7. Hostility
1. Definition: a feeling of intense anger or an attitude of antagonism or animosity, with the destructive component of intent to inflict harm and pain to another or to self; may involve hate, anger, rage, aggression, regression.
2. Operational definition:
1. Past experience of frustration, loss of selfesteem, unmet needs for status, prestige, or love.
2. Present expectations of self and others not met.
3. Feelings of humiliation, inadequacy, emotional pain, and conflict.
4. Anxiety experienced and converted into hostility, which can be:
1. Repressed, with result of becoming withdrawn.
2. Disowned to the point of overreaction and extreme compliance.
3. Overtly exhibited: verbal, nonverbal.
3. Concepts and principles:
1. Aggression and violence are two outward expressions of hostility.
2. Hostility is often unconscious, automatic response.
3. Hostile wishes and impulses may be underlying motives for many actions.
4. Perceptions may be distorted by hostile outlook.
5. Continuum: from extreme politeness to externalization as murderous rage or homicide or internalization as depression or suicide.
6. Hostility seen as a defense against depression, as well as a cause of it.
7. Hostility may be repressed, dissociated, or expressed covertly or overtly.
8. Normal hostility may come from justifiable fear of real danger; irrational hostility stems from anxiety.
9. Developmental roots of hostility:
1. Infants look away, push away, physically move away from threat; give defiant look. Role modeling by parents.
2. Three-year-olds replace overt hostility with protective shyness, retreat, and withdrawal. Feel weak, inadequate in face of powerful person against whom cannot openly ventilate hostility.
3. Frustrated or unmet needs for status, prestige, or power serve as a basis for adult hostility.
4. Assessment:
1. Fault finding, scapegoating, sarcasm, derision.
2. Arguing, swearing, abusiveness, verbal threatening.
3. Deceptive sweetness, joking at other’s expense, gossiping.
4. Physical abusiveness, violence, murder, vindictiveness.
5. Analysis/nursing diagnosis:
1. Causes
1. Anxiety related to a learned means of dealing with an interpersonal threat.
2. Risk for violence related to a reaction to loss of self-esteem and powerlessness.
3. Defensive coping related to intense frustration, insecurity, or apprehension.
4. Impaired social interaction related to low anxiety tolerance.
2. Situations with high potential for hostility:
1. Enforced illness and hospitalization cause anxiety, which may be expressed as hostility.
2. Dependency feelings related to acceptance of illness may result in hostility as a coping mechanism.
3. Certain illnesses or physical disabilities may be conducive to hostility:
1. Preoperative cancer client may displace hostility onto staff and family.
2. Postoperatively, if diagnosis is terminal, the family may displace hostility onto nurse.
3. Anger, hostility is a stage of dying the person may experience.
4. Amputee may focus frustration on others due to dependency and jealousy.
5. Patients on hemodialysis are prone to helplessness, which may be displaced as hostility.
6. Nursing care plan/implementation:
1. Long-term goal: help alter response to fear, inadequacy, frustration, threat.
2. Short-term goal: express and explore feelings of hostility without injury to self or others.
1. Remain calm, nonthreatening; endure verbal abuse in impartial manner, within limits; speak quietly.
2. Protect from self-harm, acting out.
3. Discourage hostile behavior while showing acceptance of client.
4. Offer support to express feelings of frustration, anger, and fear constructively, safely, and appropriately.
5. Explore hostile feelings without fear of retaliation, disapproval.
6. Avoid: arguing, giving advice, reacting with hostility, punitiveness, finding fault.
7. Avoid joking, teasing, which can be misinterpreted.
8. Avoid words such as anger, hostility; use client’s words (upset, irritated).
9. Do not minimize problem or give client reassurance or hasty, general conclusions.
10. Do not stop verbal expression of anger unless detrimental.
11. Respond matter-of-factly to attentionseeking behavior, not defensively.
12. Avoid physical contact; allow client to set pace in “closeness.”
13. Look for clues to antecedent events and focus directly on those areas; do not evade or ignore.
14. Constantly focus on here and now and affective component of message rather than on content.
15. Reconstruct what happened and why, discuss client’s reactions; seek observations, not inferences.
16. Learn how client would like to be treated.
17. Look for ways to help client relate better without defensiveness, when ready.
18. Plan to channel feelings into motor outlets (occupational and recreational therapy, physical activity, games, debates).
19. Explain procedures beforehand; approach frequently.
20. Withdraw attention, set limits, when acting out.
3. Health teaching: teach acceptable motor outlets for tension.
7. Evaluation/outcome criteria: identifies sources of threat and experiences success in dealing with threat.


8. Manipulation
1. Definition: process of playing on and using others by unfair, insidious means to serve own purpose without regard for others’ needs; may take many forms; occurs consciously, unconsciously to some extent, in all interpersonal relations.
2. Operational definition:
1. Conflicting needs, goals exist between client and other person (e.g., nurse).
2. Other person perceives need as unacceptable, unreasonable.
3. Other person refuses to accept client’s need.
4. Client’s tension increases, and he or she begins to relate to others as objects.
5. Client increases attempts to influence others to fulfill his or her need.
1. Appears unaware of others’ needs.
2. Exhibits excessive dependency, helplessness, demands.
3. Sets others at odds (especially staff).
4. Rationalizes, gives logical reasons.
5. Uses deception, false promises, insincerity.
6. Questions and defies nurse’s authority and competence.
6. Nurse feels powerless and angry at having been used.
3. Assessment:
1. Acts out sexually, physically.
2. Dawdles, always last minute.
3. Uses insincere flattery; expects special favors, privileges.
4. Exploits generosity and fears of others.
5. Feels no guilt.
6. Plays one staff member against another.
7. Tests limits.
8. Finds weaknesses in others.
9. Makes excessive, unreasonable, unnecessary demands for staff time.
10. Pretends to be helpless, lonely, distraught, tearful.
11. Cannot distinguish between truth and falsehood.
12. Plays on sympathy or guilt.
13. Offers many excuses, lacks insight.
14. Pursues unpleasant issues without genuine regard for or feelings of individuals involved.
15. Intimidates, derogates, threatens, bargains, cajoles, violates rules to obtain reactions or privileges.
16. Betrays information.
17. Uses communication as a medium for manipulation, as verbal, nonverbal means to get others to cooperate, to behave in certain way, to get something from another for own use.
18. May be coercive, illogical, or skillfully deceptive.
19. Unable to learn from experience, i.e., repeats unacceptable behaviors despite negative consequences.
4. Analysis/nursing diagnosis: ineffective individual coping and impaired adjustment related to:
1. Mistrust and contemptuous view of others’ motivations.
2. Life experience of rejection, deception.
3. Low anxiety tolerance.
4. Inability to cope with tension.
5. Unmet dependency needs.
6. Need to avoid anxiety when cannot obtain gratification.
7. Need to obtain something that is forbidden, or need for instant gratification.
8. Attempt to put something over on another when no real advantage exists.
9. Intolerance of intimacy, maneuvering effectively to keep others at a safe distance to dilute the relationship by withdrawing and frustrating others or distracting attention away from self.
10. Attempt to demand attention, approval, disapproval.
5. Nursing care plan/implementation:
1. Long-term goal: define relationship as a mutual experience in learning and trust rather than a struggle for power and control.
2. Short-term goals: increase awareness of self and others; increase self-control; learn to accept limitations.
3. Promote use of “three C’s” - cooperation, compromise, collaboration - rather than exploitation or deception.
4. Decrease level and extent of manipulation.
1. Set firm, realistic goals, with clear, consistent expectations and limits.
2. Confront client regarding exploitation attempts; examine, discuss behavior.
3. Give positive reinforcement with concrete reinforcers for nonmanipulation, to lessen need for exploitive, deceptive, and self-destructive behaviors.
4. Ignore “wooden-leg” behavior (feigning illness to evoke sympathy).
5. Allow verbal anger; do not be intimidated; avoid giving desired response to obvious attempts to irritate.
6. Set consistent, firm, enforceable limits on destructive, aggressive behavior that impinges on others’ health, rights, and interests, and on excessive dependency; give reasons when you cannot meet requests.
7. Keep staff informed of rules and reasons; obtain staff consensus.
8. Enforce direct communication; encourage openness about real needs, feelings.
9. Do not accept gifts, favors, flattery, or other guises of manipulation.
5. Increase responsibility for self-control of actions.
1. Decide who (client, nurse) is responsible for what.
2. Provide opportunities for success to increase self-esteem, experiencing acceptance by others.
3. Evaluate actions, not verbal behavior; point out the difference between talk and action.
4. Support efforts to be responsible.
5. Assist client to increase emotional repertoire; explore alternative ways of relating interpersonally.
6. Avoid submission to control based on fear of punishment, retaliation, loss of affection.
6. Facilitate awareness of, and responsibility for, manipulative behavior and its effects on others.
1. Reflect back client’s behavior.
2. Discourage distortion and misuse of information.
3. Increase tolerance for differences and delayed gratification through behavior modification.
4. Insist on clear, consistent staff communication.
7. Avoid:
1. Labeling client as a “problem.”
2. Hostile, negative attitude.
3. Making a public issue of client’s behavior.
4. Being excessively rigid or permissive, inconsistent or ambiguous, argumentative or accusatory.
8. Health teaching: act as a role model; demonstrate how to deal with mistakes, human imperfections, by admitting mistakes in nonshameful, nonvirtuous ways.
6. Evaluation/outcome criteria: accepts limits; able to compromise, cooperate rather than deceive and exploit; acts responsibly, self-dependent.


9. Noncompliance and uncooperative behavior
1. Definition: consistently failing to meet the requirements of the prescribed treatment regimen, e.g., refusing to adhere to dietary restrictions or take required medications.
2. Assessment:
1. Refuses to participate in routine or planned activities.
2. Refuses medication.
3. Violates rules, ignores limits, and abuses privileges; acts out anger and frustration.
3. Analysis/nursing diagnosis: noncompliance related to:
1. Psychological factors: lack of knowledge; attitudes, beliefs, and values; denial of illness; rigid, defensive personality type; anxiety level (very high or very low); cannot accept limits or dependency (rebellious counterdependency).
2. Environmental factors: finances, transportation, lack of support system.
3. Health care agent-client relationship: client feels discounted and like an “object”; sees staff as uncaring, authoritative, controlling.
4. Health care regimen: too complicated; not enough benefit from following regimen; results in social stigma or social isolation; unpleasant side effects.
4. Nursing care plan/implementation:
1. General goal: reduce need to act out by nonadherence.
1. Take preventive action - be alert to signs of noncompliance, such as intent to leave against medical advice.
2. Explore feelings and reasons for lack of cooperation.
3. Assess and allay fears in client in reassuring manner.
4. Provide adequate information about, and reasons for, rules and procedures.
5. Avoid threats or physical restraints; maintain calm composure.
6. Demonstrate tact and firmness when confronting violations.
7. Offer alternatives.
8. Firmly insist on cooperation in selected important activities but not all activities.
2. Health teaching: increase knowledge base regarding health-related problem, procedures, or treatments and consequences.
5. Evaluation/outcome criteria: follows prescribed regimen.