Benefits of Organizational Anger Management Program to Prevent Disruptive Behaviors: A Japanese Hospital Case Study

Abstract

Intervention to inhibit disruptive behavior (DB) in healthcare institutions remains an unmet need. This study intended to examine the feasibility of an organizational anger management (AM) program aimed at inhibiting DB triggered by anger. AM dissemination and awareness-building activities for all staff members (1366 individuals) were implemented from July 2020, including regularly held group AM introductory trainings, establishment of “I Will Not Get Angry Today” days (once per month), posting of AM promotion posters in all departments (changed monthly), disseminating AM-related knowledge through the in-hospital groupware application (twice per week), and introduction of AM training methods using the in-hospital periodical magazine. The number of responses to the awareness survey questionnaire 1 year after AM program was 730 (response rate: 54.2%). The results showed that the percentage of positive responses indicating that DB “Decreased” or “Somewhat Decreased” after AM program intervention was 35.8% overall. The percentages for nurses (n = 385) and non-nurses (n = 345) groups were 29.8% and 42.4%, respectively, showing a significantly lower value for nurses (p < 0.001). An organizational AM program aimed at inhibiting DB could be implemented at our facility. However, it was difficult to properly evaluate the efficacy due to the nature of the study.

1. Introduction

Problematic behaviors such as swearing, ranting, and personal attacks by healthcare professionals are referred to as disruptive behavior (DB) [1, 2]. It is well known that DB causes mental stress to the victimized staff members, inducing errors due to decreased motivation and alertness. Furthermore, DB leads to medical accidents because of communication failures and labor shortages as a result of high turnover of nursing staff and deterioration of psychological safety [3, 4, 5]. The large-scale study by Rosenstein and Daniel [4] on VHA West Coast hospitals revealed that of all the physicians and nurses who participated in the survey, 97% experienced DB at work. A total of 71% of them felt that DB could lead to a medical accident, and 27% recognized that DB could lead to the death of a patient. A survey of hospital managers by the American College of Physician Executives [6] found that 71% of the hospital managers were aware that DB occurred on a monthly basis in each hospital, and more than 11% were aware that it occurred daily. In addition, 99% of them stated that DB had a negative effect on medical care, and 21% felt that it caused a disadvantage to the patients.

Thus, DB has long been understood as a serious threat to patient safety and hospital management. In particular, various measures have been taken against disruptive physician behavior [7, 8, 9], but at present, sufficient efficacy has not been realized. Furthermore, it is well known that DB can occur not only with physicians but also with many other medical professionals such as nurses and pharmacists [10, 11, 12]. However, almost no measures for prevention have been taken in this regard [13]. To date, little research has been conducted on DB intervention, and DB management in medical institutions remains an unmet need.

In the medical field, where lives are at stake, staff members are exposed to various forms of intense stress each day, which can increase the likelihood of a reaction of anger, and is one of the factors that causes DB to occur frequently [10, 12, 13, 14]. In August 2019, we conducted on all staff members (1376 persons) of our hospital, an advanced acute care hospital, a survey on the actual condition of in-hospital DB (DB cases that occurred in the past 6 months; number of responses: 346; response rate: 25.1%). The results revealed that of the 365 reported cases of DB, DB that was thought to be triggered by anger accounted for 65% of all DB cases (total of 236 cases), including 123 cases of “Being screamed at and emotionally criticized.” Anger was the largest factor for the occurrence of DB. These results suggested that an organizational AM program may be effective in inhibiting DB.

To the authors’ knowledge, there have been no reports on organizational AM programs aimed at inhibiting DB in medical institutions. Hence, the present study intended to examine the feasibility of an organizational AM program to inhibit DB.

2. Materials and methods

After the in-hospital implementation project team for the AM program was launched in May 2020, the lead author, who acted as the team leader, obtained the Certified Anger Management Specialist-I qualification from the National Anger Management Association. From July of the same year, AM dissemination and awareness-building activities were initiated for all staff members, including part-time staff (1366 people). The categorization of staff members by occupation was as follows: 688 nurses (50.4%), 205 physicians (15.0%), 35 pharmacists (2.6%), 148 technicians (10.8%), 118 clerical staff (8.6%), and 172 other occupations (12.6%).

AM dissemination and awareness-building methods consisted of the following initiatives. First, group AM introductory training for all staff members was conducted regularly. This introductory training was imparted in accordance with the program for beginner-level AM training participants established by the Japan Chapter of the National Anger Management Association. Next, an “I Will Not Get Angry Today” declaration day was established (the first Monday of each month), and by posting “Declaration Day” awareness-raising posters in all departments of the hospital at all times, the first Monday of each month was made an opportunity to be aware of one’s feelings of anger. An announcement was broadcast twice (once in the morning and once in the afternoon) in the entire facility on the “Declaration Day.” Additionally, AM promotion posters were posted in all departments, with the training method’s theme changed each month. The posters were posted with particular emphasis on places where DB frequently occurs, such as the emergency room, operating room, and catheter room. Also, AM-related knowledge was disseminated by the in-hospital groupware application twice weekly, which could be viewed by the staff members. Lastly, the AM training methods were introduced in the periodic in-hospital public relations magazine. Participation in AM programs, such as the introductory training, was not obligatory, and it was left to the discretion of each staff member.

In July 2021 (the 13th month after the start of the AM program), an awareness survey questionnaire was administered to all employees (1348 individuals) to evaluate the efficacy of the organizational AM program with regard to inhibition of DB (Table 1). The questionnaire was administered in an anonymous manner, and personal information was strictly managed so that the respondents could not be identified. The responses to the awareness survey questionnaire were aggregated based on the occupation, divided into two groups (nurses and non-nurses), and the response selection ratios for each question were compared. Regarding the method of intergroup comparative analysis of the response selection ratio, a z-test was used to analyze the difference in the unpaired population ratios. A two-tailed test was used for statistical hypothesis testing, and the significance level was set to a risk rate of <5%. IBM SPSS 25.0 J for Windows was used for statistical processing. In the intergroup comparison analysis, Questions 1 and 2 were analyzed using the response selection ratios of the Top Box and Bottom Box. Q3 was analyzed using the response selection ratios of the Top 2 Box and Bottom 2 Box. Regarding Questions 4 and 5, the response selection ratios of the Top 2 Box and Bottom Box were used.

Administered to all staff members in July 2021 (13th month after the program start)
	Details of questions:
Question 1.	Do you know about anger management?; 1. I know about it; 2. I have heard about it, but do not know much; 3. I do not know about it
Question 2.	Do you practice anger management?; 1. I practice it on a regular basis; 2. I have practiced it but mostly do not practice it; 3. I have never practiced it
Question 3.	Do you think that disruptive behavior in your department has decreased since the start of the organizational anger management program?; 1. Decreased 2. Somewhat decreased 3. Not sure 4. Somewhat increased 5. Increased
Question 4.	Do you think that an organizational anger management program can help control disruptive behavior?; 1. Effective 2. Somewhat effective 3. Not sure 4. Ineffective
Question 5.	Would you like to recommend anger management training to your family members and acquaintances?; 1. Would recommend 2. Would somewhat recommend 3. Not sure 4. Would not recommend
Question 6.	What are your thoughts on the organizational anger management program (free response)?

Table 1.

Awareness survey on the inhibitive effects of an organizational anger management program on disruptive behavior.

2.1 Ethical considerations

Since the present study is not health-related and was conducted based on the free participation of hospital staff as part of activities to prevent disruptive behavior, ethical review based on the Ethics Committee Rules of Iwate Prefectural Central Hospital was not required. Therefore, obtaining informed consent from employees participating in the AM program was exempted.

3. Results

The group AM introductory training for all staff members was conducted 14 times in total, and the total number of participants was 1136 (attendance rate 83.2%).

The number of responses to the questionnaire on the awareness of DB inhibitory effects 1 year after the organizational AM program intervention was 730 (response rate: 54.2%) (Figure 1). Regarding the occupation ratio of the respondents, nurses accounted for the largest percentage (52.7%), followed by physicians (14.9%) and technicians (11.5%). There was no significant difference in the actual occupation ratio of the staff members. In terms of age group, the highest number of subjects were in their 40s (32.3%), followed by those in their 30s (27.7%) and those in their 20s (18.5%). Regarding Q1 “Do you know about AM?,” the percentage of the positive response “I know about it” was 89.2% overall (n = 730) (Figure 2). Groupwise, the percentages for nurses (n = 385) and non-nurses (n = 345) were 91.7% and 86.4%, respectively, showing a significantly higher figure for the nurses (p < 0.05). Regarding Question 2 “Do you practice AM?,” the percentage of the positive response of “I practice it on a regular basis” was 65.9% overall (Figure 3). Groupwise, the results were 71.4% and 59.8% for the nurses and non-nurses, respectively, showing a significantly higher figure for the nurses (p < 0.001). Regarding Question 3 “Do you think the number of cases of DB in your department has decreased after the organizational AM program started?,” the percentages of the positive responses of “Decreased” or “Somewhat Decreased” were 35.8% overall, and the percentages of negative responses of “Increased” or “Somewhat Increased” were 7.1% overall (Figure 4). The percentages of positive responses groupwise were 29.8% and 42.4% for the nurses and non-nurses, respectively, showing a significantly lower figure for the nurses (p < 0.001). The groupwise negative response rates were 10.1% and 3.7% for the nurses and non-nurses, respectively, showing a significantly higher figure for the nurses (p < 0.001). Regarding Question 4 “Do you think that organizational AM programs are effective in inhibiting DB?,” the percentage of positive responses of “Effective” or “Somewhat Effective” was 64.2% overall, and the percentage of the negative response of “Ineffective” was 7.3% overall (Figure 5). The percentages of groupwise positive responses were 55.8% and 73.6% for the nurses and non-nurses, respectively, showing a significantly lower figure for the nurses (p < 0.0001). The percentages of groupwise negative responses were 9.6% and 4.6% for the nurses and non-nurses, respectively, showing a significantly higher figure for the nurses (p < 0.05). Regarding Question 5 “Would you recommend AM training to your family and acquaintances?,” the percentage of positive responses of “Would recommend” or “Would somewhat recommend” was 69.1% overall, and the percentage of negative response of “Would not recommend” was 2.6% overall (Figure 6). The percentages of groupwise positive responses were 64.2% and 74.5% for the nurses and non-nurses, respectively, showing a significantly lower figure for the nurses (p < 0.01). In addition, in the free response (Q6) of the questionnaire, there were some opinions that the AM program had little effect on people who habitually engaged in DB (especially physicians). The respondents opined that effective initiatives aimed at such individuals are needed.

Figure 1.

Awareness survey on inhibitory effects of organizational anger management program on disruptive behavior Administered to all staff members in July 2021 (13th month after program start).

Figure 2.

Question 1 Do you know about anger management?

Figure 3.

Question 2 Do you practice anger management?

Figure 4.

Question 3 Do you think disruptive behavior in your department has diminished since the start of the organizational anger management program?

Figure 5.

Question 4 Do you think that an organizational anger management program can help control disruptive behavior?

Figure 6.

Question 5 Would you recommend anger management training to your family and acquaintances?

4. Discussion

DB is defined as any verbal or nonverbal behavior that harms or frightens other medical staff, patients, or family members, resulting in a reduction in the quality of patient care and a threat to patient safety [1]. While DB is known to have a significant impact on patient safety and hospital management, interventions aimed at inhibition of DB in medical institutions remain an unmet need. To the authors’ knowledge, the present study is the first attempt to intervene via an organizational AM program for inhibiting DB.

Past surveys at our hospital have found that the majority of DBs (about two-thirds) are caused by feelings of anger, and it is well known that the medical field has a more complete set of factors that arouse feelings of anger than other industries. Anger among healthcare workers is often attributed to a variety of reasons, including excessive workloads, life-threatening environments where mistakes are not tolerated, family issues, relationships with colleagues, hierarchical relationships between professions, and differences in mutual values. It goes without saying that hospital organizations need to work on improving the various causes of anger, if any are addressable. However, it is clear that healthcare workers should not vent their outrage in the workplace for any reason, given the serious impact it can have on the work environment. Anger-induced DBs must be viewed as a serious threat to patient safety, quality of care, work efficiency, personal career development, and hospital operations. Therefore, we have been promoting the AM project with the aim of spreading awareness of AM throughout the organization for inhibiting DB.

The results of the questionnaire survey of all employees conducted 1 year after the start of the AM program revealed that 36% of the respondents positively regarded that the frequency of DB occurrence in their department decreased because of the AM program intervention. The percentage of respondents who positively regarded the efficacy of DB inhibition by the AM program was 64%, which was much higher than the percentage of respondents who negatively regarded it (7%). These results indicate that a notable percentage of the staff members felt that the AM program intervention was effective in inhibiting DB. Although the questionnaire response rate was somewhat low (54%), more than half of the staff members responded. Taking into consideration the fact that it was an anonymous questionnaire and that the ratio of respondents based on occupation type did not differ significantly from the actual ratio, it appears that the results of this questionnaire most likely reflected the actual feelings of the staff members regarding the number of occurrences of DB within the hospital. Based on the above findings, it cannot be ruled out that the AM program in the present study might have had some effect on DB inhibition.

The questionnaire results also revealed that the nurse group, which is generally considered to be vulnerable to DB, had a higher AM awareness and AM training practice rate in comparison with the non-nurse group; throughout the questionnaire, the percentage of positive responses regarding the DB inhibition effects of the AM program was low. The factors behind the differences in feelings between occupations regarding the efficacy of this AM program remain unknown, and further verification is needed in the future.

The organizationally introduced AM program in the present study is said to have been spontaneously born in the United States during the 1970s as a correction program for perpetrators of domestic violence and misdemeanors. Subsequently, AM was gradually systematized academically [15] and has become quite common over time [16]. At present, AM has been introduced in various workplace trainings and fields, such as adult and youth education, and its efficacy has been demonstrated [17]. Thus, AM has been established as a common method of cognitive behavioral therapy.

AM training is generally conducted individually or in groups of several individuals [18]; to date, AM has been mainly used as a correction program for physicians with habitual DB in the medical field [8, 9]. Eslamian et al. reported that they introduced an AM program on a group-by-group basis to control DB among nurses in the emergency field and achieved some results in reducing the incidence of DB [19]. However, there have been no reports of attempts by medical institutions to perform intervention through an organizational AM program with the aim of inhibiting DB. In the present study, we aimed to examine the feasibility of a cross-professional AM intervention program for all employees, with the goal of inhibiting DB by fostering a workplace culture that does not tolerate DB triggered by anger. Given that the awareness of AM is still low in Japan, it was found to be necessary to widely educate hospital staff regarding AM methods. Group AM introductory training was frequently conducted at an early stage of the activities. We additionally utilized a simple and visual method of awareness building by posting AM promotion posters. We also continued to provide motivation for AM training for each individual by sending AM-related information twice a week through groupware and broadcasts within the hospital. In the awareness survey questionnaire administered 1 year after the intervention of the AM program, 66% of the staff members responded that they practiced AM on a regular basis, showing the possibility that these continuous dissemination and simple awareness-building methods might have been effective.

The present study has several limitations. First, while the results of the present study suggested that organizational AM programs in healthcare institutions might be a somewhat effective intervention to inhibit DB, the present study was a case study in a single facility. Hence, it is difficult to generalize the obtained results. Secondly, it was extremely difficult to know the actual number of occurrences of in-hospital DB before and after the AM program intervention owing to the nature of the DB reports. It is well known that in an extremely large number of cases, the victim does not report incidents of DB owing to the fear of retaliation from the perpetrator after the DB report and because of the distrust of the hospital [7, 8, 9, 11]. Therefore, it was necessary to replace these reports with the method of evaluation using an anonymous questionnaire after the intervention of the AM program. Thus, it would be advantageous that a stable DB reporting system be established in the future. Finally, due to the nature of the study, it was necessary for the AM training to rely on the individual choice to participate by each staff member. Therefore, it was difficult to appropriately evaluate the efficacy of the AM program for the inhibition of DB. Nevertheless, despite these limitations, we believe that the present study might serve as an important resource for exploring effective intervention methods for DB inhibition in other medical institutions.

In conclusion, an organizational AM program aimed at inhibiting DB could be implemented at our facility. Although the results of the present study suggest that the AM program might be an effective method of intervention to inhibit DB, it was difficult to properly evaluate its efficacy due to the nature of the study. Furthermore, AM programs may not always be effective in the same way among different occupations; hence, further research is needed.

Acknowledgments

The authors acknowledge the business department of Iwate Prefectural Central Hospital for their cooperation in the organizational AM training and questionnaire survey. We would also like to thank Enago (www.enago.jp) for English language editing. This study was supported by no specific grant from any funding agency in the public, commercial, or nonprofit sectors.

Conflict of interest

The authors declare no conflicts of interests.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.