IDENTIFYING EMOTIONAL INTELLIGENCE IN PROFESSIONAL NURSING PRACTICE BARBARA MOLINA KOOKER, DRPH,* JAN SHOULTZ, DRPH,y AND ESTELLE E. CODIER, PHDz The National Center for Health Workforce Analysis projects that the shortage of registered nurses in the United States will double by 2010 and will nearly quadruple to 20% by 2015 (Bureau of Health Professionals Health Resources and Services Administration. [2002]. Projected supply, demand, and shortages of registered nurses, 2000–2020 [On-line]. Available: http://bhpr.hrsa.gov/healthworkforce/reports/rnprojects/report.htm). The purpose of this study was to use the conceptual framework of emotional intelligence to analyze nurses’ stories about their practice to identify factors that could be related to improved nurse retention and patient/client outcomes. The stories reflected evidence of the competencies and domains of emotional intelligence and were related to nurse retention and improved outcomes. Nurses recognized their own strengths and limitations, displayed empathy and recognized client needs, nurtured relationships, used personal influence, and acted as change agents. Nurses were frustrated when organizational barriers conflicted with their knowledge/intuition about nursing practice, their communications were disregarded, or their attempts to create a shared vision and teamwork were ignored. Elements of professional nursing practice, such as autonomy, nurse satisfaction, respect, and the professional practice environment, were identified in the excerpts of the stories. The shortage of practicing nurses continues to be a national issue. The use of emotional intelligence concepts may provide fresh insights into ways to keep nurses engaged in practice and to improve nurse retention and patient/client outcomes. (Index words: Emotional intelligence; Professional nursing practice; Retention; Patient outcomes) J Prof Nurs 23:30–6, 2007. A 2007 Elsevier Inc. All rights reserved.
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MOTIONAL INTELLIGENCE HAS been recognized as an influential factor in both individual performance and organizational performance and has been hypothesized by researchers as a potentially useful concept in identifying factors in stories of nursing practice that might be related to improved retention of nurses and patient/client outcomes. The purpose of this qualitative study was to use the conceptual framework of emotional intelligence to analyze nurses’ stories about their professional practice. The goal is to gain insight
*University of Hawaii School of Nursing and Dental Hygiene, The Queen’s Medical Center, Honolulu, HI. yUniversity of Hawaii School of Nursing and Dental Hygiene, Honolulu, HI; Postdoctoral Fellow, University of California at Los Angeles-NIH/NINR T32 007077, P30 NR005041. zUniversity of Hawaii School of Nursing and Dental Hygiene, Honolulu, HI. Address correspondence and reprint requests to Dr. Kooker: The Queen’s Medical Center, 1301 Punchbowl Street, Honolulu, HI 96813. E-mail:
[email protected] 8755-7223/$ - see front matter 30 doi:10.1016/j.profnurs.2006.12.004
into issues facing the nursing workforce by listening to what nurses say about themselves and their practice. The concept of professional practice used in this analysis includes the elements first described by nurses in the original magnet hospital study (McClure, Poulin, Sovie, & Wandelt, 1983), which was updated in a 2001 study (Kramer & Schmalenberg, 2002) and expanded by Blais, Hayes, Kozier, and Erb (2005). Autonomy, accountability, mentoring, collegiality, respect, trust, integrity, knowledge, and activism are the elements essential to professional nursing practice. Furthermore, practice includes the structure and processes undertaken to provide nursing care to individuals, families, or groups. The outcomes of professional nursing practice are quality patient care, professional satisfaction, and autonomy in nursing practice (University Health Network, 2005). In short, the description acknowledges that nurses want to be able to practice nursing as it should be practiced. The research question was, bIs there evidence in the stories of professional practice that reflect the competencies of emotional intelligence as it relates to
Journal of Professional Nursing, Vol 23, No 1 (January–February), 2007: pp 30–36 A 2007 Elsevier Inc. All rights reserved.
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improved process and outcomes for patients/clients and nurses?Q Data (stories written by nurses) generated for a previous study were reanalyzed. In the previous study, which was funded by the National League for Nursing, nurses were asked to bwrite a story from your lived experience where nursing knowledge made a differenceQ (Shoultz, Kooker, & Sloat, 1998, p. 280).
Background and Significance The National Center for Health Workforce Analysis projects that the 6% shortfall of registered nurses in the United States in 2000 will double by 2010 and will nearly quadruple to 20% by 2015 (Bureau of Health Professionals Health Resources and Services Administration, 2002). In Hawaii, the shortfall of registered nurses is projected to increase from 1,041 (12.58% nurses) in 2002 to 4,593 nurses (35.79%) in 2020, according to the report of the Bureau of Health Professionals Health Resources Services Administration (2003) entitled Projected Supply, Demand, and Shortages of Registered Nurses, 2000–2020, Hawaii Revisited. This shortage points to the importance of not only recruiting individuals into nursing but also strengthening efforts at retaining valuable practicing nurses.
Conceptual Background The researchers used the conceptual framework of emotional intelligence as the prism for this extensive analysis of the stories of nurses that translate nursing knowledge into professional practice. Emotional intelligence is emerging as an influential framework in a wide range of professional arenas, including psychology; neuroscience; health psychology; developmental cognition; primary, secondary, and advanced education; clinical health practice; counseling; industrial and organizational psychology; organizational development; and business management. Emotional intelligence has been the topic of research in areas such as leadership, performance, workforce issues, health care industry, gender differences, and nursing (Cherniss, 2004). Recently, Moss (2005) related emotional intelligence to enhancement of any role in nursing, especially nursing leadership. In addition, Cummings, Hayduk, and Estabrooks (2005) described the role of emotional intelligence leadership as a mitigator of the negative impact of organizational restructuring on nurses. The concept of emotional intelligence has a long and involved history that is important in the development of this evolving concept. Cognitive-style research began in the 20th century with Jung’s work on psychological types during the 1920s and continued, for example, with the development of the Myers Briggs Trait Inventory in the 1940s to the 1950s. Jung’s work ran parallel to developments in intelligence theory with Thorndyke’s expansion of intelligence to include abstract and social intelligence. Wechsler further developed social intelligence to include intrapersonal and interpersonal components in the 1940s. For many years, there had been a heightened awareness that cognitive style and analytic
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skills and measures did not adequately account for academic and professional success, job performance, effective leadership and team relationships, or professional and personal life satisfaction (Thorndike, 1920). The next step in this developmental process was to include the role of relationships and emotions in both academic and organizational settings. In the 1940s, social–emotional learning included both intrapersonal and interpersonal components. In the 1980s, Gardner’s (1983, 1993) multiple intelligence theory identified intrapersonal and interpersonal intelligences as discrete forms of intelligence.
Models of Emotional Intelligence Currently, there are three models of emotional intelligence. The first model is based on Bar-On’s (1997) work on emotional quotient and is called the Personality Trait Model. The model built on his studies of personality traits or set of traits that he originally related to wellbeing. The next model is the Ability/Intelligence Model by Mayer and Salovey (1993), which focused on abilities related to identifying and understanding emotions in self and others, and emotional problem solving. They used the term bemotional intelligence.Q Their work was scientifically rigorous and was noticed in academic circles but had little exposure in the popular press. The third model is called the Mixed or Performance Model by Goleman (1995). It was a blend of personality traits from the first model and emotional abilities from the second model, focusing on performance as outcome. This is the most well-known model, through extensive field research, publications, assessment/educational programs, and extensive exposure in the popular press. There are four domains of emotional intelligence that are shared by all three models. These shared domains are self-awareness, self-management, social awareness, and social/relationship management, although each model uses slightly different words to describe the domains. A variety of tools have been developed to measure aspects of emotional intelligence. Each tool is derived from different ways of understanding and explaining emotional intelligence. The tools are based specifically on the different models and vary greatly in validity and reliability. Definitions of emotional intelligence show refinement of the concept over time (Table 1). The definition offered by Goleman in 2001 is the most straightforward.
Table 1. Definitions of Emotional Intelligence bThe capacity for recognizing our own feelings and those of others, for monitoring ourselves, and for managing emotions in ourselves and in our relationshipsQ (Goleman, 1998, p. 317). bThe ability to perceive and express emotion, assimilate emotion in thought, understand and reason with emotion, and regulate emotion in the self and othersQ (Mayer, Salovey, & Caruso, 2000, p. 396). bThe ability to recognize and regulate emotions in self and othersQ (Goleman, 2001b, p. 14).
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Emotional Intelligence Competencies Goleman’s emotional intelligence framework was developed through the testing of nearly 600 corporate managers, professionals, and graduate students using the Emotional Intelligence Competency Inventory and a method comparing self-reports and reports of coworkers. The initial 5 domains were collapsed into 4, and the initial 25 competencies were collapsed into 20 (Goleman, 2001a). The four domains are self-awareness, self-management, social awareness, and social/relationship management. Each domain has multiple competencies. For example, within the self-awareness domain, accurate self-assessment is one of the competencies (Table 2).
Method Design and Approach This study used the conceptual framework of emotional intelligence to analyze 16 stories written by nurses who had been asked to bwrite a story from your lived experience where nursing knowledge made a difference.Q In that original study, the stories were mailed to Table 2. Emotional Intelligence Framework: Domains and Competencies 1. Self-awareness domain 1.a) Emotional self-awareness: Recognizing one’s emotions and their effects 1.b) Accurate self-assessment: Knowing one’s strengths and limits 1.c) Self-confidence: A strong sense of one’s self-worth and capabilities
2. Social awareness domain 2.a) Empathy: Understanding others and taking an active interest in their concerns 2.b) Service orientation: Recognizing and meeting customers’ needs 2.c) Organizational awareness: Empathizing at the organizational level
3. Self-management domain 3.a) Emotional self-control: Keeping disruptive emotions and impulses under control 3.b) Trustworthiness: Displaying honesty and integrity 3.c) Conscientiousness: Demonstrating responsibility in managing oneself 3.d) Adaptability: Flexibility in adapting to changing situations or obstacles 3.e) Achievement drive/ orientation: The guiding drive to meet an internal standard of excellence 3.f) Initiative: Readiness to act
4. Social/relationship management domain 4.a) Developing others: Sensing others’ development needs and bolstering their abilities 4.b) Influence: Wielding interpersonal influence tactics 4.c) Communication: Sending clear and convincing messages 4.d) Conflict management: Resolving disagreements 4.e) (Visionary) Leadership: Inspiring and guiding groups of people 4.f) Change catalyst: Initiating or managing change 4.g) Building bonds: Nurturing instrumental relationships 4.h) Teamwork and collaboration: Creating a shared vision and synergy in teamwork, and working with others toward shared goals
research team members, who read and analyzed them individually. Next, the researchers met together to identify possible thematic concepts, which were later validated with the nurses who wrote the stories. Two of the original members of that research team hypothesized that emotional intelligence was a potentially useful concept in identifying factors in the stories of nursing practice that might be related to improved patient/client outcomes and nurse retention. The competencies of emotional intelligence had been previously defined, so this content analysis (Downe-Wambolt, 1992) placed data from the nurses’ stories within the previously defined competencies and domains. Telling stories is a way to make sense of an experience (Chan, Cheung, Mok, Cheung, & Tong, 2005; Misher, 1986) and is considered a natural human impulse (White, 1981). A fundamental assumption is that people are the experts in their own lives and that, through awareness, action can result. The use of stories adds the context that is often missing in purely empiric research studies. Stories allow the voices of participants to be heard, contributing to personal and broader social change (Berman, Ford-Gilboe, & Campbell, 1998).
Sample This purposive sample consisted of 16 stories written by nurses and collected for the earlier study. Those nurses who were invited to submit stories were known to the investigators as reflective individuals and were perceived to be visionaries beyond the boundaries of their own positions (Shoultz et al., 1998). The investigators sought to achieve a broad community representation in the selection of participants (Kooker, Shoultz, & Sloat, 1998). These stories reflected nurses with a comprehensive array of knowledge and skills with diverse experiences, practice areas, academic preparations, and clinical settings. Half of the nurses had bachelor’s degrees in nursing, and half had master’s degrees in nursing or related health fields. Approximately half of the participants practiced in acute care settings and half practiced in ambulatory care settings, and included nurses from both rural and urban communities. The participants themselves represented a high degree of retention within the profession. Five of the participants had been practicing nursing for V 5 years, five had been practicing for z 20 years, and the remainder had been practicing between 5 and 20 years. The stories themselves varied widely in a number of ways. For example, the variation in the degree of specificity may have been a reflection of the writing style of the individual nurse or of the complexity of the incidents being described, or both. Some stories were about an individual or a family, and some stories were about populations within a community. One story focused on health care in a developing country at the level of health care delivery and policy formation. Some authors were very analytical, whereas others were more descriptive, with minimal analysis. These variations are part of the richness of the stories;
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demonstrate the range of human experiences wherein nurses can make a difference; and reflect the depth, breadth, and complexity of professional nursing practice. Some stories were written in the first person in terms of the nurse’s own reaction to the incident being described. Other stories started in the third person but changed to the first person in the discussion and conclusions of the story. The context of the stories reflected multiple levels, including individual patients/ clients and families, communities, and countries. Some stories related incidents about the health care system, whereas others referred to a specific provider.
Procedure The researchers individually read the stories to gain an overview and then re-read the stories for more details. They analyzed each story by color-coding phrases representing emotional intelligence competencies (microlevel review) and domains (macrolevel review). For each story, the individual researchers tallied the color-coded phrases that reflected competencies within each domain and placed these tallies into the appropriate quadrant of 2 2 tables following the format of Table 2. Together, the researchers reviewed each color-coded phrase, compared findings, discussed differences, and negotiated consensus on competencies and domains found in each story. They reviewed the 2 2 tables for dominance of competencies across domains, horizontally (self and social awareness, and self and social management) or vertically (self-awareness and management, and social awareness and management). Then they looked for distribution—how the competencies were distributed across all four domains. Throughout this process, the researchers kept careful records of observations, impressions, questions, and conclusions in field notes as they completed their review of each individual story.
Analysis This current extensive analysis of the stories was performed through the prism of the emotional intelligence framework presented by Goleman (2001a) using the four domains and related competencies of emotional intelligence (Table 2) as units of analysis. All data were coded and counted, and the salience of the definitions of the competencies was confirmed. Reliability and validity were determined by both the exhaustiveness and exclusivity of the fit of the data within the schema of competencies and domains. Microlevel analysis was based on competencies; macrolevel analysis was performed using the four domains; and, finally, metaanalysis was performed across all stories using domains and competencies. Microlevel analysis involved coding phrases in each story by competency and highlighting phrases in the color of the domain in which that competency resides. Macrolevel analysis used Goleman’s framework, focusing on emotional intelligence domains by moving
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horizontally across Domains 1 and 2 (self and social awareness) and Domains 3 and 4 (self and social management) of Table 2. Further analysis focused on moving vertically across Domains 1 and 3 (selfawareness and management) and Domains 2 and 4 (social awareness and management) of Table 2. Metaanalysis involved looking at the dispersion of competencies and domains both within and across all stories.
Results All domains and competencies of emotional intelligence were identified across the 16 stories. Social awareness was the most commonly demonstrated domain in the stories, followed closely by social management and selfawareness. Self-management was represented much less frequently than the other domains (Figure 1). This could be related to the fact that, in two stories, no selfmanagement competencies were identified during the analysis.
Self-Awareness Domain Nurses consistently assessed their strengths and limitations and had a sense of their self-worth, which are competencies within the self-awareness domain. These competencies are especially important to retention, as reflected in the words of this advanced practice nurse, bThe knowledge that I have gained from nursing is that it is a blend. The blend is what makes it all worthwhile. Although the days are long and hard, although the world of medicine and nursing seems, at times, to be spiraling downward out of control, I will not give up on nursing. Not yet. I still have more to offer. It still gives me too much.Q
Social Awareness Domain The nurses demonstrated empathy, recognized patient/ client needs, and understood system factors, which are competencies within the social awareness domain that contributed to patient/client outcomes. A case manager in a community health center provided this insight through the story of Malia, a homeless woman with multiple health problems who was living on the beach, bBecause of our position as a managed care facility and an understanding of health care financing, a primary care provider (and their role) is introduced to Malia and anticipatory guidance is provided.. . .Because of our cultural sensitivity, allowing residents to have [a] voice
Figure 1. Percent competencies per domain.
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and [a] place is as important to their health status as having the right to self-determine [what] their lives are to them.Q These insights are especially important when working with this indigenous Native Hawaiian population where place or land is an essential part of their concept of health and well being.
Self-Management Domain Through the stories, the nurses demonstrated selfcontrol, adaptability, initiative, and conscientiousness, which are part of the self-management domain. One acute care nurse described an incident where she came upon a severe automobile accident on a remote highway where she was able to achieve a positive outcome for a woman trapped in a car. Initially, she drove on by but turned back, bI decided the only ethical choice I had was to turn around.Q As she realized the seriousness of the situation, she said, bI focused on calming myself and allowing myself to rely on my intuition to help me try to find ways to help her. . .I drew on my emergency and critical care background, trying hard to focus on headto-toe assessment. . .The windows were smashed out and I proceeded to crawl into the dark corners of the car. . .Q She rendered assistance and stabilized the woman until the ambulance arrived. In reflecting back on the situation, she said, bI did this by using intuition, medical information, and assessment knowledge. . .that caused me to know how to take charge in an emergency.Q She went on to say, bI felt rewarded and happy with all [that] the nursing profession had given me.Q In this example, self-management behaviors resulted in improved patient/client outcomes and left the nurse feeling good about herself, her actions, and the nursing profession, all of which could contribute to retention.
Social/Relationship Management Domain Through their stories, the nurses nurtured relationships, used personal influence, and acted as change agents, which are competencies of the social/relationship management domain. They were frustrated when their communications were disregarded or when their attempts to create a shared vision and teamwork leading to improved patient/client outcomes were ignored. A particularly good example of social/relationship management came from a community health nurse who was concerned about the safety a child who had been born prematurely and was coming home to parents who had fatally abused a sibling in the past. After seeing several signs that the baby was not developing well and after noting little maternal attachment behaviors, this nurse sounded the alarm that something was wrong, bI had a conference with my immediate supervisor and I became more alarmed myself when she would not agree with my recommendation for Child Protective Services and [to] the child’s pediatrician that he [the child] should be removed from his parents’ custody. My supervisor was more concerned that I was going to anger the pediatrician.Q
Before long, the child presented with bruises and burns, and was seen in the emergency room with a fractured femur. He was still returned to the care of his parents. After several weeks, the mother confessed to intentionally breaking the child’s leg. bAfter a 2-day stay in a foster home, the child had a physical exam, with me accompanying him to his pediatrician. The doc said, dI should have listened to you.T I had cleared the way for placement at a nursing home. The nurses loved the idea of caring for a child at a place where only old folks go.Q The frustration that this nurse felt at being ignored was evident in her story. However, she persisted, resulting in a good, safe outcome for the child and in the validation of this nurse’s activism, intuition, and assessment of the situation, which is important to retention.
Discussion and Implications Elements of professional nursing practice, such as autonomy, accountability, mentoring, collegiality, integrity, knowledge, activism, and the professional practice environment, were all identified in the excerpts of the stories, which also demonstrated the competencies of emotional intelligence. Compatibility between the way nurses’ knowledge dictates practice and the way the system allows them to function is critical. When conflict arises, both individual adaptability and organizational adaptability are needed to address challenges and to maximize performance. Application of the emotional intelligence framework in a practice setting can identify factors that could lead to improved nurse retention and patient/ client outcomes. The use of storytelling as a way to help nurses examine their practice led to valuable insights into the complexities of that practice. Another benefit of using stories or narratives as a strategy to analyze nursing practice was that it helped nurses reach closure. One rural nurse stated, bMy nursing soul is nourished anew. Thank you for allowing me to reflect on the subject of nursing knowledge, feel my worth as an informed compassionate caregiver, and put closure to many of my own personal struggles.Q In addition, storytelling may lead to decreased burnout from unresolved conflict, may increase retention, and may provide insights into systems issues that need attention at the unit level (Weber, 2005). Screening for emotional intelligence competencies during preemployment for practice situations and preadmission for educational situations could identify those who already possess skills in the four domains, and identify areas where additional skills development would be helpful. Because emotional intelligence competencies are developmental and emphasize human and leadership skills, they are important in both practice and educational settings. In addition, the list of emotional intelligence competencies provides measurable outcomes that can be quantified and monitored over time.
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Suggestions for Future Studies In reflecting on the field notes and stories, additional research questions emerged. One set of questions revolves around the emotional intelligence framework, its domains, and its competencies. Examples of research questions include the following: 1. Are self and social awareness precursors to self and relationship management? 2. Is relationship management a synthesis of emotional intelligence competencies reflecting a high level of professional practice? 3. How do the four domains interact in leading to successful professional practice? 4. Can one expect to find balance among the four domains in professional practice, or is the environment or context important in defining the specific blend of competencies needed for professional practice? 5. Are there unique sets of emotional intelligence competencies that are optimal for different practice settings and levels of management responsibilities? The second set of researchable questions relates to the application of emotional intelligence competencies to professional nursing practice. Examples include the following: 1. Do higher scores on nurse satisfaction scales correlate with higher scores on emotional intelligence competencies of individual nurses? 2. Do higher scores on patient/client outcomes correlate with higher scores on emotional intelligence competencies of the nurses in particular nursing units? 3. Do higher scores on nurse retention measures correlate with higher scores on the emotional intelligence of individual nurses? 4. Are emotional intelligence scores higher for nurses when there is a goodness of fit between their philosophy of practice and that of their organizations?
Conclusion Emotional intelligence competencies were clearly evident in nurses’ stories about how nursing knowledge made a difference in their professional practice. All domains of emotional intelligence were represented in their stories, with social awareness being the most prominent and with self-regulation being the least evident. In spite of the great variation in writing styles and in the richness of details, the stories reflected evidence of emotional intelligence competencies that could be related to nurse retention and improved patient/client outcomes. Elements of professional nursing practice, such as autonomy, accountability, mentoring, collegiality, integrity, knowledge, activism, and the professional practice environment, were also identified in the excerpts of the stories.
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The interaction of these elements is necessary for the enhancement of professional practice. For example, the practice environment has been identified as a significant factor in the well being of both the patient/client and the nurse. Choi, Bakken, Larsen, Du, and Stone (2004) found that a positive working environment is related to job satisfaction and fosters professional nursing practice. The recommendations of the Institute of Medicine (2003) report, Keeping Patients Safe: Transforming the Work Environment of Nurses, promotes the improvement of the work environment for patient/client safety and highlights many issues that can lead to improved retention of the nursing workforce. The study of the relationship of emotional intelligence to professional nursing practice is in its infancy. Many more research questions were generated, rather than answered, by this study. As the shortage of practicing nurses continues to be a national issue, the application of emotional intelligence concepts may provide fresh insights into ways to keep nurses engaged in professional nursing practice and to improve nurse retention and patient/client outcomes.
Acknowledgments The authors gratefully acknowledge the National League for Nursing for funding the study and the nurses who generously contributed their stories.
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