art & science

CLINICAL

The synthesis of art and science is lived by the nurse in the nursing act JOSEPHINEGPATERSON

RESEARCH

EDUCATION

Understanding the arousal of anger: a patient-centred approach

Hollinworth H, Clark C, Harland R, Johnson L, Partington G (2005) Understanding the arousal of anger: a patient-centred approach. Nursing Standard. 19,37, 41-47. Date of acceptance: January 5 2005.

Summary
The aim of this article is to enable reflection on practice by exploring a nurse-patient scenario and identifying what factors trigger anger and aggressive behaviour I t recommends strategies that can be used to tackle anger among patients, and emphasises the importance of the therapeutic relationship. Anger management, which usually refers to cognitive behavioural therapy designed to enable people to manage anger, is not explored.

Authors
Helen Hollinworth is senior teaching practitioner; Charlotte Clark is lecturer; Rowena Harland is lecturer; Linda Johnson is lecturer; Gareth Partington is lecturer. Faculty of Health, Suffolk College, Ipswich. Email; helenhollinworth@suffolk.ac.uk

Keywords
Anger; Emotions; Patients; Psychoiogy; Stress These keywords are based on the subject headings from the British Nursing Index. This article has been subject to double-blind review. For related articles and author guidelines visit the online archive at www.nursing-standard.co.uk and search using the keywords.

STRESS AND ANXIETY are common in healthcare settings. Erequently, these emotions progress to a state of anger and occasionally aggressive behaviour. Because of the fast pace of care and limited time to establish meaningful relationships with patients, nurses are being exposed to an increasing number of angry patients, relatives and visitors (Winstanley and Whittington 2004). However, it is not uncommon for practitioners unintentionally to compound these stressful situations. Nurses need to be able to recognise circumstances or changes in emotional status that trigger the anger response, and develop strategies to deal with angry individuals in a professionally appropriate manner.
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This article focuses on the arousal of anger and includes a scenario depicting the anger responses of a female patient and her male relative. Consideration is given to how anger may differ between genders, cultures and ages. Nurses' responses to anger in the work environment are explored. Strategies to counter the arousal of anger in practice are identified, including the importance of developing a therapeutic relationship. Anger and aggressive behaviour has become a problem in acute healthcare settings (Winstanley and Whittington 2004), and feelings of anger often remain with patients when they return to the care of community practitioners. It is important to be aware that people have fewer successful strategies for controlling anger than any other emotional state (Wegner and Pennebaker 1993), and that the quality of relationships that nurses develop with patients can significantly affect patients' perceptions of care and feelings of wellbeing (Milne and McWilliam 1996, McCabe 2004). However, government and management steps such as waiting list initiatives and faster throughput ofpatients (Department of Health (DH) 2004, NHS Modernisation Agency 2004) can foster a task-orientated delivery of care, which hampers nurses' attempts to provide patient-centred care. Approaches to care that are fragmented because so many different professionals are involved, or care that is perceived as insensitive, can precipitate reactions of anger. Patients' and families' distress at times of surgery can compound this emotion, particularly if the procedure precipitates a change in normal bodily function (Comb 2003, Black 2004). This barrage of differing emotions (Johnson 2002), and the way people perceive and experience events vary, but anger as a response to stress
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caused by loss of control is often overlooked (Payne and Walker 1996). While issues relating to the arousal of anger are explored in the context of a patient with a colostomy (Box 1), the circumstances will resonate with situations encountered by practitioners in many different care settings. Although people react differently to stressful situations (Sharkin 1993, Nunn and Thomas 1999), practitioners should be able to identify circumstances that trigger anger. Threatening behaviour and verbal aggression towards healthcare staff are widespread, and are not confined to accident and emergency practitioners (Winstanley and Whittington 2004). However,

being able to counteract situations of stressful arousal, and prevent frustration escalating from anger to violence and aggression, can provide practitioners with opportunities to enhance patient satisfaction and the professional standing of nurses. While anger frequently precedes violent behaviour (DiGiuseppe etal 1994), and there is a learned connection between anger and aggression (Novaco 1976), it is important to recognise that anger does not always lead to violence. Friedman and Booth-Kewley (1987) help to promote understanding when they define anger as immediate emotional arousal, hostility as a more enduring negative attitude, and aggression as the actual or intended harming of others. People can be angry without becoming aggressive or violent. Research indicates that only 10 per cent of anger episodes lead to overt

A scenario involving the arousal of anger Jane is recovering from emergency surgery which necessitated the formation of a colostomy. Her stoma appliance has been leaking, and although she has pressed her call buzzer no-one has attended to her. Her nephew, Tom, visits her and, finding her in such a predicament, looks for a nurse to help his aunt. He approaches a staff nurse who acknowledges him but continues to clean a trolley and tidy some linen. Tom demands that his aunt is given assistance immediately. The staff nurse says that she will be with Jane in a minute. Dissatisfied with the response Tom raises his voice and the loud and angry tone attracts the ward sister's attention. Tom informs her of the poor care and attention that his aunt has received. The sister tells him that the situation will be dealt with straight away and instructs Tom to wait outside Both nurses enter the patient's room. They put on their gloves and aprons, making little eye contact with the patient. Instead they discuss the staff nurse's hangover, the off duty and a colleague's poor sickness record. On addressing the patient, the sister gets her first name wrong and refers to Tom (the nephew) as Jane's son, which clearly annoys the patient The staff nurse pulls back the bedclothes and tries to reassure Jane, stating: 'At least it hasn't gone on the bed. We'll soon clean this up.' The nurses then discuss how the stoma was sited in an unusual position. This alarms the patient who asks if there is a problem. The staff nurse tells the patient that the stoma has been sited in a 'funny place' and they might have trouble getting the appliance to stick. The sister then interjects, suggesting that, if the patient had seen the stoma nurse specialist pre-operatively, there might not have been a problem. The staff nurse then continues to discuss the stoma appliance and implies that it is not as good as those used in her previous hospital. The patient is only included in this conversation when she asks them what they are doing. They reply, in a patronising manner, that the stoma looks healthy, but that Jane doesn't have to look at it yet if she doesn't feel ready. The sister tells her she will get used to it Once they have finished, the nurses turn to leave the room. The patient asks if the sister will be coming back. She replies briskly that she will try to come back in when the nurses have had their breaks. When Tom comes back into the room, Jane vents her anguish: 'The stoma is in the wrong place... the nurses don't care... they don't see me as me... they think I'm just like everyone else... I am not like everyone else, I am me.' Tom tries to reassure her, but he becomes increasingly angry as he sees how upset she has become. He storms out of the room, despite her objections, to confront the situation. He approaches the sister at the drug trolley and unleashes verbal abuse accompanied with aggressive gesturing and shouts: 'Call yourself a nurse'. (All the characters in this scenario are fictitious.) 4 2 may 25 :: vol 19 no 37 :: 2005 NURSING STANDARD

aggressive responses (Averill 1983). DiGiuseppe etal (1994) report that, in their experience with aggressive and angry dients, 2 to 5 per cent of angry episodes occur at the same time as aggressive behaviour. This suggests that most people are able to use coping strategies to modify their behaviour in situations that have aroused anger. However, when people are agitated they often act before they think (Novaco 1976). Although many angry outbursts could be avoided by a patient-centred approach that respects individual demands and negotiates individual needs (Payne and Walker 1996), nurses' responses to anger are often defensive and this can increase anger and aggressive behaviour (Thomas 2003). Patient anger Framed by the circumstances detailed in Box 1, the perspective of the female patient, male family member and the nurses involved in the situation will be explored beginning with the patient. Using this scenario, perceived differences between how women and men respond to the arousal of anger are considered. However, it is important to emphasise that these differences are debated, and culture, age and social class can also influence people's reactions. Patients get angry for a variety of reasons, but anger is an emotional state that is influenced by thoughts, or how an individual appraises a situation, which then affect behaviours (Novaco 1976). Anxiety and fear may elicit anger as a defence or response to the demands of the environment; in other words stress. However, without adequate coping skills, these reactions can affect psychological and physical health, for example, coronary heart disease (Friedman and Booth-Kewley 1987). Being unwell is enough to make many people irritable. Patients who are unhappy about their health, their physical problems, the health system, or the clinician with whom they are in contact, are likely to be emotionally distressed, which may mean they are predisposed to becoming angry (Lyon 2000, McCauley and Tarpley 2004). Feelings of vulnerability and powerlessness, as patients try to deal with inflexible hospital routines, intrusive procedures and the receipt of bad news about their future, are among the factors that can cause people to experience psychological distress (Ridner 2004). It is important to understand that as an individual's perception of personal control diminishes, anxiety often increases. The arousal of anger may be evoked to generate a sense of personal control (Novaco 1976). Therefore, lack of attention to physical or emotional needs, and failure to appreciate a patient's uniqueness, can all
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precipitate anxiety and the arousal of anger in patients (Plaas 2002, Shattell 2002). In addition to these generalised triggers for anger, the patient who has undergone emergency surgical intervention and formation of a colostomy is likely to have specific psychological and physical issues to deal with that may give rise to feelings of anxiety, frustration and perhaps anger. Metcalf (1999) describes three main factors that influence psychological adjustment following the formation of a stoma: The degree of satisfaction that a patient has with pre-operative preparation. Stoma-related factors, such as leakage, odour, sore skin and insufficient practical skills when changing stoma appliances. The patient's expectation of regaining control of the current situation. Therefore, it would not be surprising for a patient who has undergone emergency surgery and the formation of a colostomy to experience feelings of anger, frustration, sadness or an inability to cope. A further dimension to patients' feelings of anger involves triggers that relate to gender. Female expression of anger Davila (1999) describes anger as: 'A strong, uncomfortable response to a perceived injustice, a violation of rights, a negation of self, or a compromise of beliefs and values that occur to maintain the status quo.' While people have fewer coping strategies for dealing with anger than any other emotional state, including fear, anxiety and sadness (Wegner and Pennebaker 1993), anger incorporates two different concepts. These are the experience of anger as purely an emotional state, and its expression as a behavioural response to that anger (Spielberger etal 1985). Although this issue continues to be debated, there is a wealth of literature suggesting that women experience and express this emotion differently to men (Collier 1982, Sharkin 1993, Davila 1999, Turkel 2000, Gianakos 2002, Thomas 2003). Women are often perceived to suppress their anger. Lerner (1988) reports that women tend to be inhibited in their expression of anger whereas men tend not to be. Although this view may be relevant to some women, anger can function as an energising force. For example, women's feelings of anger at not being able to vote led to the women's rights' movement, and eventually to significant legal changes. Thomas (2003) quotes women using cooking metaphors such as 'stewing' or 'simmering' in relation to their unexpressed feelings of anger. This
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supports professional experience that unexpressed anger in women is often an underlying factor in depression (Johnson 2002). While a meta-analysis points to the probable existence of a disease-prone personality involving anger, hostility, depression and anxiety, the evidence of this link is weak except in the case of coronary heart disease (Friedman and Booth-Kewley 1987). Reasons for anger suppression in women are varied (Averill 1983). Several authors highlight socialisation as an explanation for this behaviour (Collier 1982, Lerner 1988, Turkel 2000). Sharkin (1993) considers that women are socialised to express their emotions more openly, with the exception of anger, which he suggests is viewed as 'unfeminine' by society. Gianakos (2002) and Thomas (2003) make the connection between a woman's reluctance to express anger and her fear of adversely affecting interpersonal relationships. This can have implications for professional practice. Patients need to be given the opportunity to express their feelings within a trusting nurse-patient relationship, but work pressures can limit nurses' ability to foster this type of relationship with patients. When women express their anger, it is often in terms of feeling hurt, or disillusioned (Turkel 2000). Thomas (2003) refers to anger as a confusing emotion for women because feelings of anger are interwoven with hurt, frustration, sadness and disillusionment. Women's anger is frequently expressed as much through tears and emotion as through physical aggression (Averill 1983, Thomas 2003). This is evident in the scenario (Box 1) where the patient with the newly formed colostomy reacted with emotional frustration that had been induced by a series of physical and psychological stresses.

allowing the patient to lie in a bed with a leaking colostomy bag was seen as unacceptable by the relative, and stimulated emotions of frustration and anger. Situations are made worse when men feel that they are unable to control what is happening and unable to fix what has gone wrong (Nunn and Thomas 1999). Jane's nephew believed that the problem could have easily been solved with minimal effort (Box 1)- not to do so seemed illogical to him and only served to heighten his anger. While some men may manifest their anger by withdrawing from the situation, others may react by physically lashing out at people, or by striking inanimate objects. Men have been socialised to express anger freely (Sharkin 1993, Turkel 2000), and this may explain why such outbursts are quite common. In general, men are perceived as more comfortable with the emotion of anger than women, and use the externalisation of anger response to express it (Nunn and Thomas 1999). Even vulnerable emotions such as disappointment, hurt and shame (emotions considered too unmanly to express) may get funnelled into anger (Turkel 2000). However, these responses to emotions, including anger, may vary depending on the culture or social environment that an individual relates to (DiGiuseppe eta/1994). Anger can escalate if people consider that their feelings are being ignored. This was evident in the scenario because the nephew's repeated attempts to deal with the progressing situation were not given due concern by the staff (Box 1). Despite his best effort to resolve the problem, nothing was being achieved - even when increased levels of anger were being displayed.

Nurses'responses to anger
In today's healthcare system it is almost taken for granted that hospitals are stressful environments. The combination of time constraints and large workloads, juxtaposed with the anxiety of dealing with acute situations, is a perfect recipe for anger in patients and staff (Thomas 2003). Fear, physical disability, confusion and pain are all associated with acute illness and can present themselves as anger (Garham 2001). Nurses can often feel defensive when they encounter anger, which can ignite an already explosive situation (Thomas 2003). It is important to remember that people say things in the heat of a stressful situation that they would not normally say (Arnold and Underman Boggs 2003). It can be difficult for a practitioner to be pleasant when being criticised or verbally attacked. Anger can threaten a nurse's energy or cause him or her to feel vulnerable. However, angry comments may be directed at the nurse
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Male expression of anger

While men and women may differ in their mode of expressing anger, this difference is not related to the degree of anger experienced (Nunn and Thomas 1999). The main gender difference is that men cry less than women when angry (Averill 1983). Men are also considered to be more aggressive than women, but women are equally capable of anger expression (DiGiuseppe eta/1994). Anger may be displayed when a person feels he or she has lost control of a situation, or feels the behaviour of other people does not conform to proper human conduct (DiGiuseppe etal 1994). In this example.
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purely because he or she is the person who is available at that time (Arnold and Underman Boggs 2003). Maintaining control of a tense situation is always desirable but it can be difficult to achieve. This is evident in Box 1 in the way the sister took an authoritarian stance when intervening between the nephew and the staff nurse. This can be threatening to someone who already feels a loss of control. The key triggers of anger in this scenario that have been overlooked or underestimated include the dismissive, insensitive attitude displayed by the nurses and the lack of empathy and patientcentred care. The experienced practitioner should use past experiences and a range of interpersonal skills, such as establishing dialogue and maintaining eye contact, to notice subtle changes in the patient's behaviour (Smith and Hart 1994). Issues relating to professionalism are also identified in Box 1. For example, an inappropriate conversation took place between the sister and staff nurse about the social activities and discipline of another nurse. Barondess (2003) advocates a dignified clinical transaction between health professionals and patients. Glearly, the conversation between the sister and staff nurse was inappropriate at the time it happened (Box 1). Components of professionalism include empathetic engagement, capacity to communicate effectively and responsiveness to individual needs (Barondess 2003). Active listening skills and the provision of adequate explanation and information are essential and it may be appropriate to apologise to the patient. The nurse should support the patient, while not condoning aggressive behaviour (Arnold and Underman Boggs 2003). The nurses in the scenario appeared to lack skills in these areas and this apparent lack of professionalism can be another trigger for anger (Thomas 2003). If appropriate, the dialogue and situation should be recorded in the patient's documents and communicated to the professional healthcare team (Nursing and Midwifery Council (NMC) 2002). However, it is important that all communication by a nurse is professional and non-judgemental. The patient should not be labelled as difficult or demanding following an episode of anger (Smith and Hart 1994). The location of the colostomy is particularly important for the rehabilitation of the patient (Black 2000). A brief negative comment from a health professional can considerably jeopardise a patient's recovery. The comment in Box 1 that it was 'in an awkward place' was inappropriate, and could have repercussions for the patient's acceptance of the stoma - especially if the stoma
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was formed as an emergency procedure (Regina 2003). Any alteration in body image, especially one that is removed from the 'ideal' can cause considerable distress (Comb 2003). In this scenario (Box 1), poorly addressing the patient's hygiene, self-esteem, education and information needs added to an already stressful situation. It is common for individuals not to have the chance to express their fears and anxieties (Deeny and McCrea 1991). In Box 1, the sister in charge of the ward ignored the patient's 'cry for help'. The quality ofthe nursepatient relationship is the largest determinant in meeting a person's needs (Deeny and McCrea 1991), but it does not appear that a therapeutic relationship had been established in this scenario. The absence of a therapeutic relationship made a difficult situation worse. The outcome of this could easily have been predicted and prevented.

Discussion
Sometimes it may be therapeutic to legitimise anger, perhaps ifthe standard of health care falls below what an individual expects. In fact, many people believe that expressing anger is healthy and necessary. However, this widespread belief that anger will be harmful unless expressed is not supported by research (Tavris 1989). It is not the anger that is legitimate and right, but the stress that underlies the anger (McKay etfl/1989). Expressing anger is also a mechanism for enhancing self-respect (Turkel 2000), and a constructive action that can lead to correcting a perceived wrong. Nurses need to be aware that anger serves an important function in coping with stress. When a person is stressed, it may be preferable to take the role of an angry, agitated person rather than be seen as anxious or apathetic (Novaco 1976). This can apply equally to men and women. People often feel anxious in healthcare situations because a strange environment can be stressful. People of all ages may outwardly express their feelings of vulnerability or agitation through anger directed at others and, in healthcare situations, this is frequently the nurse. It is also important to recognise that culture is an inextricable part of the fabric that defines each person as an individual (Black 2004). The coping strategies usually adopted in a family, social group or culture influence the arousal of anger, and subsequent reactions (DiGiuseppe et al 1994). The media, for example television dramas about hospitals, can also be influential. It may be appropriate to respond outwardly in some cultures, but people in other cultures have learned to engage coping strategies that avoid conflict and outward expression of emotion. may 25 :: vol 19 no 37 :: 2005 45

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However, a person's response is context and gender-specific. It should not be assumed that what is true of a culture is true of all members of that culture (Eysenck 1996). Age also has an impact on how an individual responds to stress. Communication deficits by healthcare staff, or not being able to communicate in the same language, may contribute to feelings of isolation and anger (Gerrish etal 1996). However, the shame and embarrassment a person feels when a stoma appliance leaks, crosses all cultures and most ages. Powerful associations have been found between shame and anger (Ferguson etaHOOO). Loneliness is also associated with anger (McKay etal 1989). This serves to emphasise the challenge for nurses to provide high quality care that meets the needs of patients of all ages in a multiethnic society. Caring for patients and their families in any healthcare organisation can be stressful, and

requires many skills, including self-awareness. Nurses lacking in self-awareness may react to angry outbursts in a way that fuels more anger. Arguing with someone who is already angry is usually counterproductive (Payne and Walker 1996). Conversely, disconnecting from the patient, transferring blame, or acting as if nothing has happened following an anger reaction are far from ideal (Smith and Hart 1994), and do not foster a therapeutic nursepatient relationship. A more helpful evidence-based strategy is to: Establish a trusting relationship with the patient. This is the most powerful aid to reducing distress in most patients in the clinical situation (Ridner 2004). Remain calm, speak softly, and listen carefully to the individual's complaint (Thomas 1998). Actively engage with the person by developing simple counselling skills (Hollinworth and Hawkins 2002), and using empathetic communication (Morse ei a/1992). Acknowledge the right to be angry - because

References
Arnold E, Underman Boggs K (2003) Interpersonal Relationships: Professional Communication Si<ilis for Nurses. Fourth edition. WB Saunders, St Louis MO. Averill JR (1983) Studies on anger and aggression: implications for theories on emotion. American Psychologist. 38,11, 1145-1160. Barondess J (2003) Medicine and professionalism. Archives of Internal Medicine. 163, 2,145-149. Beck R, Fernandez E (1998) Cognitivebehavioral therapy in the treatment of anger: a meta-analysis. Cognitive Tiierapy and Research. 2 2 , 1 , 63-74. Black P (2000) Practical stoma care. Nursing Standard. 14, 41, 47-55. Black P (2004) Psychological, sexual, and cultural issues for patients with a stoma. British Journal of Nursing. 13,12, 692-697 Collier HV (1982) Counselling Women: A Guide for Therapists. Free Press, New York NY. Comb J (2003) Role of the stoma care nurse: patients with cancer and colostomy. British Journal of Nursing. 12, 14, 852-856. Davila Y (1999) Women and anger. Journai of Psychosocial Nursing and Mental Health Services. 37 7 25-30. Department of Health (2004) The NHS Improvement Plan: Putting People at the Heart ofPubiic Services. The Stationery Office, London. Deeny P, McCrea H (1991) Stoma care: the patient's perspective. Journal of Advanced Nursing. 16,1, 39-46. DiGiuseppe R, Tafrate R, Eckhardt C (1994) Critical issues in the treatment of anger. Cognitive and Behavioural Practice. 1,1,111-132. Eysenck M (1996) Simply Psychology. Psychology Press, London. Ferguson T, Eyre H, Ashbaker M (2000) Unwanted identities: a key variable in shame-anger links and gender differences in shame. Sex Roles. 41, 3-4,133-158. Friedman H, Booth-Kewley S (1987) The 'disease-prone personality'. A metaanalytic view of the construct American Psychologist. 42, 6, 539-555. Garham P (2001) Understanding and dealing with anger, aggression and violence. Nursing Standard. 16, 6, 37-42. Johnson B (2002) Emotional Health. James Nayler Foundation, York. Lerner HG (1988) Women in Therapy. Jason Aronson Publishers, Northvale NJ. Lyon B (2000) 'Don't go from mad to worse'. Nursing. 30,12, 60-61. McCabe C (2004) Nurse-patient communication: an exploration of patients' experiences. Journal Nursing. 13,1, 41-49. McCauley J, Tarpley M (2004) Irritability (yours and theirs). Journal of the American Medicai Association 291, 8,921-923. McKay M , Rogers P, McKay J (1989) When Anger Hurts: Quieting the Storm Within. New Harbinger Publications, Oakland CA. ofCilnicai Gerrish H, Husband C, MacKenzie J (1996) Nursing for a Multi-Ethnic Society. Open University Press, Milton Keynes. Gianakos I (2002) Issues of anger in the workplace: do gender and gender role matter? The Career Development Quarterly 51, 2,155-172. Hollinworth H, Hawkins J (2002) Teaching nurses psychological support of patients with wounds. British Journal of Nursing. 11, 20, SB-S18.

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usually from the individual's perspective he or she has a right to be angry (Novaco 1976, Payne and Walker 1996). Set limits on inappropriate anger expression such as profanity (Thomas 1998). Enable the person to develop and use assertive communication skills (McKay etal 1989, Beck and Fernandez 1998). Reassure the individual that something will be done (Thomas 2003). Take positive steps to address expressed concerns. A patient-centred relationship should be the cornerstone of all nursing practice.

Conclusion
The fast pace and impersonal task-orientated approach to care evidenced in some healthcare environments can compound the anxiety and stress experienced by patients and their families. If an individual senses that personal control has

diminished, or feels anxious and vulnerable, then feelings of anger can be aroused. Sometimes, anger serves as a positive function in coping with stress, energising that person to confront injustice or perceived insensitive care. Occasionally, anger can precipitate an aggressive action in the belief that this will change the situation that provoked the angry reaction (Novaco 1976). Rather than mirroring this angry response, nurses need to stand back and reflect critically on the type of relationship they develop with patients. Practitioners should use their professional skills, intuition and expertise to identify potential triggers for the emotional turmoil that can precipitate angry reactions, and foster therapeutic relationships with patients. This requires practitioners to be selfaware, and demonstrate empathy. Nurses have the skills to communicate well with patients, and these skills should also be used when dealing with people who are angry. The key is to ensure that nurses and other healthcare professionals embrace a patient-centred philosophy of care NS

References continued
Metcalf C (1999) Stoma care: empowering patients through teaching practicai skills. British Journal of Nursing. 8,9, 593-600. Milne HA, McWilliam CL (1996) Considering nursing resources as 'caring time'. Journal of Advanced Nursing. 23, 4, 810-819 Morse J, Bottorff J, Ander^n G, O'Brien B, Solberg S (1992) Beyond empathy: expanding expressions of caring. Journal of Advanced Nursing. 17,7, 809-82L NHS Modernisation Agency (2004) 10 High Impact Changes for Service Deiivery and Improvement, www.content.modern. nhs.ul</cmsWISE/HIC/HIC+Intro.htm (Last accessed: May 9 2005.) Novaco R (1976) The functions and arousal of anger. American Journal of Psychiatry. 133,10,1124-1128. Nunn JS, TTiomas SL (1999) The angry male and the passive female: the role of gender and self-esteem in anger expression. Social Behaviour and Personality 11, 2,145-154. Nursing and Midwifery Council (2002) Code of Professional Conduct. NMC, London. Payne S, Walker J (1996) Psychology for Nurses and the Caring Professions. Open University Press, Buckingham. Plaas K (2002) Like a bunch of cattle: the patient's experience of the outpatient heaith-care environment. In Thomas SP, Poliio HR (Eds) Listening to Patients: A Phenomenoiogical Approach to Nursing Research and Practice. Springer Press, New York NY, 237-251. Regina SK (2003) Visiting a patient with a temporary ostomy: a personal reflection. Ostomy Outlook. May. www.ostomyok.org (Last accessed: April 8 2005.) Ridner S (2004) Psychological distress: a concept analysis. Journal of Advanced Nursing. 45, 5, 536-545. Sharkin BS (1993) Anger and gender: theory, research and implications. Journal of Counselling and Development. 71, 4, 386-389. Shattell M (2002) Eventually it'll be over: the dialectic between confinement and freedom in the world of the hospitalised patient. In Thomas SP, Poliio HR (Eds) Listening to Patients: A Phenomenologicai Approach to Nursing Research and Practice. Springer Press, New York NY 214-236. Smith M, Hart G (1994) Nurses' responses to patient anger: from disconnecting to connecting. Journai of Advanced Nursing. 20, 4, 643-651. Spielberger C, Johnson E, Russell, S, Crane R, Jacobs G, Worden T (1985) The experience and expression of anger: construction and vaiidation of an anger expression scale. In Chesney M, Rosenman R (Eds) Anger and Hostility in Cardiovascuiar and Behavioural Disorders. Hemisphere Publishing Corporation, New York NY 5-30. Tavris C (1989) Anger: The Misunderstood Emotion. Second edition. Touchstone, New York NY Thomas SP (1998) Transforming Nurses' Anger and Pain: Steps Towards Healing. Springer, New York NY. Thomas SP (2003) Anger: the mismanaged emotion. Dermatoiogy Nursing. 15, 4, 351-358. Turkel A (2000) The 'voice of self-respect': women and anger Journal ofthe American Academy of Psychoanalysis 28,3,527-540 Wegner DM, Pennebaker J (1993) Handbook of Mental Control. Prentice Hail, New Jersey NJ. Winstanley S, Whittington R (2004) Aggression towards health care staff in a UK general hospital: variation among professions and departments. Journai of Clinical Nursing. 13,1, 3-10.

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