Approach to angry patients and anger expression styles of emergency medical services professionals

Abstract

AimThe aim of this study is to determine the anger and anger expression styles of the emergency medical services (EMS) professionals, to determine whether they see themselves as adequate when working with angry patients or patient relatives, and contribute to the field.MethodsThe sample of the study consisted of 564 people working in Ankara EMS. Demographic Questionnaires and Anger and Anger Expression Style Scales (AAES) were used in the study. All data were analyzed using SPSS for Windows version 21.ResultsFor the participants, the mean Anger score was 19.8 (± 5.5), the mean Anger-out score was 16.8 (± 5.6), the mean Anger-in score was 17.3 (± 4.3), and the mean Anger Control score was 22.8 (± 5.8). Those who felt inadequate to approach an angry patient were found to have higher continuous anger and anger-in scores, while their anger control scores were lower.DiscussionIn this study, the rate of encountering with angry patients of employees was found to be 96.6%. According to the findings of this study, employees having high levels of anger and less anger control levels are experiencing inability to interfere with angry individuals. Employees can ignore their anger by considering patients and their relatives as angry.ConclusionsAccording to the findings, EMS workers need training on anger management and effective communication.

Keywords

Introduction

The health Professionals in EMS are facing with several different cases. In the majority of the cases, there are individuals who are frightened, anxious, intense stressed and cannot cope with the situation which they have experienced.^1-3 When these individuals are insufficient to cope with the crisis and stress situation they faced, they can exhibit anxiety, anger expression and aggressive behaviors. EMS personnel may experience an inability to manage individuals and their families who have experienced physical and mental trauma under intense stresses.^1-3 Although it is known that individuals react differently to the stress they experience, the main outcomes of this chaos environment can often be anxiety, anger, feel guilt or indecision. These feelings also can be expressed by both service receivers and service providers.⁴ EMS professionals may experience inadequate anger control and anger expression while serving individuals suffering pain and fear.^5-7 Anger is a basic feeling that people are experiencing.⁸ Anger can also be defined as a negative emotional state accompanied by thoughts of physiological arousal and hostility towards a person or object, often seen as the cause of a negative event.⁹ Spielberger (1983).¹⁰ considers continuous anger as a concept that reflects how frequently anger situation was usually experienced by the individual, “anger-in” as the tendency to suppress thoughts and emotions that bring out anger; “angerout” as the tendency tends to show aggressive behavior towards individuals or objects in the environment; “anger control” as the ability to reflect the control of anger expression. The feeling of anger that cannot be expressed by appropriate means may often result in verbal or physical violence. In many studies, it has been revealed that emergency healthcare workers are frequently exposed to violence by the patients and their relatives.^11-12 Health workers facing violent behaviors were stated mostly having anger expression feelings. Consequently, as a result of this stressful environment, the stress of anger feeds the violence and the sense of anger again.^11-12 Failure to identify and respond appropriately to angry patients may become the source of many problems, particularly violence to health professionals. The number of studies on the expression styles and approaches to “anger”, “anger-in”, “anger-out” and “anger control” is limited and it is seen that these studies are mostly directed to the personnel working in emergency clinics, and there is no study for the employees working in EMSs. This study was conducted in order to contribute to the literature in this field due to insufficient number of studies The aim of this study was to determine the anger and anger expression styles of the health professionals in Ankara 112 EMS, to determine whether they are competent to work with angry patients or their relatives.

Materials and Methods

The population of this study was composed of health centers serving in Ankara 112 EMS stations. The sample was not determined in the study and it was aimed to reach the whole population. The total number of personnel working under the presidency of emergency healthcare services is 2361. Healthcare personnel number is 1757 (113 Doctors, 99 Nurses, Midwife, Health Officer, 1131 EMT (Emergency Medicine Technician), 414 Paramedic), and 604 of them are other employees (Secretary, Housekeeper, driver, etc.). The study was conducted between June 2014 and September 2014 with 564 people who agreed to participate in the study from 1536 employees actively working in the university. Nine hundred seventy-two employees were excluded from the study due to different reasons such as not accepting to participate in the study and 221 employee’s absence due to leaves and reports. In the study, the Socio-Demographic Questionnaire developed by the researchers as a result of the literature review and “Anger/Anger Expression Style Scale (AAES)” forms were used.Socio-Demographic QuestionnaireSocio-Demographic data form consists of 7 questions about gender, age, marital status, educational status, professional status, duration of professional experience and duration of their work in 112, the questions for determining the situations that employees faced as a necessity of their jobs were including; whether or not he/she individually faced with a patient showing aggressive behavior; whether he/she feels adequate when serving the individual with aggressive behavior. Anger/Anger Expression Style Scale (AAES): It was developed by Spielberger.¹⁰ in 1983 and its validity and reliability were performed by Özer.¹³ The scale consists of 4 sub-scales and 34 items including anger-in, anger-out, anger control, and continuous anger. While the first 10 items of the scale measure the level of continuous anger, 24 items determine individuals’ anger styles (anger-in, anger-out and anger-control subdimensions). High scores on continuous anger subscale indicate high levels of anger, high scores on anger control subscale indicate individual can control the anger, high scores on the anger-out subscale indicate that anger is easily expressed, and high scores on anger-in subscale show that the anger was suppressed.¹⁴ For this study, Cronbach’s alpha coefficients were found to be 0.79 for ‘continuous anger’ dimension, 0.78 for ‘anger-out expression’ dimension, 0.62 for ‘anger-in expression dimension and 0.84 for ‘anger control’ dimensionEthical Aspect of the StudyEthical Board Permission for the study was obtained from the ethics committee of Yıldırım Beyazıt University in Ankara and in writing from the relevant institution whose name was specified in the ethics committee form (18/09/2018-41). Written informed consent was obtained from individuals who wanted to participate in the study.Statistical Analysis of the ResearchIn the statistical evaluations, socio-demographic characteristics of the patients were given as number, percentage distribution, mean, standard deviation values. The relationships between socio-demographic data, categorized open-ended questions and AAES scores were evaluated by SPSS 21 Statistical Package Program. Since the continuous variables used in the study did not show normal distribution according to the Shapiro-Wilk normality test, the post-hoc analysis of the significant variables using the Kruskal-Wallis and the Mann-Whitney U test was evaluated with the Bonferroni test in the evaluation of AAES scores with socio-demographic variables. The power analysis of the study was done with G power 3.1.9.2 Statistical Program and (n: 564), group 4, α: 0.05, effect size F: 0.15 power (1-β): 0.86 was found.

Results

Frequency distributions of socio-demographic characteristics are shown in Table 1. In our study group, 65.1% of participants were female. The mean age was 32±6,5 and 57,9 % were between 26 to 35 years of age. Those who have a bachelor’s degree accounted for 69,7 of all participants, 76,6 % of them were married. While the experience of the participants in the EMS field is mean 7.8±4,7 years, it is 10,4±5,9 years for all health services (Table 1). Comparison of scale scores of socio-demographic characteristics is given in Table 2. Table 2 shows that there was a significant difference between Professional Status and anger-in score (p <0.05). In post-hoc analyzes of the data, anger-in scores of Doctors, were statistically significant compared to other occupational groups. When we look at the working years in the unit, there was a significant difference between years and anger control score (p <0.05). In post-hoc analysis of the data, it was concluded that the anger control scores were significantly lower for people working in the unit for 20 years or more. When the scores and answers given to the question of ‘How do you find yourself to approach the patient who cannot control his anger?’ were compared, there was a significant difference between the anger, anger-in, and anger control scores (p <0.05). In advanced analyzes, it was found that those who felt incapable to approach the angry patient had higher scores in continuous anger and anger-in scores but lower anger control scores. Socio-demographic characteristics of the respondents to the question ‘How do you find yourself to approach the patient who cannot control his anger?’ are shown in Table 3.

Discussion

EMS professionals often serve individuals who experience anger. In this study, the rate of encountering with angry patients of employees was found to be 96.6%. Given that aggressive behavior is a trigger of violence, it is important for employees to have the knowledge and skills to approach angry patient and to be able to recognize their anger status and professionally keep it under control. Employees can ignore their anger by considering patients and their relatives as angry.¹⁵ In the study, when the total anger scores of the participants were evaluated, total score of Continuous Anger was found as 19.8 ± 5.5; Anger-In scores were found as 17.3 ± 4.3; Anger-Out scores were found as 16.8 ± 5.6; Anger Control scores were found as 22.8 ± 5.8. In a study conducted by Kaya et al.¹⁶ on nurses, while the mean score was 20.41 ± 4.36 for continuous anger, it was 16.22 ± 3.46 for anger-in, 15.25 ± 3.04 for anger-out 22.89 ± 4.23 for controlled anger. In our study, a comparison of the anger level and anger expression style scores of the EMS employees with the other health workers showed similarities. The majority of the participants in our study were female workers (65%, n= 367). In terms of gender, there was no significant difference between anger level and anger expression styles. In the literature, it was found that the continuous anger scores of the males were statistically significantly higher in some sources.¹⁷ and that the female anger-out scores were higher than the males.¹⁸ and there was no difference between the anger scores in terms of gender for the other studies^14-15,19 Studies investigating the relationship between gender and anger do not provide clear information in this context. According to the findings, it is recommended to do more in-depth studies in this subject. No significant relationship was found between age, education level, marital status, occupational age variables and AAES subdimensions. In Kaya et al.¹⁶ study it was found that the controlled anger scores were decreased when the age increased. Kayalı et al.²⁰ in their study, found that married and unmarried people were showing more anger control than divorced people. The results showed that the anger-out and continuous anger scores of university graduates were higher than those of high school graduates.¹⁷ Similarly, no differences were found between these variables and the anger scores in some studies.¹⁴ When compared the professional status, there was a statistically significant difference between these categories and AAES scores of anger-in scores. The post-hoc tests showed that the anger-in scores of the Doctors were significantly higher than other employees. In both domestic and foreign literature, there was not enough information about the continuous anger and anger expression styles of Doctors. However, in a study, it wasfound that emergency physicians occasionally showed verbal violent behavior, and this behavior was shown as a result of inappropriate behaviors and aggressive behaviors of the patients and their relatives.²¹ Violence against physicians was frequently heard in recent years. Therefore, new studies on the continuous anger and anger expression styles of physicians may contribute to the literature. When the answers given to the open-ended questions created by the researchers were examined, it was found that those who felt inadequate to approach the angry patient had higher scores in anger and anger, and anger control scores were lower. When the literature was examined, no information was found in this direction. In this case, it can be said that employees who cannot express their anger in appropriate ways have inability and difficulty to approach an angry patient. EMS professionals are serving in a very stressful environment. Employees may not be aware of their own feelings of anger and anger control levels when they were under stress working environment for a long period. Mutual anger can often result in violence. According to the findings of this study, employees having high levels of anger and less anger control levels are experiencing inability to interfere with angry individuals. Therefore, employees need training programs on anger management, expression of anger in an appropriate way, and skills development related to the angry patient approach.

Declarations

References

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