Anger is an emotional state experienced as the impulse to behave in order to protect, defend or attack in response to a threat or challenge, and as such can have a legitimate function. Of itself, anger is not classified as an emotional disorder. This emotional state may range in intensity from mild irritation to intense fury and rage, and becomes a problem when it is associated with poor impulse control and related behaviours.

‘Violence and aggression refer to a range of behaviours or actions that can result in harm, hurt, or injury to another person, regardless of whether the violence or aggression is physically or verbally expressed, physical harm is sustained or the intention is clear’ (NICE [208], p.6).

The phrase ‘clinically challenging behaviour’ can be used to refer to aggressive, confrontational or threatening behaviour from patients arising from any of the following:

The Health and Safety Executive (n.d.) reports that violence and aggression form the third most frequently reported group of incidents from the health and social care sector in its RIDDOR incident reporting system. Therefore, nurses will, sadly, be exposed to anger and aggression.

Poor communication is frequently a precursor to anger and aggressive behaviour (Duxbury and Whittington [85]). Aggression and abuse tend to be discussed synonymously in the literature and are reported to occur with some frequency in nursing (McLaughlin et al. [174]). Anger is felt or displayed when someone's annoyance or irritation has increased to a point where they feel or display extreme displeasure. Verbal aggression is the expression of anger via hostile language; this language can cause offence and may result in physical assault. Some people experience verbal abuse as worse than a minor physical assault (Adams and Whittington [1]).

There can be many causes of clinically challenging behaviour, including unmet care needs (such as thirst, pain or the need to eliminate) as well as a lack of meaningful activity, sensory deprivation, sleep deprivation, and impaired ability to communicate or understand a situation. NHS Protect ([200]) proposes a framework for explaining challenging behaviour. This includes considering:

Figure 5.16 presents this framework in more detail.

In some instances, challenging or difficult behaviour can be seen to be related to underlying stress and difficulty in a person's situation. Anger, aggression and violence may have ‘biological, psychological, social and environmental roots’ (Krug [146], p.25). People frequently get angry when they feel they are not being heard or when their control of a situation and self‐esteem are compromised. Institutional pressures can influence healthcare professionals to act in controlling ways and may contribute to patients’ angry responses (Gudjonsson et al. [115]). Patients are often undergoing procedures that threaten them and they may consequently feel vulnerable and react aggressively as a result (NHS Protect [200]). Threats, uncertainty and disempowerment may predispose people to anger, and living with and being treated for a serious condition can be sufficiently threatening and disempowering (NHS Protect [200]). Another source of anger can arise when personal beliefs are contravened via social or religious rules being broken by others. Nurses therefore need to strive to be aware of individual and cultural values and work with them to avoid frustration and upset.

People can become angry when they feel that they have not been communicated with honestly or feel they have been misled about treatments and their outcomes. To prevent people's frustration escalating into anger or worse, health professionals need to ensure that they are communicating openly, honestly and frequently (NHS Protect [200]).

Some patients may appear or sound aggressive when they are not intending to be and nurses must therefore use good judgement to clarify the patient's behaviour in these instances. Nurses also need to be aware of their own boundaries and capabilities when dealing with challenging or abusive situations.

For some people, anger may be the least distressing emotion to feel or display. Sometimes helplessness, sadness and loss are far harder to explore and show to others. Anger therefore can be a way of controlling intimacy and disclosure, but it can escalate to threatening, abusive or violent behaviour.

Whatever the cause of anger or aggression, people can behave in a number of challenging ways and with varying degrees of resistance to social and hospital rules. People may simply refuse to comply with a request or may behave aggressively, for example by pushing someone aside (without intent to harm) or by deliberately striking out at others. Mental capacity issues should be considered when assessing the causes of aggressive behaviours. However, some patients may feel too depleted by experiences of disease and treatment to express their anger (Bowes et al. [26]).

Prevention is the most effective method of managing anger – that is, diffusing stressful or difficult interactions before they become a crisis. Understanding why angry or challenging behaviour occurs can be helpful in establishing a comprehensive approach to prevention.

The public health model detailed in Meeting Needs and Reducing Distress (NHS Protect [200]) focuses on the prevention and management of challenging behaviour that is clinically related. It proposes that the focus should be on primary prevention (addressing the root cause before challenging behaviour happens) and then if necessary secondary prevention (using de‐escalation techniques, empathy and understanding). There should be less emphasis on tertiary responses (restrictive interventions including physical intervention and medication).

Nurses may be inclined to accept aggressive behaviour as part of the job (McLaughlin et al. [174]) due to being encouraged to be caring, compassionate and accepting of others. Despite this, nurses have the right to work without feeling intimidated or threatened and should not tolerate verbal or physical abuse, threats or assault. Personal comments, sarcasm and innuendo are all unacceptable. Any healthcare professional is legally permitted to act in self‐defence as long as the response is proportionate to the seriousness of the attack.

Employers have a responsibility to adhere to the Management of Health and Safety at Work Regulations ([166]) (see also NHS England [196], NHS Protect [200]). This involves providing a safe environment for people to work in and one that is free from threats and abuse. With any physical assault, the police should be involved.

The ideal outcome of an encounter with an angry, aggressive or threatening person is that safety is not compromised and the healthcare professional is able to de‐escalate the situation and help the person to express the reason why they are angry. Follow‐up support should be offered to help stop the person repeating the same behaviour. However, people should also be made aware of potential sanctions if they are unable to comply, for example withdrawal of treatment and involvement of the police (Box 5.17).

It can be distressing to be exposed to threatening or abusive people and it is good practice to seek a debriefing interview. This can help nurses and the institution reflect upon the experience and put procedures in place to manage such situations. The institution's occupational health or human resources department should have information on how nurses can access support facilities.