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EMOTIONAL INTELLIGENCE AND CARING BEHAVIOR IN NURSING *
Arménio RegoUniversidade de Aveiro, Campus de Santiago, 3810-193 Aveiro- Portugal
Lucinda GodinhoUniversidade de Aveiro, Campus de Santiago, 3810-193 Aveiro- Portugal
Anne McQueenThe University of Edinburgh, Nursing Studies, School of Health in Social Science
Teviot Place, Edinburgh, EH8 [email protected]
Miguel Pina e CunhaFaculdade de Economia, Universidade Nova de Lisboa
Rua Marquês de Fronteira, 20, 1099-038 Lisboa – Portugal [email protected]
ABSTRACTWe relate nurses’ emotional intelligence (understanding one’s emotions; self-control against criticism; self-encouragement; emotional self-control; empathy and emotional contagion; understanding of other people’s emotions) with their caring behaviors (respectful/trustful treatment; giving explanations). One hundred and twenty nurses self-reported their emotional intelligence, and three patients of each one (n=360) described their caring behaviors. Variance, correlation and regression analyses were conducted to study how nurses’ emotional intelligence explains caring behaviors. The findings show the following: (a) EI explains a significant but low unique variance of caring behaviors; (b) complex combinations between EI dimensions appear to be required for nurses to act as good caregivers.
Keywords: Nursing; Emotional intelligence; Caring behaviors; Quality health care
INTRODUCTIONQuality health care and service excellence are of critical and fundamental importance and are major differentiating features between health care providers (Anthony, Brennan, O’Brien, & Suwannaroop, 2004; Ford, Sivo, Fottler, Dickson, Bradley & Johnson, 2006; Rowell, 2004). Patient satisfaction is a widely recognized measure of medical care quality and a predictor of several positive consequences for organizations and patients (e.g., patient adherence to treatment regimens, malpractice suits, hospital employees’ satisfaction, and financial performance; Gesell & Wolosin, 2004). However, as Khatri (2006: 45) argued, “health care organizations are not factories” and, in comparison with industrial model of management, they require a different set of human resources practices and systems to support a particular kind of
* We are grateful to all nurses, patients and hospital administrators who contributed to the data collection.
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service. Considering their emotional, psychological and/or physical fragilities, patients are not “normal” customers. They need both instrumental and expressive care. Although both contribute to excellence in health care, the expressive caring is increasingly overshadowed by instrumental caring with a focus on technical skills and knowledge. The compassionate behavior is thus being threatened by technological concerns and economic constraints (Godkin & Godkin, 2004). The increasing emphasis on the instrumental elements threatens the integrity of the whole (Freswater & Stickley, 2004; Woodward, 1997). As Kerfoot (1996: 62) argued, “[c]continually, we experience situations where patients received excellent technical care but, when the emotional side of their care was not met, they believed that their care was inadequate”. Patient-centered quality care requires not just excellent technical actions and good management/coordination efforts, it also demands care that (a) is respectful of and responsive to individual patient preferences, needs, and values; (b) assures that patient values guide the clinical decisions and (c) provides patients with emotional support (Gesell & Wolosin, 2004; Institute of Medicine, 2001).
As pivotal figures in patient care who interact with patients more frequently than other health care providers, nurses have a major caring role (McQueen, 2000; Williams, 1997). Several authors have considered it as part of a therapeutic interpersonal relationship and even a moral imperative (Issel & Kahn, 1998). Huch (2003) stressed that nursing is a caring science, and Freswater and Stickley (2004: 94) asked emphatically: “What is nursing if it is not the provision of one human being caring for another?”
Caring “is the act of conveying individualized or person-to-person concern or regard through a specific set of behaviors” (Issel & Kahn, 1998: 44). Patients report that they feel cared for when they feel treated as individuals, receive help dealing with their illness, and when they believe that nurses anticipate their needs, are available to them and appear confident in their work (Godkin, 2001; Godkin & Godkin, 2004; Hines, 1992). The caring nurse is perceptive, supportive of patient concerns and physically present/available (Godkin, 2001; Riemen, 1986). By paying attention to the idiosyncratic physiological and emotional needs of their patients, nurses can improve patients’ satisfaction, well-being and health (Al-Mailan, 2005; Dingman, Williams, Fosbinder, & Warnick, 1999; Godkin, 2001; Godkin & Godkin, 2004; Issel & Kahn, 1998; Mahon, 1996; Meyer, Cecka & Turkovich, 2006; Williams, 1997; Wolf, Colahan, Costello, Warwick, Ambrose, & Giardino, 1998). Financial, economic and legal benefits have been reported as well in literature (Issel & Kahn, 1998; Weech-Maldonado, Neff & Mor, 2003; Wolf et al., 1998).
Considering these benefits, promoting expressive caring is a worthy and even an imperative aim (Godkin & Godkin, 2004). This requires that researchers identify the factors affecting caring behaviors and the study reported here contributes to this body of knowledge by linking caring with emotional intelligence (EI). The paper is structured as follows. After discussing the relevance of EI for a number of aspects of individual and organizational life and for nursing, we theoretically show how nurses’ EI may relate with their caring behaviors. Then we present the method, results, discussion and conclusions. Some implications for health care organizations’ management will be presented.
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EMOTIONAL INTELLIGENCESalovey and Mayer (1990: 189) defined EI as “the ability to monitor one's own and others' feelings, to discriminate among them, and to use this information to guide one's thinking and action”. Theoretical perspectives and empirical studies on what abilities comprise EI differ somewhat, although one of the most widely reported models includes four dimensions (Salovey, Mayer & Caruso, 2002): (1) perceive one’s own and others’ emotions and accurately express one’s own emotions; (2) facilitate thought and problem solving through use of emotion; (3) understand the causes of emotion and relationships between emotional experiences; (4) manage one’s own and others’ emotions. This is an “ability model”, but other perspectives (e.g., Goleman, 1998) reflect “mixed models”; combining abilities with a broad range of personality traits. Both the ability and the mixed models have strengths and limitations (Caruso, Mayer & Salovey, 2002; Mayer, Salovey & Caruso, 2000).
Empirical and theoretical evidence suggest that EI is relevant for a number of aspects of individual and organizational life (e.g., effective leadership, productivity/performance, satisfaction with life, health and well-being; see Van Roy & Viswesvaran, 2004, and the respective references for a synthesis). Studies also have shown that EI of service providers’ predicts customer satisfaction (Kernbach & Schutte, 2005) and that EI is associated to salesperson’s customer orientation (Rozell, Pettijohn & Parker, 2004).
EI is also making an appearance in nursing journals (e.g., Cadman & Brewer, 2001; Freshwater & Stickley, 2004; Kerfoot, 1996; MacCulloch, 1998; McQueen, 2004; Vitello-Cicciu, 2002, 2003). Several authors have suggested that EI is crucial for building, nourishing and sustaining the emotional labor that nurses are required to carry out in their interactions with patients. For example, Freshwater and Stickley (2004: 93) stressed that “every nursing is affected by the master aptitude of emotional intelligence” and that “it is not enough to attend merely to the practical procedure without considering the human recipient of the process”. It is more and more recognized that interpersonal and intrapersonal skills are required to cope with the complex demands of modern health care systems. These skills can improve the patients’ well-being (Dingman, Williams, Fosbinder & Warnick 1999), have positive economic consequences (Issel & Kahn, 1998) and help nurses to cope with the stress of clinical nursing practice (Cadman & Brewer, 2001). Cadman and Brewer (2001: 322) argued that the competence of nursing practitioners “. . . in dealing with their own and others’ emotions is axiomatic”.
In spite of this emerging theoretical literature, empirical studies are scarce. This is an astonishing observation, considering that nursing is mainly relational in nature and impregnated with intense emotional meaning and labor (Cadman & Brewer, 2001; McQueen, 1997, 2004). Nurses need to interpret and understand how patients feel, to ascertain their motives and concerns, and demonstrate empathy in their care (McQueen, 2004). They also need to understand and manage their own emotions, not just for high quality care, but for their own self-protection and health as well.
Literature suggests that nurses with higher EI display strong self-awareness and high levels of interpersonal skills; they are empathetic and adaptable; are more likely to ‘connect’ easily with patients and to meet their emotional needs immediately; they are able to see the patients’ perspectives and thus are more apt to understand and satisfy
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their needs (Kerfoot, 1996). This paper reports on an empirical study assessing how six dimensions of EI relate to nurses’ caring behaviors. An EI model previously developed and validated by one of the authors (Rego & Fernandes, 2005a, 2005b, 2005c) was used. Through several exploratory and confirmatory factor analyses, a factor-structure embracing six dimensions emerged: (1) understanding one’s emotions; (2) self-control against criticism; (3) self-encouragement; (4) emotional self-control; (5) empathy and emotional contagion; (6) understanding of other people’s emotions. This six-factor model fits the data well, the reliabilities are satisfactory and it can predict individual health, satisfaction with life and students’ academic achievement (Rego & Fernandes, 2005a, 2005b, 2005c). We hypothesize that the above six dimensions also impact on nurses’ caring behaviors and present arguments supporting this position. Following, each EI dimension is discussed separately, and rationale is given for possible interactions between them.
EMOTIONAL INTELLIGENCE AND CARING BEHAVIORS
Understanding one’s emotionsNurses capable of a self-reflective process become aware of their own emotions (McQueen, 2004). As a result, they can demonstrate a more judicious manner when they interact with patients and they are more likely to behave and communicate in an “appropriate” and respectful way. When nurses recognize their feelings, they are more likely to manage them. For example, they may exercise self-constraint against negative emotions they are experiencing. However, if nurses do not really understand that they are frustrated, disgusted, irritated, angered or very sad regarding a patient situation, they are less likely to control the expression of these emotions, with potentially negative effects on the patient (McQueen, 2004). In short, regardless of the situation, nurses are well-advised to keep their emotions in check and balance, and this emotional awareness component of the EI dimension can provide that ability (Rozell, Pettijohn & Parker, 2006).
Self-control against criticismEmotionally intelligent nurses can choose how to respond to different interactive situations without being emotionally overwhelmed by them (Vitello-Cicciu, 2003). This can be an important competency when, for example, a patient raises a complaint with a nurse or is threatening towards him/her in some way. A nurse with low self-control against criticisms is more likely to take some comments or questions as personal attacks on him/her, and become less available to listen to and care for such a patient (Bushell, 1998).
Use of emotions (self-encouragement)Self-encouraged nurses tend to be more persevering when facing difficulties, obstacles and crises, more persistent in giving emotional support to patients and more optimistic in the middle of a crisis, thus disseminating their competencies, strengths and positive emotions to patients (Goleman, 1998; Goleman, Boyatzis & McKee, 2002). It is also likely that such nurses would view adverse situations in a more positive light and would be willing to try new approaches and solutions without fear of failure (Rozell et al., 2006; Wright & Cropanzano, 2004). In short, provided that nursing is mostly relational in nature, it is likely that more self-encouraged nurses adopt more expressive caring behaviors in dealing with patients.
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Emotional self-controlNurses face extremes in emotion everyday. Patients exhibit unhappiness, confusion, anger, sadness and feelings of aversion. If nurses are not proficient in managing their own emotions, they may not be able to remain calm during “crises”. A loss of emotional control can have negative effects for both nurse and patient. Caring requires emotional labor, that is, mental work to manage feelings. Emotional labor can be defined as the effort, planning and control needed to express organizationally desired emotions and suppress undesirable ones during interpersonal transactions (Vitello-Cicciu, 2003). In nursing, desired emotions consist of displaying a genuine caring demeanor, expressing empathy for patients and showing an understanding for patients experiencing pain or emotional, physical and psychological fragility (Al-Mailam, 2005; Gesell & Wolosin, 2004). Nurses are also expected to demonstrate a non-judgmental manner with patients, to foster trust and a sense of security. To achieve this, nurses may require suppressing any negative feelings towards patients.
Empathy and understanding of other people’s emotionsBy understanding the patients’ emotions, and being more empathetic, nurses are more able to understand the values, worries and fears of patients. They are more apt to automatically connect with patients, appreciate the patients’ perspectives, understand the impact of their actions, understand and satisfy patients’ needs (Kerfoot, 1996) and respond appropriately (Vitello-Cicciu, 2003). Thus, they can show higher concern for their patients and generate better emotional and psychological reactions in them. Behaving more empathetically, nurses can be more compassionate as well. Von Dietze and Orb (2000) propose that compassion affects nurses’ decisions and actions, contributing to excellence in the practice of nursing. Henderson (2001) also claims that emotional involvement by nurses may improve the quality of care and is a requirement of excellence in nursing practice (McQueen, 2004).
Having identified the nature of the six EI dimensions, it is suggested that they correlate positively with nurses’ caring behaviors. However, the idiosyncrasies of nursing require some complex combinations of EI aspects so that nurses can be truly positive caregivers. For example, a nurse with accurate understanding of her own (negative) emotion (for example, after noticing the failure of the treatments applied to a “special” patient) may be very anxious about communicating openly with the patient if (s)he has insufficient self-encouragement to persevere and demonstrate appropriate behaviors and feelings. Nurses with low self-control against criticisms can reduce their caring behaviors towards patients who questioned them or complain about their treatments unless they compensate for this reactive sensitivity with a stronger self-encouragement that motivates them to persevere in adopting caring behaviors. We suppose that other interactions between EI dimensions can occur, although the exploratory state of the field does not afford clear expectations yet.
METHODHaving secured ethical approval for the study, a convenience sample comprising 120 nurses and 360 patients (three for each nurse) provided the data. Nurses self-reported their own EI and patients reported their caring behaviors. After analyzing the factorial structure and reliabilities of both constructs, variance, correlation and regression analyses were carried out to test how nurses’ EI explain caring behaviors.
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The subjects and instruments for data collectionThe subjects included both nurses and patients. The sample of nurses comprised 120 nurses, working in surgical and orthopedic services in seven Portuguese public hospitals. Seventy-nine percent were female. Mean age was 32 years (range: 21-68 years). Their positions were the following: 34% were “enfermeiro” (“nurse”, level 1), 60% were “enfermeiro graduado” (“graduate nurse”; level 2) and 6% were “enfermeiro especialista” (“specialist nurse”; level 3). Written permission for carrying out the study was obtained by the hospitals’ administration. Nurses were asked for cooperation and consent, through face-to-face contact accomplished by one author. The subjects were invited to report their own EI through the previously developed and validated instrument by the first author (Rego & Fernandes, 2005a, 2005b, 2005c). It comprises 41 seven-point Likert-type scales, devised from the literature and on the basis of the authors’ experience and expertise. The subjects were asked to assert the degree to which each statement applied to them (1: “the statement does not apply to me at all”; …; 7: “the statement applies to me completely”).
Three patients who had been nursed by each of the nurses interviewed (with at least three days of contact with the nurse) were invited to complete a questionnaire reporting on the nurses’ behaviors. They were asked to participate immediately before leaving the hospital. Consent was accepted as a willingness to complete the questionnaire. Anonymity was assured and the completed questionnaire was enclosed in an envelope by the patient before returning to the researcher.
The instrument comprised 15 five-point Likert scales. Items were worded and/or adapted from two mains sources: (1) the six caring dimensions of nursing presence (Doona, Chase & Haggerty, 1999; Godkin, 2001; Godkin & Godkin, 2004); (2) the customers’ expectations list proposed by Millar (1996), regarding two categories: nurses’ communication, and attitudes and behaviors. We were parsimonious with the number of questions to minimize time and effort for the patients.
Each patient was asked to indicate on the scales the degree to which each statement applied to the nurse with whom they were in contact. (1: “the statement does not apply to me at all”; …; 5: “the statement applies to me completely”). The average number of days of contact between patients and nurses was 5.5. The mean age of the sample was 49.6 years, 57% were male. Regarding schooling, 34 patients had four schooling years, 144 had six years, 73 had nine years, 56 had 12 years and 53 had at least a baccalaureate.
It is appropriate for patients to report nurses’ caring behaviors because they are the recipients and direct beneficiaries of them (Godkin & Godkin, 2004). Patients can accurately realize if nurses are available, treat them as unique persons, connect with their own experiences, are attentive and good listeners, behave in a sensitive way and are present. Although supervisors can report accurately the technical performance of nurses, many caring behaviors towards patients escape their careful observation. Moreover, it is the patients’ interpretation of the nurses’ caring behaviors that lead to psychological consequences for patients and, as Issel and Kahn (1998: 44) suggested, “form the basis for estimating the economic value of caring”.
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Data analysisA principal component analysis was carried out upon the data about nurses’ EI. Due to cross loadings, 18 items were removed. The 23 remaining items gave rise to a six-factor structure very similar to the one previously devised by the Rego and Fernandes (2005a, 2005b, 2005c). Thus, a confirmatory factor analysis was conducted. Because fit indices were not satisfactory, four items were removed according to the modification indices and standardized residuals (Byrne, 1998). Considering Root Mean Square Error of Approximation (RMSEA), Comparative Fit Index (CFI) and Incremental Fit Index (IFI), the resulting model fits the data adequately (Table 1). All Lambdas except one (0.44) are higher than 0.50, and all Cronbach Alphas except one (0.62) are above the 0.70 level.
TABLE 1Emotional intelligence – Confirmatory factor analysis (completely standardized
solution)Self-control against criticism (0.83)When I am defeated in a game, I lose control. (r) 0.56It is difficult for me to talk with people who do not share my points of view. (r) 0.75I become angry when others criticize me – even if I feel that they are right. (r) 0.89It is difficult for me to accept a critique. (r) 0.88Use of emotions (self-encouragement) (0.77)Usually, I encourage myself to give as well as I can. 0.72I give as well as I can to achieve my goals. 0.78Usually, I am used to setting my own aims. 0.79Emotional self-control (regulation of emotions) (0.80)I can stay calm even when the others are angry. 0.72I can calm down whenever I am furious. 0.88Rarely do I stay furious. 0.68Understanding of other people’s emotions (0.62)I do as well as I can to understand the others’ point of view. 0.62I really understand the feelings of the people I am related with. 0.60I understand the emotions and feelings of my friends by seeing their behavior. 0.57Empathy and emotional contagion (0.72)I am indifferent to the others’ happiness. (r) 0.80The others’ suffering doesn’t affect me. (r) 0.88I feel the problems that my friends face as they were my own. -0.44Understanding of one’s emotions (0.75)I understand the causes of my emotions. 0.66When I feel sad, I understand the reasons. 0.59I really know what I am feeling. 0.82Fit indicesChi-square/Degrees of freedomRoot mean square error of approximationGoodness of fit indexAdjusted goodness of fit indexComparative fit indexIncremental fit indexRelative fit index
1.60.070.840.780.900.900.73
* Completely standardized solution In brackets: Cronbach Alphas(r) reverse-coded items
Data about caring behaviors were also submitted to a principal component analysis. Due to cross loadings, six items were removed. A two-factor solution was extracted (Table 2). The first factor comprises six items, representing the degree in which the patient feels that the nurse treats him/her with dignity, respect and trust (Alpha: 0.76). It incorporates the meaning of several dimensions proposed by Cossette, Cara, Ricard
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and Pepin (2005), namely humanism, sensitivity, helping relationship and spirituality. The second factor contains three items reflecting the degree in which the patient feels that the nurse provided him/her with courteous explanations about the treatments and their consequences (Alpha: 0.83). It incorporates the meaning of the teaching dimension proposed by Cossette and associates (2005). On the whole, both factors incorporate items representing five of the six dimensions of “nursing presence” (Doona et al., 1999; Godkin, 2001): uniqueness, connecting with the patient’s experience, sensing, going beyond the scientific data and being with the patient. They also to a great extent represent the meaning of the seven items that Bulfin (2005) used to measure the patient satisfaction in his model of nursing as caring theory.
Before aggregating the scores of caring behaviors imputed to each nurse (as described by three patients), an ANOVA was run with nurse as independent variable. For both caring behaviors, F values are significant for p<0.001, thus suggesting that variance between nurses is higher than variance for each nurse (i.e., “within groups”). Thus, the caring behaviors of each nurse were scored through the mean of the scores that the three patients imputed to them. Variance, correlation and regression analyses were conducted to examine how EI relates with caring behaviors.
TABLE 2Nurse’ behaviors towards the client – Principal component analysis#
Factor 1Nurse treat
patients with dignity, respect
and trust
Factor 2Nurse give
explanations to the patients
Whenever I asked him/her, (s)he answered me. 0.80 0.15When I talked with him/her, (s)he paid regard to me. 0.83 0.21(S)he came up to me in a respectful and courteous manner. 0.69 0.12(S)he was worthy of the trust I entrusted to him/her. 0.70 0.31(S)he demonstrated availability when I came up to him/her. 0.71 0.31(S)he respected my dignity, my intimacy and my spiritual beliefs. 0.60 0.15(S)he explained me the treatments and the expected results. 0.08 0.86(S)he spent enough time for giving me explanations and talk with me.
0.29 0.75
(S)he explained to me the pain that I will feel when treatments will be applied.
0.31 0.75
Explained variance 36.9% 24.1%Cronbach Alpha 0.76 0.83
#KMO: 0.84 Bartlett’s test of sphericity: 1312.54 (p=0.000)
RESULTSTable 3 depicts the means, standard deviations and correlations between variables, at the nurse level of analysis. Patients described the caring behaviors of their nurses very positively, which is consistent with studies showing high patient satisfaction with nursing care (e.g., Al-Mailam, 2005). Considering the seven-point scale, nurses described themselves as moderately/highly emotionally intelligent, except regarding emotional self-control, with a mean score that can be described as low (3.9, against 6.0 in self-encouragement, for example).
Although most correlations between EI dimensions are positive, self-control against criticism relates negatively with self-encouragement and empathy, and emotional self-control relates negatively with empathy. It appears that nurses who are more self-
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controlled against criticisms are less self-encouraged and less empathetic. More emotionally self-controlled nurses are also less empathetic. These are surprising findings, considering that previous empirical evidence shows that, on the whole, EI dimensions tend to correlate positively (Dulewicz, Higgs & Slaski, 2003; Vakola, Tsaousis & Nikolaou, 2004). One can speculate that this is due to the nurses’ personality idiosyncrasies, and the finding steadily recommends that EI must be seen as a multidimensional construct, and that different individuals may be characterized according to different combinations of EI dimensions scores.
TABLE 3Means, standard deviations and correlations
Means SD 1 2 3 4 5 6 7 8 91. Self-control against criticism 5.1 1.0 -
2. Use of emotions (self-encouragement)
6.0 0.8 -0.27**
-
3. Emotional self-control 3.9 1.0 0.45***
-0.06 -
4. Understanding of other people’s emotions
5.3 0.7 0.22*
0.41***
0.31***
-
5. Empathy and emotional contagion 5.7 0.9 -0.24**
0.31***
-0.22*
0.11 -
6. Understanding of one’s emotions 5.2 0.8 0.11 0.38***
0.29***
0.64***
0.02 -
7. Dignity and respect 4.8 0.2 -0.09 0.19*
-0.20*
-0.05 0.16 -0.14 -
8. Explanations 4.6 0.4 0.06 0.31***
-0.09 0.16 0.08 0.01 0.53***
-
9. Nurse age 32.0 8.7 -0.01 -0.05 0.16 0.25**
-0.22*
0.18*
-0.16 0.01
10. Contact time between patient and nurse
5.5 3.5 0.09 0.08 0.22**
0.15 0.05 0.21*
-0.02 -0.04 -0.25**
*p<0.05 **p<0.01 ***p<0.00
Nurses’ self-encouragement relates positively with both caring behaviors. On the contrary, nurses’ emotional self-control relates negatively with the nurses’ dignity/respect behavior. In short, more self-encouraged nurses are described by patients as more respectful, trustful and explicative, and the more emotionally self-controlled nurses tend to be described as less respectful and trustful by patients. Nurse age correlates positively with the understanding of other people’s emotions and the understanding of their own emotions, and negatively with empathy and emotional contagion. That is to say, older nurses tend to describe themselves as more capable of understanding their own emotions and those of others, but are less empathetic. Older nurses denote longer time in contact with patients.
Hierarchical regression analyses were carried out to study how nurses’ EI explains caring behaviors. Considering that the nurses’ age and contact time between patient and nurse relate with some EI dimensions and caring behaviors, these variables were entered in the first step as control variables. Next, EI dimensions were entered. The findings (Table 4) suggest the following: (a) nurses’ EI explained unique variance of both nurse caring behaviors; (b) EI dimensions with higher predictive power were shown to be self-control against criticism and self-encouragement; (c) more self-encouraged nurses were described by their patients as adopting more respectful and explanatory caring behaviors; (b) the nurses who scored higher in self-control against criticism were described by their patients as adopting more explanatory behaviors.
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TABLE 4Hierarchical regression analyses: How nurses’ EI explain their caring behaviors
Respect, dignity and trust Explanations1st step 2nd step 1st step 2nd step
Nurse age -0.17 -0.10 0.03 0.09Contact time between patient and nurse -0.04 0.06 -0.05 -0.07F 1.52* 0.13R2 1% 0%Self-control against criticism 0.06 0.25*Use of emotions (self-encouragement) 0.24* 0.41***Emotional self-control -0.15 -0.14Understanding of other people’s emotions 0.02 0.08Empathy and emotional contagion 0.04 0.00Understanding of one’s emotions -0.20 -0.18F 1.86* 2.83**R2 5% 11%R2 change 4% 11%*p<0.05 **p<0.01 ***p<0.00
Although emotional self-control correlates significantly with one caring dimension (Table 3), the respective Beta is not significant (Table 4). Exploring the data, we found an interaction effect between this EI dimension and self-encouragement (Figure 1): the effect of self-encouragement in the explicative behavior is stronger when nurses are weakly emotionally self-controlled. In other words: (a) the nurses provide fewer explanations to patients when they are less emotionally self-controlled and less self-encouraged (maybe they fear revealing their negative emotions to the patients when providing the explanations); (b) the nurses provide more explanations when they are less emotionally self-controlled and more self-encouraged.
FIGURE 1How emotional self-control interact with self-encouragement to predict the
explanatory behaviors
4,3
4,4
4,5
4,9
4,6 4,6
4,8 4,8
4,6
4
5
Low Middle High
Emotional self-control
Expl
anat
ions
Self-encouragement _low
Self-encouragement _middle
Self-encouragement _high
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The predictive power of self-control against criticism for caring explanatory behaviors is surprising, considering that this dimension does not correlate significantly with those behaviors (Table 3). This suggests that this dimension interacts with other dimensions to predict nurses’ behaviors. We found an interaction effect between this dimension and self-encouragement. This pattern is depicted in Figure 2. Nurses with low self-control against criticism tend to decrease significantly their explicative behaviors when they are less self-encouraged, but not when they are more self-encouraged. Putting it differently: less self-encouraged nurses decrease significantly their explicative behaviors when they are less self-controlled against criticisms, but not when they are more self-controlled.
FIGURE 2How self-control against criticism interact with self-encouragement to predict the
explanatory behaviors
4,2 4,2
4,6
4,7
4,6
4,74,7
4,8 4,8
4
5
Low Middle High
Self-control against criticisms
Expl
anat
ions
Self-encouragement _low
Self-encouragement _middle
Self-encouragement _high
To explore data, we tested other interactions and found that the understanding of one’s emotions can impel the nurses to reduce explicative behaviors if they are less self-encouraged (Figure 3). One possible explanation for this finding is the following: (a) the nurses who understand their own negative emotions feel discomfort in giving explanations to patients about negative events and treatments; (b) they overtake this discomfort if they are more self-encouraged; (c) however, they “lose” if they are less self-encouraged, thus avoiding to explain some treatments and consequences to patients.
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FIGURE 3How the understanding of one’s emotions interact with self-encouragement to
predict the explanatory behaviors
4,4 4,4
3,6
4,74,8
4,4
4,84,7
4,8
3
4
5
Low Middle High
Understanding of one’s emotions
Expl
anat
ions
Self-encouragement _low
Self-encouragement _middle
Self-encouragement _high
FIGURE 4How empathy interact with self-encouragement to predict the explanatory
behaviors
4,2
4,4
4,9
4,7
4,6 4,6
4,8
4,6
4,8
4
4,5
5
5,5
Low Middle High
Empathy
Expl
anat
ions
Self-encouragement _low
Self-encouragement _middle
Self-encouragement _high
Findings show that empathy and emotional contagion do not explain caring behaviors. Although this seems surprising, there are some plausible arguments supporting the
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finding. Omdahl and O’Donnell (1999) differentiated empathetic concern and emotional contagion, and they advised nurses to use strategies that promote empathetic concern and avoid emotional contagion. The question is that nurses with high emotional contagion can be easily affected by the emotions experienced by patients, thus becoming more susceptible of emotional apprehension, stress and burnout (McQueen, 2004) and less capable to exert their role without emotional strain and with emotional discernment. This suggests differentiating both aspects of “empathy”, which is not the case of our measurement instrument. However, our findings suggest that the empathy and emotional contagion dimension is not unimportant; rather it interacts with self-encouragement in predicting caring behaviors. Figure 4 depicts this interaction pattern: (a) less empathetic nurses decrease their explicative caring behaviors when their self-encouragement is lower, but not when it is higher; (b) less self-encouraged nurses decrease their explicative caring behaviors when they are less empathetic, but not when they are more empathetic. In other words, nurses reduce their explicative caring behaviors when they are less empathetic and less self-encouraged.
FIGURE 5How the understanding of other people emotions interact with emotional self-
control to predict the explanatory behaviors
4,6
4,8
5
4,6 4,6
4,7
4,4
4,6 4,6
4
4,5
5
5,5
Low Middle High
Understanding of other people emotions
Expl
anat
ions
Emotional self-control _low
Emotional self-control _middle
Emotional self-control _high
The finding that the understanding of other people’s emotions does not predict caring behaviors is also surprising. One could expect that nurses with good capabilities in this EI aspect might be more apt to connect with patients, to see the world from the perspective of patients, to understand the impact of their actions on them and to understand and satisfy their needs. However, the finding make sense if we consider that nurses with this EI skill are more sensitive to stress (Humpel, Caputi & Martin, 2001), this negatively affecting their caring roles. The interaction pattern depicted in Figure 5 is also useful in explaining our findings. It shows that: (a) when nurses combine high understanding of the other people dimensions with low emotional self-
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control, they adopt more explicative caring behaviors; (b) when they combine low understanding of the other people dimensions with high emotional self-control, they adopt less explicative caring behaviors. The findings, however, must be interpreted with caution, since the differences between nurses’ scores are small.
DISCUSSION AND CONCLUSIONS
Making sense of the main findingsThe increasing demands of health care consumers and the shift from the caring for paradigm to the caring about paradigm (McQueen, 2000) require that nurses adopt caring behaviors contributing to the patients’ well-being and the performance of the health organizations. In this paper, we dealt with two categories of caring behaviors that likely meet both aims. For example (see Issel & Kahn, 1998, for a synthesis), by showing respect for patients, nurses improve the level of patient satisfaction. This can lead to more favorable word-of-mouth recommendations of the health organization, an increasing demand of services, a better reputation in the community, fewer lawsuits and better economic and financial results of health care organizations (Al-Mailan, 2004; Issel & Kahn, 1998; Lee, 2005; Weech-Maldonado, Neff & Mor, 2003; Wolf et al., 1998). A better patient-centered organizational climate can also emerge, thus improving the satisfaction and job commitment of personnel, reducing medication errors, perhaps reducing turnover (Gesell & Wolosin, 2004; Rathert & May, 2007). In contrast, when disrespecting and communicating poorly with patients, nurses contribute to increasing the patients’ stress, which can have negative effects in the cardiovascular and endocrine systems, such as an increase in heart rate, blood pressure, and levels of stress-related hormones.
When nurses explain treatments and their likely consequences, and do communicate effectively with patients, some reciprocal advantages can emerge. Patients may reciprocate with self-disclosure, providing nurses with important clinical information, allowing a more precise diagnosis and consequently better treatment plans. It is also likely that patients comply more with the nurses’ clinical and medication orientations (Gesell & Wolosin, 2004; Ware & Hays, 1988). In short, it is likely that patients will express their feelings honestly and disclose personal information when they feel they can trust the nurse. In such a secure relationship, nurses’ perceptions of patients tend to be more accurate, the quality of the psychological closeness tends to be enhanced, and a mutually acceptable level of intimacy and emotional involvement are more likely to be achieved (McQueen, 2000).
When patients are treated with dignity and respect, have the opportunity to make informed choices and to maintain control, patients do increase their self-esteem and self-worth. This can be important for self-care and compliance with treatment regimens. Both self-care and compliance can result in decreased need for medications and procedures, and in fewer illness complications.
The positive impact of nurses’ caring behaviors impels researchers to study their antecedents. The nurse is a pivotal figure in patient care and is best placed to provide much of the psychological and emotional care (McQueen, 2000). This demands good intra and interpersonal skills and abilities to form a healthy therapeutic relationship with patients. Our empirical research suggests that EI is one of these relevant abilities. The results show that the ability to manage emotions can lead nurses to be more
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respectful, attentive and trustful towards patients, and to provide them with more explanations regarding treatments and their respective consequences. Self-encouragement is the better predictor, nurses being more/less caregivers when they describe themselves as more/less self-encouraged. Self-encouragement also reinforces or mitigates the effects of other EI dimensions on the explicative caring behaviors. Some examples can be presented. First: less emotionally self-controlled nurses tend to adopt fewer explicative caring behaviors when they are less self-encouraged, but more of these behaviors when they are more self-encouraged (Figure 1). Second: nurses who understand their own emotions decrease their explicative caring behaviors if they are less self-encouraged, but not if they are more self-encouraged (Figure 3). Third: less empathic nurses tend do adopt less explicative caring behaviors if they are less self-encouraged, but not if they are more self-encouraged (Figure 4).
On the whole, the findings stress the relevance of several EI dimensions. Self-encouragement, in itself and/or combined with other EI dimensions, promotes the nurses’ caring behaviors, mainly the explicative ones. A low self-control against criticism is detrimental to caring behaviors if nurses are low self-encouraged as well. A high understanding of one’s emotions can be detrimental of caring behaviors if nurses are also less self-encouraged. Lower empathy can result in less caring behaviors if nurses are less self-encouraged, but not if they are more self-encouraged. A higher understanding of other people’s emotions is more conducive to caring behaviors if nurses are less emotionally self-controlled. Thus, not all EI dimensions lead automatically to more caring behaviors. It depends on how different aspects of the nurses’ EI profiles combine.
The case of emotional self-control is especially worthy of mention, because findings suggest that some less emotionally self-controlled nurses tend to adopt more explicative caring behaviors. The finding suggests the likely negative effect of a high emotional self-control over caring behaviors or, alternatively, the positive effect of a low emotional self-control. Indeed, nurses adopt more caring behaviors when they are less emotionally self-controlled and more self-encouraged as well (Figure 1). One might therefore speculate about the extent to which a low emotional self-control is a positive attribute of nurses, because, as McQueen (2000) argued, “it is now considered acceptable for nurses to show their emotions as they empathize with patients and show their humanity (Staden, 1998)”. The fact that the sample’ mean score in this EI dimension is the lowest (3.9 against an average of 5.5 in the other EI dimensions) seems to imply that many low emotionally self-controlled people elect nursing as a profession. The question is to know whether the explicative behaviors adopted by the less emotionally self-controlled nurses are really addressing the patients’ needs, or just a tendency to disclose emotions and explanations without considering their full consequences on patients.
Limitations and future studiesOur sample size is small. This can be problematic for performing the factor analysis, considering that the ratio between the number of variables and the number of subjects must be, at least, 1:3. Regarding caring behaviors, our sample is very homogenous, as it is shown by the high means scores and the low standard deviations (Table 3). This may contribute to the low predictive power of EI for caring behaviors. Future studies must collect a larger and more diversified sample. Considering that the reliability of an EI dimension is lower than 0.70, future studies must also improve the psychometric
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properties of the EI measurement instrument. It will be interesting to measure EI through other methods (ability and informant approaches; Mayer, Caruso & Salovey, 2000). Only two dimensions of caring behaviors were studied. Future studies must take into account other dimensions (e.g., Larson, 1984; Wolf, Giardino, Osborne & Ambrose, 1994) and examine whether the relevance of both dimensions studied here are not cross-culturally contingent (Lee-Hsieh, Kuo, Tseng & Turton, 2005).
The above discussion suggests other interesting avenues for future research. For example, low emotionally self-controlled nurses could negatively affect the well-being of patients if they do not manage the expression of their own emotions and are not aware of their impact on the patients. The questions that arise then are: (1) In which conditions are the low emotionally self-controlled nurses more positive caregivers? (2) What other individual features do these nurses possess to channel the expression of their emotions to patients in a careful and positive way? (3) How do both caring behaviors studied here relate with patients’ health and well-being?
This study has brought to light the complexity of EI with respect to caring behaviors and shows the relevance of the expression of different EI dimensions in individual nurses’ EI profile. Future studies are required to show (a) how nurses combine their scores in different dimensions and (b) how these configurations relate with caring behaviors in different therapeutic, interpersonal and organizational situations.
Future studies can also investigate moderating variables, such as factors within the working environment (Bardzil & Slaski, 2003). One can hypothesize that higher individual EI is positively correlated with frequent caring behaviors when the working climate is positive and facilitates the emergence of those behaviors. In contrast, it is possible that a negative working climate inhibits the nurses with higher EI to adopt more caring behaviors. Bardzil and Slaski (2003: 102) stressed the argument when they argued that “there is little point in developing emotionally intelligent individuals in order to return them to an environment that fails to support their new positive attitudes and behaviors”.
Patients’ characteristics can also moderate the relationship between nurses EI and caring behaviors (Henderson, 2001; McQueen, 2004). For example, nurses with higher EI might avoid giving some explanations to patients who experience a strong psychological distress, psychologically deny their own situation and/or verbally attack them. Different kinds of health care services can also act as moderators. For example, cancer and psychiatric patients require different caring approaches and their diseases can incur different emotional meaning and intensity. Thus, it is likely that more emotionally intelligent nurses adapt their behaviors to these different circumstances.
Future studies can also include mediating variables, such as the “mechanisms” that make the translation between EI and caring behaviors. Stress, burnout, satisfaction, occupational commitment and emotional states are likely candidates to mediate the relationships.
Implications and final commentsOur findings support the argument that measurement of EI can form part of the selection process and that the topic needs be incorporated into performance management, training programs and nursing curricula (Bellack, 1999; Cadman &
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Brewer, 2001; Freshwater & Stickley, 2004; Kerfoot, 1996; MacCulloch, 1998; McQueen, 2000, 2004). There is evidence in the literature to support the view that EI can be developed with a view to positive outcomes (Bagshaw, 2000; Cherniss & Adler, 2000; Cherniss & Caplan, 2001; Slaski & Cartwright, 2003). Thus efforts can be made to improve nurses’ EI and to stimulate them to adopt more appropriate caring behaviors. Nurses’ supervisors can reward and positively reinforce these behaviors (Bardzil & Slaski, 2003). However, our findings suggest that the relevance of EI for nurse caring is complex and not linear. High scores in some EI dimensions can be detrimental of caring behaviors if they are not combined with high scores in other dimensions. And low scores in some dimensions can have positive effects on nursing behaviors if they are combined with high scores in other dimensions.
Freswhater and Stickley (2004) argued that EI must be firmly placed at the core of nursing curricula. In this paper, we suggest that EI can be at the “heart of caring”. Furthermore, the development of EI competencies can be an antidote to the ‘MacDonaldising’ trend that some authors (e.g., Freswater & Stickley, 2004) have pinpointed to health-related services in last years, due to the emphasis on efficiency, cost reduction and productivity, while neglecting the “work of the heart”. EI is not the panacea for fostering nurses’ caring behaviors. It explains a significant but low unique variance of caring behaviors, and complex combinations between EI dimensions appear to be required for nurses becoming good caregivers. As Vitello-Cicciu (2002) suggested, caution needs to be exercised regarding the connection between EI and workplace success.
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