Resilience moderates the relationship between emotional intelligence ...

Nurse Education Today 46 (2016) 64–68

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Resilience moderates the relationship between emotional intelligence and clinical communication ability among Chinese practice nursing students: A structural equation model analysis Linghua Kong a,1, Yun Liu b,1, Guopeng Li a, Yueyan Fang a, Xiaofei Kang a, Ping Li a,⁎ a b

School of Nursing, Shandong University, 44 Wenhua West Road, Jinan, Shandong 250012, PR China People's Hospital of Liaocheng, Shandong, PR China

a r t i c l e

i n f o

Article history: Received 18 January 2016 Received in revised form 12 August 2016 Accepted 25 August 2016 Keywords: Clinical communication ability Emotional intelligence Resilience Moderator effect Practice nursing students

a b s t r a c t Objective: To examine the positive association between emotional intelligence and clinical communication ability among practice nursing students, and to determine whether resilience plays a moderating role in the relationship between emotional intelligence and clinical communication ability among Chinese practice nursing students. Methods: Three hundred and seventy-seven practice nursing students from three hospitals participated in this study. They completed questionnaires including the Emotional Intelligence Inventory (EII), Connor–Davidson Resilience Scale (CD-RISC-10), and Clinical Communication Ability Scale (CCAS). Structural equation modeling was used to analyze the relationships among emotional intelligence, resilience, and clinical communication ability. Results: Emotional intelligence was positively associated with clinical communication ability (P b 0.01). Resilience significantly affected clinical communication ability (P b 0.01) and moderated the relationship between emotional intelligence and clinical communication ability (P b 0.01). Conclusions: Emotional intelligence is positively related to clinical communication ability among Chinese practice nursing students, and resilience moderates the relationship between emotional intelligence and clinical communication ability, which may provide scientific evidence to aid in developing intervention strategies to improve clinical communication ability. © 2016 Elsevier Ltd. All rights reserved.

1. Introduction Clinical communication ability is the ability of health care providers to listen and respond effectively and to convey information clearly to patients and their families (Laidlaw et al., 2014). The clinical communication process between nurses and patients is viewed as a crucial factor in patient-centered care (Balandin et al., 2007; Taghizadeh et al., 2006). Clinical nurses with high levels of communication ability are better able to identify patients' needs and take appropriate actions to address their problems (Hajbaghery and Shahsavarloo, 2014), which leads to improvement on metrics such as increased patient satisfaction, better patient compliance, and the overall quality of nursing services (Hall and Roter, 2007; Hardee and Kasper, 2008). Therefore, it is important to improve clinical communication ability, which may serve as a useful screening indicator for professional competence. Several positive characteristics contribute to clinical communication ability. It is commonly associated with emotional intelligence (EI) (Suhaimi et al., 2014). EI is defined as the ability to monitor and ⁎ Corresponding author. E-mail address: [email protected] (P. Li). 1 The first two authors contributed equally to this work.

http://dx.doi.org/10.1016/j.nedt.2016.08.028 0260-6917/© 2016 Elsevier Ltd. All rights reserved.

discriminate emotions of oneself and others and use this information to guide one's thinking and actions (Mayer et al., 2008). In previous literature about medical education, EI has been used to determine levels of professional competence such as clinical communication ability (Fletcher et al., 2009), and it is considered as a key predictor in the development of communication ability (Raeissi et al., 2010). Furthermore, EI has been a selection criteria for enhanced clinical communication ability among nursing students (Grewal and Davidson, 2008). However, related studies have mainly focused on clinical nurses and rarely on practice nursing students who are in an important transitional period of nursing roles. Resilience, another positive characteristic, appears to promote positive development, work performance and communication ability (Ji et al., 2013; Nahar and van der Geest, 2014; Youssef and Luthans, 2007). Related findings indicate that individuals with high levels of resilience usually possess other personal resources such as well-being, hope, and optimism, which might serve as facilitators enhancing clinical communication ability (Nelis et al., 2011; Pretsch et al., 2012). For instance, one study found that those with increased well-being expressed greater positive emotion and better interpersonal functioning so that they were more likely to communicate with others effectively in their daily life (Gross and John, 2003). Also, optimistic persons were more willing to communicate with others and showed better interpersonal relationships with staff

L. Kong et al. / Nurse Education Today 46 (2016) 64–68

(Wimberly et al., 2008). Additionally, according to Davidson's theory, resilience may be a predictor or moderator of psychological responses and adjustment (Davidson et al., 2005, 2012). Therefore, we inferred that resilience may enhance the relationship between EI and clinical communication. However, research has not yet explored this relationship. Based on the above conceptualizations, the aims of this study are (1) to examine the positive association between EI and clinical communication ability among practice nursing students, and (2) to explore the moderating effect of resilience on the relationship between EI and clinical communication ability.

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students. This questionnaire consisted of 28 items categorized into six subscales: establishing rapport and respect (6 items), listening receptively (5 items), confirming the patient (5 items), sharing control (4 items), conveying information effectively (3 items), and checking perceptions (5 items). It uses a 4-point scale ranging from 1 to 4. The total score ranges from 28 to 112, and higher scores overall or on each dimension reflect stronger communication ability. Researchers have indicated that the Chinese version of the Clinical Communication Ability Scale has excellent psychometric properties and is applicable to Chinese nursing students (Wang, 2013). In this study, the internal consistency coefficient was α = 0.88.

2. Methods 2.3. Data Analyses 2.1. Participants and Procedures A cross-sectional design was adopted in this study. A convenience sample of 377 practice nursing students (308 female and 69 male) was recruited from three hospitals in Shandong province. The inclusion criteria were as follows: graduate students in nursing who were interns in the hospital and willing to participate in this study. To ensure anonymity, their names and other identifiers were not included in this study. This study was approved by the Institutional Review Board of Shandong University. 2.2. Instruments 2.2.1. Demographic Questionnaire The demographic characteristics of the participants included gender (1 = male, 2 = female), residence (1 = urban, 2 = rural), age, student leader (1 = yes, 2 = no), economic status (1 = high, 2 = medium, 3 = low), and whether they were an only child (1 = yes, 2 = no). Student leaders refer to model students who demonstrate excellent organization and leadership skills in student groups such as college students' professional and social work groups. 2.2.2. Emotional Intelligence Inventory (EII) EI was measured by the Emotional Intelligence Inventory (Bradbury and Graves, 2005). This questionnaire consists of 33 items categorized into four subscales: emotional perception (12 items), emotional selfmanagement (8 items), others' emotional management (6 items), and emotional expression (7 items). The EI scores were computed as the sum of these four subscales and varied between 94 and 160, with higher scores indicating a higher level of EI. On a 5-point scale, responses range from 1 (Never) to 5 (Always). The questionnaire has good internal consistency and construct validity (Ganji et al., 2006). Further, it is a reliable tool to measure nursing students' emotional intelligence (EspinozaVenegas et al., 2015). In this study, the internal consistency coefficient was α = 0.90. 2.2.3. Connor-Davidson Resilience Scale (CD-RISC-10) The 10-item Connor-Davidson Resilience Scale (CD-RISC10) consists of 10 items extracted from the original 25-item Connor-Davidson Resilience Scale (CD-RISC), which is a self-rated instrument for measuring resilience (Connor and Davidson, 2003). It employs a 5-point scale ranging from 0 to 4, with higher scores indicating greater resilience. The CD-RISC10 is regarded as one of the best resilience measures in terms of psychometric properties and has good internal consistency and construct validity (Campbell-Sills and Stein, 2007). Researchers have also indicated that the Chinese version of the 10-item CD-RISC has excellent psychometric properties and is applicable to Chinese populations (Wang et al., 2010). In this study, the internal consistency coefficient was α = 0.86.

Descriptive statistics, a Student's t-test, a one-way ANOVA, and Pearson correlation analysis were conducted using SPSS 22.0. Structural equation modeling (SEM) was conducted using AMOS 22.0. Student's t-test and one-way ANOVA were used to test the differences in clinical communication ability in terms of the categorical socio-demographic characteristics. Pearson correlation analyses were performed to determine the direction and size of the relationships among EI, resilience, and clinical communication ability. SEM was used to test the influence of EI on clinical communication ability. SEM can minimize the effects of measurement error. Maximum likelihood estimation was employed as a global test of models because data for all continuous variables were normally distributed. The goodness-offit of the model was evaluated by the chi-square (χ2) statistic, root mean square error of approximation (RMSEA), goodness-of-fit index (GFI), the adjusted goodness-of-fit statistic (AGFI), Tucker-Lewis fit index (TLI), and comparative fit index (CFI). The following values for acceptable fit of the model were used: RMSEA ≤ 0.08, GFI ≥ 0.90, AGFI ≥ 0.90, TLI ≥ 0.90, and CFI ≥ 0.90 (Hooper et al., 2008). Finally, multiple group analysis of SEM was computed to examine the moderating effects of resilience on the relationship between EI and clinical communication ability. Specifically, we categorized the practice nursing students into three groups according to their scores on resilience. The three groups were low, moderate, and high resilience, with their sample scores on the RISC 1 SD below the mean, within the mean ± 1 SD, and 1 SD above the mean, respectively. Multiple group analysis of SEM was then conducted to test the invariance of the final model, describing the effect of EI on clinical communication ability (see Fig. 2), across the three groups. 3. Results 3.1. Demographic Characteristics and Clinical Communication Ability Participants had a mean age of 21.36 years (SD = 1.24; range 16–24). A total of 68.7% of participants came from rural areas, and 66.8% were not student leaders. Of the participants, 70.3% were not

Table 1 Socio-demographic characteristics and differences in clinical communication ability (N = 377). Variable Gender Residence Family with only child Student leader

2.2.4. Clinical Communication Ability Scale (CCAS) The Clinical Communication Ability Scale was first developed by Steyn (1999). Using this original version, Yang et al. (2010) created a new clinical communication scale that was suitable for Chinese nursing

Economic status

Male Female Urban Rural Yes No Yes No High Medium Low

N (%)

Mean ± SD

t(F)

P

69 (18.3) 308 (81.7) 118 (31.3) 259 (68.7) 112 (29.7) 265 (70.3) 125 (33.2) 252 (66.8) 53 (14.1) 309 (82.0) 15 (4.0)

81.81 ± 10.69 86.82 ± 10.18 87.36 ± 10.81 85.25 ± 10.22 83.83 ± 10.69 86.78 ± 10.23 84.93 ± 10.96 86.39 ± 10.16 83.91 ± 12.31 86.32 ± 10.08 84.47 ± 10.51

−3.663

b0.001

1.824

0.069

−2.528

0.012

−1.283

0.200

1.361

0.258

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Table 2 Correlations between emotional intelligence, resilience and clinical communication ability (N = 377). Variable

Mean ± SD

1

2

3

1 EP 2 EM 3 ESM 4 EE 5 EI 6 RE 7 CCS 8 ERR 9 LR 10 CTP 11 CP 12 SC 13 IE

47.18 ± 6.36 37.49 ± 5.36 23.92 ± 3.49 17.33 ± 2.90 125.91 ± 15.38 28.20 ± 5.61 85.91 ± 10.44 19.03 ± 3.03 16.36 ± 2.78 15.63 ± 2.73 11.07 ± 2.34 8.72 ± 1.51 15.11 ± 2.84

1 0.691⁎⁎ 0.703⁎⁎ 0.563⁎⁎ 0.921⁎⁎ 0.588⁎⁎ 0.593⁎⁎ 0.564⁎⁎ 0.533⁎⁎ 0.501⁎⁎

1 0.656⁎⁎ 0.413⁎⁎ 0.862⁎⁎ 0.566⁎⁎ 0.412⁎⁎ 0.404⁎⁎ 0.420⁎⁎ 0.389⁎⁎

1 0.493⁎⁎ 0.840⁎⁎ 0.471⁎⁎ 0.484⁎⁎ 0.470⁎⁎ 0.504⁎⁎ 0.444⁎⁎

0.061 0.194⁎⁎ 0.423⁎⁎

−0.121 0.021 0.385⁎⁎

−0.040 0.105⁎ 0.336⁎⁎

4

1 0.678⁎⁎ 0.407⁎⁎ 0.511⁎⁎ 0.455⁎⁎ 0.448⁎⁎ 0.422⁎⁎ 0.122⁎ 0.233⁎⁎ 0.328⁎⁎

5

6

1 0.624⁎⁎ 0.595⁎⁎ 0.567⁎⁎ 0.566⁎⁎ 0.523⁎⁎

1 0.462⁎⁎ 0.460⁎⁎ 0.419⁎⁎ 0.402⁎⁎

−0.003 0.156⁎⁎ 0.447⁎⁎

−0.056 0.087 0.411⁎⁎

7

8

9

10

11

12

13

1 0.858⁎⁎ 0.832⁎⁎ 0.809⁎⁎ 0.194⁎⁎ 0.500⁎⁎ 0.745⁎⁎

1 0.719⁎⁎ 0.666⁎⁎ 0.027 0.301⁎⁎ 0.565⁎⁎

1 0.672⁎⁎ −0.037 0.223⁎⁎ 0.579⁎⁎

1 −0.149 0.243⁎⁎ 0.640⁎⁎

1 0.414⁎⁎ −0.179

1 0.193⁎⁎

1

EP: emotional perception, EM: others' emotional management, ESM: emotional self-management, EE: emotional expression, EI: emotional intelligence, RE: resilience, CCS: clinical communication ability, ERR: establishing rapport and respect, LR: listening receptively, CTP: confirming the patient, CP: checking perceptions, SC: sharing control, IE: informing effective. ⁎ p b 0.05 ⁎⁎ p b 0.01.

only children. In regard to household income, 82.0% were from a middle-income family. The scores of clinical communication ability among practice nursing students were (85.91 ± 10.44). Female interns (81.7%) reported better clinical communication ability than male interns (18.3%, t = −3.176, P b 0.001). Those participants who were not only children (70.3%) reported better clinical communication ability than those who were (29.7%, t = − 2.528, P = 0.012). There were no other demographic differences in the scores of clinical communication ability (see Table 1). 3.2. Emotional Intelligence, Resilience, and Clinical Communication Ability Means, standard deviations, and correlations among research variables are presented in Table 2. Clinical communication ability, establishing rapport and respect, listening receptively, confirming the patient and effectively conveying information were all positively correlated with resilience (r = 0.402 ~ 0.462, P b 0.01). Additionally, clinical communication ability, establishing rapport and respect, listening receptively, confirming the patient, checking perceptions, sharing control and effectively conveying information were positively correlated with emotional intelligence, emotional perception, others' emotional management, emotional self-management and emotional expression (r = 0.122 ~ 0.595, P b 0.01). Further, emotional intelligence, emotional perception, others' emotional management, emotion self-management and emotional expression were positively correlated with resilience (r = 0.407 ~ 0.624, P b 0.01). 3.3. Moderating Effect of Resilience on Emotional Intelligence and Clinical Communication Ability The SEM analysis of the effect of emotional intelligence on clinical communication ability throughout the entire sample yielded a good fit of the data to the model (see Table 3). As seen in Fig. 1, emotional intelligence was positively related to clinical communication ability (β = 0.70, P b 0.01). The multiple group analysis of SEM showed a difference in goodness-of-fit statistics in the model with restricted structural weights (see Table 3), indicating that the relationships between emotional intelligence and clinical communication ability

differed among participants with low resilience, medium resilience, and high resilience. The multiple group analysis of SEM analyses for the relationship between emotional intelligence and clinical communication ability among these three groups are presented in Fig. 2, demonstrating that emotional intelligence had insignificant (β = 0.04, p ≥ 0.05), significantly moderate (β = 0.64, p ≤ 0.01), significantly substantial effects (β = 0.70, p ≤ 0.01) on clinical communication ability among low resilience, moderate resilience, and high resilience practice nursing students, respectively. These results suggest that resilience moderates the effect of emotional intelligence on clinical communication ability among practice nursing students. 4. Discussion The direct effect of EI on clinical communication ability was further verified, and initial evidence for the moderating role of resilience in the effect of EI on clinical communication ability was found. Furthermore, this finding opened the door to a new means of improving clinical communication ability among practice nursing students that emphasizes the significant role of resilience. EI was significantly related to clinical communication ability among practice nursing students after controlling for the other variables, which is consistent with previous research (Lee and Gu, 2013; Raeissi et al., 2010). This is because nursing students with high EI may be better able to understand the patient's perspective, and they are also more likely to experience empathy (McQueen, 2004). Furthermore, EI might impact the quality of nursing students' learning, ethical decisionmaking, critical thinking, evidence and use of knowledge in practice (Smith et al., 2009), significantly affecting their clinical communication ability. In addition, when encountering stress, practice nursing students with high EI tend to adopt positive coping strategies (Montes-Berges and Augusto, 2007) and are more likely to receive support from colleagues, friends, and family, which in turn enhances the level of clinical communication ability. Resilience was positively associated with clinical communication ability, which is consistent with previous studies. For example, Ji et al. (2013) found that nursing students with higher resilience also had better communication ability. Furthermore, Tagay and Karakelle (2014)

Table 3 Goodness-of-fit statistics for the multiple group analysis. Goodness-of-fit statistics

χ2 (df)

P

Δχ2 (df)

P

CFI

GFI

TLI

RMESA

Model with no restrictions Model with restricted structural weights

196.998(99) 210.313(101)

b0.001 b0.001

– 13.315(2)

– 0.001

0.903 0.898

0.933 0.925

0.909 0.900

0.051 0.054


Fig. 1. Results of SEM analysis of the influence of emotional intelligence on clinical communication ability among the whole sample. All the coefficients in the figure are standardized and significant at level 0.01. χ2/df = 3.811, GFI = 0.932, CFI = 0.950, TLI = 0.931, and RMESA = 0.086.

showed that vocational school students with high resilience usually possessed excellent communication ability in the process of communication with others. In accordance with these findings, this study confirmed that practice nursing students with high resilience do have good clinical communication ability. Individuals with high resilience were found to possess a host of psychological resources, including optimism, tranquility, low neuroticism and high openness, which might promote easier adaptation to clinical problems in interpersonal relationships and contribute to better clinical communication ability (Nelis et al., 2011; Pretsch et al., 2012). This study not only verified the direct relationship between resilience and clinical communication ability further but also is the first to confirm the moderating effect of resilience on the relationship between EI and clinical communication ability. Resilience strengthened the positive effect of EI on clinical communication ability. That is, the relationship between EI and clinical communication ability was enhanced when resilience was high and was weakened when resilience was low. It might be that individuals with higher resilience showed a greater capacity for overcoming adversity and negative life circumstances (Ong et al., 2006) and had richer personal resources to enhance the positive effect of EI on clinical communication ability (Nelis et al., 2011), resulting in them possessing better clinical communication ability than those who had low resilience.

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Incidentally, this study found significant differences in clinical communication ability among practice nursing students according to sociodemographic variables. Female students had better communication ability, which may be that they tend to reflect maternal attachment and a willingness to communicate with other students. However, since the sample primarily comprised women, this skewness may have contributed to this result. Second, participants with siblings reported better clinical communication ability, which may suggest that they are more agreeable and approachable, and were therefore more likely to communicate with others. Finally, student leaders demonstrated better clinical communication ability compared to other students. Their role in college students' groups may have encouraged them to develop and strengthen their organization, coordination, and communication ability. These findings—EI and resilience may help improve clinical communication skills among nursing students undergoing their practicum— have significant implications for clinical practice and future research. It can help nursing educators and administrators develop intervention strategies to enhance students' clinical communication ability such as developing EI training (Zijlmans et al., 2015) and social-emotional training and training in cognitive reappraisal (Southwick and Charney, 2012). Although this study has distinct strengths, such as being the first study to explore the moderating effect of resilience in the association of EI and clinical communication ability among practice nursing students, it certainly is not free from limitations. Firstly, the current sample was recruited from only three hospitals in Shandong Province. When considering various other regions, generalization of these findings may be limited. Second, given the cross-sectional and self-report nature of the study, it should be noted that we cannot infer a causal role of these factors, and the findings from this study should be interpreted with caution. Thus, future longitudinal research should be designed to replicate the current study using a large sample drawn from different regional hospitals to further verify our results. 5. Conclusions The study results strongly suggest that EI has a direct effect on clinical communication ability among practice nursing students. In addition, we verified that resilience moderated the relationship between EI and clinical communication ability. Thus, nursing educators

Fig. 2. Results of SEM analysis of the influence of emotional intelligence on clinical communication ability among different levels of resilience. A): Low resilience, (B): moderate resilience, and (C): high resilience. All the coefficients in the figures are standardized. ***p b 0.001.

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and career counselors should pay more attention to improving clinical communication ability among practice nursing students by strengthening their EI and resilience. Consequently, this can become the basis for evidence-based development of intervention strategies. Authors' Contributions L. Kong and Y. Liu were involved in the design of the study, data acquisition, analysis and interpretation of data, drafting and revising the manuscript. G. Li, Y. Fang and X. Kang provided help with the data collection, analysis and interpretation, and revised several drafts of the manuscript. P. Li made substantive intellectual contributions to the interpretation of data and draft of the manuscript. All authors have read and approved the final manuscript. The authors declare no conflicts of interest. Acknowledgments The study was supported by grants from Shandong Province Natural Science Foundation (ZR2015HM064), and the Innovation Foundation for Young Talent Team of Shandong University (IFYT15010). We are thankful for the generous contributions of the research participants and the staffs who assisted with data collection during the study. References Balandin, S., Hemsley, B., Sigafoos, J., Green, V., 2007. Communicating with nurses: the experiences of 10 adults with cerebral palsy and complex communication needs. Appl. Nurs. Res. 20, 56–62. Bradbury, T., Graves, J., 2005. Emotional intelligence (skills and tests). J. Grieves.–. Campbell-Sills, L., Stein, M.B., 2007. Psychometric analysis and refinement of the ConnorDavidson Resilience Scale (CD-RISC): validation of a 10-item measure of resilience. J. Trauma. Stress. 20, 1019–1028. Connor, K.M., Davidson, J.R., 2003. Development of a new resilience scale: the ConnorDavidson resilience scale (CD-RISC). Depress. Anxiety 18, 76–82. Davidson, J.R.T., Payne, V.M., Connor, K.M., et al., 2005. Trauma, resilience and saliostasis: effects of treatment in post-traumatic stress disorder. Int. Clin. Psychopharmacol. 20, 43–48. Davidson, J., Stein, D.J., Rothbaum, B.O., et al., 2012. Resilience as a predictor of treatment response in patients with posttraumatic stress disorder treated with venlafaxine extended release or placebo. J. Psychopharmacol. 26, 778–783. Espinoza-Venegas, M., Sanhueza-Alvarado, O., Ramírez-Elizondo, N., Sáez-Carrillo, K., 2015. A validation of the construct and reliability of an emotional intelligence scale applied to nursing students. Rev. Lat. Am. Enfermagem 23, 139–147. Fletcher, I., Leadbetter, P., Curran, A., O'Sullivan, H., 2009. A pilot study assessing emotional intelligence training and communication skills with 3rd year medical students. Patient Educ. Couns. 76, 376–379. Ganji, H., Mirhashemi, M., Sabet, M., 2006. Bradberry-Greaves' emotional intelligence test: preliminary norming-process. J.Thought Behav. 1, 23–35. Grewal, D., Davidson, H.A., 2008. Emotional intelligence and graduate medical education. JAMA 300, 1200–1202. Gross, J.J., John, O.P., 2003. Individual differences in two emotion regulation processes: implications for affect, relationships, and well-being. J. Pers. Soc. Psychol. 85, 348. Hajbaghery, M.A., Shahsavarloo, Z.R., 2014. Assessing the nursing and midwifery students competencies in communication with patients with severe communication problems. Nurs. Midwifery Stud. 3.

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