Emotional intelligence in professional nursing practice: A concept review using Rodgers's evolutionary analysis approach

Abstract

Background

Knowledge around emotional intelligence originated in the 1990s from research regarding thoughts, emotions and abilities. The concept of emotional intelligence has evolved over the last 25 years; however, the understanding and use is still unclear. Despite this, emotional intelligence has been a widely-considered concept within professions such as business, management, education, and within the last 10 years has gained traction within nursing practice.

Aims and objectives

The aim of this concept review is to clarify the understanding of the concept emotional intelligence, what attributes signify emotional intelligence, what are its antecedents, consequences, related terms and implications to advance nursing practice.

Method

A computerized search was guided by Rodger's evolutional concept analysis. Data courses included: CINAHL, PyschINFO, Scopus, EMBASE and ProQuest, focusing on articles published in Canada and the United Stated during 1990–2017.

Results

A total of 23 articles from various bodies of disciplines were included in this integrative concept review. The analysis reveals that there are many inconsistencies regarding the description of emotional intelligence, however, four common attributes were discovered: self-awareness, self-management, social awareness and social/relationship management. These attributes facilitate the emotional well-being among advance practice nurses and enhances the ability to practice in a way that will benefit patients, families, colleagues and advance practice nurses as working professionals and as individuals.

Conclusion

The integration of emotional intelligence is supported within several disciplines as there is consensus on the impact that emotional intelligence has on job satisfaction, stress level, burnout and helps to facilitate a positive environment. Explicit to advance practice nursing, emotional intelligence is a concept that may be central to nursing practice as it has the potential to impact the quality of patient care and outcomes, decision-making, critical thinking and overall the well-being of practicing nurses.

1. Case study

Mr. K is a 43-year-old male who has been admitted to the coronary care unit after experiencing a myocardial infarction which led to a cardiac arrest. Mr. K has maintained a healthy and active lifestyle since his myocardial infarction three years ago. Prior to his admission, Mr. K was at home running on his treadmill as part of his morning routine. His wife, Mrs. K, heard a loud noise and ran downstairs to find Mr. K lying prone on the treadmill with a head injury and no pulse. Mrs. K called 9-1-1. Cardiopulmonary resuscitation (CPR) was not initiated until paramedics arrived, and it was approximately 45 min until Mr. K had a return of spontaneous circulation. Mr. K was intubated at home and then brought into hospital where he was seen immediately by the cardiac team, which included an advanced practice nurse (APN). The APN's role was to gather information about what might have led to Mr. K's event and to consider the current goals of care. Given the estimated downtime (time without adequate blood circulation), the APN acknowledges that Mr. K would most likely suffer from severe anoxic brain injury, and his prognosis would be poor.

Although nothing had been confirmed by the physician, the APN recognized that there was a possibility that she would have needed to support Mrs. K through the withdrawal of care of her husband. After considering this, the APN became overwhelmed with emotion; as she thinks about her spouse who is the same age as Mr. K. In addition, the APN also experienced profound frustration; as to why the Mrs. K did not initiate CPR for her husband. As the team continues to aggressively work on Mr. K, the APN will be Mrs. K's initial point of contact and will work closely with her to meet the overall goals of care for Mr. K.

2. Background

The concept of emotional intelligence (EI) can be described as the ability to manage one's emotions and the emotions of others [1]. EI has emerged across several disciplines and has gained traction in the nursing profession as EI promotes the well-being of nurses, which subsequently impacts patients and families. With several competing definitions and EI models, there is a general lack of understanding of EI and its overall meaning and significance. Unclear concepts can lead to a great deal of confusion and misapprehension when applied in practice [2]; as EI is a concept already rife with confusion, clarity is necessary. A clear understanding of EI and its complexities is helpful in nursing practice; by understanding how emotions merge with cognition. In general, EI enables nurses to make better decisions, manage their patients more effectively, improve relationships, and positively impacts the quality of care received by patients and families [[3], [4], [5], [6]]. Due to the influence EI has on nursing actions, understanding what is known about EI may improve its application within the profession. Overall, the purpose of this paper is to gain an overarching understanding of EI within advance nursing practice. The following analysis offers a hypothetical case study to provide context for exploring the concept of EI, followed by a review of the conceptual underpinnings of EI using Rodger's evolutionary concept analysis methodology. In an attempt to provide conceptual clarity, this review also explores how EI is a pragmatic concept that can be applied to advanced nursing practice.

3. Methods

3.1. Concept analysis

Clarification of concepts such as EI is appropriate within nursing practice, as concepts play an important role in the development of knowledge. Unclear definitions and attributes of concepts substantially inhibit the fundamental use of the concept, as there may be confusion regarding the concept and similar or related concepts. Methods of concept analysis are employed to provide clarity for concepts as then, the concept may be used more effectively, and its strengths and limitation may be evaluated so that concepts have the potential to provide enhanced contributions to knowledge and application [2,7].

3.2. Rodgers's evolutionary concept analysis

There are several methods to concept analyses that can be used. Rodgers's (1989) evolutionary method for concept analysis was the method used for the concept review, as it allows for a viewpoint that concepts are subject to change [7]. Rather than being considered as a set of fixed and necessary conditions, Rodgers's believes that concepts are identified by a cluster of attributes, situations or phenomena that are encountered in reference to similarities. Rodgers's method states that concepts are continually refined, and sanctions that conceptual variations and innovations may be introduced over time, as concepts are used and passed on through education and social interactions [7].

The concept of interest will be identified along with any surrogate terms associated with the concept. An appropriate selection/sample of data will be collected through a literature search, and attributes of the concept will be clearly identified and elucidated [7]. Rodgers's recommends retrieving studies from multiple disciplines. If there is a large amount of relevant studies, then every fifth article will be chosen starting from a random number [2]. This rule was not applied in this concept review, as it was felt that seminal work regarding EI would be missed. References, antecedents and consequences of the concept will be clarified if possible. Finally, related concepts will be acknowledged, and a model case of the concept will be identified to help provide conceptual clarity.

3.3. Data source

A comprehensive review of the literature was done to explore the concept of EI using Rodgers evolutionary method. Rodgers's approach to concept analysis provides the best strategy to examine EI within several contexts, as it does not seek to define an ultimate truth, but rather is an approach which values conceptual changes occur over time, and thus, these changes can be taken into account when formulating a general understanding of EI [8].

In efforts to support Rodgers's evolutionary approach, no specific range or limitations were identified regarding the dates of publications. Databases were searched from the earliest publications starting from 1990 to 2017 to provide an overview of the development of EI over time. The key terms “emotional intelligence”, “concept analysis” and “nursing” were searched in databases, including CINAHL, PyschINFO, Scopus, EMBASE and ProQuest. A total of 15,173 articles were retrieved. According to Rodgers, the process to limit findings would be to choose every fifth article starting from a random number [2]. This approach was not used as it was felt that seminal work on EI would be missed. The Boolean approach was used, (i.e. connecting each key word with “AND”) to narrow results. The purpose of the literature review was to retrieve published peer reviewed articles that were in English. Inclusion criteria included articles that had “emotional intelligence” in the title and in abstracts. Articles that were not published in North America were excluded from this search, as this is a preliminary conceptual review of EI within a North American context. Furthermore, given the incongruencies in the definition and operationalization of the term advanced practice nurse (APN) (clinical nurse specialist, nurse practitioner) globally, this concept review was limited to North America where the term APN, as well as clinical nurse specialist and nurse practitioner, has consistency [9]. It is noteworthy that several results in the literature linked EI with problem solving skills, stress and mental health across these disciplines. In general, the number of published articles related to EI began to increase after 2004, several of which focused on both the relationship between EI and the behaviours of adolescence and EI within the context of disease management. Given that the purpose of this paper is to gain a general understanding of EI, these articles were excluded because they were too specific. A manual search of relevant journal articles and significant references was also conducted to ensure that seminal work was not missed. Several disciplines emerged when conducting the search for EI, such as psychology, business and management, education, and healthcare. After the inclusion and exclusion process was complete and duplications were removed, a total of 23 articles were included in this concept review.

4. Results

4.1. Definitions of emotional intelligence

There are several different types of intelligences that are identified in the realm of psychology. While some of these intelligences are independent of one another, others are not independent, such as EI [10]. For example, cultural intelligence builds on and is related to social intelligence and EI [11]. EI is considered to be grounded within the theory of multiple intelligence, where the role of relationship and emotions within the concept of intelligence was first considered [11,12].

The primary seminal work behind EI was conceptualized by Salovey and Mayer in the 1990s [13]. John Mayer and Peter Salovey coined the term EI and have defined it as “the ability to monitor one's own and others' emotions, to discriminate among them, and to use the information to guide one's thinking and actions” [14]. Since the work of Mayer and Salovey, other authors such as Reuven Bar-On and Daniel Goleman have built on this work and created other definitions of EI. The definition provided by Mayer and Salovey, Bar-On and Goleman are all similar in that they recognize how one's own emotion can impact another. However, there is disagreement as to whether EI can be defined as a cognitive ability or as a personality trait [15]. Traditionally, Mayer and Salovey believed that EI is an ability that can be learned, however, Bar-On believed it was a personality trait that individuals possessed. Goleman took the ideas of both and believed that EI is a combination of both abilities and personality traits [4].

The original definition of EI is conceptualized as a set of interrelated abilities. Today, EI is described as an eclectic mix of traits, rather than an ability [16]. A more recent definition of EI that is used widely, including the discipline of nursing was defined by Goleman (1995): “the capacity for recognizing our own feelings and those of others, for monitoring ourselves, and for managing emotions in ourselves and in our relationships” [17]. It is imperative to consider how and why this definition of EI is commonly used to date, and the contributions of Mayer and Salovey, Bar-On, and Goleman are noteworthy as they each developed their own models of EI: the ability or intelligence model, the personality trait model, and the mixed or performance model, respectively. Due to the various EI models, it is not surprising that one model may influence another, leading to overlap. Ultimately, this overlaphas led to a lack of clarity as to what EI is or what it should be [16,17].

4.2. Attributes of emotional intelligence

Attributes are the defining characteristics of a concept [8]. Defining the attributes of EI is challenging, as there are three EI models, each of which are guided by different beliefs, and thus have endorsed their own attributes [12]. Although the idea of three separate EI models may contribute to the lack of concept clarity, all three models are supported by similar attributes. The discrepancy lies within the terminology and the language used. Not long after in 1995, Goleman brought rise to EI outside of academia into professional settings such as business, management and healthcare. Goleman whose model of EI is one which is most recent, attempted to blend and add onto the seminal work of Salovey and Mayer and Bar-On and ultimately is responsible for propagating EI [3]. After a review of each EI model, it was recognized that Goleman's recent mixed EI model attempted to amalgamate the terminologies used to describe EI into four attributes that have been widely accepted across several disciplines, including nursing. The four attributes of EI are: self-awareness, self-management, social awareness, and social/relationship management [5,18,19]. These attributes will be used to understand the conceptualization and operational understanding of EI.

Attributes of EI can be grouped into two categories: personal and social attributes. First, personal attributes include self-awareness and self-management. Self-awareness involves recognizing and understanding one's own emotions and motivations [17,20]. Self-awareness can be achieved by monitoring one's own state and identifying emotions, strengths, weaknesses and individual needs. Self-management is the ability to control or redirect emotions constructively. It allows an individual to withhold judgment until enough information is gathered and to think before acting [20]. Second, the social attributes are social awareness and relationship management. Social awareness is the ability to observe and understand emotions, needs and concerns of others, pick up on emotional cues and the ability to see things with other people's viewpoints. Relationship management is the ability to manage relationships with others by utilizing emotions of one's self and of others to develop and maintain good relationships, communicate clearly, and to inspire and influence others [5,17,20,21].

4.3. Related and surrogate terms

Surrogate terms are words that express a concept's ideas through words other than the concept being studied [8]. Emotional effectiveness and emotional competence are used interchangeably with EI and are considered surrogate terms [5]. Reflection and reflexivity are terms that are related to EI insofar as they are words that have something in common with EI but do not possess the same characteristics [2]. Reflection allows us to look back at what we did, what we saw, what we felt and what we knew about a situation. Reflexivity causes individuals to acknowledge how emotions play a key role in the construction of knowledge and how this knowledge is applied [21]. In other words, we recognize that emotions will play a part in determining the focus and choices we make when reflecting upon our actions [17]. In general, the concepts of reflection and reflexivity are related to EI in that they are actions that an individual can engage with in order to demonstrate emotionally intelligent behaviours.

4.4. Antecedents

According to Rodgers, antecedents are the events or attributes that must arise prior to a concept's occurrence [2]. The literature exposes incongruences with respect to the number of attributes identified. In particular, the terms “motivation” and “empathy” were used interchangeably as attributes and antecedents. The term “motivation” was used primarily within the context of management [20], and the term “empathy”, when identified as an attribute of EI, was not within a nursing context. As such, despite the ambiguity, for the purpose of this paper that is aimed towards understanding EI within advanced practicing nursing, it is accepted that motivation and empathy are considered antecedents of EI.

Motivation means to possess an innate drive to achieve, and empathy is the ability to understand another person's emotions, thoughts and perspectives [20]. An individual would have to be motivated in wanting to understand emotions and would have to be open to accepting their emotions and the emotions of others [12]. Self-awareness and self-management are crucial factors for maintaining overall well-being for both the APN and their patients [3,12]. In short, APNs who are motivated to cope with their own emotions and who have a better developed sense of empathy are less likely to experience job dissatisfaction, stress and burnout; all of which has the potential to affect the care of patients, their families, and the overall well-being of nurses. Furthermore, EI is also understanding the impact of emotions on others and subduing one's own emotions at times so as not to be disruptive to others, averting potential conflicts [6,22].

4.5. Consequences of emotional intelligence

Consequences are events or incidents that can happen because of the occurrence of a concept [2]. Identifying consequences within the context of the case scenario will improve the transparency of EI within the context of nursing practice. Consequences of EI within nursing were related to the well-being of nurses as working professionals. As such, the literature focuses on job satisfaction, stress levels, burnout, and retention [22]. In relation to patient and family care, an APN who possess EI will understand how to engage in affective forecasting; the ability to anticipate one's future emotional reactions [16]. The APN has the potential to aid the development of positive therapeutic relationships as they will able to predict how they may feel, react, and respond to a future event or interaction.

In the case study of Mr. K, the APN was surprised that Mrs. K did not initiate CPR on her husband. The notion that Mr. K might have had a better outcome without any deficits led to the APN's feelings of frustration. If the APN did not recognize her emotions, she may not be cognizant of her own behaviours [18]. Inappropriate reactions could result in negative implications to family care. In short, EI allows individuals to be aware of their own emotions and reactions and shapes the way they respond to others [14].

The APN's feelings of frustration and dismay could translate into formulating judgements. If the APN forms a negative judgement of Mrs. K, this may have the potential to hinder the development of a therapeutic relationship. As a result, if a therapeutic relationship is not developed, the concerns and needs of Mrs. K may not be adequately communicated and addressed [23]. In addition to her feelings of frustration, the APN was also troubled by her thoughts, given how Mr. K reminds her of her own spouse. Awareness of her emotions may either help the APN to empathize with Mrs. K, or may allow her emotions to interfere of how she delivers care [13].

Being in charge of one's emotions allows one to engage in emotional forecasting. Affective forecasting predicts how an individual will feel in response to a future event [16]. In Mr. K's case, knowing that his medical emergency was unexpected and that his prognosis was poor enables the APN to be observant of Mrs. K's feelings under various conditions, and thus anticipate future responses as changes occur with the care of her husband. An APN who is emotionally intelligent is able to recognize and manage her emotions in a way that will positively influence her working relationship with Mrs. K [15]. Ultimately, as the APN recognized his/her own emotions, their ability to do this has the potential to facilitate and strengthen their ability in providing supportive care to Mrs. K during this time. An APN who possess EI also has the ability to recognize and understand that Mrs. K may be experiencing significant negative feelings. This information may help to inform the APN's next actions in planning care and support that is individualized to Mrs. K, as the APN is able to reach a point within his/her practice where he/she can effectively work through their emotional state and translate that into supportive actions towards Mrs. K, this ultimately cultivates the antecedent of empathy.

5. Discussion

5.1. Nursing implications

The primary focus of the case study was to understand how EI will influence the practice of an APN, whose primary focus is to meet the needs of individuals, families, communities and/or a population [24]. In the case of Mr. K, the APN addresses her own emotions in order to understand how they may influence her ability to provide direct clinical care to Mr. K and his wife, how it may impact collaboration, and how emotions will impact her ability to demonstrate leadership.

The consideration of emotions is as an essential component of critical decisions and is a key component of quality of clinical-decision making. Decision-making requires a broad base of nursing expertise that directly impacts patient and family care [3]. The APN continues to experience an overwhelming flood of emotions as she envisions Mr. and Mrs. K's situation as her own. She is reminded of her spouse and of her own fundamental values. Gaining social awareness of Mrs. K's emotions, concerns and the potential needs affirms that decisions are always in the best interest of Mrs. K and her husband, and are not influenced by the emotions, values and needs of the APN [4,15,22]. As such, decisions are more empathetic and patient and family-focused, thus supporting and enhancing the role of APNs providing direct clinical care. The APN in this situation demonstrates the personal and a social component that EI encompasses and also depicts EI's meaningful role in both the perception of moral dimension and in sensitivity in clinical practice. Self-awareness allows nurses to connect emotions, thoughts and actions in an effective manner, and therefore is an essential ability in decision-making and creative processes that may be grounded on feelings and intuition. EI encourages nurses to use empathy as a resource for understanding situations that are based on professional reflection and moral judgements related to decision-making [4,25].

Through collaboration and consultation with Mrs. K and the health care team, the APN can allocate the appropriate resources for the plan of care [6,24]. Emotions may impact an APNs ability to effectively interact with the interdisciplinary team, as emotions may inadvertently be shared when discussing Mr. K's story [25]. For instance, if the APN did not redirect her emotions regarding the fact that Mrs. K did not start CPR on her husband, her emotions of dismay, judgment, and blame may be passed on to others on the team. The ability for others to develop a relationship with Mrs. K may not reach its full potential, and the needs of Mr. and Mrs. K may not be met. Thus, EI may improve an APNs ability to collaborate and ultimately improve patient and family outcomes. Effectively monitoring and managing one's own emotions correlates with motivation in that the APN in the case of Mr. K could channel their emotions in a way that demonstrates motivation to wanting to preserve the continuity of care for both Mr. and Mrs. K, therefore, demonstrating leadership abilities [26].

Within the context of nursing, EI has been correlated with stress, mental health and emotional well-being and help-seeking behaviours [25]. Patients who are unable to appropriately manage their emotions are less willing to seek help or support [23]. If nurses embody a practice that is emotionally intelligent, the ability to promote emotional management to their patients and their families may help facilitate therapeutic relationships between patients and nurses. In the case of Mr. K, the APN has an opportunity to guide Mrs. K through management of her emotions – contributing to care that is individually tailored. Ultimately, the development of EI within clinical nursing could be a valuable resource for empowerment among patients and their families, leading to positive health outcomes [25,27]. Furthermore, EI is also linked with problem-solving skills, stress and mental health with regards to nurses, as these concepts have the potential to deteriorate practitioners. EI offers a platform for nurses to better cope with stress as nurses are able to better access their own resources and apply successful coping strategies, which cultivates positive emotional health, contributing to overall improved mental health and can furthermore translate into willingness to invest in their career [25]. As valued leaders within nursing and in health care, APNs who engage in emotionally intelligent behaviours within their leadership roles demonstrate less emotional exhaustion and psychosomatic symptoms, better emotional health, greater workgroup collaboration and teamwork, more satisfaction with their jobs, and fewer unmet patient care needs [27]. Furthermore, given that APNs are leaders and are a resource to staff nurses [24], APNs who demonstrate behaviours of EI will contribute to the growth of this concept within nursing practice as they may influence others to become emotionally intelligent as well [18], therefore supporting transformational leadership within nursing practice [26]. Since EI is a concept that is not always recognized among nurses, APNs may engage in research and education to further advance this concept and its importance to nursing practice, as generating, synthesizing, and using research evidence is central to advanced nursing practice [24]. Interventions to advance EI in nursing should continue to focus on integrating the development of EI within the nursing curriculum [6]. APNs have the potential to impact and encourage this integration by use of knowledge-transfer techniques to put research-based knowledge regarding EI into practice [24]. In essence, nurses have the potential to make a significant contribution to health care by empowering themselves, their patients and families, and colleagues through EI [4,25]. Therefore, a continued effort in research regarding EI and its conceptual clarity within nursing practice is necessary and will ultimately help refine the quality and delivery of nursing care.

6. Limitations

Two limitations were identified when formulating this concept review. First, since this conceptual review was limited to a North American context, seminal work regarding EI and nursing could have potentially been missed. As such, a call for continued conceptual review to include international publications is necessary to broaden the understanding of EI within nursing practice. Secondly, this review did not discuss any of measurement tools such as the Multifactor Emotional Intelligence Scale as this review focused primarily on the conceptual clarity of EI. Finally, it is noteworthy that the discussion of EI within advance nursing practice is limited, and is saturated within the context of management, as such it is recommended that EI be further explored within other nursing environments (e.g. EI in nurses working on an oncology unit).

7. Conclusion

EI has become an important facet in nursing practice in recent years, as sensitivity to mood and emotions is an integral part of care and should not be taken in isolation from how we think and act as professionals [25]. While a great deal of work has been done to understand, and expose EI as a concept, there remains much work to be done, specifically with regards to the inconsistency of attributes. In the context of advance nursing practice, EI helps to facilitates emotional well-being among APNs and helps to enhance the ability to practice competencies in a way that will benefit patients, patient's families, colleagues and themselves as working professionals and as individuals. Ultimately, EI promotes much more than simply awareness of emotions, it allows for nurses to be more equipped to provide quality care and support to their patients, their families, and colleagues. Despite the confusion and misapprehension regarding EI as a concept, it is clear that the ability to recognize and understand EI will remain a vital part of nursing practice moving forward.