Does nurses emotional intelligence affect their ability to be critical thinkers/reasoners in the clinical setting?

Written by Hayley Black

  Introduction

Central to professional nursing practice are critical thinking skills, regardless of the nurses speciality area (Fawcett, 2005).  A characterisation of an individual with a high level of emotional intelligence (EI) is one who has the capacity and ability to understand, recognise and regulate their own emotions; perceive others emotions, and the ability to apply feelings to critical thought (Wang, Hong, Bowers, Brown & Zhang, 2018). Firstly, this essay will discuss my clinical issue, if nurses EI was impacting on their ability to think critically. Formulation of a research question is an important initial stage in the research project. Therefore, I will include the PECOT model to define my clinical issue into a review question. Then by using best evidence literature I will research and review what is EI and critical thinking, compare two different EI models and discuss the link between EI and critical thinking skills. I will discuss the positive and negative implications of having EI or lack of EI on nursing practice. Finally, I will summarise my recommendations and rationale regarding my clinical issue.

  Clinical Issue

At the early stages in nursing education and throughout the three-year degree emotional demands that are encountered by nurses became evident. There is an increased emphasis on the nurse having the ability and skills to think critically to be able to make sound clinical decisions.  The practice of nursing has evolved from simple nurturing care to performing highly complex procedures and analyses (Stevens, 2002). To respond to these changes in complex systems, nurses are assuming leadership functions and moving into independent nursing environments. Nursing care often requires the nurse to work in emotionally demanding situations involving patients, family/whānau and other health care professionals. A commonly heard phrase throughout the Bachelor of Nursing Degree is “critical thinker”. It is a core competency that nurses can demonstrate critical thinking skills in order to be a safe and effective registered nurse (RN) (Nursing Council of New Zealand [NCNZ], 2007). The consensus is that by the end of the three-year degree the student nurse has developed critical thinking skills.

My exposure in the clinical setting and hearing other students’ stories led me to wonder if one’s EI was impacting on their ability to be able to think critically. I started to critically think about what was affecting the nurses ability to self-regulate their emotions and act professionally under various pressures in the clinical setting.

  Review Question

My overall goal of this assignment was to research and analyse evidence-based articles that focused on EI, critical thinking/reasoning and nursing practice.  My preliminary search identified critical thinking provides a vital link between intelligence and emotions and seeks to determine the quality of EI (Smith, Profetto-McGrath & Cummings, 2009).  Also, that registered nurses (RN’s) in the 21st-century critical thinking skills need to be developed to solve complex problems; so nurses have the ability to function in the often highly emotional charged and demanding nursing practice (Nurse Journal, 2019).  There was an overwhelming literature focusing on student nurses and EI. Although I feel it is highly relevant to take into consideration if nursing students have the characteristic of someone who possess EI, it was not the aim/goal of this research assignment.  Therefore, articles were excluded if the focus was only on student nurses EI and ability to think critically. If the research design or quality of information was poor and or did not mention EI, critical thinking or nursing practice it was also excluded from my findings. I will not fully omit age from my research if evidence shows age is a key factor to EI and critical thinking but it is not the focus of this paper.  My exposure and observations on the wards identified that many “younger” nurses could self-regulate their emotions better than some “older” nurses and I do not want to discriminate against age and a person’s EI.

  PECOT Formulation

According to Schneider, Whitehead, LoBiondo-Wood & Haber (2013), the PECOT model is used to develop a good review question which then guides clinical research.  I will use the acronym PECOT to break down my clinical issue to a review question.

PECOT category

Information relating to the question

Explanation

Population

RN’s all ages and genders, who are working in clinical practice.

I wanted to research this population because as student nurses there is an emphasis throughout the degree that as future RN we need to be critical thinkers. I started to question if you can teach somebody to think critically, in the often stressful, emotionally challenging nursing career if he/she does not have the ability to self-regulate, and control/manage his/her emotions.

Exposure (intervention)

RN’s in the clinical practice setting.

I will be researching literature and theories/models about EI and critical thinking skills in nurses and if there is a link between the two. Also, if there is a link between EI and nurse burnouts and EI and leadership roles.

Comparison/control

Compare evidence-based research, statistics and data around variables that interfere with RN’s ability to think critically.

I wish to investigate EI and critical thinking/reasoning and whether it is possible to have the skills to think critically if the nurse is not able to self-regulate, or identify their emotions or others.

Outcome

To understand the role EI plays in nursing practice and the RN’s ability to be able to critically think.  

If the research shows there is a relationship between EI and the nurses ability to think critically does The Nursing Council of New Zealand (NCNZ) need to have a specific EI competency? Should there be programmes/workshops solely based around EI implemented into the practice setting? Could EI screening be a prerequisite for employment and if so could it improve nursing practice?

Time

No time frame.

 

 

Research question: Does nurses emotional intelligence affect their ability to be critical thinkers/reasoners in the clinical setting?

  Research and Findings

According to almost three decades of research EI results from interactions of intelligence and emotion and refers to an individuals capacity to understand and manage emotions (Mayer, Roberts & Barsades, 2008).  EI is one conception linked to critical thinking and can play an essential role in one’s capability to think and make decisions (Vitello-Cicciu, 2003). In 1990, psychologists John Mayer and Peter Salovey developed their first EI model which subsequently became popularised in 1995 by psychologist Daniel Goleman’s book: Emotional Intelligence (Iberkis, 2016).

The Mayer and Salovey model suggest EI is a set of cognitive abilities that enables individuals to generate and use emotions in problem solving (Vitello-cicciu, 2003).  The model recognises that cognitive abilities are different but also associated with general intelligence. Over several years of research in 1997 they updated their 1990 model to add a four-branch model of skills involved in EI which are: 1. Perceive/identify emotions. 2. Facilitating emotions with thought processes. 3. The ability to understand emotions. 4. Reflectively regulating/ management of emotions (Drigas, & Papoutsi, 2018). The ability to perceive/identify emotions, refers to the capacity and ability of recognising and identifying emotions in one’s self and others.  Facilitating emotions with thought process is having the ability to generate an emotion and reasons with these emotions.  Understanding emotions refers to having the aptitude to comprehend complex emotional information and knowing how emotions are linked to relationships. Finally, reflectively regulating/managing emotions requires the individual to promote emotionally, intellectually and personally growth (Vitello-Cicciu, 2003).  These abilities/skills play a crucial role in the nurses ability to interpret or become aware of his/her own and other’s emotions. According to Mayer and Salovey (as cited in Drigas & Papoutsi, 2018) understanding and linking emotions are skills that can develop as a person matures. Mayer and Salovey state that EI can increase with age due to the accumulation of knowledge about emotion and its social context (as cited in Smieja, Orzechowski & Stolarski, 2014).

The Mayer, Salovey, and Caruso Emotional Intelligence Test (MSCEIT) measures, assesses and gains unprecedented insights about one’s EI.  The test applies the four branches of the model to help predict and develop one’s EI abilities and therefore, enhance one’s success. Participants answer 141 questions that are based on everyday scenarios and the correct answers are identified by emotional experts (Brackett & Salovey, 2006).  The test questions measure the participants' ability to perceive, use, understand and regulate emotions measures. Evidence-based research identified that nurses that scored high in a MSCEIT maintain a heightened emotional awareness of others and of self in comparison to those who scored lower (Bracket & Salovey, 2003).                                    

Goleman's 1995 model broadened Mayer and Salovey’s four branched system and consists of five areas and main elements: 1. Self-regulation. 2. Self-awareness. 3. Motivation. 4. Empathy 5. Social Sills (Sadri, 2012).  Goleman defines EI as the ability for one’s capacity to recognise his/her feelings and those of others. Also to be able to motivate oneself and have the ability to monitor and manage one’s own emotions in ourselves and relationships (Harrison & Fopma-Loy, 2010).  Goleman states “I found the role of emotional intelligence in leadership particularly compelling” (Goleman, n.d. para 12).  His focus is on a wide array of competencies and skills that he states drive leadership performance (Sadri, 2012).   He reports EI can be taught but it’s not enough to lecture individuals, it should be allowed to be seen through role modelling.  Kadda (2019) states to what extent EI can be developed or taught is unclear but evidence supports teaching EI may increase feelings of control and EI competence.  Goleman suggests that EI is vital for the successful, positive outcomes in one’s professional and personal life (Sadri, 2012). The human mind has emotional and rational components and Goleman states that is what leads to one’s emotional response and decisions.  He believes that emotional responses need to be tempered by rationality and that feelings can, and often do come before the rational mind and thought (Sadri, 2012).

The Global Emotional Intelligence Test (GEIT) questions are derived from four of Goleman’s EI model, which asks the participants 40 questions.  Research suggests that EI can be a better predictor of job performance, employee engagement and leadership ability (Drigas & Papoutsi, 2018). This EI test measures and evaluates how well one perform tasks and solve emotional problems and will suggest ways to improve it (Global Leadership Foundation, n.d.).  

Reflective journaling helps the nurse to focus on his/her thoughts and feelings, which may result in a changed outlook about a clinical situation or experience (Pawlak, 2016).  Donald Schon book, The Reflective Practitioner, identifies that nurses can expand and deepen their understanding of practice by reflecting before-action, in-action, on-action and beyond action (Edwards, 2017).  Reflection in-action requires the nurse to be able to regulate his/her emotions to think critically in the moment so he/she can make appropriate clinical decision (Edwards, 2017).  Reflecting on and beyond-actions allows the nurse to continually monitor his/her thinking, questioning and reflecting on the quality of their nursing practice (Pawlak, 2016). Therefore, being able to reflect beyond action, the nurse can analyse situations and understand what triggered a positive or negative emotional response.  

Critical thinking skills promote interprofessional and interpersonal therapeutic relationships, with other health care professionals and health care consumers (NCNZ, 2007). EI has been found to be a moderately significant predictor of transformational leadership in nurse managers (Wang et al., 2018).  Nurse leaders can affect change by fostering working environments that value emotions and team work (Sadri, 2012). The nurse leader then becomes a positive role model who can give constructive criticism and be honest with nurses. This enables the nurse to trust their nurse leader, so he/she can truly reflect and incorporate what he/she has learnt into their nursing practice (Sadri, 2012).  According to Vitello-Cicciu (2001) nurse leaders are expected to frequent the emotional side of leadership and therefore requires nurse leaders to possess El.  Transformational leaders interact and respond to individual needs by empowering and aligning the goals of individuals, the group, and the larger organization.  An example of a transformational nurse manager role within the dynamic healthcare setting is the nurse leader influences behaviours and attitudes by interacting, nourishing and inspiring nurses to challenge assumptions to reframe problems (Lopes & Salovey, 2008).  

  Implications on Practice

The first major theme related to EI is that a core nursing skill requires nurses to understand, identify and deal with his/her and others emotions. This is due to the labile nature of nursing in this era of growing healthcare demands, as nursing shortages and consumer demands mount. By not fostering development of EI within the nursing practice, it may impact health care for a variety of reasons, namely negative patient outcomes and nurse burnouts (Szcygiel & Mikolajzak, 2018). Clinical decisions are often being made in contexts that are emotionally demanding which require nurses to manage their own emotions. The online Nurse Journal (2019) states that self-regulation is a key critical thinking skill and one should not make unwarranted assumptions and be aware of one’s own bias (Nurse Journal, 2019).  Errors that arise in nursing due to a lack of critical thinking can cause incorrect assumptions and the wrong conclusion can lead to incorrect clinical decisions/actions. Emotional influences guiding thought processes not only impacts on incorrect clinical actions and patient care, it can affect intrapersonal levels with other healthcare professionals (Bulmer-Smith, Profetto-McGrath & Cummings, 2009).  A research study done by Stevens (2002) did not clearly demonstrate that years of registered nursing experience was correlated with critical thinking ability but both theories and research contradict his findings (Echevarria, 2015).  

Nurses that make assumptions about the patient thoughts/feelings can create communication barriers which can led to unsuitable care planning, causing negative patient outcomes.  Research supported by the National Natural of Science Foundation found that individuals with higher quality critical thinking skills can recognise and regulate their emotions, through processes in the brain that interpret and make something clear (Yao et al., 2018).  Although external factors are important factors in burnout and job satisfaction, research has shown that a person’s internal or personal abilities will have external consequences (Farmer, 2004). The lack of EI is a component of emotional exhaustion which in turn leads to burnout and can affect the nurses ability to develop therapeutic relationships with patients/clients and their family/whānau.  It is essential that nurses can give themselves at an emotional or psychological level in their everyday nursing practice (Stevens, 2002). Emotional exhaustion can affect the nurses ability to think critically due to feelings of depersonalization in which they begin to regard their patients/clients objectively (Farmer, 2004). Unpredictable client circumstances cannot be taught by regular repetition. It requires the nurse to be able to self-regulate his/her emotions and to think critically to make decisions that promote a positive health outcome for the patient/client (Pawlak, 2016).

  Recommendations and Rationale
  1.  Integration of EI Training/Workshops into the Practice Setting:

Rationale: Results from a study examining nurses identified that EI training could be implemented to prevent adverse effects of negative emotions, regarding factors contributing to job burnout (Szczygiel & Mikolajczak, 2018).  By implementing emotional learning programmes as part of a nurses scope of practice he/she could acquire knowledge, attitudes and skills that are necessary for understanding and managing emotions.  The emphasis of the training/workshops should be placed on providing nurses with knowledge of the effectiveness of various emotion regulation strategies, to enhance self-awareness and their understanding of others (Szcygiel & Mikolajzak, 2018).  The nurse leader/manager taking these workshops could follow up with preceptorship, transferring knowledge and encouraging EI evidence use within the nursing environment. A way to measure if these workshops and preceptorship were enhancing nurses EI could be through a comparison of verbal and written reflections, and or using the Mayer, Salovey and Caruso MSCEIT, prior and following the workshops.  By integrating EI training workshops into the clinical practice environment it could provide the nurse with a greater opportunity to understand themselves, their colleagues and patients. Therefore, creating a way in which the nurse can build healthy, therapeutic relationships with others in the working environment. Which will improve communication within the practice setting, creating a positive working environment and improving nurse retention as well as providing appropriate, effective care planning for patient/clients (Echevarria, 2015).

  1.   EI Screening as a Prerequisite for Employment:

Rationale: Nurses who are equipped to identify their emotions, analyse what happened and reflect on his/her actions, enables the nurse to think critically on how to improve his/her practice (Burgess, 2003).  Hospital executives responsible for employing and making determinations of future nurses could incorporate EI behavioural screening tools during the interview process. Additionally, nurse job descriptions may be revised to include criteria which supports EI behaviours as a desirable skill set of skills. Due to the nursing profession being prone to stress, it would be preferable to employ nurses that have high EI so he/she can respond effectively to the emotional reactions of their patients/clients and colleagues (Smith, Profetto-McGrath, & Cummings, 2009). Research shows employing nurses with EI characteristics is important for building leaderships roles, enhancing nursing practice and reducing nurse burn-outs (Smith, Profetto-McGrath, & Cummings, 2009).  

  1. Specific EI Competency:

Rationale: The NCNZ competences set standards to ensure nurses are providing safe and effective care (NCNZ, 2017). After my research findings, I believe that nurses need to identify, through a specific NCNZ EI competency, how they have applied EI in their nursing practice.  The use of EI concepts provide fresh insights into ways to keep nurses engaged in practice, improve nurse retention and patient/client outcomes (Raghubir, 2018). An example of the competency could require the nurse to provide evidence, based around the four branches of Mayer and Salovey’s model, on how he/she has applied EI into his/her nursing practice. The competency could allow the nurse to identify his/her own EI strengths and limitations. By nurses having to identify how they perceive, manage, and understand their own and other emotions it could lead to better stress management and performance of nursing tasks.  Nurses reflecting on an emotionally skill competency could provide fresh insights to keep nurses engaged in practice. Consequently, nurses will gain an understanding of complex emotional information which will encourage him/her to think about the implications of emotions and enhance their critical thinking skills.

  Conclusion

EI is a fundamental skill to identify, understand, and use emotions positively to manage conflicts, solve problems, empathise, handle stress and overcome issues (Raghubir, 2018).   The nurses level of EI will indicate his/her ability to function, act and manage emotionally challenging situations that nurses are often faced with in their daily practice (Raghubir, 2018). Nurses need to be able to think critically to be able to confidently and quickly assess clinical situations, ensuring that his/her patient/client is receiving the best care.  Nursing requires the nurse to maintain composure and self-regulation of his/her emotions to have the ability to handle emotional or stressful situations. Mayer and Salovey’s model maintain that emotional skills can be learned and EI therefore can be enhanced (Vitello-Cicciu, 2003). EI and critical thinking skills are essential nursing traits but lack of EI may negatively influence one’s standard of work, including clinical decision making. EI is an important skill set for nurses and research has revealed nurses with high levels of EI have higher job satisfaction, less burn outs, ability to think critically, take on leadership roles and positive patient/client health outcomes.  Nurse managers who use transformational leadership create an environment with a higher level of work morale which are vital factors to providing positive patient outcomes.  Nurses with a higher level of EI are more adaptive to make the right clinical decisions and implement their choices in the right way.

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