The LOWLINE approach to de-escalating anger draws on established principles in communication and empathetic listening, and can help to resolve difficult situations
As newly qualified staff nurses settle into their roles, they will inevitably experience stress, which can be exacerbated if they do not feel well equipped to deal with the situation.This article considers the issues facing new staff nurses confronted with an anger event and offers insights into ways of resolving such situations. It proposes a new model for practice, which involves a sequence that lends itself to logical progression towards resolution. The LOWLINE model draws on established principles in communication and empathetic listening, which play an important part in understanding anger.
Citation: Lowry M et al (2016) De-escalating anger: a new model for practice. Nursing Times; 112: online issue 4, 4-7.
Authors: Mike Lowry is a former lecturer in nursing skills; Graham Lingard is lecturer in learning-disability nursing; Martin Neal is lecturer in mental health and dementia studies; all at the School of Nursing, University of Bradford.
- This article has been double-blind peer reviewed
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Dealing with people who are angry can be difficult, particularly for those with little experience of doing so in a way that defuses the situation. Newly qualified staff nurses learn by watching others and by asking their preceptors questions about the situations they encounter. On occasion, they will be confronted by new and unfamiliar events, but will lack the internal resources or experience to devise a plan of action to deal with them. Such situations could include being confronted with an angry patient, visitor or colleague. Thomas (2010) discusses the effect that aggressive situations can have on newly qualified nurses and students, and stresses the vital role of continuing education in preparing nurses to prevent and manage violence. Training should focus on supporting and empowering those involved to deal with violent situations (Box 1).
Paradoxically, Eslamian et al (2010) claim that, while training in anger management techniques leads to a reduction in psychological violence, it does not lead to a reduction in physical violence. Problem-based approaches are said to lend themselves better to conflict resolution, through development of personal insight and greater interpersonal skills awareness (Seren and Ustun, 2008).
In times of crisis, newly qualified nurses may have to call on their managers for support, leading to potential feelings of defeat and the fear of being labelled ineffective. To pre-empt this, they might attempt to resolve a situation independently – for example, in cases where patients are angry – but this can lead to a further escalation of anger. Self-doubt, lack of experience and the need to seek help are part of the experience of being a newly qualified staff nurse. However, there are strategies they can use to address situations in which they have to deal with an angry patient; they can also be used with others, such as visitors and colleagues.
Box 1. Dealing with violent situations
An education programme to prepare nurses could include:
- Confrontation tips
- Implementation of violence-free contracts
- Participation in role-play activities
- Adoption of a professional communication technique
- Keeping a reflective journal journaling and cognitive recognition
- Use of nurse preceptors and practice partnerships
Source: Thomas (2010)
Identifying anger in others
Anger is not in itself always bad – it is a feeling or emotion, often a response to a perceived negative situation. We all get angry at times and sometimes this can lead to positive outcomes. Anger can dissipate or escalate; which way the situation goes may be determined by the actions or responses of the nurse.
People become angry for different reasons, and the way it is manifested varies between individuals and situations, so it can be difficult to recognise the extent to which someone is angry. There will often be indications of the depth of anger, but these may be subtle; for example, one person might sulk or become uncharacteristically quiet, while another might display agitated behaviour or verbal hostility. It is important to be aware of the warning signs and act accordingly. If there are few outward signs of anger, it does not necessarily mean that the potential for a dangerous escalation is less.
One group of patients with whom newly qualified staff nurses often struggle, in terms of managing their anger, are people with a co-morbid diagnosis of dementia. The anger often arises out of the person’s confusion, frustration or fear, and is not necessarily aimed at those to whom it is expressed. This poses difficulties in environments in which patients who have dementia are nursed alongside others who do not (Lakey, 2009).
Managing the anger of patients with dementia requires a specific skill set and approach. An understanding of Feil’s (2012) principles of validation and Kitwood’s (1997) principles of person-centred dementia care would equip nurses with practical strategies to enhance their communication. One immediate strategy that significantly helps reduce anger in people with dementia is to stop using the direct question “why”, as the word can be challenging to them – their cognitive impairment may leave them unable to elicit the reasons for their fear or anger. Avoiding the use of “why” when responding to people with dementia can have a significant effect on reducing anger that has been inadvertently triggered (Feil, 2012).
Causes of anger
The cause of anger is almost always an unmet need – for control, information, to be listened to, to feel safe or to be pain-free; it may have psychological antecedents or be triggered by fear.
A common cause of anger described by Parrott et al (2003) is the effect of drugs, especially alcohol, which can significantly affect how readily individuals express anger, especially when provoked. Manifestation of anger can also be affected by negative reactions from nurses or other perceived authority figures.
Even the most placid individuals can experience frustration in an unfamiliar environment in which they perceive things to be beyond their control. For example, frustration and fear can be triggered when people are admitted to hospital and become inpatients; some will become angry, in part, due to the release of adrenaline (Stemmler et al, 2001). Fear and its associated anger response may act as a form of defence against the perceived threat to their autonomy or reduced control over a situation. This is exacerbated when a patient tries to understand the situation and encounters staff responses that appear unsympathetic or insensitive. In busy clinical environments, staff have less time to notice the subtle signals that indicate when a patient is becoming frustrated or fearful; patients may also be reluctant to ask for help if they perceive that staff are overworked. It is little surprise that this can result in anger.
Acceptance that anger is almost inevitable in some circumstances means it is wise to consider how best to deal with it, other than to take it personally or use the incident to offload onto already hard-pressed colleagues. Once warning signs have been identified, it is essential for nurses to respond at the earliest opportunity. This would be determined by a number of factors, not least individual nurses’ confidence in their own abilities. It is far better to anticipate the problem and develop workable strategies for dealing with it effectively.
It is essential for nurses to be assertive in their approach to an angry person. People often wrongly confuse assertive behaviour with aggressive behaviour. Assertiveness is a way of behaving in an open, honest manner to communicate feelings, thoughts and beliefs without violating the feelings, thoughts and beliefs of others (Adam and Taylor, 2014).
An aggressive or passive response to anger might result in an escalation of the situation. Nurses need to be aware of themselves and how they are presenting to patients who appear angry by maintaining eye contact, a clear, calm voice and showing attentiveness; their posture should be non-threatening, relaxed and open. Nurses also need to be aware of the patient, observing changes in behaviour or other signs of escalation or de-escalation, and to react accordingly. While this may be difficult, it is important to present as caring and willing to help, rather than as an authority figure and representative of the organisation.
The LOWLINE theoretical model contains elements for effective listening. It evolved as a distillation of common approaches to skilled communication:
It might be tempting to make statements early in the engagement, but saying nothing can be powerful at the beginning of the de-escalation process. What constitutes good communication skills – in other words, active listening – is not simply hearing the words being said by the person who is angry. Skilled listening can make it possible to pre-empt an angry outburst by looking for, or reading, non-verbal signals, or by listening to paraverbal communication, that is, tone, inflection and volume. Patients are unlikely to have chosen to be in their relatively vulnerable situation; it is likely they might be fearful, so anger may be the response.
Active listening uses non-directive, non-intrusive verbal feedback to let angry patients know they are being paid attention to. The use of open-ended questions is an effective active listening technique. Questions such as “can you tell me more about that?”; “what happened after that?”; and “do you have other thoughts and feelings about that?” can help the patient explore the cause of the anger and possible solutions. Anything that causes the patient to explain, rather than argue, would help lower the confrontation level.
Nurses should offer reflective comments, which should be brief and use the words spoken by the angry patient. Unless they acknowledge that the patient is feeling angry, it is unlikely that they would be able to work together to deal with the anger. Therefore, when a patient appears to be angry or is demonstrating early signs of anger, it is important for nurses to notice it and to state what they see or hear, so the patient can be sure their feelings are being taken seriously. At this stage, it is wise to avoid comments that could be seen as devaluing, such as “I can’t see why you are angry”, because that is likely to inflame the situation. It is better to say, for example: “I notice you are angry.”
After acknowledging the anger, nurses should ask what the angry person perceives to be the cause. People in this situation might not be able to pinpoint the cause, but simply respond that they “felt unease” about something. Nonetheless, they need the opportunity to explore their feelings, rather than allow these to fester and worsen. A useful technique is to offer them the opportunity to air their feelings. This involves letting them speak, giving them a chance to ventilate and discharge their frustration harmlessly. While patients do this, nurses should not argue, proffer advice or defend themselves, but should give patients space to continue. The purpose is to let them “blow off steam”, providing the space to express their anger and thereby decrease it.
Nurses should avoid the temptation to fill the void with words. If the situation feels uncomfortable, a good technique is to count slowly down from 10. That is usually more than long enough for the silence to be broken.
Although eye contact is important, it should be appropriate to the patient. Nurses should consider how much direct contact is likely to be acceptable. For example, while it is important to establish eye contact, unremitting stares should be avoided. It is essential to remember that facial expressions can give a lot away: smile, if appropriate, and maintain a neutral expression if not.
Inclining the head is useful to affirm interest. A slightly inclined head often serves to present a non-threatening posture.
An occasional and appropriate nod can demonstrate continued attention and a willingness to listen without interrupting.
Nurses should express a desire to understand/express empathy. It is important to keep it brief, for example, by saying “I expect that made you feel worse”, “you must have felt isolated” or “I can appreciate why you felt that way”. Paraphrasing can be an effective way to express empathy. This involves feeding back that which the person said has been heard, but using different words. In a situation that involves dealing with an angry person, paraphrasing communicates that their concerns are being taken seriously. After paraphrasing, it is helpful to let them know that their story has been heard by summarising the content of the encounter. This also enables the nurse to check information and to amend understanding.
The next stage
After their anger has been de-escalated, patients should be encouraged to explore options to meet their unmet needs and to address issues. Nurses should encourage them to maintain ownership, but offer appropriate support and advice, such as “what can we do to resolve this?”
Nurses should identify how angry patients would like the cause or focus of their anger to be dealt with, and by whom. For example, they might ask to speak with a senior member of staff to complain about something. Equally, what they might really be seeking is some measure that their concerns are being dealt with and not merely paid lip service to. Having someone listen to their concerns and offer a way to deal with them may be sufficient to de-escalate their anger.
All options should be considered. There is rarely a single way of reaching a solution, but it is essential not to promise unachievable solutions. Given that adults are generally used to making decisions for themselves, offering them a range of options enables them to take an active part in solving the problem or, at least, reducing their feelings of anger.
It is also important to commit to a timeframe for dealing with the cause of the anger, but it is essential not to promise unattainable options. It is pointless going through the stages described above, then leaving things unresolved. Far better to commit to what is to be done, by whom and when. That way there is visible acknowledgement that the perceived cause of the anger is being addressed. It is, however, useful to build in some flexibility with timing to help manage expectations, such as saying “we will try to get your results by the end of the day”. Making an absolute commitment that is not fulfilled could serve to heighten the anger. It is important to review the patient’s feelings towards the perceived cause of anger.
Once the anger has subsided, nurses should discuss with the patient how best to avoid a recurrence. It is helpful to remember that patients are often more likely to get angry again within 90 minutes of an initial outburst (Murphy, 2001). They may be able to identify triggers for their anger, for which strategies can be devised to avoid or reduce these in future. Good relationships sometimes come out of strained beginnings, and patients are likely to feel more appreciative towards a nurse when they have shared an experience that has had a satisfactory resolution. Any effective strategies should be shared with colleagues to reduce the risk of recurrence. It is essential to document the event and review the situation with the person.
Resolution of own feelings
Being involved in dealing with an anger event is enough to affect how nurses feel on a personal level. Therefore, it is always helpful for them to debrief after the event and to use what they have experienced to increase their portfolio of understanding for the future. This can be done with colleagues or individually, but a structured reflection is useful and can be used as revalidation evidence (Lowry, 2016). This could include consideration of the following questions:
- What happened? The nurse should think about who was involved, what was happening before and consider if there were any obvious triggers;
- How did the nurse feel at the time? Nurses should explore how they felt when they first became aware of the anger;
- Was the situation a surprise – did it seem unreasonable at the time?
- How does the nurse feel now? Hindsight is only of benefit if we learn from it. Nurses should think about how they feel after dealing with the person and their concerns. After having time to reflect, what level of personal hurt did they feel, for example, if the factors that caused the patient’s anger were outside of their control?
- What advice would the nurse offer to a newly qualified colleague in a similar situation?
It is almost inevitable that new staff will have to deal with anger in others at some time. A little preparation and forethought can make things smoother for all those involved. Being empathetic can help newly qualified nurses remain grounded by having an awareness of the situation from the patient’s perspective. Considering what it is like to be in the patient’s position can be a useful strategy to understand the causes and ideally prevent anger escalating.
De-escalation training should be a mandatory part of nurse education; it should be followed up as a mandatory part of preceptorship. Using a framework, such as LOWLINE, can add structure to a nurse’s practice and make them better equipped to deal with anger and its effects.
- Newly qualified nurses may have to deal with anger at times when they feel underprepared or isolated
- Nurses need strategies to help them address anger and diffuse situations
- Newly qualified staff need to maintain a sense of proportion when dealing with anger in others
- Staff involved in dealing with an angry patient or relative need time and support to debrief
- Nurses should reflect on what the engagement may have taught them about how to deal with anger in others
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