- Email: [email protected]
Brief Training on Patient Anger Increases Oncology Providers' Self-Efficacy in Communicating With Angry Patients
Accepted Manuscript Brief Training on Patient Anger Increases Oncology Providers’ Self-Efficacy in Communicating with Angry Patients James Gerhart, PhD, Veronica Sanchez Varela, PhD, John Burns, PhD PII:
S0885-3924(17)30305-6
DOI:
10.1016/j.jpainsymman.2017.07.039
Reference:
JPS 9467
To appear in:
Journal of Pain and Symptom Management
Received Date: 13 March 2017 Revised Date:
18 July 2017
Accepted Date: 20 July 2017
Please cite this article as: Gerhart J, Sanchez Varela V, Burns J, Brief Training on Patient Anger Increases Oncology Providers’ Self-Efficacy in Communicating with Angry Patients, Journal of Pain and Symptom Management (2017), doi: 10.1016/j.jpainsymman.2017.07.039. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
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Brief Training on Patient Anger Increases Oncology Providers’ Self-Efficacy in Communicating with Angry Patients
Veronica Sanchez Varela, PhD2 John Burns, PhD1
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James Gerhart, PhD1*
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1. Department of Behavioral Sciences, Rush University Medical Center, Chicago, IL
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2. Vacaville, CA *Corresponding Author 1725 W. Harrison, Suite 1004
Phone: 312-942-9932
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Chicago, IL 6012
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Email: [email protected]
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Abstract
Context: Anger is a common reaction to pain and life-limiting and life-threatening illness, is
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linked to higher levels of pain, and may disrupt communication with medical providers. Anger is understudied compared to other emotions in mental health and healthcare contexts, and many providers have limited formal training in addressing anger.
providers’ self-efficacy in responding to patient anger.
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Objectives: To assess if a brief provider training program is a feasible method for increasing
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Methods: Providers working in stem cell transplant and oncology units attending a brief training session on responding to patient anger. The program was informed by cognitive behavioral models of anger, and included didactics, discussion and experiential training on communication and stress management.
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Results: Provider rated self-efficacy was significantly higher for nine of 10 skill outcomes (p<.005) including acknowledging patient anger, discussing anger, considering solutions, and using relaxation to manage their own distress. All skill increases were large in magnitude
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(Cohen’s d = 1.18 – 2.22).
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Conclusion: Providers found the program to be useful for increasing their confidence in addressing patient anger. Discussion, didactics, and experiential exercises can support provider awareness of anger, shape adaptive communication, and foster stress management skills.
Keywords: Anger, Aggression, Burnout, Cancer, Communication, Training, Providers
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Brief Training on Patient Anger Increases Oncology Providers’ Self-Efficacy in Communicating with Angry Patients
Anger is a common reaction experienced by individuals with life threatening illness including
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patients with cancer, their family members and caregivers1-4. When well regulated, anger may enable individuals to assert their needs, and persevere through frustration4-5. However, when patients do not regulate their anger well, they may experience higher levels of pain6, and have
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difficulty engaging social support systems7. Anger may also have detrimental effects on patientprovider communication if the provider feels threatened or frustrated and responds with
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avoidance or hostility 6,8. Anger has also been linked to negativistic expectations of cancer prognosis9, and use of non-medical cancer remedies10. Anger is particularly common when difficult decisions must be made regarding treatment and goals of care or when pain and other side effects are not adequately managed11. Despite the ubiquity of anger, many mental health
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clinicians, and medical providers lack specific training in acknowledging, understanding and responding to patient expressions of anger. This lack of anger specific training is troubling because medical providers are frequently the targets of patient anger and litigation8.
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Anger tends to be relatively understudied even in the mental health specialties 12-13, and
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so medical providers are left to rely on clinical anecdote, prior personal experiences or momentary emotions as they consider how react to difficult encounters with patients, family and caregivers 14-15. In the context of cancer, current cultural trends tend to cast cancer treatment within the language of warfare, and patients are explicitly encouraged to “get angry” and “fight cancer” 4,16. Although this celebrated anger could be useful for motivating patients and providers to persist in the face of fears and frustrations, once anger is primed it may spill over and interfere with patient-provider relationships and decision making. Some patients who express or display
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anger are often labeled as difficult, prompting intentional or unintentional negative responses from providers, provider burnout, and inadvertent impacts on patient treatment 17. Although many strong emotions in oncology settings can be addressed in minutes or less18, the aftermath
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of a difficult encounter may persist, particularly if providers do not have time to return to their emotional baseline before meeting with the next patient. Therefore, addressing anger requires that providers have strategies to address their own distress and physiological arousal as they go
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about their workday. Given these complex and systemic pressures on providers, targeted training
and recuperating from patient anger.
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is needed to help providers increase their confidence in understanding, appropriately engaging,
This manuscript describes a quality improvement program entitled, “Managing Anger for Providers and Patients (MAPP)”. MAPP was designed to enhance the provider’s confidence and perceived self-efficacy in communicating with patients, family and caregivers in the context of
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stem cell transplant. The program was informed by cognitive behavioral models of anger and principles of patient centered communication. MAPP was developed with the premise that understanding the cognitive behavioral determinants of anger can help providers re-
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conceptualize anger as a normative, and at times, functional response to unmet needs, as well as
anger.
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guide the provider to be more discerning in how they respond to, avoid, or acquiesce to patient
Method
Participants and Procedure Twelve clinicians from an SCT team and inpatient oncology nursing staff from a large Midwestern academic medical center participated in the MAPP training program. One clinician
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had to leave the training to attend to other tasks and did not provide ratings. The clinicians included physicians, mid-level providers (nurse practitioners, physician assistants), and nurses who regularly cared for SCT patients. Given the quality improvement focus of the program,
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demographic data were not collected.
The MAPP training program was conducted over the course of a one-hour, midday, in-
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service by a licensed clinical psychologist and a postdoctoral fellow in clinical health
psychology. Both trainers had experience treating patients with cancer, and had experience
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working with anger and aggression from prior professional roles in forensic/correctional facilities. A pocket primer to the program is included as an appendix. MAPP emphasized three levels or “roads on the MAPP”. At the patient level, providers learned to understand anger within a cognitive behavioral framework, and respond to and defuse anger (see appendix slide 2). At the provider level, providers learned to manage stress and recover from angry encounters with
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patients. At the unit or systems level, providers learned to reduce anger contagion by changing how difficult cases are discussed and managed by the team.
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The MAPP training was developed within the framework of Self-Efficacy Theory 19, which poses that behavior change is more likely to occur to the extent that individuals can
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specify targets for behavioral change and increase their self-perceived levels confidence and competence in enacting those behaviors. Being the target of another’s anger may be intimidating and threaten one’s sense of confidence. Therefore, increasing self-efficacy regarding the skills needed to effectively engage and respond to patient anger is an important step for preparing clinicians to improve their communication with angry patients.
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The Institutional Review Board deemed that this program was quality improvement and exempt from review. Training included didactics, modeling and experientials to enhance skill acquisition. In order to gauge the acceptability of the intervention, the providers were asked to
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complete a questionnaire regarding their perceived self-efficacy in communicating with angry patients.
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Program Description
Table 1 outlines the session agenda. The program opened with a video clip of an angry
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patient berating a clinician to engage participant interest and elicit discussion on providers’ experiences with patient anger. The first component of MAPP (i.e., understanding anger) aimed to develop provider’s proficiency in conceptualizing anger in terms of the Reformulated Frustration – Aggression Hypothesis 20, and the Anger Avoidance Model 5. These models focus
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on the functional determinants, manifestations and consequences of anger and aggressive behaviors. With regard to its functional determinants, didactics focused on the ways that anger tends to be elicited by pain, fear, frustration20, and other aversive conditions that are ubiquitous
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in oncology settings. An emphasis was placed on the ways that hostile misperceptions and mistrust could lead patients and families to engage critical and aggressive communication with
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providers. Providers were also encouraged to consider how angry behaviors can be reinforced to the extent that they result in social dominance, staff attention or instrumental gains (e.g. discharge, pain medications, unwarranted aggressive treatment). Armed with the ability to conceptualize anger this way, providers could then attend to the many sources of frustration, fear, and pain that elicit anger, and foster empathy for the stress experienced by many of their patients. Consistent with a cognitive behavioral framework, the discussion explicitly challenged myths and assumptions that patient anger is necessarily unhealthy, or a personal threat toward
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the provider. Providers were instead encouraged to reframe patient anger as an opportunity to explore unmet needs (see appendix slide 3).
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The second component then shifted to responding to and defusing anger with specific strategies such as reflective listening, building rapport, and discerning when to shift to solutionfocused discussions. This component included the two psychologists role-playing an angry
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encounter, as well as role plays within participant dyads. Because addressing anger requires many providers to stay present in the midst of their own discomfort and avoidant tendencies, it
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was emphasized that participants “act in character”. A first step for providers was learning to acknowledge and make reflective statements about the patient’s frustration and anger. Once strong emotions are processed and acknowledged, solution-focused strategies convey concern and help patients identify strategies for addressing unmet needs (e.g. pain management, increasing social support). Here verbal commitments to return to the conversation after a “time
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out” and other statements of care and concern can buffer the patient-provider bond and prevent patients from feeling abandoned. In the psychologists’ role-play the patient character remained angry and skeptical but agreed to keep working with the treatment team. The patient remained
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angry in order to demonstrate that in many cases strong anger will linger but incremental
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communication outcomes can be still be achieved. The third component of the training (i.e., managing stress in providers and units) included
experiential practice in stress management practices of diaphragmatic breathing, muscle relaxation, and challenging unhelpful thought processes (see Lehrer, Woodfolk, & Sine, 200721 for an extensive summary of stress management). Burnout and compassion fatigue are salient in oncology and palliative care settings22, and in the absence of specific training providers may fall back on avoidant coping strategies. MAPP recommends stress management practices such as
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meditation and muscle relaxation for extended personal practice at home, brief relaxation and self-care strategies that can be implement between patient encounters, and targeted practices for remaining open and attentive when directly involved in patient care (see appendix slide 4).
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Taking a breath, compassionate subjective self-talk, and refocusing attention on the conversation at hand can help providers stay grounded in particularly challenging moments.
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Strong negative emotions may also reverberate through and across treatment teams.
Anger contagion may occur through nonverbal communication, and verbally through “venting”
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negative attributions of patient behavior. Whereas venting may be intended to cathartic and rally support and validation from peers, it may inadvertently reinforce rumination and anger about the frustrating event. The concept of “positive venting” was introduced as a way to communicate and debrief stressful encounters in a way that elicits peer support while reinforcing compassionate and CBT-consistent attributions of patient behavior (see appendix slide 5). In
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addition to increasing emotional support within the team, MAPP recommends taking a team approach to patients who repeatedly test professional boundaries. Being consistent with expectations and limits across the team reduces the likelihood that aggressive or unsafe patient
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Measure
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behaviors will be inadvertently or intermittently reinforced by the treatment team.
Self-Efficacy in Responding to Patient Anger (SERPA23) was assessed pre- and post-
MAPP training session with a 10-item de novo scale based on Bandura’s 19 recommendations for constructing self-efficacy scales. Participants were asked to report their feelings of confidence and competence for dealing with patients’ anger on a 1 (Not at all True) to 10 point scale (Completely True). Specific items were “acknowledge patient anger,” “be respectful when
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addressing patient anger,” “understand patients’ anger,” “talk about patients’ anger with the patient,” “discuss solutions for patients anger,” “acknowledge my stress about patients’ anger,” “understand my stress about patients’ anger,” “use relaxation to manage my stress about
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patients’ anger,” “change my perspective to reduce my stress about patients’ anger,” and “vent my stress about patients anger in a positive way.”. The scale demonstrated good internal
consistency at the pre-training assessment (α = .74) and the post-training assessment (α = .82).
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Participants completed the measure below immediately before and after the MAPP training
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session. Analysis
Analyses were conducted in SPSS. Descriptive statistics for the pre and post-training SelfEfficacy scores were calculated and tested for assumptions of normality. All items met screening
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criteria for normality, besides item 10 on the post-treatment assessment. Therefore, changes in the first nine items were assessed using paired sample t-tests. Change in the final item was assessed using Wilcoxon’s sign rank test. Bonferroni correction was applied for 10 comparisons
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Results
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(p = .05 / 10 tests = .005). Cohens d was calculated as a preliminary estimate of effect size.
Pre-MAPP and Post-MAPP Self-Efficacy scores are presented in Table 2. Prior to the training, on average the clinicians endorsed higher levels of self-efficacy with regard to acknowledging patient anger, and being respectful when addressing patient anger suggesting that providers perceive themselves as fairly confident in their awareness and understanding of patient anger. However, providers reported lower levels of perceived self-efficacy with regard to venting stress about patient anger in a positive way and using relaxation to manage stress. For ease of
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interpretation differences in pre to post self –efficacy scores are depicted in Figure 1. After correction for multiple tests (p<.005) increases in all variables around each skill remained significant with the exception of venting stress positively (p <.007). All effects were large in
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magnitude. The largest changes were observed in providers ability to discuss solutions for patients’ anger ( d = 2.22 ), followed by use of relaxation to manage stress ( d = 1.91). Discussion
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Responding to patient anger can be challenging for many health care providers. In
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addition to fears of complaints, providers working in medical settings may experience frustration, annoyance or shame when a patient expresses anger. Although anger is common in oncology settings, the literature on patient anger is largely anecdotal, and various providers may diverge in their opinions of patient anger and their confidence in effectively responding to patient anger. Oncology providers were receptive to brief group-based training on patient anger that
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included conceptualization of anger around common cancer-related frustrations and unmet needs, direct practice using patient-centered and solution-focused communication around anger,
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and evidenced-based stress management techniques. From a pedagogical standpoint, Self-Efficacy Theory and related-learning theories
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emphasize multiple processes including modeling, reinforcement, and instruction to support skill acquisition19,24. Targeting the cognitive level, didactics and discussion assist providers in challenging common myths about anger that may otherwise undermine provider confidence and communication. Providers are freed to think more creatively and flexibly when they view anger as something to work with rather than defend against. Fostering emotional awareness among providers is also an important process so that providers can accept their own stress and frustration, and identify strategies for regulating their moods. Evocative materials including
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video clips of popular culture healthcare dramas, trainer self-disclosure statements about their own reactions to difficult encounters, and participant debriefing can help providers identify and process their personal reactions to anger. Targeting the behavioral level, role-plays and
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simulation offer an opportunity to expand oncology providers’ communication repertoires25. Behavioral rehearsal also has specific promise in relation aggression and other self-control
problems26, as anger tends to motivate individuals to approach problems with impulsive and
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hostile reactions20. Behavioral rehearsal is intended to increase the habit strength of problemsolving and stress management skills so that providers overcome other ineffective prepotent
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responses to patient anger.
MAPP can be tailored to the multiple contexts, manifestations, perspectives and consequences of patient anger. With regard to MAPP content, education can also address determinants of anger including mental status change, substance abuse, traumatization, and
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personality traits. MAPP included introductions to progressive muscle relaxation, and diaphragmatic breathing. Mindfulness-based interventions may also be promising for reducing provider distress with the added benefit of enhancing provider empathy and perspective taking 27.
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Individuals can be expected to vary in regard to their open-mindedness and willingness to
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address their own psychological distress (Hoerger). Provider buy in can be increased by acknowledging the biological underpinnings of aggression, and providers’ own practical benefits of addressing anger (e.g. fewer complaints, higher patient satisfaction). Given the climate of litigation, providers may benefit from reminders to engage medical ethic consults, patient advocates and risk management when anger relates to medical error, safety concerns, or formal complaints.
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In conclusion, anger is a common reaction to life-threatening illness. Providers can be encouraged to reframe anger as an opportunity to address patient needs. Helping patients work through anger and resolve concerns can be a professionally satisfying experience for providers
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when they are empowered to do so with cognitive behavioral tools that support their patients,
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themselves, and their units.
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13 References
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1. Kübler-ross E, Wessler S, Avioli LV. On death and dying. JAMA. 1972;221(2):174-179. 2. Holland JC, Geary N, Marchini A, Tross S. An international survey of physician attitudes and practice in regard to revealing the diagnosis of cancer. Cancer Invest. 1987;5(2):151-4. 3. Julkunen J, Gustavsson-lilius M, Hietanen P. Anger expression, partner support, and quality of life in cancer patients. J Psychosom Res. 2009;66(3):235-244. 4. Thomas SP, Groer M, Davis M, Droppleman P, Mozingo J, Pierce M. Anger and cancer: an analysis of the linkages. Cancer Nurs. 2000;23(5):344-3449. 5. Gardner FL, Moore ZE. Understanding clinical anger and violence: the anger avoidance model. Behav Modif. 2008;32(6):897-912.5. 6. Gerhart JI, Sanchez varela V, Burns JW, Hobfoll SE, Fung HC. Anger, provider responses, and pain: prospective analysis of stem cell transplant patients. Health Psychol. 2015;34(3):197-206. 7. Greenwood KA, Thurston R, Rumble M, Waters SJ, Keefe FJ. Anger and persistent pain: current status and future directions. Pain. 2003;103(1-2):1-5. 8. Okifuji A, Turk DC, Curran SL. Anger in chronic pain: investigations of anger targets and intensity. J Psychosom Res. 1999;47(1):1-12. 9. Gerhart J, Schmidt E, Lillis T, O'mahony S, Duberstein P, Hoerger M. Anger Proneness and Prognostic Pessimism in Men With Prostate Cancer. Am J Hosp Palliat Care. 2016; epub. 10. Pruyn JF, Rijckman RM, Van brunschot CJ, Van den borne HW. Cancer patients' personality characteristics, physician-patient communication and adoption of the Moerman diet. Soc Sci Med. 1985;20(8):841-7. 11. Philip J, Gold M, Schwarz M, Komesaroff P. Anger in palliative care: a clinical approach. Intern Med J. 2007;37(1):49-55. 12. Iyer P, Korin MR, Higginbotham L, Davidson KW. Anger, anger expression, and health. Handbook of health psychology and behavioral medicine. 2010:120-32. 13. DiGiuseppe R, Tafrate RC. Anger Treatment for Adults: A Meta‐Analytic Review. Clinical Psychology: Science and Practice. 2003 Mar 1;10(1):70-84. 14. Jain SH. The racist patient. Ann Intern Med. 2013;158(8):632. 15. Nakao M. The racist patient. Ann Intern Med. 2013;159(3):227-8. 16. Bleakley A, Marshall R, Levine D. He drove forward with a yell: anger in medicine and Homer. Med Humanit. 2014;40(1):22-30. 17. Haas LJ, Leiser JP, Magill MK, Sanyer ON. Management of the difficult patient. Am Fam Physician. 2005;72(10):2063-8. 18. Simpson M, Buckman R, Stewart M, et al. Doctor-patient communication: the Toronto consensus statement. BMJ. 1991;303(6814):1385-7. 19. Berkowitz L, Harmon-jones E. Toward an understanding of the determinants of anger. Emotion. 2004;4(2):107-30.
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20. Bandura A. Guide for constructing self-efficacy scales. Self-efficacy beliefs of adolescents. 2006;5(307-337). 21. Lehrer PM, Woolfolk RL, Sime WE, editors. DH. Principles and practice of stress management. Guilford Press; 2007 22. Gerhart, J, Burns W. Varela Sanchez. Self-Efficacy in Responding to Patient Anger Scale. 2013. 23. Kamal AH, Bull JH, Wolf SP, et al. Prevalence and Predictors of Burnout Among Hospice and Palliative Care Clinicians in the U.S. J Pain Symptom Manage. 2016;51(4):690-6. 24. Bandura A. Self-efficacy: toward a unifying theory of behavioral change. Psychol Rev. 1977;84(2):191-215. 25. Epstein RM, Duberstein PR, Fenton JJ, et al. Effect of a Patient-Centered Communication Intervention on Oncologist-Patient Communication, Quality of Life, and Health Care Utilization in Advanced Cancer: The VOICE Randomized Clinical Trial. JAMA Oncol. 2017;3(1):92-100. 26. Ronan G, Gerhart JI, Dollard K, Maurelli KA. An analysis of survival time to re-arrest in treated and non-treated jailers. Journal of Forensic Psychiatry & Psychology. 2010 Jan 1;21(1):102-12. 27. Krasner MS, Epstein RM, Beckman H, et al. Association of an educational program in mindful communication with burnout, empathy, and attitudes among primary care physicians. JAMA. 2009;302(12):1284-93.
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Managing Anger for Patients and Providers (MAPP): A Pocket Primer
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James Gerhart, Ph.D. Veronica Sanchez Varela, Ph.D. John Burns, Ph.D.
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3 Roads on the MAPP
Goals
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Process 1. Patient Road: Raise awareness and empathic responding to patient anger.
1. 2. 3.
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2. Provider Road: Raise awareness of negative effects of patient anger on provider, manage stress “on the go.”
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3. Unit Road: Raise awareness of anger contagion, and learn effective ways to share anger and frustration with other team members.
1. 2.
3. 1. 2. 3.
Understand and challenge assumptions about patient anger. Respond with empathy to patient anger. Address unmet needs. Acknowledge own stress. Practice realistic, positive and compassionate coping statements. Practice stress management. Understand anger contagion. Practice “positive venting”. Foster genuine team relationships.
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Serious illness can lead patients to become angry and to express anger and frustration to you.
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•
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Patient Road: Acknowledge the Anger
• Anger is a natural and human reaction.
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• Use this as an opportunity: Listen for fear, pain, and frustration below the surface. Label the anger. Stay present. Address the unmet needs.
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Provider Road: Work with your own reactions
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• Notice when your guard goes up. Label your emotion. Accept it as a human response. Use self-talk that keeps you present: – Its natural to feel his way…I don’t need to bury this stress... – Being triggered doesn’t stop me from being effective/professional/kind…
A Few Stress Management Ideas “In the moment”
Diaphragmatic Breathing
Mindful Breaths
Progressive Muscle Relaxation / Mindfulness
Tense & Relax Major Muscle Groups
Compassionate Thoughts (Patient and Provider)
Seek Social Support
Mindful Steps
Active Listening
Exercise
Hungry? Get a snack!
Problem Solving
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Journaling
“On the Go”
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“At Home”
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Unit Road: Raise Awareness of Anger Contagion
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• Connect the patient’s anger and our own frustration to softer emotions and unmet needs.
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– “That guy just told me off, but you know, he’s really scared and doesn’t know what to do.” – “You know I’m frustrated, but I’m also scared for this guy. It seems like he’s going downhill, and it’s hard to watch.”
• Take a team approach to patients who repeatedly test limits and boundaries.
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• Do team building, story circles and assertive communication to foster positive team rapport.
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Table 1. MAPP Training Agenda Training Target
Educational Activity Video and Discussion
5 minutes
Understanding
Anger Didactic
Enhance Communication and
Communication Didactic
Problem Solving
Trainer Communication Demonstration
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Anger Awareness and
Time
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15 minutes 5 minutes 5 minutes
10 minutes
Manage Stress in Providers and
Stress Management Experiential
15 minutes
Units
Unit Level Didactic
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Provider Role-Play & Debrief
5 minutes
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Table 2. Comparison of Self-Efficacy Scores Pre and Post MAPP Training
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Pre-MAPP Post-MAPP Mean SD Mean SD p Cohen's d 6.50 1.27 8.73 0.90 <.003 1.30 7.70 1.49 8.91 1.04 <.003 1.31 6.00 2.00 8.82 1.08 <.002 1.39 5.60 2.07 8.36 1.21 <.002 1.43 5.20 2.04 7.91 1.58 <.001 2.22 5.30 2.21 8.45 1.21 <.005 1.18 5.10 2.08 7.91 1.30 <.002 1.37 4.40 2.17 8.36 1.36 <.001 1.91 5.30 2.16 8.36 1.21 <.004 1.24 W 4.00 1.76 7.64 2.50 <.007 1.68
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Item Acknowledge patient anger Be respectful when addressing patient anger Understand patients’ anger Talk about patients’ anger with the patient”, Discuss solutions for patients anger Acknowledge my stress about patients’ anger Understand my stress about patients anger Use relaxation to manage my stress about patients’ anger Change my perspective to reduce my stress about patients’ anger Vent my stress about patients anger in a positive way
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Note. W refers to the p-value obtained from the Wilcoxon Sign-Rank Test. All other p-values were derived obtained from paired samples t-tests. Cohen’s d refers to standardized difference between pre and post scores.
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Running head: ANGER COMMUNICATION
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Figure 1. Change in Self-Efficacy in Responding to Patient Anger.
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10 S e l f
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6
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0
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E f f i c a c y
Note. Possible scores ranged from 1 (Not at all True) to 10 (Completely True).
Pre Post
S0885-3924(17)30305-6
DOI:
10.1016/j.jpainsymman.2017.07.039
Reference:
JPS 9467
To appear in:
Journal of Pain and Symptom Management
Received Date: 13 March 2017 Revised Date:
18 July 2017
Accepted Date: 20 July 2017
Please cite this article as: Gerhart J, Sanchez Varela V, Burns J, Brief Training on Patient Anger Increases Oncology Providers’ Self-Efficacy in Communicating with Angry Patients, Journal of Pain and Symptom Management (2017), doi: 10.1016/j.jpainsymman.2017.07.039. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
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Brief Training on Patient Anger Increases Oncology Providers’ Self-Efficacy in Communicating with Angry Patients
Veronica Sanchez Varela, PhD2 John Burns, PhD1
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James Gerhart, PhD1*
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1. Department of Behavioral Sciences, Rush University Medical Center, Chicago, IL
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2. Vacaville, CA *Corresponding Author 1725 W. Harrison, Suite 1004
Phone: 312-942-9932
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Chicago, IL 6012
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Email: [email protected]
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Abstract
Context: Anger is a common reaction to pain and life-limiting and life-threatening illness, is
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linked to higher levels of pain, and may disrupt communication with medical providers. Anger is understudied compared to other emotions in mental health and healthcare contexts, and many providers have limited formal training in addressing anger.
providers’ self-efficacy in responding to patient anger.
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Objectives: To assess if a brief provider training program is a feasible method for increasing
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Methods: Providers working in stem cell transplant and oncology units attending a brief training session on responding to patient anger. The program was informed by cognitive behavioral models of anger, and included didactics, discussion and experiential training on communication and stress management.
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Results: Provider rated self-efficacy was significantly higher for nine of 10 skill outcomes (p<.005) including acknowledging patient anger, discussing anger, considering solutions, and using relaxation to manage their own distress. All skill increases were large in magnitude
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(Cohen’s d = 1.18 – 2.22).
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Conclusion: Providers found the program to be useful for increasing their confidence in addressing patient anger. Discussion, didactics, and experiential exercises can support provider awareness of anger, shape adaptive communication, and foster stress management skills.
Keywords: Anger, Aggression, Burnout, Cancer, Communication, Training, Providers
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Brief Training on Patient Anger Increases Oncology Providers’ Self-Efficacy in Communicating with Angry Patients
Anger is a common reaction experienced by individuals with life threatening illness including
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patients with cancer, their family members and caregivers1-4. When well regulated, anger may enable individuals to assert their needs, and persevere through frustration4-5. However, when patients do not regulate their anger well, they may experience higher levels of pain6, and have
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difficulty engaging social support systems7. Anger may also have detrimental effects on patientprovider communication if the provider feels threatened or frustrated and responds with
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avoidance or hostility 6,8. Anger has also been linked to negativistic expectations of cancer prognosis9, and use of non-medical cancer remedies10. Anger is particularly common when difficult decisions must be made regarding treatment and goals of care or when pain and other side effects are not adequately managed11. Despite the ubiquity of anger, many mental health
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clinicians, and medical providers lack specific training in acknowledging, understanding and responding to patient expressions of anger. This lack of anger specific training is troubling because medical providers are frequently the targets of patient anger and litigation8.
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Anger tends to be relatively understudied even in the mental health specialties 12-13, and
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so medical providers are left to rely on clinical anecdote, prior personal experiences or momentary emotions as they consider how react to difficult encounters with patients, family and caregivers 14-15. In the context of cancer, current cultural trends tend to cast cancer treatment within the language of warfare, and patients are explicitly encouraged to “get angry” and “fight cancer” 4,16. Although this celebrated anger could be useful for motivating patients and providers to persist in the face of fears and frustrations, once anger is primed it may spill over and interfere with patient-provider relationships and decision making. Some patients who express or display
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anger are often labeled as difficult, prompting intentional or unintentional negative responses from providers, provider burnout, and inadvertent impacts on patient treatment 17. Although many strong emotions in oncology settings can be addressed in minutes or less18, the aftermath
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of a difficult encounter may persist, particularly if providers do not have time to return to their emotional baseline before meeting with the next patient. Therefore, addressing anger requires that providers have strategies to address their own distress and physiological arousal as they go
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about their workday. Given these complex and systemic pressures on providers, targeted training
and recuperating from patient anger.
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is needed to help providers increase their confidence in understanding, appropriately engaging,
This manuscript describes a quality improvement program entitled, “Managing Anger for Providers and Patients (MAPP)”. MAPP was designed to enhance the provider’s confidence and perceived self-efficacy in communicating with patients, family and caregivers in the context of
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stem cell transplant. The program was informed by cognitive behavioral models of anger and principles of patient centered communication. MAPP was developed with the premise that understanding the cognitive behavioral determinants of anger can help providers re-
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conceptualize anger as a normative, and at times, functional response to unmet needs, as well as
anger.
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guide the provider to be more discerning in how they respond to, avoid, or acquiesce to patient
Method
Participants and Procedure Twelve clinicians from an SCT team and inpatient oncology nursing staff from a large Midwestern academic medical center participated in the MAPP training program. One clinician
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had to leave the training to attend to other tasks and did not provide ratings. The clinicians included physicians, mid-level providers (nurse practitioners, physician assistants), and nurses who regularly cared for SCT patients. Given the quality improvement focus of the program,
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demographic data were not collected.
The MAPP training program was conducted over the course of a one-hour, midday, in-
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service by a licensed clinical psychologist and a postdoctoral fellow in clinical health
psychology. Both trainers had experience treating patients with cancer, and had experience
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working with anger and aggression from prior professional roles in forensic/correctional facilities. A pocket primer to the program is included as an appendix. MAPP emphasized three levels or “roads on the MAPP”. At the patient level, providers learned to understand anger within a cognitive behavioral framework, and respond to and defuse anger (see appendix slide 2). At the provider level, providers learned to manage stress and recover from angry encounters with
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patients. At the unit or systems level, providers learned to reduce anger contagion by changing how difficult cases are discussed and managed by the team.
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The MAPP training was developed within the framework of Self-Efficacy Theory 19, which poses that behavior change is more likely to occur to the extent that individuals can
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specify targets for behavioral change and increase their self-perceived levels confidence and competence in enacting those behaviors. Being the target of another’s anger may be intimidating and threaten one’s sense of confidence. Therefore, increasing self-efficacy regarding the skills needed to effectively engage and respond to patient anger is an important step for preparing clinicians to improve their communication with angry patients.
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The Institutional Review Board deemed that this program was quality improvement and exempt from review. Training included didactics, modeling and experientials to enhance skill acquisition. In order to gauge the acceptability of the intervention, the providers were asked to
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complete a questionnaire regarding their perceived self-efficacy in communicating with angry patients.
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Program Description
Table 1 outlines the session agenda. The program opened with a video clip of an angry
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patient berating a clinician to engage participant interest and elicit discussion on providers’ experiences with patient anger. The first component of MAPP (i.e., understanding anger) aimed to develop provider’s proficiency in conceptualizing anger in terms of the Reformulated Frustration – Aggression Hypothesis 20, and the Anger Avoidance Model 5. These models focus
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on the functional determinants, manifestations and consequences of anger and aggressive behaviors. With regard to its functional determinants, didactics focused on the ways that anger tends to be elicited by pain, fear, frustration20, and other aversive conditions that are ubiquitous
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in oncology settings. An emphasis was placed on the ways that hostile misperceptions and mistrust could lead patients and families to engage critical and aggressive communication with
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providers. Providers were also encouraged to consider how angry behaviors can be reinforced to the extent that they result in social dominance, staff attention or instrumental gains (e.g. discharge, pain medications, unwarranted aggressive treatment). Armed with the ability to conceptualize anger this way, providers could then attend to the many sources of frustration, fear, and pain that elicit anger, and foster empathy for the stress experienced by many of their patients. Consistent with a cognitive behavioral framework, the discussion explicitly challenged myths and assumptions that patient anger is necessarily unhealthy, or a personal threat toward
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the provider. Providers were instead encouraged to reframe patient anger as an opportunity to explore unmet needs (see appendix slide 3).
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The second component then shifted to responding to and defusing anger with specific strategies such as reflective listening, building rapport, and discerning when to shift to solutionfocused discussions. This component included the two psychologists role-playing an angry
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encounter, as well as role plays within participant dyads. Because addressing anger requires many providers to stay present in the midst of their own discomfort and avoidant tendencies, it
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was emphasized that participants “act in character”. A first step for providers was learning to acknowledge and make reflective statements about the patient’s frustration and anger. Once strong emotions are processed and acknowledged, solution-focused strategies convey concern and help patients identify strategies for addressing unmet needs (e.g. pain management, increasing social support). Here verbal commitments to return to the conversation after a “time
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out” and other statements of care and concern can buffer the patient-provider bond and prevent patients from feeling abandoned. In the psychologists’ role-play the patient character remained angry and skeptical but agreed to keep working with the treatment team. The patient remained
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angry in order to demonstrate that in many cases strong anger will linger but incremental
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communication outcomes can be still be achieved. The third component of the training (i.e., managing stress in providers and units) included
experiential practice in stress management practices of diaphragmatic breathing, muscle relaxation, and challenging unhelpful thought processes (see Lehrer, Woodfolk, & Sine, 200721 for an extensive summary of stress management). Burnout and compassion fatigue are salient in oncology and palliative care settings22, and in the absence of specific training providers may fall back on avoidant coping strategies. MAPP recommends stress management practices such as
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meditation and muscle relaxation for extended personal practice at home, brief relaxation and self-care strategies that can be implement between patient encounters, and targeted practices for remaining open and attentive when directly involved in patient care (see appendix slide 4).
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Taking a breath, compassionate subjective self-talk, and refocusing attention on the conversation at hand can help providers stay grounded in particularly challenging moments.
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Strong negative emotions may also reverberate through and across treatment teams.
Anger contagion may occur through nonverbal communication, and verbally through “venting”
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negative attributions of patient behavior. Whereas venting may be intended to cathartic and rally support and validation from peers, it may inadvertently reinforce rumination and anger about the frustrating event. The concept of “positive venting” was introduced as a way to communicate and debrief stressful encounters in a way that elicits peer support while reinforcing compassionate and CBT-consistent attributions of patient behavior (see appendix slide 5). In
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addition to increasing emotional support within the team, MAPP recommends taking a team approach to patients who repeatedly test professional boundaries. Being consistent with expectations and limits across the team reduces the likelihood that aggressive or unsafe patient
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Measure
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behaviors will be inadvertently or intermittently reinforced by the treatment team.
Self-Efficacy in Responding to Patient Anger (SERPA23) was assessed pre- and post-
MAPP training session with a 10-item de novo scale based on Bandura’s 19 recommendations for constructing self-efficacy scales. Participants were asked to report their feelings of confidence and competence for dealing with patients’ anger on a 1 (Not at all True) to 10 point scale (Completely True). Specific items were “acknowledge patient anger,” “be respectful when
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addressing patient anger,” “understand patients’ anger,” “talk about patients’ anger with the patient,” “discuss solutions for patients anger,” “acknowledge my stress about patients’ anger,” “understand my stress about patients’ anger,” “use relaxation to manage my stress about
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patients’ anger,” “change my perspective to reduce my stress about patients’ anger,” and “vent my stress about patients anger in a positive way.”. The scale demonstrated good internal
consistency at the pre-training assessment (α = .74) and the post-training assessment (α = .82).
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Participants completed the measure below immediately before and after the MAPP training
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session. Analysis
Analyses were conducted in SPSS. Descriptive statistics for the pre and post-training SelfEfficacy scores were calculated and tested for assumptions of normality. All items met screening
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criteria for normality, besides item 10 on the post-treatment assessment. Therefore, changes in the first nine items were assessed using paired sample t-tests. Change in the final item was assessed using Wilcoxon’s sign rank test. Bonferroni correction was applied for 10 comparisons
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Results
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(p = .05 / 10 tests = .005). Cohens d was calculated as a preliminary estimate of effect size.
Pre-MAPP and Post-MAPP Self-Efficacy scores are presented in Table 2. Prior to the training, on average the clinicians endorsed higher levels of self-efficacy with regard to acknowledging patient anger, and being respectful when addressing patient anger suggesting that providers perceive themselves as fairly confident in their awareness and understanding of patient anger. However, providers reported lower levels of perceived self-efficacy with regard to venting stress about patient anger in a positive way and using relaxation to manage stress. For ease of
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interpretation differences in pre to post self –efficacy scores are depicted in Figure 1. After correction for multiple tests (p<.005) increases in all variables around each skill remained significant with the exception of venting stress positively (p <.007). All effects were large in
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magnitude. The largest changes were observed in providers ability to discuss solutions for patients’ anger ( d = 2.22 ), followed by use of relaxation to manage stress ( d = 1.91). Discussion
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Responding to patient anger can be challenging for many health care providers. In
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addition to fears of complaints, providers working in medical settings may experience frustration, annoyance or shame when a patient expresses anger. Although anger is common in oncology settings, the literature on patient anger is largely anecdotal, and various providers may diverge in their opinions of patient anger and their confidence in effectively responding to patient anger. Oncology providers were receptive to brief group-based training on patient anger that
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included conceptualization of anger around common cancer-related frustrations and unmet needs, direct practice using patient-centered and solution-focused communication around anger,
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and evidenced-based stress management techniques. From a pedagogical standpoint, Self-Efficacy Theory and related-learning theories
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emphasize multiple processes including modeling, reinforcement, and instruction to support skill acquisition19,24. Targeting the cognitive level, didactics and discussion assist providers in challenging common myths about anger that may otherwise undermine provider confidence and communication. Providers are freed to think more creatively and flexibly when they view anger as something to work with rather than defend against. Fostering emotional awareness among providers is also an important process so that providers can accept their own stress and frustration, and identify strategies for regulating their moods. Evocative materials including
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video clips of popular culture healthcare dramas, trainer self-disclosure statements about their own reactions to difficult encounters, and participant debriefing can help providers identify and process their personal reactions to anger. Targeting the behavioral level, role-plays and
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simulation offer an opportunity to expand oncology providers’ communication repertoires25. Behavioral rehearsal also has specific promise in relation aggression and other self-control
problems26, as anger tends to motivate individuals to approach problems with impulsive and
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hostile reactions20. Behavioral rehearsal is intended to increase the habit strength of problemsolving and stress management skills so that providers overcome other ineffective prepotent
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responses to patient anger.
MAPP can be tailored to the multiple contexts, manifestations, perspectives and consequences of patient anger. With regard to MAPP content, education can also address determinants of anger including mental status change, substance abuse, traumatization, and
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personality traits. MAPP included introductions to progressive muscle relaxation, and diaphragmatic breathing. Mindfulness-based interventions may also be promising for reducing provider distress with the added benefit of enhancing provider empathy and perspective taking 27.
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Individuals can be expected to vary in regard to their open-mindedness and willingness to
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address their own psychological distress (Hoerger). Provider buy in can be increased by acknowledging the biological underpinnings of aggression, and providers’ own practical benefits of addressing anger (e.g. fewer complaints, higher patient satisfaction). Given the climate of litigation, providers may benefit from reminders to engage medical ethic consults, patient advocates and risk management when anger relates to medical error, safety concerns, or formal complaints.
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In conclusion, anger is a common reaction to life-threatening illness. Providers can be encouraged to reframe anger as an opportunity to address patient needs. Helping patients work through anger and resolve concerns can be a professionally satisfying experience for providers
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when they are empowered to do so with cognitive behavioral tools that support their patients,
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themselves, and their units.
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13 References
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1. Kübler-ross E, Wessler S, Avioli LV. On death and dying. JAMA. 1972;221(2):174-179. 2. Holland JC, Geary N, Marchini A, Tross S. An international survey of physician attitudes and practice in regard to revealing the diagnosis of cancer. Cancer Invest. 1987;5(2):151-4. 3. Julkunen J, Gustavsson-lilius M, Hietanen P. Anger expression, partner support, and quality of life in cancer patients. J Psychosom Res. 2009;66(3):235-244. 4. Thomas SP, Groer M, Davis M, Droppleman P, Mozingo J, Pierce M. Anger and cancer: an analysis of the linkages. Cancer Nurs. 2000;23(5):344-3449. 5. Gardner FL, Moore ZE. Understanding clinical anger and violence: the anger avoidance model. Behav Modif. 2008;32(6):897-912.5. 6. Gerhart JI, Sanchez varela V, Burns JW, Hobfoll SE, Fung HC. Anger, provider responses, and pain: prospective analysis of stem cell transplant patients. Health Psychol. 2015;34(3):197-206. 7. Greenwood KA, Thurston R, Rumble M, Waters SJ, Keefe FJ. Anger and persistent pain: current status and future directions. Pain. 2003;103(1-2):1-5. 8. Okifuji A, Turk DC, Curran SL. Anger in chronic pain: investigations of anger targets and intensity. J Psychosom Res. 1999;47(1):1-12. 9. Gerhart J, Schmidt E, Lillis T, O'mahony S, Duberstein P, Hoerger M. Anger Proneness and Prognostic Pessimism in Men With Prostate Cancer. Am J Hosp Palliat Care. 2016; epub. 10. Pruyn JF, Rijckman RM, Van brunschot CJ, Van den borne HW. Cancer patients' personality characteristics, physician-patient communication and adoption of the Moerman diet. Soc Sci Med. 1985;20(8):841-7. 11. Philip J, Gold M, Schwarz M, Komesaroff P. Anger in palliative care: a clinical approach. Intern Med J. 2007;37(1):49-55. 12. Iyer P, Korin MR, Higginbotham L, Davidson KW. Anger, anger expression, and health. Handbook of health psychology and behavioral medicine. 2010:120-32. 13. DiGiuseppe R, Tafrate RC. Anger Treatment for Adults: A Meta‐Analytic Review. Clinical Psychology: Science and Practice. 2003 Mar 1;10(1):70-84. 14. Jain SH. The racist patient. Ann Intern Med. 2013;158(8):632. 15. Nakao M. The racist patient. Ann Intern Med. 2013;159(3):227-8. 16. Bleakley A, Marshall R, Levine D. He drove forward with a yell: anger in medicine and Homer. Med Humanit. 2014;40(1):22-30. 17. Haas LJ, Leiser JP, Magill MK, Sanyer ON. Management of the difficult patient. Am Fam Physician. 2005;72(10):2063-8. 18. Simpson M, Buckman R, Stewart M, et al. Doctor-patient communication: the Toronto consensus statement. BMJ. 1991;303(6814):1385-7. 19. Berkowitz L, Harmon-jones E. Toward an understanding of the determinants of anger. Emotion. 2004;4(2):107-30.
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20. Bandura A. Guide for constructing self-efficacy scales. Self-efficacy beliefs of adolescents. 2006;5(307-337). 21. Lehrer PM, Woolfolk RL, Sime WE, editors. DH. Principles and practice of stress management. Guilford Press; 2007 22. Gerhart, J, Burns W. Varela Sanchez. Self-Efficacy in Responding to Patient Anger Scale. 2013. 23. Kamal AH, Bull JH, Wolf SP, et al. Prevalence and Predictors of Burnout Among Hospice and Palliative Care Clinicians in the U.S. J Pain Symptom Manage. 2016;51(4):690-6. 24. Bandura A. Self-efficacy: toward a unifying theory of behavioral change. Psychol Rev. 1977;84(2):191-215. 25. Epstein RM, Duberstein PR, Fenton JJ, et al. Effect of a Patient-Centered Communication Intervention on Oncologist-Patient Communication, Quality of Life, and Health Care Utilization in Advanced Cancer: The VOICE Randomized Clinical Trial. JAMA Oncol. 2017;3(1):92-100. 26. Ronan G, Gerhart JI, Dollard K, Maurelli KA. An analysis of survival time to re-arrest in treated and non-treated jailers. Journal of Forensic Psychiatry & Psychology. 2010 Jan 1;21(1):102-12. 27. Krasner MS, Epstein RM, Beckman H, et al. Association of an educational program in mindful communication with burnout, empathy, and attitudes among primary care physicians. JAMA. 2009;302(12):1284-93.
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Managing Anger for Patients and Providers (MAPP): A Pocket Primer
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James Gerhart, Ph.D. Veronica Sanchez Varela, Ph.D. John Burns, Ph.D.
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3 Roads on the MAPP
Goals
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Process 1. Patient Road: Raise awareness and empathic responding to patient anger.
1. 2. 3.
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2. Provider Road: Raise awareness of negative effects of patient anger on provider, manage stress “on the go.”
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3. Unit Road: Raise awareness of anger contagion, and learn effective ways to share anger and frustration with other team members.
1. 2.
3. 1. 2. 3.
Understand and challenge assumptions about patient anger. Respond with empathy to patient anger. Address unmet needs. Acknowledge own stress. Practice realistic, positive and compassionate coping statements. Practice stress management. Understand anger contagion. Practice “positive venting”. Foster genuine team relationships.
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Serious illness can lead patients to become angry and to express anger and frustration to you.
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•
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Patient Road: Acknowledge the Anger
• Anger is a natural and human reaction.
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• Use this as an opportunity: Listen for fear, pain, and frustration below the surface. Label the anger. Stay present. Address the unmet needs.
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Provider Road: Work with your own reactions
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• Notice when your guard goes up. Label your emotion. Accept it as a human response. Use self-talk that keeps you present: – Its natural to feel his way…I don’t need to bury this stress... – Being triggered doesn’t stop me from being effective/professional/kind…
A Few Stress Management Ideas “In the moment”
Diaphragmatic Breathing
Mindful Breaths
Progressive Muscle Relaxation / Mindfulness
Tense & Relax Major Muscle Groups
Compassionate Thoughts (Patient and Provider)
Seek Social Support
Mindful Steps
Active Listening
Exercise
Hungry? Get a snack!
Problem Solving
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Journaling
“On the Go”
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“At Home”
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Unit Road: Raise Awareness of Anger Contagion
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• Connect the patient’s anger and our own frustration to softer emotions and unmet needs.
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– “That guy just told me off, but you know, he’s really scared and doesn’t know what to do.” – “You know I’m frustrated, but I’m also scared for this guy. It seems like he’s going downhill, and it’s hard to watch.”
• Take a team approach to patients who repeatedly test limits and boundaries.
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• Do team building, story circles and assertive communication to foster positive team rapport.
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Table 1. MAPP Training Agenda Training Target
Educational Activity Video and Discussion
5 minutes
Understanding
Anger Didactic
Enhance Communication and
Communication Didactic
Problem Solving
Trainer Communication Demonstration
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Anger Awareness and
Time
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15 minutes 5 minutes 5 minutes
10 minutes
Manage Stress in Providers and
Stress Management Experiential
15 minutes
Units
Unit Level Didactic
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Provider Role-Play & Debrief
5 minutes
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Table 2. Comparison of Self-Efficacy Scores Pre and Post MAPP Training
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Pre-MAPP Post-MAPP Mean SD Mean SD p Cohen's d 6.50 1.27 8.73 0.90 <.003 1.30 7.70 1.49 8.91 1.04 <.003 1.31 6.00 2.00 8.82 1.08 <.002 1.39 5.60 2.07 8.36 1.21 <.002 1.43 5.20 2.04 7.91 1.58 <.001 2.22 5.30 2.21 8.45 1.21 <.005 1.18 5.10 2.08 7.91 1.30 <.002 1.37 4.40 2.17 8.36 1.36 <.001 1.91 5.30 2.16 8.36 1.21 <.004 1.24 W 4.00 1.76 7.64 2.50 <.007 1.68
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Item Acknowledge patient anger Be respectful when addressing patient anger Understand patients’ anger Talk about patients’ anger with the patient”, Discuss solutions for patients anger Acknowledge my stress about patients’ anger Understand my stress about patients anger Use relaxation to manage my stress about patients’ anger Change my perspective to reduce my stress about patients’ anger Vent my stress about patients anger in a positive way
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Note. W refers to the p-value obtained from the Wilcoxon Sign-Rank Test. All other p-values were derived obtained from paired samples t-tests. Cohen’s d refers to standardized difference between pre and post scores.
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Running head: ANGER COMMUNICATION
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Figure 1. Change in Self-Efficacy in Responding to Patient Anger.
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10 S e l f
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Note. Possible scores ranged from 1 (Not at all True) to 10 (Completely True).
Pre Post