Role of emotional intelligence in nursing leadership

FigureNursing leaders have a widely acknowledged impact on the work environment of the nurses and staff they supervise. Nurse leaders influence nursing turnover, job satisfaction, patient outcomes, organizational commitment, safety compliance, and unit culture.1,2 Additionally, as nurses continue to retire and leave the profession, more than 200,000 openings are projected each year through 2031.3 Meeting the demand for nurses will heighten the focus on resilience, retention, and reducing nurses' intent to leave. Although the need for healthcare services has remained constant, strategies for improving nurses' work environments have been in flux. As healthcare grows more complex, the role of nurse leaders keeps evolving. Future nurse leaders may need skill sets entirely different from those proven successful in the past. One such skill is emotional intelligence (EI). EI can better equip the nurse leader to deal with the stresses of the healthcare environment, such as increasing work demands, work-life balance, mental well-being, and burnout.4-6 Furthermore, the nurse leader's EI quotient has the potential to positively impact healthcare outcomes. Thus, the authors developed a series of workshops to enhance nurse leaders' EI competency and to explore whether increasing nurse leader EI would impact resilience and turnover intent. BACKGROUND Early researchers defined EI competency as an individual's ability to accurately identify, understand, and manage emotions, and employ it in reasoning.7 As EI research progressed, the question, “What is true intelligence?” persisted. For decades, the gold standard of intelligence has been the intelligence quotient (IQ). However, cognitive tests don't always predict one's ability to be successful.7 Although various definitions of EI exist, simply stated, it's the ability to understand others' and one's own emotions and the skill to effectively use and control emotions.8 Although less understood than IQ, EI is recognized as an important skill. One essential distinction of humans compared with other primates is a larger prefrontal cortex with intrabrain connections, permitting greater abilities in navigating social interactions.9 Skills for navigating social and emotional interactions are required to garner cooperation, motivate others, foster a shared vision, and impact the work environment. A study found that increases in the EI of leaders improved staff performance by 18.3%, directly linking EI to outcomes.10 Additional research has demonstrated that EI has a direct impact on leaders' job performance.3,6,7,11 Several recent studies have demonstrated that, unlike IQ, EI can be taught and fostered.12,13 One study that used a two-group method, in which one group attended an EI workshop followed by one-on-one coaching and a control group received no training, demonstrated significant elevations in EI scores for the experimental group.11 Qualitative studies have demonstrated similar results, with increased perceptions of resilience, greater capacity for empathy and compassion, and improved nontechnical work skills.13 Many EI studies focus on new graduates and the transition to practice. However, when viewed through the broader lens of nursing leadership, the impact of EI can be magnified. EI is linked to higher-level nursing skills, including clinical reasoning and critical thinking.14 As an effective countermeasure to stressful nursing environments, EI education is beneficial in reducing burnout, increasing work wellness, improving resilience, and decreasing turnover.12,13,15-17 Nurse leader EI education may significantly benefit all staff and nurses working on nursing units. Chikobvu and Harunavamwe investigated the link between EI, resilience, and work engagement and found that EI influenced work engagement through resilience.18 The study highlighted that resilience reserves are depleted through work and stress and that EI aids in replenishing those reserves.18 One common goal of nurse leaders is to motivate and engage staff. EI can provide the tools to accomplish this goal. Another study found significant correlations between EI scores and nurses' intent to stay, suggesting that nurse managers employing EI can directly impact the day-to-day work of nurses, thereby influencing patient care and nurse well-being.14 PROJECT DESIGN AND PURPOSE The project had a quantitative design with single group pre- and postintervention data collection using a survey. The goals guiding the project are listed below. 1) Coaching on EI and related concepts will positively impact overall nurse leader EI scores. 2) Coaching on EI and related concepts will impact nurse leader resilience scores. 3) Higher resilience and EI will lead to a higher nurse leader intent to stay. Mayer and colleagues provided the framework used in the coaching and instructional sessions with the nurse leaders.7 The competencies identified include: 1) correctly identifying emotion, 2) understanding emotion, 3) using emotion to reason, and 4) managing emotion. The sessions were developed to help nurse leaders attain the four competencies and, subsequently, gain EI skills. Project sample Nurse leaders from one acute care hospital were asked to participate in the project. The nurse leaders managed single units or groups of units within the acute care facility. All participants were RNs employed by the acute care facility with the title of nurse manager or nurse director. A total of 17 nurse leaders met the criteria. The acute care facility is located in a border community between the US and Mexico. PROJECT PLANNING AND IMPLEMENTATION The project aimed to explore the relationship between nurse leader EI, resilience, and turnover intent. Step 1: Establish goals and guidelines. Addressing resilience, nurse fatigue, and job satisfaction postpandemic has become a priority for many organizations. Nelson postulates that to build back nursing to a better state than prepandemic, leaders will need to focus on well-being at work.19 Clinical partners from academia and an acute care facility met and brainstormed ideas to address the current issues related to postpandemic nursing. Nurse leaders' impact on the work environment has been noted in the literature.1,2,4,11,16 The plan developed included providing nursing leaders with tools that would benefit them personally and lead to higher staff satisfaction, improved resiliency, and a reduction in turnover intent. EI was the tool chosen. The first month of the project was dedicated to planning and garnering support from the acute care facility's stakeholders. Step 2: Develop the content and structure for the EI education sessions. A 10-month timeline was developed to include education sessions that aligned with EI competency attainment (see Figure 1). Five sessions, each lasting 2 hours, were planned. The sessions were spaced at 2-month intervals to maximize learning and the implementation of each competency. The time between each session also allowed the nurse leaders to reflect and purposefully practice skills to develop each EI competency. Each session provided education on EI, followed by activities simulating real-life situations for nurse leaders.FIGURE 1:: Competency timelineStep 3: Deliver and promote engagement for the EI education sessions. Sessions were a combined effort of both the academic and clinical partners. Coaching and feedback occurred during the cognitive rehearsal portion of the sessions. Cognitive rehearsal is an evidence-based pedagogic strategy that allows learners to safely rehearse stressful situations.20 Coaching and reflection occurred after role-playing and interactive scenarios. Each session focused on real-life scenarios and situations related to nurse leaders' experiences during their everyday leadership and management duties. The nurse leaders were also given homework, which consisted of targeted implementation of ideas or concepts presented in the educational portion of the sessions on their nursing units, thereby ensuring competency attainment and retention. Step 4: Collect data and evaluate the sustainability of EI education and competency attainment. Data were collected during the first session and again at the completion of the last (fifth) coaching session. There was an ongoing dialogue regarding the sustainability of the project. Sustainability is often influenced by the organization's social, cultural, economic, and political environment.21 Equipping nurse leaders with a higher level of EI is a proven tool to improve the work environment. The results of the data collection were identified as potential support for continuing the project. In addition, subsequent positive outcomes in staff engagement, turnover, and other metrics were determined to be an effective countermeasure in dealing with the challenges of sustainability at the organizational level. INSTRUMENT Data were collected using a self-reported survey. The survey tool consisted of four parts: a biographical/demographic section, a tool for measuring EI, a turnover intention scale, and a resilience scale. Biographical data included age, sex, marital status, and years of nursing experience (tenure) as a nurse. The Wong and Law Emotional Intelligence Scale (WLEIS) was used to measure emotional intelligence.22 The WLEIS is a 16-item survey using a 7-point Likert-type scale that measures four domains (use of emotion, self-appraisal of emotions, others' emotional appraisal, and regulation of emotion). The Cronbach alpha ranges from 0.76 to 0.89, demonstrating acceptable reliability.22,23 Gurgan developed the resilience scale in 2006 that was used in this project.24 The scale consists of 25 questions, with each statement rated on a 7-point Likert-type scale (ranging from strongly disagree to strongly agree). Cronbach alpha ranges from .87 to .95.24 Additionally, the Turnover Intention Scale was used to measure turnover intentions on a 5-point Likert-type scale ranging from 1 (strongly disagree) to 5 (strongly agree). The scale is reliable and has a Cronbach alpha of .89.25 PROGRAM OUTCOMES Survey data analysis was performed using the Statistical Package for Social Sciences (IBM SPSS) version 27.0 software. Due to the small sample size, descriptive analysis was chosen for project evaluation. The presession survey was coded as T1, and the postsession survey (after all five sessions) was coded as T2. The project was approved by the institutional review board as a quality improvement project. There were 17 nurse leaders who began the 10-month series, and 14 of them completed the sessions. Data from nurse leaders who completed the sessions were used in the analysis (see Table 1). Most nurse leaders completing the sessions were between the ages of 45 and 54 (n = 6), with only one participant younger than 35. Respectively, most nurse leaders had 16 to 20 years of nursing experience (n = 6) and 6 to 10 years of management experience (n = 6). Nearly 86% were female (n = 12), and two males participated (14%). Most participants were Hispanic/Latino (71.5%, n = 10). TABLE 1: - Demographic data (N = 14) Variable n % Age (years) 25-34 1 7.1 35-44 5 35.7 45-54 6 42.9 55-64 2 14.3 Sex Female 12 85.7 Male 2 14.3 Race Hispanic/Latino 10 71.5 White 3 21.4 Did not answer 1 7.1 Marital status Single 3 21.4 Married 10 71.5 Divorced 1 7.1 Tenure as RN (years) 6-10 3 21.4 11-15 3 21.4 16-20 6 42.9 20+ 2 14.3 Management experience (years) 1-3 4 28.6 4-5 3 21.4 6-10 6 42.9 11-15 1 7.1 Intent to leave Turnover intent was divided into two categories: those with no intent to leave and those with an intent to leave. The mean scores for all variables are found in Table 2. The mean score for the question “I have no plans to leave” at T1 and T2 were 3.07 (SD = 1.14) and 4.07 (SD = 0.91), respectively. The higher score in this measure indicates an increased intent to stay when measured from T1 to T2. The mean scores for the questions related to “I plan on leaving in (1, 2, 5 years)” or “I wish I could leave” were grouped together, displaying a mean of 2.36 (SD = 0.91) and 2.01 (SD = 0.90) at T1 and T2, respectively. The lower score for T2 in the measure of intent to leave indicates a reduction in the nurse leader's intent to leave the organization. TABLE 2: - Mean scores (N = 14) Survey Mean SD SEM Turnover intent (yes) T1 2.36 0.91 0.25 T2 2.01∗ 0.90 0.24 Turnover intent (no) T1 3.07 1.14 0.30 T2 4.07∗ 0.91 0.24 Resilience average T1 147.71 7.13 1.91 T2 148.93∗ 7.3 1.88 Emotional self-appraisal T1 5.70 0.60 0.16 T2 5.86∗ 0.41 0.11 Others' emotional appraisal T1 5.87 0.70 0.19 T2 5.96∗ 0.34 0.09 Use of emotion T1 6.12 0.56 0.15 T2 6.23∗ 0.46 0.12 Regulation of emotion T1 5.44 0.75 0.20 T2 6.01∗ 0.51 0.13 EI average T1 5.78 0.55 0.15 T2 6.02∗ 0.32 0.09 Key: T1 = First survey (presession); T2 = Second survey (postseries)∗Indicates that the T2 score represents an improvement in the measured variable compared with the T1 score. Resilience The cumulative resilience scores for each nurse leader were ranked as low, moderate, moderately high, and high.24 The average nurse leader scores were 147.71 (SD = 7.13) and 148.93 (SD = 7.03) for T1 and T2, respectively, indicating moderately high resilience levels. Individual scores for T1 indicate four nurse leaders had a moderately high level of resilience, with the others scoring at a high level. There was a slight change at T2, with three participants reporting moderately high resilience levels and the others scoring in the high resilience level. There was an overall increase in the mean scores for resilience between T1 and T2. EI EI average is the cumulative average from four categories measured: emotional self-appraisal, others' emotional appraisal, use of emotion, and regulation of emotion (see Table 2). Of the four categories, the lowest scoring area for T1 was regulation of emotion, and the highest scoring area was the use of emotion. The use of emotion remained the highest scoring category for T2. However, the lowest scoring area changed from regulation of emotion to emotional self-appraisal. An increase in the EI average (mean of all four categories) was noted from T1 to T2. DISCUSSION Nursing is a challenging and stressful career. The nurse leader role has additional responsibilities, making it arguably one of the most challenging roles in nursing. The project's first goal was to determine if education and coaching on EI would improve nurse leaders' EI. All four components of EI measured demonstrated increases in the mean scores. These results correspond to prior studies.12,13 Kozlowski and colleagues11 conducted a one-time or single training workshop with nurses, demonstrating an increase in mean EI scores. One difference between the Kozlowski and colleagues study and the current project is that the former study provided one-on-one follow-up with participants 2 weeks after training.12 Hurley and colleagues found that nursing students with EI training reported an improved ability to handle emotional and psychological demands in patient care compared with those students who had no training.13 However, the increase in compassion scores was statistically significant, whereas the increase in EI scores wasn't significant. All four EI competencies increased from T1 to T2. The greatest increase was in the competency of regulation of emotion. Based on findings from the literature, more one-on-one coaching and cognitive rehearsal would be beneficial to improve emotional regulation. The second goal of the project was to determine if increases in EI would result in subsequent increases in resilience scores. Current literature has reported strong correlations between EI and resiliency.9,13,17,18 The current project findings support this goal. There was an increase in both EI and resilience from T1 to T2. Results from a study conducted on competence development and career sustainability found that acquiring knowledge and competence significantly improved career longevity and perceptions of success.21 Career longevity may be another benefit from EI development and competence. The current project reports improvements in EI and resilience scores from T1 to T2. Similarly, Mao and colleagues found a 12% change in resilience scores post EI training.11 The current project had an improvement in scores but didn't meet the 12% threshold. One reason may be the high resilience scores reported by nurse leaders at T1. Montgomery and Patrician also found high baseline resilience scores among nurse leaders in their study, with leaders consistently ranking moderately to highly resilient.26 In the current project, one leader moved from moderate-high resilience to high resilience following education/coaching, indicating a 7.2% change. The project's third goal was to determine if higher resilience and EI would lead to a higher intent to stay. The average or mean scores for resilience and for nurse leaders who indicated no turnover intent increased from T1 to T2. Several links among turnover, resilience, and EI can be found in current literature. A study on team culture found significant correlations between leader EI and turnover retention.1,15 Resilience is also linked with intent to stay. A study of new graduates found higher levels of resiliency decreased turnover intent.14 The nurse leader resiliency levels in the current study were high in T1, which could explain why the improvement in resiliency wasn't as substantial as in the other measures. However, turnover intent decreased 14.83% and no turnover intent increased 24.57% post-EI education/coaching, which is a positive indication that EI competence may impact turnover. Limitations As with all self-reported survey tools, there's a concern about participants reporting results that are reflective of higher levels of function or are more socially acceptable. This may be a particular concern when the questions relate to emotions and emotional reactions. Smaller sample sizes and the use of a single location are acceptable for exploratory or pilot studies. However, the findings have limited generalizability. IMPLICATIONS FOR PRACTICE Nursing leadership roles are pivotal in meeting organizational goals and ensuring organizational success. Thus, healthcare organizations should implement strategies that promote nurse leader resilience because nurse leaders have the potential to influence, negatively or positively, nursing practice and, consequently, the quality of patient care. Organizations must be cognizant of EI in their current leadership team and in potential recruits. EI can be developed, and organizational awareness of current leader competence can determine the need for ongoing EI coaching. As projected needs for nurses grow, an emphasis on the retention of skilled nurses and nurse leaders will be vital. The challenge of promoting a healthy workplace to retain a skilled nursing workforce is a pivotal function of the nurse leader. An increase in resilience can impact turnover intention.26 Improving EI competency through ongoing coaching is one strategy that organizations can employ to retain competent nurse leaders. A study of nurse leader turnover found that mentorships promote individual career development and retention. Including EI coaching as a part of a mentorship program can promote the mentor-mentee relationship and may reduce turnover intent. This project demonstrates the importance of EI as it impacts resilience in nursing leadership. Through education and coaching, EI traits and skills can be developed in nursing leaders, thus improving nurse leader competence. Strategies such as cognitive rehearsal can further equip nurse leaders to deal with stressful and emotionally charged situations. The with coaching and competencies in nurse leaders is small compared with the potential impact on nursing and the organization. EI This project investigated the use of EI and impact on EI resilience, and turnover intent among nurse leaders in an acute care facility. The project and current knowledge in two found improvement in both EI and resilience scores. Nurse leaders demonstrated higher EI scores after In addition, resilience scores Resilience has been with lower and the current nursing workforce needs to be a given the projected need for nurses in the EI skills and competencies can be taught and This has for both nursing leadership and for direct care a workforce will improve outcomes from the of the and organization.