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J Nurs Care Qual Vol. 29, No. 2, pp. 174–181 c 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Copyright
The Relationship of Bedside Nurses’ Emotional Intelligence With Quality of Care Kelly L. Adams, MSN, RN, PCCN; Jackeline I. Iseler, MSN, RN, ACNS-BC Emotional intelligence, a predictor of productivity and success, may impact behaviors responsible for quality of care. This study examined if emotional intelligence of units’ bedside nurses is related to the quality of care delivered to the patients. In this study, emotional intelligence was found to be correlated to the number of Clostridium difficile infections, MRSA infections, patient falls with injury, and pressure ulcer screenings (P < .001) in the inpatient acute care setting. Key words: emotional intelligence, guideline adherence, nurses, outcome and process assessment (health care), quality of healthcare
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MOTIONAL INTELLIGENCE (EI) is becoming an increasingly important concept in describing human interactions and performance in the workplace setting.1-6 Emotional intelligence research and tools
Author Affiliations: College of Nursing at Michigan State University, East Lansing (Ms Adams), and Frederik Meijer Heart and Vascular Institute, Spectrum Health Hospitals, Grand Rapids (Ms Iseler), Michigan. This research was supported by a grant from the Nurse Education Research Fund at Spectrum Health. The authors thank the Research Team comprising Karen Vander Laan, Patricia Burgess, Katie Emery, Jody H. Mendez, Christoffer Schmidt, Trudy Pyle, and Carol Sadat-Akhavi. The authors declare no conflict of interest. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (www.jncqjournal.com). Correspondence: Kelly Adams, College of Nursing at Michigan State University, Bott Building for Nursing Education and Research, 1355 Bogue St, Room No. C300, East Lansing, MI 48824 ([email protected] .edu). Accepted for publication November 2, 2013. Published ahead of print: December 18, 2013 DOI: 10.1097/NCQ.0000000000000039
are being used in both business and health care settings to determine which individuals possess the greatest aptitude for leadership responsibilities.7,8 The body of research exploring EI in general workplace settings presents limitations as it lacks a comprehensive description of the unique environment of the health care workplace. Specifically, the impact of the EI of a nurse on patient care outcomes is unknown. Thus, this study provides an initial examination of the EI of direct patient care nurses and its potential influence on patient outcomes. According to the theory of multiple intelligences, every human being possesses a variety of individual capacities (ie, “intelligences”), with each of these areas of intelligence evolving in relation to the various interactions and experiences in the person’s life.9 Bedside nurses’ EI is important because it is central to their ability to manage and respond to emotions in patient care situations in 2 ways. First, when individuals are overcome by their own emotions, their cognition and behavior is affected;10 this can be the case for both nurses and the patients for whom they are caring. Second, nurses are responsible for responding to the emotional needs of patients by expressing empathy as caring behaviors.6 As such, the caring behaviors subsequently
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Bedside Nurses’ Emotional Intelligence and Quality of Care influence outcomes such as patient satisfaction and indicators of care quality.11 Because it is likely that EI may have a considerable influence on patient outcomes, this study sought to identify the relationship, if any, between EI and quality indicators, specifically to determine if higher EI among nurses on a unit could predict higher quality patient care on those units. There were 5 research questions: is the unit’s quality of care (QOC) or compliance with care (CWC) related to the unit’s (1) bedside nurses’ overall EI; (2) bedside nurses’ experiential or strategic EI; (3) operational indicators such as hours per patient day (HPPD), registered nurse (RN) turnover, or skill mix; (4) an interaction of a unit’s bedside nurses’ overall EI and its HPPD; and (5) patient satisfaction scores? REVIEW OF LITERATURE EI research Although EI has been described as a set of noncognitive abilities that influence an individual’s capacity to be successful,12 EI researchers have not yet achieved consensus on a unified definition of the concept.7,13-18 For the purpose of this study, EI was defined as the ability to monitor, discriminate, and respond to affect-inducing situations in both the self and in others. As this definition implies, individuals are able to recognize emotions to varying degrees, and then as their EI capacity increases, they are able to more accurately predict emotional responses in themselves and in others.14,18 A variety of dependent variables have been correlated to EI. Correlations exist between EI and decreased stress and anxiety, increased cognitive performance, increased job satisfaction, and decreased burnout.15,19-21 Researchers have suggested that EI is equal to (if not more important than) academic intelligence.7 Moreover, beyond intelligence, mental health and social support have been positively correlated with EI in relation to understanding emotions and seeking social support, emotion regulation and seeking social
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support, and emotion regulation and mental health.22 Although not a focus of this study, these findings suggest that EI likely influences the social support and mental health of others, such as patients in the health care setting. However, while it may seem intuitive that EI would have an impact on patient satisfaction, findings of prior research have indicated no correlation between these concepts.20 Nurses’ EI Professional nurses desire to engage emotionally with their patients, patients’ families, and colleagues.10,23 This was evidenced in a study examining nurses’ reflective stories, which provided support that all of the components of EI were described in the narratives from every nurse studied.24 Nurses’ self-awareness, self-regulation, social skill, empathy, and motivation aided their identification of processes to improve outcomes for their patients and nurse colleagues. In addition to improving patient outcomes, these EI constructs also were suggested as a way to improve retention of nurses.4 Moreover, the increasing number of similar studies indicates a trending rise in research on the effect of EI in professional nurses.25 Nurse-patient relationships are integral to optimal patient care; thus, nurses’ emotions can have implications for their abilities to provide care and respond empathetically in support of their patients’ healing processes.6,12 With health care becoming increasingly technical, it is important to assess for EI in nurses as a means for maintaining and promoting the human qualities of love, compassion, and empathy, as each is thought to influence patients both directly and indirectly.12 This concept is particularly critical for individuals experiencing chronic and acute disease as they are particularly vulnerable to emotional distress, as evidenced by higher rates of depression and anxiety.26-29 There are many different factors that affect nurses’ EI such as time management, relationships, stress management, leadership qualities, professional growth, empowerment, retention, autonomy, and patient
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satisfaction.4,12,30 Individuals with higher EI are more tolerant of stress and have a greater potential to be successful in a leadership role.17 Thus, individuals with high EI are well-suited for high-stress careers, including nursing.31 Emotional intelligence was also found to be a strong predictor of performance on a clinical ladder, as well as an indicator of organizational commitment and retention.2 It is unclear in correlations of nurse performance measures and EI whether EI leads to improved skills or vice versa.2,4,8,12,30 Even though these correlations are not explicitly understood, there is a focus on improving EI in nurses. This starts in nursing education, where the use of motivation, practice, and feedback while training nurses in EI is found to encourage growth throughout the nurses’ careers.8 METHODS Scope A correlational, cross-sectional design was used to identify the relationships between EI and QOC. The study was conducted in 2 urban metropolitan hospitals (one >700 beds and one 200-299 beds) within a health care system located in the Midwestern United States. The study was approved by the system’s institutional review board. Participants A sample of RNs from adult inpatient units in both hospitals was recruited. Eligible units included adult critical care, progressive care, and medical-surgical units. Participants were selected for inclusion in the study population if they were full- or part-time RNs who (a) worked primarily as bedside staff on the eligible units, (b) had worked on the unit for 1 year or longer, and (c) consented to participate in the study. Registered nurses who worked in a leadership capacity on the units (ie, nurse managers, nurse educators, clinical nurse specialists, and nursing supervisors) were excluded. A total of 1138 RNs met the inclusion criteria, and 361 participated for a response rate of 31.7%. Of the 8 nursing units
analyzed, 5 were from the larger of the 2 hospitals and 3 were from the smaller hospital. The units represented various levels of care in the 2 hospitals: 5 medical-surgical units, 2 progressive care units, and 1 intensive care unit. A post hoc power analysis of 0.86 was calculated for the sample size of 8 units, an r2 of 0.514, and an alpha error probability of 0.05. Instruments and quality indicators Mayer-Salovey-Caruso Emotional Intelligence Test The Mayer-Salovey-Caruso Emotional Intelligence Test (MSCEIT) is a measure of EI. It covers areas such as the ability to perceive, use, understand, and regulate emotions. Completion of the 141 questions on the MSCEIT was estimated to take approximately 30 to 45 minutes. The MSCEIT reliability has been reported as 0.91,32-34 with a test-retest reliability of 0.86 by 60 participants measured twice over 3 weeks.35 For the purposes of this study, total EI was composed of the strategic use of emotions and the experiential emotions. These 2 subscales were determined through factor analysis in which the strategic use of emotions included how individuals understand and manage emotions.34 The experiential emotions subscale included the ability to perceive and facilitate emotions. The MSCEIT measured each of these components separately and provided a total EI score. Quality indicators Five QOC indicators that refer to patient outcomes and 5 CWC indicators that refer to nurse expectations for providing patient care were selected. The QOC indicators included falls (per 1000 patient days), falls with injury (per 1000 patient days), medication administration error rate (per 1000 patient days), clostridium difficile (per 10 000 patient days), and methicillin-resistant Staphylococcus aureaus (MRSA) (per 10 000 patient days). The CWC indicators included adult pneumonia vaccination status screening, telephone/verbal order documented and read
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Bedside Nurses’ Emotional Intelligence and Quality of Care back, hand hygiene compliance, Braden screening compliance, and critical test response documentation. Three operational indicators that refer to unit staffing patterns were also selected and included: nursing care HPPD, nursing skill mix, and RN separation (turnover). These indicators were being tabulated and assessed by the hospitals’ quality departments. Patient satisfaction The Press Ganey standardized questionnaire was used to assess patient satisfaction. These scores are reported quarterly for each unit within this organization. The Press Ganey questionnaire includes various components of a patient’s stay including hospital environment and various service providers. The overall satisfaction with nursing score was used to assess patient satisfaction specific to nursing. Instrument completion Participants completed all of the surveys online. To ensure confidentiality, these surveys were submitted to a third party who provided the researchers with the raw data and subscale scores. Data analysis Descriptive statistics were generated for all study variables, with comparisons of demographic and EI results among participating units. The QOC variables were calculated as percentages with the number of incidences divided by the number of patient days; the CWC variables were calculated as percentages similarly with the number of correct actions divided by the number of opportunities. A multivariate linear regression analysis was used to explore the relationship of EI (total, strategic use, experiential use) with unit QOC and CWC variables. Of the operational indicators, only unit HPPD was added as a predictive variable in a simple linear regression analysis, along with total EI to determine whether this interaction was significant in predicting unit QOC or CWC. Finally, a correlation analysis was conducted comparing strategic and experiential EI and patient satisfaction for the
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nursing units. All analyses were carried out using the Statistical Package for Social Sciences 20.0 (IBM Corp, Armonk, New York). RESULTS Demographic characteristics The Supplemental Digital Content Table (available at http://links.lww.com/JNCQ/A54) provides a description of the unit characteristics and nurse demographics within those units. Chi-square analysis of nurses’ demographics found no significant differences between participants’ highest levels of education (χ 2 7 = 13.43, P = .062). However, there were significant differences in nurses’ ages across units (χ 2 7 = 25.46, P = .001) and years of experience on the units (χ 2 7 = 31.31, P < .001). Of those participants reporting demographic information on the MSCEIT, the majority of the sample was female (92%) and Caucasian (98%), which is representative of nurses in these Midwestern hospitals. Emotional intelligence The Figure displays the ranges of total EI scores for nurses on each unit; using the Kruskal-Wallis independent samples test, it was determined that the total EI scores did not vary significantly between units (P = .371). Nurses on 5 of the 8 units had a median total EI score above 100, which is reported as a desired benchmark for EI.34 The Cronbach alpha of MSCEIT results for the 89 participants was 0.75 for the 141 items. Relationship of EI and QOC or CWC The total EI scores were tested for fit with a multivariate linear regression model including QOC and CWC variables. Total EI scores for each individual were tested with the individual QOC and the CWC variables using the nursing unit as a fixed variable (Table). Emotional intelligence was significantly correlated (P < .001) with the QOC variables of C difficile infections, MRSA infections, and patient falls with injury. Emotional intelligence
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Figure. Boxplot of Total Emotional Intelligence Scores per unit.
was significantly correlated (P < .001) with only 1 CWC variable—pressure ulcer screening. The variables of falls, medication errors, vaccination screening, telephone verbal order read back documentation, hand hygiene, and critical test response documentation were not significant. Relationship of EI subscales (strategic, experiential) to QOC or CWC The strategic EI scores and the experiential use EI scores for each unit were tested independently for correlation with the QOC and CWC variables using multivariate linear regression. These results mimicked those of
the total EI scores; for both strategic and experiential use of EI, QOC variables of C difficile infections, MRSA infections, and falls with injury, and the CWC variable of pressure ulcer screening were significantly correlated (P < .001). There were no differences between strategic and experiential EI scores evident in the analysis. Interaction of nurses’ total EI and its HPPD in predicting differences QOC or CWC A simple linear regression was calculated. The interaction of total EI and nursing HPPD accounted for 61.4% of the
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Bedside Nurses’ Emotional Intelligence and Quality of Care Table. Multiple linear regression of EI and operational indicators with QOC and CWCa
Analysis Total EI and QOC
Total EI and CWC
Predictors Clostridium difficile rates of infection MRSA rates of infection Medication errors Falls with Injury Falls Pressure ulcer Pneumonia vaccination Telephone verbal order readback Hand hygiene
Type III Sum of Squares
df
Mean Square
F Statistic
P
0.000
9
5.146 e-7
3.724 e29
.000
0.000 1328.045 0.000 0.000 1.081 0.000 0.307
9 9 9 9 9 9 9
3.000 e-6 147.561 7.563 e-6 2.391 e-5 0.120 0.000 0.034
3.596 e30
.000
4.828 e29
.000
2.755 e30
.000
0.060
9
0.007
Abbreviations: CWC, compliance with care; EI, emotional intelligence; QOC, quality of care. a Multiple linear regression was completed on QOC and CWC variables separately as 2 distinct analyses.
variance in QOC outcomes and 41.2% of the variance in CWC outcomes. This explained more than total EI alone, which accounted for 51.4% of variance in QOC and 13.5% of variance in CWC outcomes. However, the interaction of EI and nursing HPPD did not significantly predict either QOC (F2,5 = 4.457, P = .077) or CWC (F2,5 = 1.755, P = .265). Operational indicators and patient satisfaction Spearman’s rho did not detect any significant correlations between operational indicators such as HPPD, RN turnover, or skill mix and QOC or CWC variables. To help explain how EI may relate to patient satisfaction, a correlation analysis of Press Ganey patient satisfaction scores of the units was calculated with perception and strategic use of emotions. This analysis did not demonstrate any significant findings (P = .846 and P = .829), indicating that EI is not correlated with patient satisfaction. DISCUSSION The results provide some evidence that there is a relationship between the EI of nurses on a unit and select patients’ QOC vari-
ables and CWC variables. It is curious that EI is significantly associated with only select measures of QOC and CWC. Hospital organizations are concerned with the QOC provided and engage in campaigns directed at increasing QOC.36 With this organizational attention, self-awareness of the nurses to select variables may be attributable to the relationship of EI and care delivered. This pilot study provided evidence that the total EI of nursing staff was associated with the QOC provided. Nursing staff EI scores were correlated with QOC, specifically C difficile, MRSA, and falls with injury, and with pressure ulcer screening in CWC on the different units. This suggests that by increasing the EI of the nursing staff, QOC on those units may be improved. Study limitations Limitations of this study include those of recruitment and survey completion. The primary issue is that findings were based on a minimum 20% response rate from nurses on the participating units. Thus, the resulting small sample size of units (n = 8) and a largely female, Caucasian group of nurse participants limits the generalizability of the study. In addition, it is not possible to determine directionality of the results from this small sample size;
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this study can only show that a relationship exists. There were also issues related to MSCEIT completion, particularly the time needed to complete the MSCEIT, which required approximately 30 to 45 minutes of uninterrupted time for completion. An additional limitation is that the MSCEIT test was not as reliable as expected, with lower Cronbach alpha scores in this sample compared with other previously reported alphas (0.75 vs 0.91).32,33,34 CONCLUSIONS AND RECOMMENDATIONS This pilot study serves as the basis for further examination of how the EI of nurses is potentially correlated with QOC and CWC variables. With no correlation between Press Ganey patient satisfaction scores of the units and experiencing and strategic use of emotions, these results mimic those seen in EI and patient satisfaction of physicians.20 Although patient satisfaction is important, quality of pa-
tient care should guide hospital policy, as patient satisfaction is responsible for only 30% of total value-based incentive payment by the Centers for Medicare and Medicaid Services, whereas the clinical process is weighted at 70%.36 Research supports the notion that using self-reflective exercises and assessing EI in simulation and bedside experiences provides nurses with realistic opportunities to develop higher levels of EI.8,37 In everyday situations, nurses can take opportunities to ask their patients or peers to verbalize their emotions, helping to validate and refine their perceptions and actions on the basis of their own EI judgments. Nurses demonstrate EI in assessing patients and identifying their needs through their sensitivity to patients’ emotions.10 Perhaps nurses with higher EI are more adept at understanding a patient’s emotional needs while caring for them. This attention to emotional needs is manifested in the patients’ QOC and CWC.
REFERENCES 1. Downey LA, Lee B, Stough C. Recruitment consultant revenue: relationships with IQ, personality, and emotional intelligence. Int J Sel Assess. 2011;19(3):280286. 2. Codier E, Kamikawa C, Kooker BM, Shoultz J. Emotional intelligence, performance, and retention in clinical staff nurses. Nurs Admin Q. 2009;33(4):310316. ¨ The 3. G¨ ulery¨ uz G, G¨ uney S, Aydın EM, As¸an O. mediating effect of job satisfaction between emotional intelligence and organisational commitment of nurses: a questionnaire survey. Int J Nurs Stud. 2008;45(11):1625-1635. 4. Kooker BM, Shoultz J, Codier EE. Identifying emotional intelligence in professional nursing practice. J Prof Nurs. 2007;23(1):30-36. 5. Morand D. The emotional intelligence of managers: assessing the construct validity of a nonverbal measure of “people skills.” J Bus Psychol. 2001;16(1): 21-33. 6. Rego A, Godinho L, McQueen A, Cunha MP. Emotional intelligence and caring behaviour in nursing. Serv Ind J. 2010;30(9):1419-1437.
7. Mandell B, Pherwani S. Relationship between emotional leadership style: a gender comparison. J Bus Psychol. 2003;17(3):387-404. 8. Vitello-Cicciu JM. Exploring emotional intelligence: implications for nursing leaders. J Nurs Admin. 2002;32(4):203-210. 9. Gardner H. Intelligence Reframed: Multiple Intelligences for the 21st Century. New York, NY: Basic Books; 1999. 10. McQueen A. Emotional intelligence in nursing work. J Adv Nurs. 2004;47(1):101-108. 11. Smith KB, Profetto-McGrath J, Cummings GG. Emotional intelligence and nursing: an integrative literature review. Int J Nurs Stud. 2009;46(12):16241636. 12. Freshwater D, Stickley T. The heart of the art: emotional intelligence in nurse education. Nurs Inq. 2004;11(2):91-98. 13. Bar-On R. Emotional and Social Intelligence: Insights From the Emotional Quotient Inventory. San Francisco, CA: Jossey-Bass; 2000. 14. Goleman D. Emotional intelligence. New York, NY: Bantam Books; 1995.
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Bedside Nurses’ Emotional Intelligence and Quality of Care 15. Lam LT, Kirby SL. Is emotional intelligence an advantage? An exploration of the impact of emotional and general intelligence on individual performance. J Socl Psychol. 2002;142(1):133-133-143. 16. Matthews G, Zeidner M, Roberts RD, eds. The Science of Emotional Intelligence: Knowns and Unknowns. New York, NY: Oxford University Press; 2007. 17. Salovey P, Grewal D. The science of emotional intelligence. Curr Dir Psychol Sci. 2005;14(6):281-285. 18. Salovey P, Mayer JD. Emotional intelligence. Imagination Cog Pers. 1990;9(3):185-211. 19. Armstrong AR, Galligan RF, Critchley CR. Emotional intelligence and psychological resilience to negative life events. Pers Indiv Differ. 2011;51(3):331-336. 20. Weng H-C, Hung C-M, Liu Y-T, et al. Associations between emotional intelligence and doctor burnout, job satisfaction and patient satisfaction. Med Educ. 2011;45(8):835-842. 21. Costarelli V, Demerzi M, Stamou D. Disordered eating attitudes in relation to body image and emotional intelligence in young women. J Hum Nutr Diet. 2009;22(3):239-245. 22. Montes-Berges B, Augusto J-M. Exploring the relationship between perceived emotional intelligence, coping, social support and mental health in nursing students. J Psychiatr Ment Health Nurs. 2007;14:163171. 23. Muller-Smith P. Yet another workplace crisis. J Perianesth Nurs. 1999;14(4):217-220. 24. Goleman D, Boyatzis RE, McKee AB. Primal Leadership: Realizing the Power of Emotional Intelligence. Boston, MA: Harvard Business School Publishing; 2002. 25. Akerjordet K, Severinsson E. The state of the science of emotional intelligence related to nursing leadership: an integrative review. J Nurs Manage. 2010;18(4):363-382. 26. Banati M, Sandor J, Mike A, et al. Social cognition and Theory of Mind in patients with relapsing-remitting multiple sclerosis. Eur J Neurol. 2010;17(3):426-433.
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27. Kravvariti E, Maridaki-Kassotaki K, Kravvaritis E. Emotional intelligence and coronary heart disease: how close is the link? Glob J Health Sci. 2010;2(1):127137. 28. Luyster FS, Hughes JW, Gunstad J. Depression and anxiety symptoms are associated with reduced dietary adherence in heart failure patients treated with an implantable cardioverter defibrillator. J Cardiovasc Nurs. 2009;24(1):10-17. 29. Warmuz-Stangierska I, Baszko-Błaszyk D, Sowi´ nski J. Emotions and features of temperament in patients with Addison’s disease. Pol J Endocrinol. 2010;61(1):90-92. 30. Cadman C, Brewer J. Emotional intelligence: a vital prerequisite for recruitment in nursing. J Nurs Manag. 2001;9(6):321-324. 31. Hunt N, Evans D. Predicting traumatic stress using emotional intelligence. Behav Res Ther. 2004;42(7):791-798. 32. Ciarrochi JV, Chan AYC, Caputi P. A critical evaluation of the emotional intelligence construct. Pers Indiv Differ. 2000;28(3):539-561. 33. Mayer JD, Salovey P, Caruso DR. Mayer-SaloveyCaruso Emotional Intelligence Test Manual. Toronto, Ontario, Canada: Multi-Health System; 2002. 34. Mayer JD, Salovey P, Caruso DR, Sitarenios G. Measuring emotional intelligence with the MSCEIT V2.0. Emotion. 2003;3(1):97-105. 35. Brackett MA, Mayer JD. Convergent, discriminant, and incremental validity of competing measures of emotional intelligence. Pers Soc Psychol B. 2003;29(9):1147-1158. 36. Centers for Medicare and Medicaid Services. Open Door Forum: Hospital Value-Based Purchasing. Baltimore, MD: Centers for Medicare & Medicaid Services; 2011. 37. Harrison PA, Fopma-Loy JL. Reflective journal prompts: a vehicle for stimulating emotional competence in nursing. J Nurs Educ. 2010;49(11): 644-652.
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J Nurs Care Qual Vol. 29, No. 2, pp. 174–181 c 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Copyright
The Relationship of Bedside Nurses’ Emotional Intelligence With Quality of Care Kelly L. Adams, MSN, RN, PCCN; Jackeline I. Iseler, MSN, RN, ACNS-BC Emotional intelligence, a predictor of productivity and success, may impact behaviors responsible for quality of care. This study examined if emotional intelligence of units’ bedside nurses is related to the quality of care delivered to the patients. In this study, emotional intelligence was found to be correlated to the number of Clostridium difficile infections, MRSA infections, patient falls with injury, and pressure ulcer screenings (P < .001) in the inpatient acute care setting. Key words: emotional intelligence, guideline adherence, nurses, outcome and process assessment (health care), quality of healthcare
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MOTIONAL INTELLIGENCE (EI) is becoming an increasingly important concept in describing human interactions and performance in the workplace setting.1-6 Emotional intelligence research and tools
Author Affiliations: College of Nursing at Michigan State University, East Lansing (Ms Adams), and Frederik Meijer Heart and Vascular Institute, Spectrum Health Hospitals, Grand Rapids (Ms Iseler), Michigan. This research was supported by a grant from the Nurse Education Research Fund at Spectrum Health. The authors thank the Research Team comprising Karen Vander Laan, Patricia Burgess, Katie Emery, Jody H. Mendez, Christoffer Schmidt, Trudy Pyle, and Carol Sadat-Akhavi. The authors declare no conflict of interest. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (www.jncqjournal.com). Correspondence: Kelly Adams, College of Nursing at Michigan State University, Bott Building for Nursing Education and Research, 1355 Bogue St, Room No. C300, East Lansing, MI 48824 ([email protected] .edu). Accepted for publication November 2, 2013. Published ahead of print: December 18, 2013 DOI: 10.1097/NCQ.0000000000000039
are being used in both business and health care settings to determine which individuals possess the greatest aptitude for leadership responsibilities.7,8 The body of research exploring EI in general workplace settings presents limitations as it lacks a comprehensive description of the unique environment of the health care workplace. Specifically, the impact of the EI of a nurse on patient care outcomes is unknown. Thus, this study provides an initial examination of the EI of direct patient care nurses and its potential influence on patient outcomes. According to the theory of multiple intelligences, every human being possesses a variety of individual capacities (ie, “intelligences”), with each of these areas of intelligence evolving in relation to the various interactions and experiences in the person’s life.9 Bedside nurses’ EI is important because it is central to their ability to manage and respond to emotions in patient care situations in 2 ways. First, when individuals are overcome by their own emotions, their cognition and behavior is affected;10 this can be the case for both nurses and the patients for whom they are caring. Second, nurses are responsible for responding to the emotional needs of patients by expressing empathy as caring behaviors.6 As such, the caring behaviors subsequently
174
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
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February 3, 2014
23:48
Bedside Nurses’ Emotional Intelligence and Quality of Care influence outcomes such as patient satisfaction and indicators of care quality.11 Because it is likely that EI may have a considerable influence on patient outcomes, this study sought to identify the relationship, if any, between EI and quality indicators, specifically to determine if higher EI among nurses on a unit could predict higher quality patient care on those units. There were 5 research questions: is the unit’s quality of care (QOC) or compliance with care (CWC) related to the unit’s (1) bedside nurses’ overall EI; (2) bedside nurses’ experiential or strategic EI; (3) operational indicators such as hours per patient day (HPPD), registered nurse (RN) turnover, or skill mix; (4) an interaction of a unit’s bedside nurses’ overall EI and its HPPD; and (5) patient satisfaction scores? REVIEW OF LITERATURE EI research Although EI has been described as a set of noncognitive abilities that influence an individual’s capacity to be successful,12 EI researchers have not yet achieved consensus on a unified definition of the concept.7,13-18 For the purpose of this study, EI was defined as the ability to monitor, discriminate, and respond to affect-inducing situations in both the self and in others. As this definition implies, individuals are able to recognize emotions to varying degrees, and then as their EI capacity increases, they are able to more accurately predict emotional responses in themselves and in others.14,18 A variety of dependent variables have been correlated to EI. Correlations exist between EI and decreased stress and anxiety, increased cognitive performance, increased job satisfaction, and decreased burnout.15,19-21 Researchers have suggested that EI is equal to (if not more important than) academic intelligence.7 Moreover, beyond intelligence, mental health and social support have been positively correlated with EI in relation to understanding emotions and seeking social support, emotion regulation and seeking social
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support, and emotion regulation and mental health.22 Although not a focus of this study, these findings suggest that EI likely influences the social support and mental health of others, such as patients in the health care setting. However, while it may seem intuitive that EI would have an impact on patient satisfaction, findings of prior research have indicated no correlation between these concepts.20 Nurses’ EI Professional nurses desire to engage emotionally with their patients, patients’ families, and colleagues.10,23 This was evidenced in a study examining nurses’ reflective stories, which provided support that all of the components of EI were described in the narratives from every nurse studied.24 Nurses’ self-awareness, self-regulation, social skill, empathy, and motivation aided their identification of processes to improve outcomes for their patients and nurse colleagues. In addition to improving patient outcomes, these EI constructs also were suggested as a way to improve retention of nurses.4 Moreover, the increasing number of similar studies indicates a trending rise in research on the effect of EI in professional nurses.25 Nurse-patient relationships are integral to optimal patient care; thus, nurses’ emotions can have implications for their abilities to provide care and respond empathetically in support of their patients’ healing processes.6,12 With health care becoming increasingly technical, it is important to assess for EI in nurses as a means for maintaining and promoting the human qualities of love, compassion, and empathy, as each is thought to influence patients both directly and indirectly.12 This concept is particularly critical for individuals experiencing chronic and acute disease as they are particularly vulnerable to emotional distress, as evidenced by higher rates of depression and anxiety.26-29 There are many different factors that affect nurses’ EI such as time management, relationships, stress management, leadership qualities, professional growth, empowerment, retention, autonomy, and patient
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satisfaction.4,12,30 Individuals with higher EI are more tolerant of stress and have a greater potential to be successful in a leadership role.17 Thus, individuals with high EI are well-suited for high-stress careers, including nursing.31 Emotional intelligence was also found to be a strong predictor of performance on a clinical ladder, as well as an indicator of organizational commitment and retention.2 It is unclear in correlations of nurse performance measures and EI whether EI leads to improved skills or vice versa.2,4,8,12,30 Even though these correlations are not explicitly understood, there is a focus on improving EI in nurses. This starts in nursing education, where the use of motivation, practice, and feedback while training nurses in EI is found to encourage growth throughout the nurses’ careers.8 METHODS Scope A correlational, cross-sectional design was used to identify the relationships between EI and QOC. The study was conducted in 2 urban metropolitan hospitals (one >700 beds and one 200-299 beds) within a health care system located in the Midwestern United States. The study was approved by the system’s institutional review board. Participants A sample of RNs from adult inpatient units in both hospitals was recruited. Eligible units included adult critical care, progressive care, and medical-surgical units. Participants were selected for inclusion in the study population if they were full- or part-time RNs who (a) worked primarily as bedside staff on the eligible units, (b) had worked on the unit for 1 year or longer, and (c) consented to participate in the study. Registered nurses who worked in a leadership capacity on the units (ie, nurse managers, nurse educators, clinical nurse specialists, and nursing supervisors) were excluded. A total of 1138 RNs met the inclusion criteria, and 361 participated for a response rate of 31.7%. Of the 8 nursing units
analyzed, 5 were from the larger of the 2 hospitals and 3 were from the smaller hospital. The units represented various levels of care in the 2 hospitals: 5 medical-surgical units, 2 progressive care units, and 1 intensive care unit. A post hoc power analysis of 0.86 was calculated for the sample size of 8 units, an r2 of 0.514, and an alpha error probability of 0.05. Instruments and quality indicators Mayer-Salovey-Caruso Emotional Intelligence Test The Mayer-Salovey-Caruso Emotional Intelligence Test (MSCEIT) is a measure of EI. It covers areas such as the ability to perceive, use, understand, and regulate emotions. Completion of the 141 questions on the MSCEIT was estimated to take approximately 30 to 45 minutes. The MSCEIT reliability has been reported as 0.91,32-34 with a test-retest reliability of 0.86 by 60 participants measured twice over 3 weeks.35 For the purposes of this study, total EI was composed of the strategic use of emotions and the experiential emotions. These 2 subscales were determined through factor analysis in which the strategic use of emotions included how individuals understand and manage emotions.34 The experiential emotions subscale included the ability to perceive and facilitate emotions. The MSCEIT measured each of these components separately and provided a total EI score. Quality indicators Five QOC indicators that refer to patient outcomes and 5 CWC indicators that refer to nurse expectations for providing patient care were selected. The QOC indicators included falls (per 1000 patient days), falls with injury (per 1000 patient days), medication administration error rate (per 1000 patient days), clostridium difficile (per 10 000 patient days), and methicillin-resistant Staphylococcus aureaus (MRSA) (per 10 000 patient days). The CWC indicators included adult pneumonia vaccination status screening, telephone/verbal order documented and read
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Bedside Nurses’ Emotional Intelligence and Quality of Care back, hand hygiene compliance, Braden screening compliance, and critical test response documentation. Three operational indicators that refer to unit staffing patterns were also selected and included: nursing care HPPD, nursing skill mix, and RN separation (turnover). These indicators were being tabulated and assessed by the hospitals’ quality departments. Patient satisfaction The Press Ganey standardized questionnaire was used to assess patient satisfaction. These scores are reported quarterly for each unit within this organization. The Press Ganey questionnaire includes various components of a patient’s stay including hospital environment and various service providers. The overall satisfaction with nursing score was used to assess patient satisfaction specific to nursing. Instrument completion Participants completed all of the surveys online. To ensure confidentiality, these surveys were submitted to a third party who provided the researchers with the raw data and subscale scores. Data analysis Descriptive statistics were generated for all study variables, with comparisons of demographic and EI results among participating units. The QOC variables were calculated as percentages with the number of incidences divided by the number of patient days; the CWC variables were calculated as percentages similarly with the number of correct actions divided by the number of opportunities. A multivariate linear regression analysis was used to explore the relationship of EI (total, strategic use, experiential use) with unit QOC and CWC variables. Of the operational indicators, only unit HPPD was added as a predictive variable in a simple linear regression analysis, along with total EI to determine whether this interaction was significant in predicting unit QOC or CWC. Finally, a correlation analysis was conducted comparing strategic and experiential EI and patient satisfaction for the
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nursing units. All analyses were carried out using the Statistical Package for Social Sciences 20.0 (IBM Corp, Armonk, New York). RESULTS Demographic characteristics The Supplemental Digital Content Table (available at http://links.lww.com/JNCQ/A54) provides a description of the unit characteristics and nurse demographics within those units. Chi-square analysis of nurses’ demographics found no significant differences between participants’ highest levels of education (χ 2 7 = 13.43, P = .062). However, there were significant differences in nurses’ ages across units (χ 2 7 = 25.46, P = .001) and years of experience on the units (χ 2 7 = 31.31, P < .001). Of those participants reporting demographic information on the MSCEIT, the majority of the sample was female (92%) and Caucasian (98%), which is representative of nurses in these Midwestern hospitals. Emotional intelligence The Figure displays the ranges of total EI scores for nurses on each unit; using the Kruskal-Wallis independent samples test, it was determined that the total EI scores did not vary significantly between units (P = .371). Nurses on 5 of the 8 units had a median total EI score above 100, which is reported as a desired benchmark for EI.34 The Cronbach alpha of MSCEIT results for the 89 participants was 0.75 for the 141 items. Relationship of EI and QOC or CWC The total EI scores were tested for fit with a multivariate linear regression model including QOC and CWC variables. Total EI scores for each individual were tested with the individual QOC and the CWC variables using the nursing unit as a fixed variable (Table). Emotional intelligence was significantly correlated (P < .001) with the QOC variables of C difficile infections, MRSA infections, and patient falls with injury. Emotional intelligence
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Figure. Boxplot of Total Emotional Intelligence Scores per unit.
was significantly correlated (P < .001) with only 1 CWC variable—pressure ulcer screening. The variables of falls, medication errors, vaccination screening, telephone verbal order read back documentation, hand hygiene, and critical test response documentation were not significant. Relationship of EI subscales (strategic, experiential) to QOC or CWC The strategic EI scores and the experiential use EI scores for each unit were tested independently for correlation with the QOC and CWC variables using multivariate linear regression. These results mimicked those of
the total EI scores; for both strategic and experiential use of EI, QOC variables of C difficile infections, MRSA infections, and falls with injury, and the CWC variable of pressure ulcer screening were significantly correlated (P < .001). There were no differences between strategic and experiential EI scores evident in the analysis. Interaction of nurses’ total EI and its HPPD in predicting differences QOC or CWC A simple linear regression was calculated. The interaction of total EI and nursing HPPD accounted for 61.4% of the
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Bedside Nurses’ Emotional Intelligence and Quality of Care Table. Multiple linear regression of EI and operational indicators with QOC and CWCa
Analysis Total EI and QOC
Total EI and CWC
Predictors Clostridium difficile rates of infection MRSA rates of infection Medication errors Falls with Injury Falls Pressure ulcer Pneumonia vaccination Telephone verbal order readback Hand hygiene
Type III Sum of Squares
df
Mean Square
F Statistic
P
0.000
9
5.146 e-7
3.724 e29
.000
0.000 1328.045 0.000 0.000 1.081 0.000 0.307
9 9 9 9 9 9 9
3.000 e-6 147.561 7.563 e-6 2.391 e-5 0.120 0.000 0.034
3.596 e30
.000
4.828 e29
.000
2.755 e30
.000
0.060
9
0.007
Abbreviations: CWC, compliance with care; EI, emotional intelligence; QOC, quality of care. a Multiple linear regression was completed on QOC and CWC variables separately as 2 distinct analyses.
variance in QOC outcomes and 41.2% of the variance in CWC outcomes. This explained more than total EI alone, which accounted for 51.4% of variance in QOC and 13.5% of variance in CWC outcomes. However, the interaction of EI and nursing HPPD did not significantly predict either QOC (F2,5 = 4.457, P = .077) or CWC (F2,5 = 1.755, P = .265). Operational indicators and patient satisfaction Spearman’s rho did not detect any significant correlations between operational indicators such as HPPD, RN turnover, or skill mix and QOC or CWC variables. To help explain how EI may relate to patient satisfaction, a correlation analysis of Press Ganey patient satisfaction scores of the units was calculated with perception and strategic use of emotions. This analysis did not demonstrate any significant findings (P = .846 and P = .829), indicating that EI is not correlated with patient satisfaction. DISCUSSION The results provide some evidence that there is a relationship between the EI of nurses on a unit and select patients’ QOC vari-
ables and CWC variables. It is curious that EI is significantly associated with only select measures of QOC and CWC. Hospital organizations are concerned with the QOC provided and engage in campaigns directed at increasing QOC.36 With this organizational attention, self-awareness of the nurses to select variables may be attributable to the relationship of EI and care delivered. This pilot study provided evidence that the total EI of nursing staff was associated with the QOC provided. Nursing staff EI scores were correlated with QOC, specifically C difficile, MRSA, and falls with injury, and with pressure ulcer screening in CWC on the different units. This suggests that by increasing the EI of the nursing staff, QOC on those units may be improved. Study limitations Limitations of this study include those of recruitment and survey completion. The primary issue is that findings were based on a minimum 20% response rate from nurses on the participating units. Thus, the resulting small sample size of units (n = 8) and a largely female, Caucasian group of nurse participants limits the generalizability of the study. In addition, it is not possible to determine directionality of the results from this small sample size;
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this study can only show that a relationship exists. There were also issues related to MSCEIT completion, particularly the time needed to complete the MSCEIT, which required approximately 30 to 45 minutes of uninterrupted time for completion. An additional limitation is that the MSCEIT test was not as reliable as expected, with lower Cronbach alpha scores in this sample compared with other previously reported alphas (0.75 vs 0.91).32,33,34 CONCLUSIONS AND RECOMMENDATIONS This pilot study serves as the basis for further examination of how the EI of nurses is potentially correlated with QOC and CWC variables. With no correlation between Press Ganey patient satisfaction scores of the units and experiencing and strategic use of emotions, these results mimic those seen in EI and patient satisfaction of physicians.20 Although patient satisfaction is important, quality of pa-
tient care should guide hospital policy, as patient satisfaction is responsible for only 30% of total value-based incentive payment by the Centers for Medicare and Medicaid Services, whereas the clinical process is weighted at 70%.36 Research supports the notion that using self-reflective exercises and assessing EI in simulation and bedside experiences provides nurses with realistic opportunities to develop higher levels of EI.8,37 In everyday situations, nurses can take opportunities to ask their patients or peers to verbalize their emotions, helping to validate and refine their perceptions and actions on the basis of their own EI judgments. Nurses demonstrate EI in assessing patients and identifying their needs through their sensitivity to patients’ emotions.10 Perhaps nurses with higher EI are more adept at understanding a patient’s emotional needs while caring for them. This attention to emotional needs is manifested in the patients’ QOC and CWC.
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