Anger Expression Modes and its Association with Interpersonal Problem-Solving and Self-Esteem Among Bachelor Nursing Students

Background: Anger is the most frequent emotional problem among nursing students that arises from stress. It might negatively affect overall health, self-esteem; ways of solving interpersonal problems, academic achievement and the quality of care that bachelor nursing students are anticipated to do in the clinical practice. Aim: To assess anger expression modes and its association with interpersonal problem-solving and self-esteem among bachelor nursing students. Design: A descriptive correlational design. Setting: The study was conducted at Faculty of Nursing, Tanta University. Subjects: All bachelor nursing students in the fourth academic year 2022-2023 (550 students). Tools : Anger Expression Questionnaire (AEX), Interpersonal Problem-Solving Inventory (IPSI) and Rosenberg Self-esteem Scale(RSS). Results: A statistically significant positive correlation between anger expression modes (in &out) and maladaptive problem-solving approaches was detected. Moreover, a statistically significant positive correlation was confirmed between anger control mode with adaptive problem-solving approaches and self-esteem Conclusion: It can be concluded that diminished ability to express anger properly among the present students leading them to suppress it inward which consequently result in excessive use of maladaptive problem-solving approaches and negatively affect their level of self-esteem. Recommendations : Expressive skill program needs to be implemented for nursing students to learn them how to express anger openly and honestly which will impact positively on their problem-solving abilities and self-esteem.


Introduction
Nursing students are the core of the professional nurses in the future.They will interact with health care providers and provide the care for patients and their family caregivers regularly (Ali , 2021).Nursing students are more stressed than other colleges students as shown in the Research.( Zheng et al., 2022, Ching et al., 2020) .They have similar demands in addition to a rigorous course load, clinical competency requirements, constant examinations, research papers and assignments, lack of free times and face many challenges about the future occupation (Jacobson& Forbes, 2020).Sustained stress can cause anger which influence on university education and eventually lead to lower quality of nursing care and practice.(Khatoon et al., 2019).
Anger is a universal emotion shared by all people and a natural reaction that arises in a variety of circumstances depending on how people interact with their surroundings.(Hwang &Kim , 2022).Anger can be expressed in three different modes namely; anger-in /out/control.Anger in mode refers to the dysfunctional expression of anger, which includes directing anger towards oneself, denying memories or thoughts related to the situation that provoked anger or the extent to which individuals suppress anger which in turn can result sin feelings of remorse, anxiety, low selfesteem, and depression because the person feels responsible for the situation that made them angry (Jun et al., 2021).
The other dysfunctional mode of expressing anger is the Anger Out mode.It is conceptualized as expressing anger towards someone or something by physical act, verbal abuse, insult, or criticism.Those displayed this mode are frequently labelled as aggressors and lack adaptive interpersonal skills.On the other hand, Anger Control Mode is considered a functional behavior of anger expression.It is also called assertive anger and includes attempts to handle and express the feeling of anger in appropriate manner and at the same time without violation of the rights and emotions of the other person and utilizing non-aggressive language (Jang &Jeon,2017, Hassan et al.,2019,).
Anger is a frequent yet neglected experience that deserves more attention.Improper expression of anger is closely associated with psychological problems, such as suicide, anxiety, depression, addiction, antisocial behaviors and interpersonal relation problems.It was adopted by the researchers from Spielberger et al.,1985.It composed of 20 items divided into three subscales describing how an individual handles anger.The Anger-In (AEX-In) describes the anger that is experienced but suppressed (items 3, 5, 6, 10, 12, 14, 15, 18).
The Anger-Out (AEX-Out) describes the anger that is expressed towards other people or objects in the environment (items 2, 7, 9, 11, 13, 17, 19, 20).The Anger Control (AEX-Control) describes a person"s attempt to manage the anger feelings (items 1,8,16).Anger Total (AEX _TOT) items from 1 to 20.Each item is rated on a 4-point Likert scale (1 = never to 4= almost).A higher score reflects a higher level of anger.Tool II: The Interpersonal Problem-Solving Inventory (IPSI): It was adopted by the researchers from Cam & Tümkaya , 2007 and used to assess problem-solving approaches among university students.It consists of fifty items divided into five subscales.Each subscale consists of 10 items namely, approaching problems in negative way, constructive problem solving, the lack of self-confidence, unwillingness to take responsibility, and the insistent persevering approach.Students "responses rated on five-points Likert scale ranged from 1 =strongly disagree to 5=strongly agree.Higher mean scores for each subscale indicate that the characteristics of interpersonal problem solving is higher.

Tool III: Rosenberg Self-esteem Scale (RSS)
It was adopted by the researchers from Rosenberg, 1965 and used to measure the global self-worth.It is composed of 10 items that.All items are rated on a 4point Likert scale ranging from strongly disagree =1 point, disagree= 2 points, agree= 3 points and strongly agree= 4 points.The score was reversed on items 2, 5, 6, 8, 9. Higher scores indicate higher self-esteem.The total score as follow:

Method
The researchers attained an official approval from the Dean of Faculty of Nursing to collect the study data.

-Ethical consideration:
The approval of the Faculty of Nursing Scientific Research Ethical Committee was obtained (Code242-4-2023).The subjects were guaranteed about confidentiality and anonymity of the data and informed about their right to refuse the participation or withdraw from the study at any time.-Pearson's correlation coefficient was used to assess the correlation between the variables.

Results
Regarding the sociodemographic characteristics of the studied nursing students.More than half of the studied subjects 65% were female compared to 35% were male.Speaking about residence, the highest percentage of the studied subjects lived in rural areas 83.4% while 16.4% in urban areas.Regarding marital status, the majority of them 83% were single compared to 17% were married.Regarding working while studying, the highest percentage of them 72% were working while studying compared to 28% were not working while studying.
Figure (1) illustrates the distribution of studied subjects according to level of AEX.The figure illustrates that 46.20% of the studied subjects reported moderate level of anger in mode compared to 18.50% who had high level.Regarding anger out, it was noticed that more than half of the studied subjects 58.20% had low level in anger out whereas 5.20% only were high in anger out.Additionally, the figure shows that more than half 54.80% of the studied subjects had low level in anger control compared to only 20.60% who had moderate level.39.20% of the studied subjects were low in total anger expression compared to 26.20% who were high in total anger expression.
Table (1) shows the mean of the anger expression modes scale among the studied subjects.It can be observed that the highest mean was for Anger Expression In (AEX -In) 12.10 ± 3.47, followed by Anger Expression Out (AEX-Out) 8.4 ± 2.89 while the least mean was for Anger Expression Control (AEX -Con) with a total mean for anger expression is 38.5 ± 6.20.2) reveals the distribution of the studied subjects according to their level of self-esteem.It can be noticed that 51% of the studied subjects had a moderate level of self-esteem compared to 28% only who had high level of selfesteem with a total mean score of (18.71 ± 4.32) Table (3) represents the correlation matrix between anger expression modes, interpersonal problem-solving skills, and self-esteem among bachelor nursing students.There was a highly statistically significant negative correlation between anger expression in\out\total and adaptive interpersonal problem solving skills (CPS and IPA)), while a highly statistical significant positive correlation was found between anger expression in \out\total and maladaptive interpersonal problem solving skills (NSP, LSC& UTR) ).On the contrary, a highly statistically significant positive correlation was detected between anger expression control (AEX-Con) and adaptive interpersonal problem solving skills (CPS &IPA) , while a statistically significant negative correlation was detected between anger expression control (AEX-Control and LSC) but not significant with (NSP and UTR).(P=0.263 and 0 .110respectively) Also, it was found a highly statistically significant negative correlation between anger expression in\out\total and self-esteem (P=0.000**,0.019** and 0.000** respectively).On the other hand, there was a highly statistically significant positive correlation between anger expression control and self-esteem (P=0.000**).
The matrix also revealed a highly statistically significant positive correlation between adaptive interpersonal problem solving skills (CPS&IPA) and self-esteem (P=0.000**), while a statistically significant negative correlation was detected between self-esteem and (LSC and UTR) (P=0.001**) but not significant with (NSP)(p=0.358).Hence, the present study aimed to assess anger expression modes and its association with interpersonal problem solving and self-esteem among bachelor nursing students.
According to the current study, more than half of nursing students unable to control their anger and nearly half of them suppressing their anger.They experience and suppress anger instead of controlling it.Suppression of anger has a negative outcome particularly on physical health and mental stability.(Temel et al., 2017).Suppression of anger does not eradicate it; it merely keeps it from being expressed.Nursing students reported that they tend to display avoidance response when there are angry because they may not have any other alternative to deal with the feelings appropriately.(Choi.,2009).In the same direction, a study by Choi , 2009 found that significant proportion of nursing students belonging to the anger-in mode.Additionally, Moustafa et al., 2022 found that the most of the studied nursing students displayed inappropriate mode of anger expression.In contrast, Lee& Park, 2015 found that nursing students actively controlling and resolving their anger.
This may be due to lack of anger selfcontrol skills that help them to control their anger and express it in appropriate way in addition to lack of anger management training program that can manage nursing students" anger level and teach them the alternatives for handling anger in proper way.This assumption supported by Mostafa et al., 2022 found that while most of the students under study had risky or inappropriate anger expression prior to the program, most of them had appropriate or non-risky expression of anger after the program .Similarly, Jun et al., 2021 revealed that the intervention group had higher mean scores for the anger-control expression Vol.32.No. 1 (Supp 2) ,February 2024 style and significantly lower mean scores for the trait anger, anger-in, and anger-out expression styles when compared to the control group.This result might be attributed to the high level of stress among nursing students.They persistently exposed to various stressors such as academic burdens, assignments, continuous examinations, in addition to clinical training and interaction with patients and health care providers.Supporting this explanation Khatoon et al., 2019 &Abo Elyazeed 2022 claimed that Sustained stress can cause anger which negatively affect overall health, academic achievement and the quality of clinical training.
Another assumption for suppressing anger is the influence of culture norms.It displays a substantial role in shaping how individual express anger.In some culture, expressing anger openly is considered forbidden and met with social stigma.Supporting this rational a study by Hofstede 2001 claimed that there was relationship between cultural dimensions and expressive display rules for anger.Additionally, Childhood trauma such as all forms of abuse and neglect actually or potentially harm the child's health, survival, development or dignity might explain this result.(McKay 2021).A child's sense of safety and security can be disrupted by traumatic experiences, which can result in feelings of helplessness, fear, and anxiety.Traumatized children may also find it difficult to control their emotions, which can result in angry or other negative outbursts.Adle et al 2020 found significant associations between childhood trauma and anger in adulthood.
Moreover, the fear of rejection in the relationship especially with the clinical nursing staff in the clinical settings.A statistically significant positive correlation was found between self-esteem and anger expression control, but a statistically significant negative correlation was found between anger expression in/out/total and self-esteem.People who lack confidence in themselves find it difficult to assume responsibility for solving problems; instead, they act more recklessly, fearfully, and with more avoidant way.It was similar with a Atay et al. (2013) showed that students who experienced anger, unable to control it and displayed anger expression in/out have low self-esteem.
A significant positive correlation was found in this study between nursing students' self-esteem and their ability to solve interpersonal problems in an adaptable way (CPS and IPA).Self-esteem is very important in the process of solving interpersonal problems.When people have self-worth they positively respond to other people and themselves, coping adequately with the challenges of growing and confident in their abilities to achieve what they need and facing disappointments (Fawzy et al.,2020).All of these characteristics help them to think critical, create best solution, think about the consequences and make sound decision.Alongside with this result, Helly et al 2018 & Gamal 2012 found a strong correlation between nursing students' selfesteem and their capacity for problemsolving.

Conclusion:
Based on the results of the present study it can be concluded that diminished ability to express anger properly among the present students leading them to suppress it inward which consequently result in excessive use of maladaptive problem-solving skills and negatively affect their level of self-esteem. Self confidence and self-esteem should be enhanced in nursing students through various methods as increase focus on their positive aspects, praise achievement, improve their relationship with the instructors as well as the colleagues, stress the importance of their role in health team and the value of their contribution.All of these will impact on their ability to express themselves confidently and improve their problem-solving skills.

Figure ( 1 )
Figure (1) distribution of the studied subjects according to level of AEX.

Figure ( 2 )
Figure (2) Distribution of the studied subjects according to their level of self-esteem.