Leigh Steiner, PhD

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,

 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 

 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 cases

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 

 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 

 in January, on the other hand, does not shy away from using the word 

 in relation to her experience with COVID-19

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.”

To be sure, anger is increasingly cropping up in the literature about HCPs coping with the pandemic.

 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.

 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.

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 

 lists 7 things that can make nurses angry, including “feeling overloaded and overwhelmed” and “feeling powerless or lacking control over the work environment.

Anger has been reported by a variety of different disciplines in response to stressful situations, including among medical students,

 emergency department nurses dealing with domestic violence presentations,

 Nurses experience anger toward patients who self-harm

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.”

 Therapists may be especially likely to feel anger toward borderline patients who express rage.

Nurses may experience anger when dealing with aggressive patients in the behavioral health setting.

 Nurses’ reported anger was significantly positively correlated with their endorsement of restraint as an approach to managing patient aggression.

 HCP anger can in turn exacerbate patient aggression.

 Among female nurses, low confidence in dealing with aggressive situations was associated with higher levels of anger.

 Mindfulness training has been shown in a limited number of studies to be effective in reducing therapists’ anger.

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.

 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.

This article was originally published by sister publication Psychiatric Times.

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. 

. 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. 

. 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 response. 

5. Gloster AT, Zacharia M, Karekla M. Psychological aid for frontline healthcare workers. 

6. Stuijfzand S, Deforges C, Sandoz V, et al. Psychological impact of an epidemic/pandemic on the mental health of healthcare professionals: a rapid review. 

7. Brophy JT, Keith MM, Hurley M, McArthur JE. Sacrificed: Ontario healthcare workers in the time of COVID-19. 

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 pandemic. 

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 Registry. 

10. Boertje J. How to get off the anger-go-around. 

. 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? 

12. Christensen M, Metcalfe LL, O'Reilly R. Emergency department nurses experiences of female domestic violence presentations: a review of the qualitative literature. 

13. Myszkowski N, Villoing B, Zenasni F, et al. Monitoring stress a

mong internal medicine residents: an experience-driven, practical and short measure

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-harm. 

15. Stovall M, Hansen L, van Ryn M. A critical review: moral injury in nurses in the aftermath of a patient safety incident. 

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. 

17. Nadelson T. Borderline rage and the therapist's response. 

18. Jalil R, Dickens GL. Systematic review of studies of mental health nurses' experience of anger and of its relationships with their attitudes and practice. 

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 survey. 

20. Haugvaldstad MJ, Husum TL. Influence of staff's emotional reactions on the escalation of patient aggression in mental health care. 

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 situations. 

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 training. 

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 services. 

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

Leigh Steiner, PhD

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