, Montgomery A. (How) do medical students regulate their emotions? BMC Med Educ. 2016;16(1):312.

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13. Myszkowski N, Villoing B, Zenasni F, et al. Monitoring stress among internal medicine residents: an experience-driven, practical and short measurePsychol Health Med. 2017;22(6):719-726.

14. Karman P, Kool N, Gamel C, van Meijel B. From judgment to understanding: mental health nurses' perceptions of changed professional behaviors following positively changed attitudes toward self-harmArch Psychiatr Nurs. 2015;29(6):401-406.

15. Stovall M, Hansen L, van Ryn M. A critical review: moral injury in nurses in the aftermath of a patient safety incidentJ Nurs Scholarsh. 2020;52(3):320-328.

16. Pope KS, Tabachnick BG. Therapists’ anger, hate, fear, and sexual feelings: national survey of therapist responses, client characteristics, critical events, formal complaints, and training. Prof Psychol Res Pr. 1993;24(2):142-152.

17. Nadelson T. Borderline rage and the therapist's responseAm J Psychiatry. 1977;134(7):748-751.

18. Jalil R, Dickens GL. Systematic review of studies of mental health nurses' experience of anger and of its relationships with their attitudes and practiceJ Psychiatr Ment Health Nurs. 2018;25(3):201-213.

19. Jalil R, Huber JW, Sixsmith J, Dickens GL. Mental health nurses' emotions, exposure to patient aggression, attitudes to and use of coercive measures: cross sectional questionnaire surveyInt J Nurs Stud. 2017;75:130-138.

20. Haugvaldstad MJ, Husum TL. Influence of staff's emotional reactions on the escalation of patient aggression in mental health careInt J Law Psychiatry. 2016;49(Pt A):130-137.

21. Shimosato S, Kinoshita A. 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 situationsJ Psychosoc Nurs Ment Health Serv. 2018;56(9):51-59.

22. Rodriguez Vega B, Melero-Llorente J, Bayon Perez C, et al. Impact of mindfulness training on attentional control and anger regulation processes for psychotherapists in trainingPsychother Res. 2014;24(2):202-213.

23. van Boekel LC, Brouwers EPM, van Weeghel J, Garretsen HFL. Healthcare professionals' regard towards working with patients with substance use disorders: comparison of primary care, general psychiatry and specialist addiction servicesDrug Alcohol Depend. 2014;134:92-98.