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Facing challenges to family-centered care II: anger in the clinical setting. (Family Matters).

Department Editor's Note: This article follows an article in the previous issue in which Terry Griffin discussed another common challenge in providing family-centered care: visiting policies.

The provision of nursing care to children and their families can be deeply fulfilling, but it also poses challenges. One area of conflict between parents and professionals arises when expectations of parents are not met and angry feelings erupt.

Parental anger can be particularly upsetting to nursing staff for several reasons. Parental anger can be interpreted personally, leading the nurse to believe that his or her care is undervalued or that he or she is not appreciated. Nurses can become angry or defensive in response to a family's anger, adding to the level of tension and complicating the conflict. Additionally, when parents begin to raise their voices, nurses may fear that the anger will escalate to physical violence (Griffin, 2001). It is not uncommon for inappropriate calls to hospital security to be made when parents display angry emotions.

Bruce and Ritchie (1997) argue that to implement family-centered care, comprehensive policies and programs must be developed that provide both education and emotional support to meet the needs of the staff. Nurses must be educated and supported to deal effectively with and provide understanding and support to angry parents (Griffin, 2001).

Staff nurses, nurse managers, and nurse-administrators can anticipate the need for planning, education, and support to effectively deal with anger in the clinical setting. Ideally, nursing units would prospectively develop a philosophy of care and establish education and support for both staff and parents regarding these challenging situations. A family-centered philosophy of care can provide the needed guidance to both reduce conflict in these situations and aid professional decision making.

Several elements of family-centered care that are particularly applicable to managing anger and conflict in the clinical setting include the following (Shelton, Jeppson, & Johnson, 1987):

* a recognition of family individuality and respect for different methods of coping

* a readiness to implement policies and programs that are comprehensive and provide support to meet the needs of families

* a commitment to facilitate parent-professional collaboration at all levels of health care

* a readiness to share unbiased and complete information with parents about the child's care on an ongoing basis and in an appropriate and supportive manner

* the facilitation of parent-to-parent support

Understanding common sources of parental anger is the first step in deciding how to respond to it. Certain situations in the hospital setting are more likely than others to cause families to feel angry. Examples include visiting restrictions (see discussion in Griffin, 2003), an unexpected change in the child's health status, confusion resulting from conflicting or insufficient information provided by the staff, and feeling undervalued in the care of their infant or child. This article will discuss how nurses can handle these situations. How nurses can handle both their own anger and escalating anger in the clinical situation are also addressed. Finally, the benefit of developing parent-to-parent support networks is described.

An Unexpected Change in the Child's Health Status

Health care providers are aware that it is not uncommon for a child's condition to fluctuate, even deteriorate for a time, when recovering from an acute illness. Yet, parents who encounter an unexpected change in their child's condition may express anger at the situation. The change is upsetting, and the lack of anticipatory guidance or notification can also be upsetting. Parents usually expect, and sometimes request, to be notified if there is a change in their child's condition. When parents are not provided with this information in a timely fashion and arrive on a unit only to find their child in a different bed space or with additional equipment, they may express anger. In such situations, parents had trusted the staff to keep them apprised of changes in their child's condition, and they feel that trust was broken.

In other situations, "changes" in a child's status can be interpreted differently by staff and parents. For example, in the neonatal intensive care unit (NICU), blood transfusions are commonplace, and transfusion consents are often obtained on admission. In one situation, the mother of an infant in the NICU was extremely angry that she was not notified in advance of a blood transfusion for her preterm infant. She was angry that she had missed the opportunity to be at her infant's bedside during the procedure. The blood transfusion obviously had very different meanings for the mother and the staff who did not think it necessary to notify the mother of a "routine" transfusion. Staff members may also minimize or negate parental feelings when parents are upset about a clinical situation that staff members see as "minor" compared to other medical problems. Parental anger in situations such as these can also result in staff members feeling defensive or angry themselves.

It is possible that in any of these situations, the staff may have tried unsuccessfully to reach the family. Perhaps the nurse was unable to reach them because they were not in, perhaps they were en route to the hospital. In some circumstances, there may not have been adequate time to phone the family. In all of these situations, the staff was working diligently to correct the clinical problems that arose. Therefore, it is understandable that staff members may resent parental anger when they feel that the parents should instead be grateful that the child's problems are being cared for appropriately.

Yet, to provide family-centered care, staff must accept the following principles: (a) recognize and respect different methods of coping and (b) demonstrate a willingness to share unbiased and complete information with the parents, on an ongoing basis, in an appropriate and supportive manner (Shelton et al., 1987).

There are several ways to implement these principles in relation to parents' anger. First, staff members can be trained to recognize anger as a common first response to a very frightening and unexpected situation. To accept the parents' coping methods and to facilitate communication, the first step must be to acknowledge their anger. Staff members may simply state, "I see that you are angry. I do not blame you for this. I would be angry too. This change in--'s condition was unexpected." The next step is to provide information about the child's condition, the need for changes in the level of care, and any attempts made or plans that were in place to contact the family. Parents may feel less anger when they understand the child's condition and any efforts made or plans to contact them.

When appropriate, staff and parents must discuss ways to avoid future angering situations such as these. For example, if staff members truly tried to reach the parent, is there a pager or a cellular phone number that would make it easier?

On the other hand, if staff members did not make an attempt to notify the parents, acknowledgment of the mistake is of paramount importance. The responsible staff member(s) should apologize for creating mistrust and acknowledge how upsetting the situation is to the parents. The development of mistrust must be discussed and remedies sought to rebuild trust. It is important to tell the parents that the staff wants to work with them so that the situation does not re-occur. The staff should promise to notify parents of future tests/procedures/clinical changes and then fulfill this promise.

Staff members can also be educated in communication approaches that would avoid this type of situation. Early in the hospitalization, staff members can provide parents with prospective information about topics and issues that can be a common source of stress for families (e.g., changes in physician coverage, primary nursing, bed space, and room changes). Staff members and families can also establish in advance when parents would like to be notified of "common" procedures such as blood transfusions, eye examinations, and the like, so that they have a choice about whether to be present.

Confusion Resulting From Conflicting or Insufficient Information Provided by the Staff

Parents typically find themselves communicating with many staff members over the course of a hospitalization. At times, staff members may give conflicting information. This conflicting or inconsistent information can be confusing, stressful, and can lead to angry feelings. One example of this problem occurring is in discharge planning. Parents may receive different discharge plans from different physicians. This can be extremely unsettling and even upsetting to the family. Parents may find themselves confused and anxious about what to expect, and react in anger.

In order to support the parents, staff members must acknowledge parental feelings of confusion and anger. Parental decision making and caregiving cannot be achieved if the parents feel alienated by the staff. For parents and staff members to successfully be partners in the child's care requires effective communication. Then, efforts must be made to improve the communication patterns and clarify the information and plans given to the family. Communication is the key to successful implementation of family-centered care.

Feeling Undervalued in the Care of Their Infant or Child

Parents who feel undervalued in the care of their infant or child may also feel or express anger towards the nursing staff. An example of this occurred when a NICU nurse was compelled to remove a clinically unstable infant from Kangaroo Care. Once the infant was placed in the incubator, the mother became verbally aggressive and shouted at the nurses about being inconsequential in her infant's care. After this incident, it became apparent to staff members that the mother felt ignored and undervalued in caring for her infant. Throughout the remainder of the infant's hospitalization, the nursing staff worked diligently to assure the mother's centrality in her infant's care by applying the principle of family-centered care, recommending facilitation of parent-professional collaboration at all levels of health care (Shelton et a1.,1987). This mother desired involvement in every aspect of her infant's care. So, nurses collaborated with her in developing a care plan that included developmental aspects of care such as positioning, bath schedules, and feeding regimens. Since her infant was not ventilated, she was taught to remove her infant from the incubator without having to wait for an available nurse and to weigh her son and monitor his growth.

Nurses' Feelings of Anger

As previously mentioned, if nurses feel that a parent's anger is unjustified, they may begin to feel defensive and angry themselves (Griffin, 2001). For example, the mother of a critically ill infant with complex congenital heart disease was extremely upset by the placement of a scalp intravenous catheter and was concerned that the scalp IV was somehow detrimental to the infant. The infant's nurse was disturbed at what she perceived as the mother's "unjustified" response, and angrily complained to her peers that this mother was in for a big surprise when her infant returned from heart surgery. The nurse suggested that the mother would then realize how ridiculous her behavior regarding the scalp IV was.

The nurse's defensiveness and anger is unfortunate, but can be understood in the context of the stresses of her work. She was caring for a critically ill infant. It is possible that the nurse expected gratitude from the mother for being able to insert the scalp IV in this critically ill infant. Instead, she was met with the mother's anger.

At the same time, an angry reaction is not the most professional or helpful. Nurses need support and education to feel valued and to be better prepared to provide understanding and support to angry families.

Nurses need support when confronting challenging clinical situations. Opportunities should be provided to debrief from and process difficult situations so that emotions can be aired and appropriate responses can be developed. Nurses experienced in responding therapeutically to parental anger can serve as mentors to less experienced nurses to help them overcome defensiveness and anger and to offer examples of therapeutic responses to anger, such as some of those described previously.

In-service training should also be offered on managing anger in the clinical setting. As one approach, discussion of the family-centered principle of recognizing family individuality and respecting different methods of coping (Shelton et al., 1987) may be used to help nurses to understand that parents and staff view the child's illness, treatment, and recovery in different ways. Although staff and parents work side by side toward the care and cure of children, staff members utilize a diagnosis and treatment approach, while parents experience the child's hospitalization on an emotional level. Understanding and accepting these differences may help to avoid or minimize staff member defensiveness and anger in response to parental anger.

The best education about family-centered care may come from the families who have had children hospitalized. Their unique perspectives and insights can offer a valuable lesson for all staff. All units should incorporate ongoing education around family issues and invite veteran parents to share their ideas. Inviting veteran parents to discuss some of the feelings of anger they experienced during their child's hospitalization and providing a facilitator for the discussion can help nurses consider the validity of parental anger in a less emotionally charged setting. Involving families in staff education shows a commitment to the family-centered principle of facilitating parent-professional collaboration at all levels of health care (Shelton et al., 1987).

Escalating Anger

Nurses must be adequately prepared to deal with angry parents in a supportive manner. Yet, nurses also must be prepared to identify situations that can escalate into violence. Because most nurses feel uncomfortable with anger, it is not unusual for nurses to phone security once a parent raises his or her voice. In many cases, this response is an over-reaction.

Anger is a common feeling in parents of hospitalized children. When a parent becomes loud, the nurse should acknowledge the anger and his or her desire to help. A calm, supportive manner can often diffuse parental anger and re-direct the discussion to offering needed support or solving the problem at hand. In some situations it may become necessary to gently request that the parents move to a private room to continue the discussion. Although parents have a right to their feelings, it is not appropriate to allow parents to disturb the other infants and families. Staff members can simply say, "I care very much about this incident. I want to hear more about your experience. Let's go to another place where we can talk." At the same time, nurses should recognize that if a parent becomes verbally or physically threatening, security must be notified.

Parent-to-Parent Support

Just as nurses may benefit from seeking support and education from other experienced nurses, parents may benefit when they are linked with other parents familiar with their situation. Thus, perhaps, the most vital principle of family-centered care nurses should encourage and facilitate is parent-to-parent support. This principle of family-centered care principle benefits many parents who can relate to each other by virtue of their shared experience. Parental anger and other stressful feelings are common when a child is hospitalized, and veteran parents can best understand. Implementing a parent- to-parent support program in the unit or institution demonstrates a readiness to implement policies and programs that are comprehensive and provide support to meet the needs of families (Shelton et al., 1987).

There are many parent and staff conflicts that challenge nurses in the application of principles of family-centered care. A personal question for each nurse is to determine whether his or her own practice is family or staff centered. It is not possible to be both family and staff centered. Only one of these philosophies can guide care. Only one is the standard for care today.


Bruce, B., & Ritchie, J. (1997). Nurses' practices and perceptions of family-centered care. Journal of Pediatric Nursing, 12(4), 214-222.

Griffin, T. (2001). Nurses and families in the NICU: Angry families in the NICU. Journal of Neonatal Nursing, 20(8), 59-60.

Griffin, T. (2003). Facing challenges to family-centered care h Conflicts over visitation. Pediatric Nursing, 30(3), 135-137.

Shelton, T.L., Jeppson, E.S., & Johnson, B.H. (1987). Family-centered care for children with special health care needs. Association for the Care of Children's Health: Washington, DC.

The Family Matters section focuses on issues, information, and strategies relevant to working with families of pediatric patients. To suggest topics, obtain author guidelines, or to submit queries or manuscripts, contact Elizabeth Ahmann, ScD, RN; Section Editor; Pediatric Nursing; East Holly Avenue Box 56; Pitman, NJ 08071-0056; (856) 256-2300 or FAX (856) 256-2345.

Terry Griffin, MS, RNC, NNP, is a Neonatal Nurse Practitioner, Rush Children's Hospital, Chicago, IL.
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Author:Griffin, Terry
Publication:Pediatric Nursing
Date:May 1, 2003
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