International Journal of Commerce and Finance, Vol. 2, Issue 2, 2016, 27-39 DETERMINATION OF ANGER EXPRESSION AND ANGER MANAGEMENT STYLES AND AN APPLICATION ON OPERATING ROOM NURSES Hülya Aslan, (Nurse Supervisor Assc.) Yeditepe University Hospital, Istanbul Nilay Gemlik, (Dr.) Faculty of Health Sciences, Marmara University, İstanbul Gülfer Bektaş, (Dr.) Acibadem University, School of Healthcare Management, İstanbul Abstract: This research has been carried out in order to determine anger expression and anger management styles in operating room nurses. By applying an in-depth interview technique on operating room nurses working in a private hospital, a qualitative study has been performed in order to determine anger expression and anger management styles in operating room nurses. The interview consisted of ten questions such as demographic questions addressing the workers’ age, sex, education level and duration of employment in the organization they work, aiming to determine their anger expression and anger management styles. Since operating room environments contain various risk factors, and require active team work in a stressful dynamic setting under excessive workload, , it has been found that operating room nurses display their anger through loud speaking, fail to settle their anger positively, fail to control their anger in a behavioural pattern despite their cognitive awareness in anger management. Thus, it has been suggested that operating room nurses should be trained on anger management methods so that they can manage their anger in a stressful operating room environment. Keywords: Anger, Anger Expression, Anger Management Methods, Operating Room Nurses 1. Introduction Like love and joy experienced in human life, anger is a - feeling observed in all living species in nature. Like other feelings, anger is a feeling that affects many systems cognitively and physiologically. Although anger is considered to be a negative emotion, it can be turned to a positive one if properly managed, and is universal. Expression of anger is an acquired behaviour. Majority of anger-related problems are caused by inappropriate expression of anger, and how critical it is to express the anger properly is still debated. One of the most important things to know about anger is that, emergence or experience of anger may not be avoided as anger is a natural emotion. Therefore, feeling anger is something that can never be ignored. For an individual to experience his anger, which is a natural emotion, without harming himself and the environment, the individual should first recognize and identify anger, and then express it in a positive way (Sülün, 2013:2). A very healthy and natural feeling when expressed appropriately, anger leads to significant problems in business life, personal relationships and overall quality of life when it becomes uncontrollable and destructive. In addition, failure to express anger appropriately depletes the individual’s energy and makes it difficult for the individual to control his behaviours (Baran, 2009:1). In te rn a ti o n a l Jo u rn a l o f C o m m e rc e a n d F in a n c e 28 Hülya Aslan, Nilay Gemlik, Gülfer Bektaş Due to intensive working conditions, higher number of patients, paucity of budget and economic resources and conflicts within the team, nursing profession is considered to be an occupational group frequently exposed to anger. This study has been conducted to identify how operating room nurses express and control their anger. 2. Overview 2.1. The concept of anger There are many definitions for the feeling of anger which we frequently experience in our daily and business life. Lexically, anger is defined as the aggressive reaction, annoyance, rage and fury in response to frustration, offence or threat (www.tdk.gov.tr Date of access: April 19, 2015). Anger is one of the five basic emotions of a person, others of which are happiness, sadness, fear and hate (Bilge and Ünal,2005:189-196). Anger is an important sign indicating that we are hurt, our rights are violated, our requirements or demands are not properly satisfied, or simply things go wrong (Lerner,2014:5-15). As an inborn sense developing early in life, anger is a quite natural, universal, aggression- and violence-free and life- enriching emotional reaction necessary to sustain in response to unsatisfied demands, undesired results and unmet expectations (Albayrak and Happy 2009: 57-69). Based on these definitions, we experience the feeling of anger as a result of unrealized expectations in daily and business life, dissatisfaction about the life, unhappiness, encountering various undesired situations, and reduced tolerance. When expressed quite naturally and properly like other feelings, anger is indeed constructive and can enhance communication between individuals. However, anger may also turn to an uncontrolled behavioural abnormality potentially culminating in aggressive and highly destructive reactions. 2.1.1. Functions of anger Although anger is commonly perceived as a negative emotion harming people, it is in fact a humane, normal and healthy emotion. It is necessary for the individual to safeguard his presence and establish it in his environment. Despite commonly connoting negativity, anger is also known to have a set of functions that make one’s life easier. The functions of anger are summarized as follows;  Anger energizes,  Anger prevents disturbing internal reactive behaviours that further infuriate one’s emotions,  Anger facilitates the expression of negative feelings towards others,  Anger also makes a person bold in achieving his demands,  Anger warns a person that he is being irritated,  Anger builds a defence against the risk of damage to ego resulting from the orientation of the concern to external conflicts (Falcon, 2005: 1-22). Expression of anger constructively fosters trust, intimacy and empathy in interpersonal relationships, and founds a basis for communication by giving a sense of self-control (Batıgün and Falcon, 2009: 1-193). While directly warning the individual for a problem and allowing him to protect himself, anger may, on the other hand, harm the individual and his environment if not controlled. Hence, it has both positive and negative functions (Soyka, 2000: 19-27). 29 Hülya Aslan, Nilay Gemlik, Gülfer Bektaş Briefly, anger is an efficient, productive and motivating condition when not suppressed and denied. Yet, when denied and suppressed, anger turns into a condition that harms individuals as well as their environment. The resulting frustration deteriorates relationships between people and its suppression leads to mental and physical disorders. Furthermore, when intense feelings of anger are experienced, verbal and non-verbal aggression may occur. 2.1.2. Causes of anger Anger may develop both from internal and external causes. Anger may be directed at a specific person or a specific event, as well as being a result of general individual problems. Given the complex nature of anger, abundance of internal and external factors involved in evaluating anger is remarkable. Internal causes: Basic feelings underlying internal causes driving anger are jealousness, sadness, worry, loneliness, alienation, anxiety, frustration, injustice, not being understood and distress. Such primary feelings lead to anger when they accumulate, harden and solidify (Tatlıoğlu and Karaca, 2013:1102-1123). External causes: Injustice, physical harm and injury, getting harassed, attacked and threatened. While external causes of anger may be the physical environmental factors or individual disputes arising from disagreement, a variety of social and cultural factors introduced by the social life may also take place (Tatlıoğlu and Karaca, 2013: 1102- 1123). Many people and events we encounter in our daily lives and at work may trigger anger. It may be our mother, a friend, a man on the street, traffic jam or a work-related problem. While our own personal delusions may be responsible for our anger, it may also be the memories of a past frustrating event that drive the anger. Frustration, rejection, unpleasant situations, disrespect for our personal rights as well as economic, cultural, social and biological factors we encounter at particular times in our lives constitute the stimuli that cause anger. 2.1.3. Types of anger In literature, anger is studied in two ways depending on its occurrence and expression. 2.1.3.1. Trait-destructive anger This refers to individual tendency to get angry. These individuals have higher levels of anger and get angry more often. Since anger is employed destructively, feelings of hatred, revenge, hostility, resentment, sadness, aggression and fear are experienced more intensely (İlhan, 2014:162-165). Destructive anger may cause problems in the work and family environment, interpersonal relationships, and/or the person’s quality of life. Driving individuals to behave aggressively, anger is destructive and entails negative emotions (Kaplan, 2007:1). 2.1.3.2. Situational-constructive anger Situational anger is the form of anger that has accumulated in the individual over time and that erupt suddenly. Despite being apparently exhibited and called in the form of anger, situation anger is in fact underlain by the individual’s sense of disappointment, injustice, suffering, frustration, offence and dissatisfaction of expectations (Ozmen, 2004: 30). In constructively expressing the anger, the angry person establishes a positive relationship with others. People exhibit direct and true, positive and healthy behaviours upon their feelings (Karslı, 2008:23). 30 Hülya Aslan, Nilay Gemlik, Gülfer Bektaş 2.1.4. Dimensions of anger There are dimensions that trigger, create and effect the expression of anger. Typically, these are physical and physiological dimensions, cognitive and emotional dimensions, and behavioural and reactive dimensions. Anger is addressed as an all-round structure composed of various variables including physiological (generally sympathetic stimulation, acceleration of heartbeat, increased blood pressure), cognitive (irrational beliefs), perceptual (subjective recognition of anger), and behavioural (mimics, verbal or behavioural expression) variables. In other words, the root causes of behavioural responses are not principally related to the events, but are rather associated with the meanings, interpretations and thoughts produced by the individual in his mind, as well as the beliefs underlying them. Such ways of thinking are formed by social experiences we are involved in since early childhood. Thus, anger and expression thereof may be said to be the collective outcome of biology and culture, our cognitive structures, and the body (Sülün, 2013:37). Anger is an emotion experienced in a broad spectrum of intensities ranging from very mild to intense. Like other emotions, physiological and biological changes are felt together. If the person is attentive, his body informs him that he is angry. There are also physical signs of anger. The stimuli mobilizes the emotion, stress and tension are initiated, and energy-driving adrenalin excretion starts followed by more frequent breathing, faster heart beating, increased blood pressure, and the body and the mind get ready for the “Fight or escape” response (Kökdemir, 2004:7-10). Cognitive and emotional approach reveals how the person perceives and interprets the anger. Once anger is detected and redirected by the central nervous system, the intensity of anger is determined by the person’s response to anger and nature of this response, way of expressing the anger, person’s rational or irrational ways of thinking, beliefs, prejudices, past experiences and their association with events (Herdem, 2009:25). Depending on the type of stimulus and the individual cognitive structure, individuals display various reactions to the anger perceived. While some individuals tend to suppress or repress their anger under the effect of the community and the social system they are involved in, some attempt to exhibit their anger in different ways or express it (Peters, 2004:28). 2.1.5. Positive and negative aspects of anger Besides its positive aspects, anger has also negative ones particularly when it is not expressed properly and healthily. When anger harms interpersonal relationships, it transforms into an unhealthy state of feeling. Such mode of anger is destructive, harmful and includes aggressive behaviours. Persons that cannot control their anger commonly display certain behaviours including severe and sudden outbursts of anger, utilizing anger as an instrument to gain power, substance abuse to cope with the underlying causes of anger, overreacting to critics and rejection, and denying the responsibility for their own behaviours and blaming others. Transformed mode of anger may be in the form of “finding a whipping boy”, namely deflection. Sometimes, it may be expressed in the opposite direction in the form of excessively polite reaction. And sometimes it may affect and impair mental health. It may lead to paralysis and tics. Anger is the underlying reason of some psychosomatic diseases such as headaches, ulcer, reflux, gastritis, high blood pressure and asthma.. Anger may be expressed in the form of slander, gossip and conspiracy as well. Moreover, anger affects the individual’s cognitive abilities. Individual starts to consider and judge the events from that point of view. Since an angry person will judge events negatively, anger also represents a barrier to positive thinking. In this respect, sudden responses driven by anger constitute negative responses of anger. This feeling that cannot be exhibited in a positive way leads to negative results in interpersonal relationships (Genç, 2007:18). 31 Hülya Aslan, Nilay Gemlik, Gülfer Bektaş In persons with high level of anger, regretting and drawing lessons from the negative experiences for which anger is expressed is less probable and interpersonal problems are more frequent (Dilekler et al., 2014:44-59). Anger is known as a negative emotion by almost everyone. In fact, anger dresses and protects the individual against tough and dangerous situations. By reminding that something has to change, anger helps to promote interpersonal relationships into a more productive and healthy form (İmamoğlu, 2003:35). When energy released by anger is employed constructively, anger is considered as a normal and positive feeling. By guiding the individual to react properly, it imparts to the individual strength, superiority and the ability to control events. When openly expressed, anger renders relationships meaningful, prevents interpersonal conflicts, and provides individual with the necessary motivation for change (Tambağ and Öz, 2005:11-22). On the other hand, unhealthy form of anger does not represent a tool for solving a problem, taking revenge, blaming and controlling others, and proving to be right. Unhealthy anger leads to problems in business life and overall life quality, and causes impairment of health. Anger is experienced healthily when it is expressed towards the appropriate person for appropriate reasons in a controlled manner. Anger is a reaction to a negative experience. By reminding us that something has to change, this feeling helps to transform relationships and situations into a more efficient and positive state. 2.2. Expression of anger 2.2.1. Anger expression patterns Expression of anger varies from person to person. These can be classified as inward anger, outward anger and controlled anger. While repression includes restraining and expressing anger, outward expression is manifested physically such as hitting, damaging objects, as well as verbally such as yelling, insulting and criticizing. Controlling anger means that the individual is patient and tolerant in his relationships with others, and maintains an attitude of controlling the anger. In environments based upon a good communication, the individual desires to express his feelings comfortably and wants to be understood by others. In life, the milieu occasionally strives to control and guide the individual’s feelings and thoughts. People attempting to control and guide the feelings, thoughts and behaviours of others in life induce negative effects on people's psychological health. In this case, the primary response from the other person would be to deny and resist to the control directed to him. And this is manifested in the form of anger and exhibition of the angry behaviour. In other words, the individual harshly shows a furious reaction to the external control directed to him. The secondary response to be shown by the individual involved in such a communication may occur in the form of repressing the anger and resigning himself to the control of the external stimuli (Özmen, 2006:39-56). Whatever the sources of anger are, all people tend to get angry. However, how the anger is expressed or what induces the anger most varies by individual. Individuals displaying anger aggressively without considering the cause of their anger fail to control their reactions as they usually act without thinking. And due to such uncontrolled behaviours, they experience problems in communicating with the people around and lose their friendship. On the other hand, an individual who has attained the emotional maturity allowing him to control his feelings and behaviours first tends to temper the same excitement of anger and exhibit it without hurting others. Yet, individuals failing to exhibit their anger and constantly suppressing it may have some psychosomatic or depressive issues (Yılmaz, 2007:171-172). 2.2.2. Repressing the anger Some people have great difficulty in expressing their anger, and block the expression of anger due to the intrinsic rules and obstacles they have. Non-exhibited anger leads to physiological effects in the individual further culminating in physical health problems. It is important for such individuals to recognize their anger first. 32 Hülya Aslan, Nilay Gemlik, Gülfer Bektaş Individuals with repressed anger have difficulty in accepting that they are angry. Reaction of these individuals to anger usually consists of passive responses. Such passive reactions to anger usually occur in the form of frowning, pout, sulk and resentment. These individuals hope that others recognize and read their thoughts. Eventually, this may end up with suffering, resentment or frowning. Individuals with repressed anger do not immediately exhibit an aggressive response when faced with an anger-triggering situation, but rather think for a long time over the severity of the situation and the reaction to give (Özmen, 2006:39-56). Finally, isolation from others and refusing to cooperate with them, silence, forgetfulness, psychosomatic disorders, depression and guilt, susceptibility to accidents, resistance to cooperation, addictive behaviours, excessive tolerance, unsociable behaviours, crying, hopes for violence and crime, intense discomfort and feeling of stress, unhappiness and tension, resentment and presence of mental suffering are the signs and symptoms of indirect expression of anger (Soykan, 2003:19-27). 2.2.3. Outward expression of anger Outward expression of anger and frequently expressing it verbally is the uncontrolled release of anger. Individuals outwardly expressing their anger need to learn how to express their anger in a more controlled and useful manner rather than releasing it in an uncontrolled way. Some individuals act despotically in a way to hurt and humiliate others. Even though such outward expression of anger provides a temporary relief, it depletes individual’s energy, makes it difficult to control the behaviours, and render the individual aggressive and offensive. If these individuals keep releasing their senses of anger in an exposed and uncontrolled manner, they will most probably face difficulties in their interpersonal communications, be excluded from communities they are involved, and begin to have conflicts in the family, at work and in social relationships (Beyazaslan, 2012: 24). Anger may also be released through verbal forms including yelling and reprimanding, as well as non-verbal forms including glowering or hostile glances. And further, anger may be outwardly expressed in indirect forms including vilification, defamatory humour or gossip (Engin, 2004:9). 2.2.4. Controlling the anger Anger control means the acquirement of the ability to express anger properly. Anger control is one of the most challenging emotions. It is important for the individual to understand what anger is and how to manage it. What’s critical in the control of anger is the positive rather than negative response to the situation arousing the anger. For individual happiness at home and workplace, psychological health and social cohesion, one of the important skills that an individual should have is the ability to control anger. In anger control, various skills such as using humour, maintaining a peaceful, flexible and accommodating attitude, relaxing, acknowledging, identifying and confronting the problem as well as focusing on and solving it, enhancing communication skills, sharing thoughts and feelings, changing the mindset, and being able to recognize the anger are effective ( Özkaya up and Buga, 2010:50- 59). Anger and aggressive behaviours should never be perceived as a tool for problem solving, taking revenge, blaming others, justification for committing a crime, reason for violence, and a tool for advocacy and controlling others. What is healthier is to render personality as the protective instrument for the psychological and social health by constructively redefining this emotion, which initially appears negative, through appropriate trainings and methods (Tatlıoğlu and Karaca, 2013:1102-1123). 33 Hülya Aslan, Nilay Gemlik, Gülfer Bektaş 2.2.5. Methods for controlling anger There are many methods teaching anger management, yet, the accurate method depends on the individual. The selection of the appropriate method should be based on the individual’s own personality and lifestyle. Methods for controlling anger contain cognitive, emotional, communicational and behavioural dimensions. In the cognitive method, confronting the situation inducing the anger, avoiding it, describing the event from different angles, and thinking in different perspectives may direct the individual towards more accurate responses. In addition, individual should strive to control his anger through his own guiding sentences such as “Do not let the anger seize you”, “Take a deep breath” etc. (Bilge and Ünal, 2005: 189-196). Next, in the emotional method, detecting the early signs of anger, being aware of the resulting feelings, discovering how the body reacts, reducing physical stimulation such as gritting teeth and fists, stomach cramps, difficulty in swallowing, biting lips, etc., and employing anger as a hint to change the thoughts and behaviours are effective (Kökdemir, 2004:7-10). Moreover, communication should be used properly to control anger. This means listening to the partner, calming down, correctly analysing the events, and criticizing positively instead of saying what immediately comes to mind during anger (Karadal, 2009:75). The purpose of the behavioural method is to prevent aggressive behaviours. It further means creating efficient, namely productive anger behaviour, avoiding and protecting from destructive and provocative behaviours, and reviewing and reassessing the root causes of and underlying the anger as well as their results. Hence, improper actions triggered by anger would be replaced by more favourable alternatives (www.aktuelpsikoloji.com). Date of access: May 16, 2015). Briefly, it is not always possible to change, fend off or move away from people that drive us angry. However, it is in our hands to learn how to control our reactions. Acknowledging anger as a normal feeling and being aware of our reactions at the time of anger are critical for controlling the anger. 2.3. An Overview On Hospitals, Operating Rooms And Nurses 2.3.1. The Hospital Environment Hospitals are among the most complex organizations, and therefore have a great potential for conflicts. Hospitals harbour various conflict inputs primarily including the involvement of many professionals from a broad range of disciplines, continuous service at full capacity, heavy workload, disputes among staff in the patient treatment process, complexity of roles, and uncertainty of tasks, leading to the frequent emergence of anger cycles. Hospitals typically represent non-profit service organizations where all varieties of health services are produced continuously and cost-effectively. Hospitals offer education, research and public health services, interact with the milieu in the healthcare industry, process various inputs into useful outputs, and display complex, expensive and specific various functions (Yılmaz, 1996:5). Furthermore, hospitals are organizations where different disciplines should collectively work across a common purpose. They offer vital services to people, race against time, employ distinct technologies, intensely interact with a big mass of people, and are hence exposed to conflicts and tension. 2.3.2. Operating Room Setting Operating rooms are typically the spaces where sophisticated technology, tools and equipment are used, various surgical techniques and methods are employed in the light of new and advanced information, and where teamwork is http://www.aktuelpsikoloji.com/ 34 Hülya Aslan, Nilay Gemlik, Gülfer Bektaş critical to take and implement proper decisions rapidly. Since critical and high-risk procedures are conducted in operating rooms, their atmosphere frequently triggers anger. In addition, operating rooms are isolated sections of the hospital where required surgical treatment is conducted upon the diagnosis. An operating room can also be defined as a physical and functional space where surgical procedures are conducted. Physical components of this space are the architectural design, engineering, equipment and surgical tools. Functional components comprise systems used to apply the treatment safely, reliably and cost- effectively (Uludoğan, 2010:23). Due to the working atmosphere inside, operating rooms accommodate major issues that may be faced by operating room nurses potentially leading to anger most frequently, including anaesthesia gases leaking from the anaesthesia machine, stab wounds, non-ergonomic equipment positions and postures, solutions used for sterilization/disinfection, exposure to radioactive rays, communication issues within the team arising from the difficulty to handle a self-opinionated group, stress due to the necessity of showing utmost attention for the specific nature of the work, psychosocial problems induced by dark and lack of daylight, and disarrangement of working conditions, particularly resting and meals. 2.3.3. Operating room nurses While nurses working in an operating room provide an all-round dynamic nursing care demanding utmost attention and close observation in an isolated environment due to rapid circulation of patients, they are also supposed to use complex technological tools and equipment. Such working conditions affect operating room nurses, frequently entailing anger resulting from intense stress. Besides typical roles of getting acquainted with new knowledge and applications, new technological trends, implementing, organizing, inspecting, as well as evaluating the results, operating room nurses are also supposed to carry the skills of thinking straight, acting fast, being attentive, showing prudence, observing, being inclined to teamwork and developing good communication within the team (Gümüşkaya, 2010:9). Anger is also defined as an emotional response to frustration and intense stressors encountered at work. Negative factors impairing patient care, conditions associated with the physical work environment, heavy workload, poor social support, high mass of patients, standing for a long time, and working indoors are the compelling factors for operating room nurses. At this point, stressful working environment, absence of common goals, poor consultation within the organizational process, competition between teams, and poor communication within the team cause nurses to tend to get into conflicts and experience a rage (Bayrı, 2007:19). Operating room nurses are exposed to myriad of risks in their work environment. These are typically stress-related factors including long-term work, heavy workload, time pressure, difficult or complex tasks, insufficient rest intervals, monotony and physically poor work conditions (location, temperature and lighting). Besides, standing for long time depending on the service load, lack of sleep during on-call service, and eating disorders also add to the level of stress faced by nurses, culminating in physical, mental and social impacts (Tan et al., 2009:67-68). Operating room nursing has different characteristics from other nursing functions. Nurses are supposed to work in harmony with other members of the team within such a critical field characterized by rapid scientific and technological advancements, intensive teamwork, high level of patient dependency, and strict intolerance to unsatisfactory knowledge and skills. To maintain teamwork within the operating room is a very difficult task. There is a set of problems that the team faces. These are mainly differences in the educational background, ambiguity of roles entailing false expectations, authority, power struggle, hierarchic conflicts, and personal characteristics of team members, all frequently leading to tension within the team and inducing anger in operating room nurses (Uludoğan, 2010:25). 35 Hülya Aslan, Nilay Gemlik, Gülfer Bektaş 3. Material And Method The aim of this study is to identify how operating room nurses express and control their anger in the operating room. First, the researcher has attempted to identify the underlying causes of anger induced in nurses working in operating rooms that can be characterized as complex spaces harbouring myriad of risk factors strictly requiring a mistake-free teamwork, and further to figure out whether nurses are knowledgeable about anger management in such a complex environment. The research is a qualitative study where in-depth interviews were made through the semi-structured interview guide. This is because in a qualitative study, it is a quite strong tool as it better unveils the personal data, opinions, experiences and feelings of individuals, and is based on speech, which is the most common form of communication. Qualitative research is based on the principle of induction. Researcher is in an attempt to determine the key themes of the studied problem based on descriptive and detailed data gathered, and translate this data into a meaningful form, namely to develop a theory based on this data. Case-related factors (environment, individuals, events, processes, etc.) are explored in a holistic approach with emphasis in how they affect the case (Yıldırım and Şimşek, 2013:63). Upon the consent of participants, interview minutes and data were gathered through the semi-structured interview guide according to the convenience sampling and in-depth interview method. The in-depth interview method is a preferred method in comprehending, understanding and interpreting social reality. The interview form ensures the coverage of all dimensions and questions relating to the research problem. (Cevahir, 2013:123). In designing the questions, 2 academic researchers have been consulted with. The convenience sampling method was selected as the study method because the researcher was in the intent of involving into the study the individuals agreeing to meet at hospitals. Research was carried out through in-depth interviews as accompanied by eight operating room nurses. Each interview lasted for 15 to 20 minutes. Interview is composed of 10 questions. While creating the interview form, the emphasis was to include open-ended targeted questions that are clear and that suit the experiences of interviewees, allowing the individuals to provide more detailed answers. Also during the interview, directive reactions were avoided. Questions were structured in an order ranging from the private to common, with questions on sensitive issues being at the end of the form, and questions on knowledge and skills were logically associated with experiences (Yıldırım and Şimşek, 2013:156). Questions on the guide were aimed at identifying the demographics of employees such as date of birth, gender, educational background, term of employment in the organization, as well as their way of expressing anger and their knowledge on and experiences in anger management. To ensure the validity and reliability of the research, interviews with participants were held in the operating room, and clear, detailed and deep-focussed data were gathered during the research through long-term interaction allowing researcher’s evaluation by the researcher, so that expert could review and the participant could assess the data gathered. 4. Results Anger may be found in majority of the employees regardless of their age, education and work experience. This study was conducted on operating room nurses at a private hospital through the in-depth interview method. Briefly, the following results have been derived from the research. Title: Operating room nurse Number of participants: 8 Gender: Female Year of birth: between 1975-1989 36 Hülya Aslan, Nilay Gemlik, Gülfer Bektaş Educational background: Postgraduate Degree (1), Graduate Degree (1), Associate Degree (1), High School (5) Experience in the organization (years): 5 years and over in average The majority of the group defined anger as extreme tension and uncontrolled reactions resulting from injustice and dissatisfaction. Seven participants acknowledged that they are generally angry while only one stated occasional anger. The general statement of the group is that they frequently experience anger upon the mistakes of others, when they are frustrated, not understood, and in case of poor physical environment, cold, hunger, staying indoors, conflict within the team, failure and feeling worthless. Since causes of anger are common throughout the group, no association is built with their demographics. Only two of the nurses stated that they occasionally repress their anger while other nurses stated that they generally raise their voices, satirize and talk with third parties about the person making them angry. Four of the nurses stated that they experience frequent outbursts of anger while the remaining four stated rare outbursts. Four of the nurses described control of anger as the ability to manage tension at the time of anger while three described it as the ability to understand the other party, and one stated that she has no knowledge about anger management. While five of the nurses preferred to move off during anger, one stated that she tries to take a deep breath, and two stated that they are unable to control anger and have no knowledge about it. While five of the nurses stated that they go angry when they work indoors without daylight, three stated that they are used to this situation and do not experience any anger. Additionally, it was found that nurses with a term of employment of 5 years or above are stressed more when they work indoors. While eight of the nurses stated that they feel frustrated in the operating room, four stated that they get angry because of irresponsible, indifferent and insensitive behaviours of their colleagues, and the other four stated that heavy workload, long-time hunger, standing, and poorly limited resting drive them angry. 5. Discussion Majority of the operating room nurses frequently experience anger because of the risk factors in the operating room, long-time hunger and standing, poorly limited resting, staying indoors, mistakes within the team, heavy workload, and disinterested and irresponsible behaviours of colleagues in some cases. It has been found that the whole group frequently experiences anger commonly because of the mistakes of others, not being understood by others, poor physical environment, conflicts within the team, failure, and perfectionist attitudes of some. It has further been found that, at the time of anger, six of the nurses raise their voice, satirize and talk with third parties about persons making them angry, and outwardly express their anger, while two occasionally repress it. Five of the nurses exhibit verbal aggression rather than physical aggression at the time of anger, and sleep disorders entailed by their on-call service cause them feel angry. Eight of the nurses often display their angry outwardly through fury and shouting. Four of the nurses often experience outbursts of anger at home and work. The nurses generally describe the control of anger as the ability to manage tension and understand the other party at the time of anger. The nurses commonly state that they fail to control their anger, and rather prefer to leave the site. 37 Hülya Aslan, Nilay Gemlik, Gülfer Bektaş Finally, it has been found that majority of the operating room nurses tend to confront the situation causing the anger, avoid them, describe the events from different angles, and ask themselves the questions of “at the time of anger, where am I?, who am I with?, what happens?, what do I expect?” in order to consider different points of view. 6. Conclusion Anger is an emotional response necessary to survive directed to unsatisfied requests, undesired outcomes and unmet expectations. The most important thing to know about anger is that the emergence or experience of anger is unavoidable. For an individual to develop the ability of experiencing anger without harming himself and his environment, he needs to first recognize and identify anger, and then express it in a positive way. Operating rooms are typically the spaces where sophisticated technology, tools and equipment are used, various surgical techniques and methods are employed in the light of new and advanced information, and teamwork is critical to take and implement proper decisions rapidly. While nurses working in an operating room provide an all- round dynamic nursing care demanding utmost attention and close observation in an isolated environment due to rapid circulation of patients, they are also supposed to use complex technological tools and equipment, and therefore such tough working conditions induce intensive stress and frequently cause anger in them. They often express anger by expressing it outwardly. Though they are cognitively aware of anger management, they fail to control anger at the behavioural side. In addition, the results of other researches provided below suggest that nurses fail to properly express and control their anger, and therefore experience various problems. In his study where the association between the way nurses express their anger and their overall health condition is explored, Bayrı (20007) has found that nurses have a high level of anger and suffer some health problems as they fail to express their anger properly. In his study where the influence of anger level on job satisfaction is explored for nurses, Baran (2009) has found that job satisfaction decreases as the scores of outward expression and repression of anger rise. In his study exploring for nurses the level of anger and way of expressing it in the working environment, İlhan (2014) has found that nurses fail to express their anger properly, leading to problems in their professional relationships. In his study exploring how nurses express their anger and communicate, Yılmaz (2009) has found that, as the level of assertiveness increases, their level of anger is reduced and they manage to control their anger. Surprisingly, there are already researches in the literature on the expression and control of anger in nurses, however there is no study specifically on operating room nurses. Though some of the operating room nurses have a high level of cognitive awareness, they fail to control anger at the behavioural side. And finally based on the foregoing facts and results, I recommend that a training support should be procured from expert professionals on the control of tension and anger in operating rooms that are highly exposed to stress. References Albayrak B, Kutlu Y., (2009), “Ergenlerde Öfke İfade Tarzı ve İlişkili Faktörler”, Maltepe University, Journal of Nursing Science and Art, 3, 57-69. Balkaya F, Şahin H., N., (2003), “Journal of Turkish Psychiatry”,14,3,192-202. Baran M., (2009). Influence of Anger Level on Job Satisfaction for Nurses. Atatürk University, Institute of Health Sciences, Master Thesis, Erzurum, (Supervisor: Asst. Assc. Dr. A. Okanlı). 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