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Research article

First published online November 9, 2017

Role of Irrational Beliefs and Anger Rumination on Nurses’ Anger Expression Styles

Eun-Mi Ham, PhD, RN, and Mi-Jin You, RN [email protected]View all authors and affiliations

https://doi.org/10.1177/2165079917737090

Abstract

The aim of this study was to identify whether certain cognitive factors, such as irrational beliefs and anger rumination, affect nurses’ anger expression styles. A total of 335 nurses employed at four tertiary hospitals in Korea completed surveys between July 29 and September 25, 2015. The surveys included Shortened General Attitude and Belief Scale, the Korean Version of the Anger Rumination Scale, and the State-Trait Anger Expression Inventory–Korean version. Results revealed that higher levels of irrational beliefs and anger rumination were associated with more anger-in and anger-out, and less anger-control expressions. Findings indicate that the presence of specific cognitive characteristics could lead to maladaptive anger expressions. Active consideration of these cognitive risk factors is essential when developing anger-management programs for nurses.

Recent studies have focused on how individuals express experienced anger rather than investigating the nature of an individual’s anger feelings. Although individuals may experience similar levels of anger, expressions can differ, leading to a variety of outcomes (Choi, 2012). In other words, when anger is expressed in an appropriate manner, benefits can result; however, if anger is expressed inappropriately, negative outcomes emerge (E. H. Park, 2010). “Inappropriateness” in this context refers either to the direct external expression of anger or internal suppression. Existing literature suggests that inappropriate anger expression styles negatively affect physical and psychological health. Furthermore, within the field of nursing, several attempts have been made to identify differences in occupation- and organization-related factors influencing nurses’ anger expressions. However, existing research has merely focused on identifying nurses’ anger levels and resultant negative outcomes from those expressions; less attention has been paid to the causal factors influencing these anger expression styles.

The primary negative emotions experienced by nurses at work include anger, anxiety, and depression. Anger, in particular, is the most frequent, accounting for 44.4% of the negative emotions experienced in a typical week (J. I. Lee, 2003). Moreover, anger among nurses can be higher than that of physicians or medical technicians (Hong, Lee, Won, & Han, 2016). Not only do nurses experience anger more frequently than physicians and other health care personnel, but they also tend to employ more inappropriate anger expression styles, including suppression and unfiltered release (W. H. Lee et al., 2006), with anger suppression being the most common (Oh, 2013). Owing to work characteristics, nurses often feel the need to suppress their anger and remain pleasant during interactions (J. Y. Kim, 2012b), which may prevent nurses from managing their anger expressions in a constructive manner, eventually leading to stress, fatigue, and burnout (D. O. Kim, 2005; H. S. Park, Bae, & Jeong, 2003; K. H. Kim, 2015; You, 2011). Additional research suggests that anger suppression is associated with low levels of organizational performance, organizational commitment, and job satisfaction (J. E. Kim, 2015; W. H. Lee et al., 2009; You, 2011). In short, previous studies have solely focused on levels of anger and resultant negative outcomes based on expression styles; however, less is known about the precedent factors that influence the emergence of particular anger expression styles. Currently, interest in the clinical significance and level of dysfunction associated with anger is prevalent in the broader field of psychology including examinations of cognitive factors involved in processing anger triggers and therapeutic techniques for managing anger (Ellis & Tafrate, 1997; G. B. Lee & Cho, 2008; Min & Park, 2015; Shin & Cho, 2014; Suh, 2004). This focus seems applicable for better understanding anger expression styles among nurses as well.

According to Ellis (1962), who first offered a cognitive theory for understanding anger processing, individuals have their own subjective viewpoints when recognizing and interpreting the same incident; thus, the same experience can elicit varying emotions among individuals. In other words, negative feelings do not arise from the event itself, but through individual beliefs and attitudes, which sometimes can be irrational. Such extreme and absolute beliefs can foster negative emotions and behavior (Ellis, 1973; Shim, 2011).

Individuals who internalize these irrational beliefs, such as excessive desires to be recognized and unrealistic self-expectations, can experience frustration and self-blame when events or situations do not meet their expectations. As a result, these individuals may experience self-destructive and self-defeating emotions and behaviors. In contrast, these individuals may consider others to be at fault, leading to aggressive or hostile behaviors (Shim, 2011; Song, 2010; Suh, 2011). Thus, individuals with strong irrational beliefs are likely to exhibit maladaptive anger expressions (i.e., anger suppression or inappropriate release).

Aside from irrational beliefs, the concept of “rumination” is also a key factor influencing nurses’ anger expression styles. Anger rumination refers to a tendency of repeatedly thinking about an event or situation that has produced anger, dwelling on thoughts related to blame, inequity, and revenge (Ellis & Tafrate, 1997; J. Y. Kim, 2012a). For instance, prior research shows that anger rumination is a predictor of aggressive behavior among athletes (Maxwell, 2004) and is positively related to physical and verbal aggressiveness among adolescents (J. Y. Kim, 2012a; Peled & Moretti, 2010). Here, anger rumination maintains and magnifies angry feelings; moreover, such rumination is thought to strongly influence inappropriate anger expression styles that can cause physical or verbal harm (J. Y. Kim, 2012a; So, 2011).

Irrational beliefs and anger rumination have been given little attention as explanatory factors regarding anger expressions among nurses. Therefore, the goal of the present study was to assess these two cognitive factors to provide a basis for developing anger-management programs for nurses.

Method

Study participants were 335 nurses, selected through convenience sampling, who were working at four different tertiary hospitals in Seoul, Republic of Korea. All participants gave written consent to participate. The four tertiary hospitals were similar in respect to size, administrative system, number of nurses, and inpatient characteristics. The minimum sample size necessary for multiple regression analysis was calculated using G power 3.1.9.2; the first attempt at securing the sample used a medium effect size of .15, significance level of .05, a power of .80, and six predictors, requiring a minimum of 98 participants. At this time, based on coefficients of determination (i.e., R² = .25-.26) from a previous study investigating factors influencing anger expression styles among middle school students (E. S. Kim, 2011), the authors calculated a value of f² = .34-.35 using the Free Statistics Calculators version 4.0 (www.danielsoper.com). In addition, the number of nurses working in Korea was estimated at 110,000 using data from the Ministry of Health and Welfare (2014). The required sample was calculated (confidence level: 95%, confidence interval: 5) using software provided by the Creative Research System, suggesting a sample of 383. One hundred nurses were selected from each hospital (total N = 400), and 350 responded to the survey (87.5%). Fifteen questionnaires lacking response data were eliminated, leading to a total sample of 335 (95.6%): 90 (94.7%) nurses from K district, 80 (94.1%) nurses from D district, 82 (98.8%) nurses from S district, and 83 (95.4%) nurses from Y district.

Measures

Irrational beliefs

This study used the Korean Version of the Shortened General Attitude and Belief Scale (S-GABS), initially developed by Lindner, Kirkby, Wertheim, and Birch (1999) and modified and amended by Song (2010). This tool consists of 26 questions measured on a 5-point scale from not at all to strongly agree, with higher scores indicating higher levels of irrational beliefs. The reliability of this measure (Cronbach’s alpha) was .90 for the present sample.

Anger rumination

The Korean Version of the Anger Rumination Scale (K-ARS), initially developed by Sukhodolsky, Golub, and Cromwell (2001) and standardized by G. B. Lee and Cho (2008), was employed. This measure consists of 16 questions assessed on a 4-point scale from not at all to strongly agree, with higher scores indicating higher rumination tendencies. The reliability of this measure (Cronbach’s alpha) was .90 for the present sample.

Anger expression styles

The State-Trait Anger Expression Inventory–Korean version (STAXI-K), developed by Spielberger, Kranser, and Solomon (1988) and modified and amended by Jeon, Han, Lee, and Spielberger (1997), was used in the present study. This measure is comprised of 24 questions with eight questions in each subdomain. Each item is measured on a 4-point scale from not at all to strongly agree, with higher scores within each subdomain indicating higher anger expression tendencies. Reliabilities from the present sample are as follows: .86 for anger-in, .81 for anger-out, and .83 for anger-control.

Data Collection and Ethical Considerations

This study was reviewed and approved by the Konkuk University Institutional Review Board (IRB No. 7001355-201504-HR-048) before data were collected. From July 29 to September 25, 2015, a researcher visited four tertiary hospitals. The surveys were distributed to nursing units. Each participant was provided an explanation regarding the goals and content of the study, assurance of confidentiality that no harmful effects would result from participating, all data would only be used for study purposes, and that participants could cease participation at any time. Agreement to participate was documented through written informed consent. The survey was self-administered and took approximately 10 to 15 minutes to complete; participants were asked to store the survey in a secure, sealed envelope to be collected by the researcher. Participants were provided white socks with a nurse image logo as a small gift for participating.

Data Analyses

Data collected were analyzed using the Statistical Package for the Social Sciences (SPSS) Version 18.0 (IBM Corp., Armonk, New York, USA). General characteristics, as well as levels of irrational beliefs, anger rumination, and anger expression styles, were analyzed using frequencies, percentages, means, and standard deviations. Differences in irrational beliefs, anger rumination, and anger expression styles by participant characteristics were analyzed using t-tests and one-way ANOVAs (post hoc tests were performed using Scheffe’s method for multiple comparisons), and relationships between irrational beliefs, anger rumination, and anger expression styles were analyzed using Pearson correlation coefficients. To identify factors predicting anger expression methods, stepwise multiple regression analyses were conducted. Significance level was set at p < .05.

Results

A total of 94.9% of participants were women with an average age of 32.7 years; the largest age group (46.6%) was comprised of those in the 20 to 29 age range. A total of 70.4% of respondents held a bachelor’s degree, 64.8% were unmarried, 55.2% did not report a religious affiliation, and 66.3% worked in general medical and surgical departments. The average years worked was 7.9, with 24.5% having worked between 3 years and 5 years; 84.8% were staff nurses and 75.5% worked a three-shift schedule. The irrational beliefs score average was 2.65 ± 0.45 of 5, with the average anger rumination score at 2.41 ± 0.41 points of 4. Average anger expression style scores were 2.39 ± 0.40 points, 2.32 ± 0.43 points, and 2.66 ± 0.33 points (of 4) for anger-in, anger-out, and anger-control, respectively. Participant characteristics are summarized in Table 1.

Table 1. Characteristics of Study Participants

Characteristics	Categories	n (%)	M ± SD	Range
Gender	Male	17 (5.1)
Gender	Female	318 (94.9)
Age (years)			32.7 ± 11.32
	20-29	156 (46.6)
	30-39	150 (44.8)
	40-49	26 (7.8)
	≥50	3 (0.9)
Education	Diploma	77 (23.0)
	Bachelor	236 (70.4)
	Master	22 (6.6)
Marital status	Single or other^†	217 (64.8)
Marital status	Married	118 (35.2)
Religion	Yes	150 (44.8)
Religion	No	185 (55.2)
Department	Medical general	96 (28.7)
	Surgical general	126 (37.6)
	Special department (ICU, ER, OR etc.)	64 (19.2)
	Other (including OPD)	49 (14.5)
Total career (years)			7.9 ± 14.01
	≤2	69 (20.6)
	3-5	82 (24.5)
	6-8	72 (21.5)
	9-11	52 (15.5)
	≥12	60 (17.9)
Position	Staff nurse	284 (84.8)
	Charge nurse	37 (11.0)
	Head nurse	14 (4.2)
Work-shift	Fixed	59 (17.6)
	2 shifts	23 (6.9)
	3 shifts	253 (75.5)
Irrational beliefs			2.65 ± 0.45	1-5
Anger rumination			2.41 ± 0.41	1-4
Anger expression style
Anger-in			2.39 ± 0.40	1-4
Anger-out			2.32 ± 0.43	1-4
Anger-control			2.66 ± 0.33	1-4

Note. ICU = intensive care unit; ER = emergency room; OR = operating room; OPD = outpatient department.

†

separation, divorce, separation by death.

Anger Expression Styles by Participant Characteristics

Anger-in styles were more frequently reported by women than men (t = 3.99, p = .047). Anger-out expressions were more frequently endorsed among those with 6 to 8 years of experience compared with those nurses with less than 2 years of experience (F = 2.96 p = .020). Staff nurses and head nurses reported more anger-out strategies compared with charge nurses (F = 6.25, p = .002). Anger-control was higher among charge nurses compared with staff nurses (F = 3.40, p = .034; Table 2).

Table 2. Anger Expression Styles by Participant Characteristics

Characteristics	Categories	Anger expression style
		Anger-in		Anger-out		Anger-control
		M ± SD	t or F(p) Scheffé	M ± SD	t or F(p) Scheffé	M ± SD	t or F(p) Scheffé
Gender	Male	2.20 ± 0.39	3.99 (.047)	2.24 ± 0.41	0.52 (.471)	2.74 ± 0.31	0.93 (.336)
Gender	Female	2.40 ± 0.40	3.99 (.047)	2.32 ± 0.43	0.52 (.471)	2.66 ± 0.33	0.93 (.336)
Age (years)	20-29	2.38 ± 0.42	0.45 (.720)	2.31 ± 0.43	0.82 (.970)	2.64 ± 0.34	0.67 (.571)
	30-39	2.39 ± 0.40		2.32 ± 0.44		2.68 ± 0.33
	40-49	2.39 ± 0.28		2.34 ± 0.39		2.64 ± 0.31
	≥50	2.13 ± 0.00		2.38 ± 0.33		2.88 ± 0.25
Education	Diploma	2.30 ± 0.35	2.47 (.086)	2.30 ± 0.35	0.41 (.664)	2.67 ± 0.30	1.10 (.333)
	Bachelor	2.41 ± 0.41		2.33 ± 0.46		2.65 ± 0.34
	Master	2.42 ± 0.39		2.25 ± 0.39		2.76 ± 0.34
Marital Status	Single or other†	2.37 ± 0.41	0.57 (.453)	2.31 ± 0.45	0.21 (.650)	2.65 ± 0.34	0.23 (.629)
Marital Status	Married	2.41 ± 0.37	0.57 (.453)	2.33 ± 0.40	0.21 (.650)	2.67 ± 0.31	0.23 (.629)
Religion	Yes	2.37 ± 0.41	0.22 (.637)	2.31 ± 0.43	0.02 (.892)	2.67 ± 0.33	0.31 (.581)
Religion	No	2.39 ± 0.39	0.22 (.637)	2.32 ± 0.43	0.02 (.892)	2.65 ± 0.33	0.31 (.581)
Department	Medical general	2.34 ± 0.42	3.02 (.060)	2.29 ± 0.49	0.26 (.301)	2.66 ± 0.35	0.17 (.918)
	Surgical general	2.34 ± 0.38		2.30 ± 0.41		2.66 ± 0.31
	Special department (ICU, ER, OR etc.)	2.43 ± 0.41		2.41 ± 0.38		2.64 ± 0.32
	Other (including OPD)	2.48 ± 0.34		2.29 ± 0.41		2.68 ± 0.36
Total career (years)	≤2^a	2.37 ± 0.45	0.16 (.957)	2.23 ± 0.51	2.96 (.020) a<c	2.66 ± 0.36	0.14 (.968)
	3-5^b	2.38 ± 0.42		2.29 ± 0.36		2.67 ± 0.31
	6-8^c	2.41 ± 0.38		2.46 ± 0.44		2.64 ± 0.35
	9-11^d	2.40 ± 0.38		2.26 ± 0.38		2.65 ± 0.32
	≥12^e	2.38 ± 0.40		2.31 ± 0.43		2.68 ± 0.33
Position	Staff nurse^a	2.40 ± 0.40	1.12 (.329)	2.33 ± 0.42	6.25 (.002) a,c>b	2.65 ± 0.32	3.40 (.034) a<b
	Charge nurse^b	2.30 ± 0.41		2.10 ± 0.47		2.78 ± 0.37
	Head nurse^c	2.35 ± 0.23		2.49 ± 0.42		2.56 ± 0.38
Work-shift	Fixed	2.43 ± 0.34	0.57 (.566)	2.41 ± 0.32	2.55 (.080)	2.66 ± 0.31	1.87 (.156)
	2 shifts	2.39 ± 0.35		2.42 ± 0.41		2.53 ± 0.39
	3 shifts	2.37 ± 0.41		2.29 ± 0.45		2.67 ± 0.33

Note. ICU = intensive care unit; ER = emergency room; OR = operating room; OPD = outpatient department.

†

separation, divorce, separation by death.

^{a, b, c, d, e} post-hoc (Scheffé) comparison results for ANOVA.

Correlations Between Irrational Beliefs, Anger Rumination, and Anger Expression Styles

Irrational beliefs were strongly and positively correlated with anger-in (r = .47, p < .001) and anger-out (r = .34, p < .001), and weakly and negatively correlated with anger-control (r = −.12, p = .032). Anger rumination was strongly and positively correlated with anger-in (r = .59, p < .001) and anger-out (r = .43, p < .001), and weakly and negatively correlated with anger-control (r = −.12, p = .028; Table 3).

Table 3 Correlations Between Irrational Beliefs, Anger Rumination, and Anger Expression

Variable	Irrational beliefs	Anger rumination
Variable	r (p)	r (p)
Anger-in	.47 (<.001)	.59 (<.001)
Anger-out	.34 (<.001)	.43 (<.001)
Anger-control	−.12 (.032)	−.12 (.028)

Factors Predicting Anger Expression Styles

Stepwise multiple regression analyses were conducted with irrational beliefs, anger rumination, gender, career, and position as independent variables. Gender and position, because they were categorical variables, were transformed to dummy variables. The residual distribution was confirmed as satisfying normality assumptions. When multicollinearity between the independent variables was tested, tolerance was .67-1.00 for anger-in, .66-1.00 for anger-out, and 1.00 for anger-control; the variance inflation factor (VIF) was 1.00-1.50 for anger-in, 1.00-1.51 for anger-out, and 1.00 for anger-control, confirming that analyses were void of multicollinearity.

Anger rumination (β = .47, p < .001) and irrational beliefs (β = .19, p < .001) positively predicted anger-in and gender (β = −.09, p = .031) negatively predicted anger-in, all of which accounted for 37% of the variance in anger-in expressions (F = 66.96, p < .001). Anger rumination (β = .32, p < .001), career (β = .16, p = .001), and irrational beliefs (β = .15, p = .010) positively predicted anger-out and position (β = −.12, p = .017) negatively predicted anger-out, all of which explained 23% of the variance in anger-out expressions (F = 25.95, p < .001). Finally, position (β = .13, p = .016) positively predicted anger-control, accounting for 1% of the variance in anger-control (F = 5.90, p = .001; Table 4).

Table 4. Factors Influencing Anger Expression

Variable	Categories	B	SE	β	t	p
Anger-in	Anger rumination	.46	.05	.47	8.95	<.001
	Irrational beliefs	.17	.05	.19	3.61	<.001
	Gender	−.17	.08	−.09	−2.16	.031
		R ² = .38, Adjusted R ² = .37, F = 66.96, p < .001
Anger-out	Anger rumination	.34	.06	.32	5.46	<.001
	Career	.17	.05	.16	3.34	.001
	Irrational beliefs	.15	.06	.15	2.58	.010
	Position	−.16	.07	−.12	−2.40	.017
		R ² = .24 Adjusted R ² = .23, F = 25.95, p < .001
Anger-control	Position	.14	.06	.13	2.43	.016
		R ² = .02, Adjusted R ² = .01, F = 5.90, p = .016

Discussion

Level of irrational beliefs in the present sample was somewhat high, especially compared with a previous study assessing university students (M. S. Kwon, 2015). This finding likely reflects nursing job characteristics, which require flawless performance, and prompt and strict compliance to protocols for treating patients. Ellis (1995) stated that irrational beliefs derive from a general belief system learned mainly through past experiences. This system can trigger inappropriate emotions or behaviors. Thus, it is likely that nurses develop strong irrational beliefs, including perfectionism, acknowledgment, and high self-expectations based on their training as well as a strong sense of duty and responsibility within their profession.

The authors also observed relatively high levels of anger rumination in the present study, even higher than those observed in adolescent and adult (H. J. Kwon, 2014) and university student (S. E. Lee, 2014) samples. Nurses are likely more susceptible to anger rumination due to expectations for suppressing negative emotions when providing health care services. Results from a previous study revealed that nurses who experienced violence in the workplace reported feeling angry but chose to suppress their anger as a coping strategy (Kang & Park, 2015). Thus, nurses may be dissuaded from directly expressing their anger to patients and other caregivers (who tend to be the main sources of workplace violence); anger rumination increases the tendency to suppress anger. Based on Korean cultural norms, nurses are expected to be extremely deferential and kind to patients and their families and caregivers (K. H. Kim, 2015). This expectation could facilitate higher tendencies toward anger rumination compared with other nursing contexts (i.e., outside Korea) where the nursing workforce is responsible for nursing and caretaking.

Anger-control was the most frequent anger expression style reported in the present study, followed by anger-in and anger-out styles. This finding is consistent with prior literature (J. E. Kim, 2015; Oh, 2013) using the same measures as the present study. However, these results are contrary to those from another study (H. K. Park & Jeon, 2002) that reported the following ordering for nurses providing care to patients with hypertension: anger-in, anger-control, and anger-out. One possibility for the discrepancy is that nurses in the present study actually provided direct patient care, which likely prompted the excessive use of anger-control to maintain professional decorum.

It should be noted that the nurse staff-to-patient ratio in Korea is much higher than in other countries (i.e., the nurse to patient ratio in tertiary and general hospitals is 1:7 in Japan, 1:5 in the United States, and 1:15-30 in Korea; Ahn & Kim, 2014). The number of nurses in Korea is about 5.6 nurses per 1,000 individuals (2.9 individuals excluding nursing assistants, which is nearly the Organization for Economic Cooperation and Development [OECD] average of 9.6 per 1,000). The number of per capita licensees, number of practicing nurses compared with number of licensees, number of nurses with acute illnesses in Korea are all lower than other nations worldwide. Also, the fact that 37% of general hospitals (including tertiary hospitals) with the highest patient acuity do not meet the legal standard for appropriate nurse staffing is a serious problem (Cho, Lee, June, Hong, & Kim, 2016). Although in most OECD countries, the number of hospital beds has decreased in the past 5 years, in Korea, hospital beds have increased roughly 1.4 times (Organization for Economic Cooperation Development, 2016). Thus, Korean nurses must care for more than twice the number of patients as in other advanced countries (Ahn & Kim, 2014), leaving nurses more susceptible to inappropriate emotional expressions. To improve Korean nurses’ psychological health, as well as increase patient safety and health care quality, support policies must be actively developed to address these issues.

Regarding general characteristics, charge nurses reported engaging less in anger-out strategies while relying more on anger-control compared with staff nurses. These results are counter to previous studies reporting that more seasoned nurses actually demonstrate poorer psychological health (K. H. Kim, 2015). One possibility for this difference could be related to target hospital size and work environments within the nursing organization. Moreover, although charge nurses may have the resources available to control their situations and emotions (as reflected in improvements in their professional abilities and self-control compared with staff nurses), charge nurses also experience higher levels of conflict due to their work roles including training and supervision of subordinate nurses. This explanation could lead to charge nurses expressing anger more inappropriately compared with other nurses.

Study results also revealed that women were more likely to use anger-in strategies than men, similar to previous work (Howells & Day, 2003; M. S. Kim, 2014). This finding could be due to gender expectations within Korean culture, whereby women are expected to cede, obey, endure, and persevere within a paternalistic Confucian society (Fields et al., 1998). Thus, Korean nurses, the majority of whom are women, are expected to suppress their anger. However, excessive anger-suppress, without the actual resolution of internalized anger, can lead to over-controlled anger later (Jeon, 2007). Therefore, providing intervention strategies, such as communication, self-expression, and interpersonal skills training, could be beneficial for nursing organizations. This training could change perceptions about gender expectations for emotional expression, fostering a more egalitarian society.

Irrational beliefs and anger rumination were significant predictors of anger-in and anger-out strategies, but not anger-control, in the present study. In other words, higher irrational beliefs and anger rumination were predictive of more dysfunctional anger expressions. These results are similar to previous studies observing the role of cognitive factors on anger expression styles (Suh, 2004), with irrational beliefs (Yoon, 2005) and anger rumination (H. J. Kwon, 2014; M. S. Kim, 2014) influencing anger-in and anger-out expressions. One explanation is that such cognitive characteristics may actually facilitate the emergence of negative emotions (e.g., frustration, uncertainty, anger) in a way that challenges nurses to use appropriate expression style. In particular, anger rumination had the greatest influence on dysfunctional anger expressions, which is consistent with results from a previous study (Lim, 2014). Thus, cognitive ruminative processes appear to relate directly to anger expression tendencies.

Implications for Practice and Future Research

The majority of previous studies on anger experiences focus on the behavioral aspects of expressions. Recently, the role of cognitive factors has gained traction. The present study is the first to assess the role of cognitive factors on anger expression styles among nurses. Considering the risks involved in suppressing and inappropriately expressing anger in health care settings, the present findings could provide a foundation for cognitive-behavioral interventions targeted at providing nurses with proper anger-management techniques. The results of this study also suggest that workers with a strong tendency toward expressing anger have a high incidence of physical illnesses such as cancer, digestive disorders, and cardiovascular diseases. In addition, individuals with a strong propensity to suppress anger are more likely to experience depression (Jang & Won, 2009; K. S. Lee & Kim, 2000). Hence, elucidating factors that facilitate anger-control and reduce anger antecedents is needed. For instance, cognitive-behavioral therapy focused on anger behavior modification could be useful. Furthermore, it is possible performance within the organization could be enhanced by providing educational interventions for appropriate assertive anger expression. These new behaviors could be encouraged by creating a workplace culture that accommodates the need for appropriate expression of anger and frustration.

A few study limitations should be noted. First, the authors distributed self-administered questionnaires, which may not fully capture how participants actually experience and express anger at work. It is possible that social desirability factors could have affected participants’ responses. Therefore, it is necessary to assess anger experiences and expression through more objective methods, such as observational ratings from peers, patients, and supervisors in future studies. Furthermore, a variety of other cognitive factors not assessed in the present study could affect anger expression styles. Thus, a wider range of plausible intervening factors should be addressed in the future. Finally, it is necessary to further investigate the functional aspects of anger rumination and its role in proper anger expressions (Shin & Cho, 2014). This focus could assess how specific aspects of anger rumination are more or less adaptive.

Conclusion

The present study was conducted to investigate the relationship between irrational beliefs, anger rumination, and anger expression in nurses. Results showed that reports of irrational beliefs and anger rumination were related to more anger-in and anger-out expressions as well as less anger-control. The present findings indicate that higher levels of certain cognitive characteristics, specifically irrational beliefs and anger rumination, lead to heightened experiences of anger and a greater tendency toward inappropriate anger expressions among nurses. Thus, occupational health nurses must prioritize the development of anger-management programs to help nurses express work-elicited anger in more adaptive and productive ways, with a particular focus on the cognitive factors underlying these processes.

Applying Research to Practice

Considering the risks involved with the suppression and inappropriate expression of anger within a nursing context, cognitive factors (e.g., irrational beliefs, anger rumination) should be considered when applying anger-management interventions. Such considerations should increase nurses’ physical and psychological health to be more productive and efficient within their organizations.

Acknowledgments

We thank all nurses who participated in this study and appreciate the nursing staff in four tertiary hospitals who collected data.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

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

References

Ahn H. K., Kim H. J. (2014). Tasks for implementing a full-service nursing service for hospitalized patients. Korean Institute of Hospital Management, 4, 6-16.

Abstract

Method

Measures

Irrational beliefs

Anger rumination

Anger expression styles

Data Collection and Ethical Considerations

Data Analyses

Results

Anger Expression Styles by Participant Characteristics

Correlations Between Irrational Beliefs, Anger Rumination, and Anger Expression Styles

Factors Predicting Anger Expression Styles

Discussion

Implications for Practice and Future Research

Conclusion

Acknowledgments

Declaration of Conflicting Interests

Funding

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