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EMOTIONAL INTELLIGENCE AND CARING BEHAVIOR IN

NURSING *

Arménio Rego
Universidade de Aveiro, Campus de Santiago, 3810-193 Aveiro- Portugal
arego@egi.ua.pt

Lucinda Godinho
Universidade de Aveiro, Campus de Santiago, 3810-193 Aveiro- Portugal
lucinda.figueira@netvisao.pt

Anne McQueen
The University of Edinburgh, Nursing Studies, School of Health in Social Science
Teviot Place, Edinburgh, EH8 9AG
A.McQueen@ed.ac.uk

Miguel Pina e Cunha


Faculdade de Economia, Universidade Nova de Lisboa
Rua Marquês de Fronteira, 20, 1099-038 Lisboa – Portugal
mpc@fe.unl.pt

ABSTRACT
We 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

INTRODUCTION
Quality 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 INTELLIGENCE
Salovey 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 emotions


Nurses 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 criticism


Emotionally 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-control
Nurses 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 emotions


By 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.

METHOD
Having 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 collection
The 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 analysis
A 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 1
Emotional intelligence – Confirmatory factor analysis (completely standardized
solution)
Self-control against criticism (0.83)
When I am defeated in a game, I lose control. (r) 0.56
It is difficult for me to talk with people who do not share my points of view. (r) 0.75
I become angry when others criticize me – even if I feel that they are right. (r) 0.89
It is difficult for me to accept a critique. (r) 0.88
Use of emotions (self-encouragement) (0.77)
Usually, I encourage myself to give as well as I can. 0.72
I give as well as I can to achieve my goals. 0.78
Usually, I am used to setting my own aims. 0.79
Emotional self-control (regulation of emotions) (0.80)
I can stay calm even when the others are angry. 0.72
I can calm down whenever I am furious. 0.88
Rarely do I stay furious. 0.68
Understanding of other people’s emotions (0.62)
I do as well as I can to understand the others’ point of view. 0.62
I really understand the feelings of the people I am related with. 0.60
I understand the emotions and feelings of my friends by seeing their behavior. 0.57
Empathy and emotional contagion (0.72)
I am indifferent to the others’ happiness. (r) 0.80
The others’ suffering doesn’t affect me. (r) 0.88
I feel the problems that my friends face as they were my own. -0.44
Understanding of one’s emotions (0.75)
I understand the causes of my emotions. 0.66
When I feel sad, I understand the reasons. 0.59
I really know what I am feeling. 0.82
Fit indices
Chi-square/Degrees of freedom 1.6
Root mean square error of approximation 0.07
Goodness of fit index 0.84
Adjusted goodness of fit index 0.78
Comparative fit index 0.90
Incremental fit index 0.90
Relative fit index 0.73
* 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 2
Nurse’ behaviors towards the client – Principal component analysis#
Factor 1 Factor 2
Nurse treat Nurse give
patients with explanations to
dignity, respect the patients
and trust
Whenever I asked him/her, (s)he answered me. 0.80 0.15
When 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 0.29 0.75
me.
(S)he explained to me the pain that I will feel when treatments will 0.31 0.75
be applied.
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)

RESULTS
Table 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 3
Means, standard deviations and correlations
Means SD 1 2 3 4 5 6 7 8 9
1. Self-control against criticism 5.1 1.0 -

2. Use of emotions (self- 6.0 0.8 -0.27 -


encouragement) **
3. Emotional self-control 3.9 1.0 0.45 -0.06 -
***
4. Understanding of other people’s 5.3 0.7 0.22 0.41 0.31 -
emotions * *** ***
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 5.5 3.5 0.09 0.08 0.22 0.15 0.05 0.21 -0.02 -0.04 -0.25
nurse ** * **
*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 4
Hierarchical regression analyses: How nurses’ EI explain their caring behaviors
Respect, dignity and trust Explanations
1st step 2nd step 1st step 2nd step
Nurse age -0.17 -0.10 0.03 0.09
Contact time between patient and nurse -0.04 0.06 -0.05 -0.07
F 1.52* 0.13
R2 1% 0%
Self-control against criticism 0.06 0.25*
Use of emotions (self-encouragement) 0.24* 0.41***
Emotional self-control -0.15 -0.14
Understanding of other people’s emotions 0.02 0.08
Empathy and emotional contagion 0.04 0.00
Understanding of one’s emotions -0.20 -0.18
F 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 1
How emotional self-control interact with self-encouragement to predict the
explanatory behaviors
5

4,9

4,8 4,8

4,6 4,6
Explanations

4,5

4,4

4,3
Self-encouragement _low

Self-encouragement _middle

Self-encouragement _high

4
Low Middle High

Emotional self-control

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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 2
How self-control against criticism interact with self-encouragement to predict
the explanatory behaviors
5

4,8 4,8

4,7 4,7

4,6 4,6
Explanations

Self-encouragement _low

Self-encouragement _middle

Self-encouragement _high

4,2 4,2

4
Low Middle High

Self-control against criticisms

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.

11
FIGURE 3
How the understanding of one’s emotions interact with self-encouragement to
predict the explanatory behaviors
5

4,8 4,8 4,8


4,7 4,7

4,4 4,4 4,4


Explanations

Self-encouragement _low
3,6
Self-encouragement _middle

Self-encouragement _high

3
Low Middle High

Understanding of one’s emotions

FIGURE 4
How empathy interact with self-encouragement to predict the explanatory
behaviors
5,5

Self-encouragement _low

Self-encouragement _middle
5
Self-encouragement _high 4,9
Explanations

4,8 4,8
4,7
4,6 4,6
4,5
4,4

4,2

4
Low Middle High

Empathy

Findings show that empathy and emotional contagion do not explain caring behaviors.
Although this seems surprising, there are some plausible arguments supporting the

12
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 5
How the understanding of other people emotions interact with emotional self-
control to predict the explanatory behaviors
5,5

Emotional self-control _low

Emotional self-control _middle

5 5
Emotional self-control _high
Explanations

4,8
4,7
4,6 4,6 4,6
4,5
4,4

4
Low Middle High

Understanding of other people emotions

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-

13
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 findings


The 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

14
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 studies


Our 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

15
psychometric 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 comments


Our findings support the argument that measurement of EI can form part of the
selection process and that the topic needs be incorporated into performance

16
management, training programs and nursing curricula (Bellack, 1999; Cadman &
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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