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Emotional Intelligence in Healthcare

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Effective nursing leadership in organizations requires numerous talents, skills, and competencies and types of knowledge. At its core, leadership is about relationship with other people. Leaders’ accomplishments are largely achieved through the individual and coordinated efforts of others. Without followers, there are no leaders.

Leadership research has expanded our traditional understanding by focusing on leadership behaviors at different levels and within different functional areas of organizations: • women’s leadership styles,

• leader diversity as a competitive advantage to organizations, • multicultural and global leadership,
• the role of leaders in attaining safety and quality outcomes, • an acknowledgement that “no one size fits all” practicing leaders.

What is Emotional Intelligence (EI)?

Emotional intelligence is defined as “the capacity for recognizing our own feelings and those of others, for motivating ourselves, and for managing emotions well in ourselves and in others.” Emotional intelligence includes capabilities distinct from, but complimentary to, intelligence or the purely cognitive measured by intelligence quotient.

Emotional competence is defined as “learned capabilities based on emotional intelligence that contribute to effective performance at work.” Emotional intelligence has been found out to matter twice as much as intelligence quotient and technical skill combined in producing superior managerial job performance (according to Goleman and his associates in The Hay Group of Boston).

Emotional intelligence develops in humans as a result of genetic inheritance and the socializing intelligence of childhood, adolescence and adulthood; emotional competence is a result of emotional intelligence plus opportunities we have to develop related competencies.

The nursing profession requires a high degree of emotional labor – the ability of nurses to regulate their own emotions and the expression of emotions for the sake of their patient’s needs. Nurses are expected to display emotions that convey caring, understanding and compassion toward patients while regulating their emotions

The role of nurse leaders become “in creating a supportive and positive working environment to help nurses cope with the stress managing their own others’ emotions” concurrently.

The ANA defines a nurse administrator as one who “orchestrates and influences the work of others in a defined environment… to enhance the shared vision of the organization” and identifies emotional intelligence as one of the nine frameworks of administrative practice.


The emotional intelligence framework consists of 2 dimensions: the ability to understand and manage oneself and the ability to understand and relate with others. These dimensions are further subdivided into self-awareness and self-management and social awareness and relationship management.

Self-awareness can be considered the inner barometer, or rudder, people have to understand and direct the moment-to-moment and situation-situation variation in emotional internal emotions. Self-management extends one’s emotional intelligence by allowing for self-control of emotions, maintenance of one’s integrity and adaptability to emerging situations.

Without a solid base of self-understanding, self-control, emotional security, trustworthiness and adaptability, it is virtually impossible to open to others and constructive in work relationships. Thus, good leaders must know themselves well and be able to choose how they will respond in social situations.

Social awareness and relationship management are qualities which are considered “social radar” – the ability to understand others and work with them productively.

Social awareness is grounded, most directly, in skills of empathy: sensing others’ feelings, needs, and concerns and taking an active interest in them. Relationship management encompasses competencies in inspiring and influencing others, visioning, developing others, collaboration and teamwork, leading change initiatives and managing conflicts.

The Five Components of Emotional Intelligence at Work

What distinguishes great leaders from merely good ones? It isn’t IQ or technical skills, says Daniel Goleman. It’s emotional intelligence: a group of five skills that enable the best leaders to maximize their own and their followers’ performance. The EI skills are:

a. Self-Awareness
People with strong self-awareness are neither overly critical nor unrealistically hopeful. Rather, they are honest— with themselves and with others. People who have a high degree of self-awareness recognize how their feelings affect them, other people, and their job performance.

Self-awareness extends to a person’s understanding of his or her values and goals. A person who lacks self-awareness is apt to make decisions that bring on inner turmoil by treading on buried values.

How can one recognize self-awareness? First and foremost, it shows itself as candor and an ability to assess oneself realistically. People with high self-awareness are able to speak accurately and openly—although not necessarily effusively or confessionally—about their emotions.

Self-aware people know their limitations and strengths, and they often demonstrate a thirst for constructive criticism.

Self-aware people can also be recognized by their self-confidence. They have a firm grasp of their capabilities and are less likely to set themselves up to fail.

b. Self- Regulation
Self-regulation, which is like an on-going inner conversation, is the component of emotional intelligence that frees us from being prisoners of our feelings.

Why does self-regulation matter so much for leaders? First of all, people who are in control of their feelings and impulses are able to create an environment of trust and fairness. In such an environment, politics and infighting are sharply reduced and productivity is high.

Second, self-regulation is important for competitive reasons. Everyone knows that business today is rife with ambiguity and change. When a new program is announced, they don’t panic; instead, they are able to suspend judgment, seek out information, and listen to the executives as they explain the new program.

The signs of emotional self-regulation, therefore, are easy to see: a propensity for reflection and thoughtfulness; comfort with ambiguity and change; and integrity—an ability to say no to impulsive urges.

c. Motivation
If there is one trait that virtually all effective leaders have, it is motivation. They are driven to achieve beyond expectations—their own and everyone else’s. The key word here is achieve.

How can you identify people who are motivated by the drive to achieve rather than by external rewards? The first sign is a passion for the work itself—such people seek out creative challenges, love to learn, and take great pride in a job well done.

People with high motivation remain optimistic even when the score is against them. In such cases, self-regulation combines with achievement motivation to overcome the frustration and depression that come after a setback or failure.

Leaders trying to recognize high levels of achievement motivation in their people can look for one last piece of evidence: commitment to the organization. When people love their jobs for the work itself, they often feel committed to the organizations that make that work possible.

It’s not difficult to understand how and why a motivation to achieve translates into strong leadership. If you set the performance bar high for yourself, likewise, a drive to surpass goals and an interest in keeping score. And of course, optimism and organizational commitment are fundamental to leadership.

d. Empathy
Of all the dimensions of emotional intelligence, empathy is the most easily recognized. But empathy doesn’t mean a kind of “I’m OK, you’re OK”. It doesn’t mean adopting other people’s emotions as one’s own and trying to please everybody. Rather, empathy means thoughtfully considering employees’ feelings—along with other factors—in the process of making intelligent decisions.

Leaders with empathy do more than sympathize with people around them: They use their knowledge to improve their companies in subtle but important ways.

e. Social Skill
The first three components of emotional intelligence are self-management skills. The last two, empathy and social skill, both concern a person’s ability to manage relationships with others. As a component of emotional intelligence, social skill is not as simple as it sounds. Social skill is friendliness with a purpose: moving people in the direction you desire, whether that’s agreement on a new marketing strategy or enthusiasm about a new product.

Socially skilled people tend to have a wide circle of acquaintances, and they have a knack for finding common ground with people of all kinds—a knack for building rapport. It means they work according to the assumption that nothing important gets done alone.

Social skill is the culmination of the other dimensions of emotional intelligence. Socially skilled people, for instance, are adept at managing teams—that’s their empathy at work. Likewise, they are expert persuaders—a manifestation of self-awareness, self-regulation, and empathy combined. And motivation makes such people excellent collaborators.


Emotional competencies are developed from life experiences in combination with an individual’s innate emotional intelligence.

18 work competencies constitute the emotional intelligence framework. Four clusters – self-awareness, self-management, social awareness and relationship management – contain list of emotional competencies relevant to self and others. Five of which are core competencies on which all the other competencies depend: • For knowing and managing oneself: Emotional self-awareness, Accurate self-assessment, Self-confidence and Emotional self-control • For working with others: Empathy

The upper left are the competencies of self-awareness: emotional self-awareness, accurate self-assessment, and self-confidence. They are the foundation for effective leadership.

Self-awareness is a prerequisite for the social competency of empathy. The individual who is emotionally self-aware or has accurate self-assessment knows his or her own strength and weaknesses and is comfortable “owning” them around people. Comfort with one’s own capabilities, values and skills leads to self-confidence and the potential for behavioral integrity. Any leader in today’s health care settings needs to have some “toughness” to survive; self-confidence is a core component of a good survival strategy. In the lower left cell shows the capacity for good self-management, including the emotional competencies of emotional self-control, transparency, adaptability, the drive to achieve, initiative, and optimism.

Emotional self-control prevents us from being hijacked from our feelings but it does not imply that the expression of all our emotions at work is undesirable. The key to self-control is that the individual is aware of his or her own feelings and makes a choice as to whether to express them or as to keep them submerged in view.

Transparency – being honest, open, trustworthy and authentic – is the competency that most supports an individual’s integrity. Transparent leaders can be depended on and trusted. They model ethical behavior. Trust in a leader gives rise to positive emotions in employees, and positive emotions are what attach people to their work.

The emotional competency of adaptability enables leaders to be flexible in changing situations or in overcoming obstacles to getting the work done. It provides for emotional resilience in the face of multiple demands, complex situations, shifting priorities and painful realities. Because healthcare organizations are complex, fast moving and concerned with the health of humans, adaptability is important for any nurse leader, but equally knows those areas in which existing practices should be maintained.

The ability to harness internal motivation, the readiness to take responsibility and to persist, and the drive to stretch for high performance, take risks and accomplish goals typify leaders high in achievement orientation and initiative. High achievers are inwardly directed holding challenging standards for themselves.

In health care, high achievers/initiators operate in a constant state of readiness. They are frequently results oriented and focus on performance improvements by mobilizing themselves and others.

An optimistic leader is the one who carries a “can do” attitude and who persist despite obstacles and setbacks. Optimism enables a leader and his or her employees to learn from mistakes and move forward. He or she is a carrier of hope.

The upper right cell shows the competencies of social awareness: empathy, social awareness, and service orientation. As a core competency, empathy provides the foundation for the two remaining competencies in this cell as well as the ability to manage relationships.

Empathy is a “sine qua non of all social effectiveness in working life”, a critical competency of working with a diverse group of people and those from different cultures.

Political astuteness, a competency of organizational awareness derives from being attuned to individuals, groups and organizational power dynamics; and knowing how to use other people and processes to advance one’s own interests. It is found out that the competency of organizational awareness is best learned through mentoring experiences with politically gifted leaders. Service orientation draws on the ability of the leader to grasp the customer’s perspective and to create actions to that perspective. He or she seeks ways to increase satisfaction and loyalty.

The lower right cluster lists the emotional competencies of relationship management; these too are built on a foundation of the core competencies of emotional self-awareness, accurate self-assessment, self-control, self-confidence and empathy. These too are built on the foundation of the core competencies.

Healthy organizations cultivate formal and informal leadership throughout the system by developing leaders. Like for example, a nurse executive play a pivotal role in the development of a nurse manager.

To guide others, leaders must first have a clear sense of their own direction, values and priorities. Inspiring leaders rely on core values to orient decisions; they are intentional and authentic, leading by example, whether supporting people through day-to-day challenges or episodes of difficult change. Any leader in health care is a change agent: it comes with the job. Most health care leaders essentially lead change all the time. The best change agents do not give ultimatums; they use competencies to give employees and lead successful change efforts. Because change is always occurring, the skills and abilities of change managers need to be fully integrated into the daily practices of managers.

The desire to influence can be directed at individuals or groups. Influence skills are built on self-awareness and empathy – being in touch with your own priorities and sensing how others are likely to respond, and then fine tuning your appeal to engage others. The persuasive leader intentionally uses his or her emotions and body language to affect the emotions of others.

Managing conflict in organizations can include such actions as intervening in interpersonal or group frictions, confronting one’s boss and addressing interdepartmental conflicts. It is one of the most demanding of emotional intelligence competencies.

Teamwork is one of the most consistently valued attributes of managers. Teamwork and collaboration are related to the emotional intelligence of the groups and are the means by which all work is accomplished in health care organizations. Collaborative styles typically reflect an equal focus on task accomplishment and concern for relationships.

As a result of synergies of “social intelligence” well-functioning teams consistently outperform the contributions of skilled individuals. Combined talents and knowledge on a healthy team interactively and unpredictably catalyze the best in everyone. Thus leaders who are good team builders and facilitators greatly enhance work performance while generating an atmosphere of friendly collegiality.

It is important to note that all forms of interactions at work needs to be considered relevant to emotionally intelligent behaviors. This means that all forms of communications are all improved by the same sensitivities that the emotional competencies employ.

No leaders, good or bad, have equal strengths or equal weaknesses in all 18 emotional competencies. Leaders and managers have their own unique constellations of the components of emotional intelligence.


All emotional competencies can be learned and developed. The 5 core competencies are fundamental and therefore the most important. A leader deficient in the core competencies will encounter difficulty mastering any of the remaining 13 competencies.

Developing emotional competencies first requires an awareness of areas of strength and weakness and then an identification of what an ideal behavior would be in a targeted area of weakness.

|Steps to Developing Emotional Competencies

Source: Based on research conducted by Goleman, 1995, 1998a; Goleman et al., 2002; The Hay Group 2004. |

Behavior change is most effective when it comes to activities in the individual’s work life that are most in need of and likely to show improvements. Self-development in such situation might focus on self-awareness and self-confidence.

Change in behaviors driven by emotional habits requires that as we practice new behaviors, we actively seek to unlearn the old behaviors. The old behaviors become a source of resistance and backsliding unless they are identified, acknowledged and actively transformed. This kind of change depends on the ability to engage one’s own emotions in order to change them.

Behavior change requires practice, typically sustained over weeks and months – often up to 6 months – to develop a new competency. Supplementary activities can facilitate behavior change. Finally, even without intentional behavioral change, there is evidence that humans intuitively develop emotional competencies with age and experience.


Emotional Intelligence often referred also as Emotional Intelligence Quotient is the ability of an individual to perceive, assess and manage emotions of his own self and of other people. Emotional Intelligence has four main components, namely, the ability to:

1. Perceive emotions;
2. Utilize these emotional perceptions to accomplish various activities or tasks;
3. Understand emotional variations; and
4. Manage emotions to achieve goals.

The nursing profession demands that the nurse, in the process of care, has to interact with the patients, the medical fraternity and the health care workers constantly. Hence, “Nurse-Patient Interaction” is the pulse of the nursing practice. This interaction is not just conversation.

The concept of emotional intelligence has grown in popularity among nurses over the last two decades, generating interest both at a social and a professional level (Dawn Freshwater and Theodore Stickley, 2004). Today, patient care not only includes quality medical care but also a care concept that encompasses respecting patient’s goals, preferences and choices, obliging their emotional, social and spiritual needs using the strengths of interdisciplinary resources.

Thus, care cannot be confined to the physical aliment but also the psychological and spiritual needs. Hence, the role of Emotional Intelligence in the nursing profession should be viewed in two dimensions:

1) The Nurse’s perception and understanding of the patient’s emotions, and 2) The Nurse’s utilization of these perceptions to achieve the goal of managing complex situations towards quality patient care.

It should be recognized that the nurses are confronted not only by the patient emotions but also their own. Nurses have to confront and manage their own emotions also in situations, where, some terminally ill patients request for assistance for suicide.

Advantages of Application Of Emotional Intelligence in Nursing Practice

Studies conducted to examine the role of perceived emotional intelligence (PEI), in the use of stress-coping strategies, in the quantity and quality of social support and in the mental health of nursing students have shown that emotional intelligence minimizes the negative stress consequences (Montes & Augusto ,2007).

Anne (2004), by a literature review concludes that the modern day demands of nursing depend on the skills of emotional intelligence to achieve a patient centered care. There is no doubt that Emotional intelligence in nursing leads to more positive attitudes, greater adaptability, improved relationships and increased orientation towards positive values (Kristin and Elisabeth, 2007).

The study has highlighted the nurse relationship with the patient, supervision, motivation and responsibility are important factors in Emotional Intelligence.

It should be recognized that emotional competencies are not mere innate talents, but learned capabilities that must be developed to achieve outstanding performance (Goleman, 2001). Nursing empathy, the ability of the nurse to perceive and reason, as well as the capacity to interact are seen as core characteristics of a nurse to build relationship with the ill (Reynolds et.al, 2000) towards care.


The nurse manager’s leadership behaviour has been implicated as the interaction most likely to improve retention of hospital staff nurses because of the manager’s ability to improve job satisfaction (Andrews & Dziegielewski 2005).

The importance of EI in the profession of nursing involves studying how the level of EI of nursing leaders impacts the level of job satisfaction and, therefore, retention of their employees. Currently, there is a gap in the knowledge regarding the impact of EI levels of nursing leaders and the relationship with job satisfaction of nursing staff (Cadman & Brewer 2001).

The model of “Emotional Intelligence of Managers as Leaders” identifies four skills or abilities for the emotionally intelligent manager. George (2000) and others (Mayer et al. 1999) summarize the four dimensions of EI as: the perception of emotion, the integration and assimilation of emotion, knowledge about emotions, and management of emotions.

1. The first ability is the accuracy with which an individual can identify emotions and emotional content in their own thoughts and in other people. It is how an individual can express emotions accurately, and discriminate between accurate and inaccurate feelings.

2. The second ability is concerned with emotional acting or intelligence and describes emotional events that assist intellectual processing. The individual can prioritize thinking by directing attention, and generating emotions to assist judgment. 3. The third ability is the ability to utilize emotional knowledge. It is the ability to label and recognize relations among emotions, and interpret meanings that emotions convey, as well as understand complex feelings.

4. The fourth ability is the conscious regulation of emotions to enhance emotion in intellectual growth. It is the ability to stay open to feelings, engage or detach from an emotion, and reflectively monitor emotions (Caruso & Salovey 2004).

Health care leaders are charged with the responsibility of meeting the needs of staff by helping them to develop better interpersonal and communication skills, while at the same time becoming more democratic and humanistic themselves (Vitello-Cicciu 2002).

Successful health care organizations focus on enhancing the self-awareness, self-management, social awareness, and social skills of their leaders (referred to as EI). EI is perhaps the most relevant clue for nurses about what makes a superior leader; the leader’s role is getting others to do their job more effectively (Snow 2001).

According to Segal (2002), EI is essential for social and spiritual competency in any field, but can be more important in health care where feelings affect individual as well as institutional health. Health care leaders who are emotionally intelligent can improve the health of the institutions at many levels, beginning with their own employees. Leaders need to be aware of their own feelings and emotions to enable them to accurately identify the emotions of the group and of individual followers, to express emotions accurately, and to differentiate between honest and phony emotional expressions.

According to Caruso et al. (2002), using emotions allows leaders to understand and motivate others through expression of multiple perspectives that can enable planning and engagement of employees in activities. Managing emotions allows leaders to deal with the stress of failure or decisions leading to poor outcomes. Leaders with more effective coping strategies are able to deal with the emotion itself, instead of the cause, such as with denial (Caruso et al. 2002).

Health care is thought to have leaders with high EI because of the nature of the profession and the necessity of dealing with the fact that the most significant problems facing society are health related. Therefore, health administrators and managers must contend with providing a quality service to their customers during a period of limited fiscal and human resources (Freshman & Rubino 2002).


The investigation of EI in relation to healthcare was primarily conducted in the areas of patient care and medical education. EI has been shown to lead to higher patient satisfaction and improved clinical performance.

Akerjordet and Severinsson (2004) concluded, “EI integrates important personal and interpersonal skills, which can lead to flexibility in handling change and better quality of care in the future, creating a more humanistic, compassionate and healing environment within health care”.

McMullen (2002) stated that, “Since emotional problems account for about 30% of general practice consultations, it is reasonable to expect that a doctor would learn about emotional intelligence during training”.

Several studies have provided evidence that empathy, a key component of EI, actually declined in medical students during the course of their medical education and was considered difficult to develop. Empathy is most often demonstrated through the interpersonal communication between patient and physician (Hojat, et al., 2002). The ability to communicate effectively is important, not only in clinical settings but also in administrative settings.

The value of EI to healthcare administration has been investigated and described as, “fundamental for getting along in the workplace and is a primary leadership and managerial competency”.

The Value of EI in Healthcare Leadership Practice

EI is the ability to recognize one‘s own emotions, sense emotional input from others, and react appropriately to that input (Noland, 2008). The concept of EI is tightly linked to IQ (Goleman, 1995) hence EI has also been called Emotional Quotient or EQ (Bar-on, 1988). Currently, there are three major conceptual models of EI (Spielberger, 2004).

The first was presented by Salovey and Mayer (1990). Salovey and Mayer 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”. Essentially, EI was the ability to process emotional information.

Mayer, Salovey, and Caruso (2000) continued to develop the theory and eventually presented a four branch model of EI.

1. The first branch, emotional perception and identification, ―involves recognizing and inputting information from the emotional system.

2. The second and third branches, emotional facilitation of thought and emotional understanding, involve the further processing of emotional information with an eye to problem solving.

3. The fourth branch, ―emotion management, concerns emotional self-management and the management of emotions in other people.

The second significant conceptual model of EI was offered by Bar-on (1988). Bar-on (1988) proposed EI, called EQ in Bar-on‘s research, as a mix of personality traits or abilities.

EI Model: Bar-on
|Sub-scale |Definition | |Self-Regard (SR) |Ability to be aware of, understand, accept, and respect oneself | |Emotional Self-Awareness (ES) |Ability to recognize and understand one‘s emotions | |Assertiveness (AS) |Ability to express feelings, beliefs, and thoughts and to defend one‘s rights in a | | |non-destructive manner | |Independence (IN) |Ability to be self-directed and self-controlled in one‘s thinking and actions and to be free of | | |emotional dependency | |Self-Actualization (SA) |Ability to realize one‘s potential and to do what one wants to do, enjoys doing, and can do | |Empathy (EM) |Ability to be aware of, understand, and appreciate feelings of others | |Social Responsibility (RE) |Ability to demonstrate oneself as cooperative, contributing and constructive member of one‘s | | |social group | |Interpersonal Relationships (IR) |Ability to establish and maintain mutually satisfying relationships that are characterized by | | |emotional closeness, intimacy, and by giving and receiving affection | |

Stress Tolerance (ST) |Ability to withstand adverse events, stressful situations and strong emotions without ―falling | | |apart‖ by actively and positively coping with stress | |Impulse Control (IC) |Ability to resist or delay an impulse, drive, or temptation to act, and to control one‘s emotions| |Reality Testing (RT) |Ability to assess the correspondence between what is internally and subjectively experienced and | | |what externally or objectively exists | |Flexibility (FL) |Ability to adjust one‘s feelings, thoughts, and behavior to changing situations and conditions | |Problem Solving (PS) |Ability to identify and define personal and social problems as well as to generate and implement | | |potentially effective solutions | |Optimism (OP) |Ability ― to look at the brighter side of life‖ and to maintain a positive attitude, even in the | | |face of adversity | |Happiness (HA) |Ability to feel satisfied with one‘s life, to enjoy oneself and others, and to have fun and | | |express positive emotions |

(Bar-on, pp. 365-366)

The third significant conceptual model of EI was developed and popularized through a series of books and articles by Goleman. Goleman‘s model mixed abilities and personality traits.

Goleman (2006) further refined the EI construct by distinguishing between emotional and social intelligence. Goleman proposed that earlier EI models which included social intelligence competencies did not accurately represent the complex interactions in human relationships.

Goleman’s Social Intelligence Model
|Social Awareness—referred to a spectrum that runs from instantaneously sensing another‘s inner state, to understanding feelings and thoughts, to ―getting‖ | |complicated social situations. It included: | |Primal empathy: Feeling with others; sensing non-verbal
emotional signals. | |Attunement: Listening with full receptivity. | |Empathic accuracy: Understanding another person‘s thoughts, feelings, and intentions. | |Social cognition: Knowing how the social world works. | |Social Facility—sensing how another feels, or knowing what they think or intend, does not guarantee fruitful interactions. Social facility builds on social| |awareness to allow smooth, effective interactions. The spectrum of social facility included: | |Synchrony: Interacting smoothly at the nonverbal level. | |Self-presentation: Presenting ourselves effectively. | |Influence: Shaping the outcome of social interactions. | |Concern: Caring about others‘ needs and acting accordingly. |

(Goleman, 2006)

developing Emotional Intelligence for Health care leaders

Skills in emotional intelligence (EI) help healthcare leaders understand, engage and motivate their team. They are essential for dealing well with conflict and creating workable solutions to complex problems. EI skills are grounded in personal competence, upon which build the skills for social competence, including social awareness and relationship management.

Tools required for healthcare leaders to succeed generally fall into two categories: hard and soft (Klaus 2008). • For physicians in particular, but also for many other healthcare leaders, “hard skills” are the technical skills traditionally emphasized in training. • The “soft skills” are more nuanced and include interpersonal and communication skills and professionalism which, until recently, have received far less attention in formal training for either medicine, nursing or healthcare administration.

Emotional Intelligence, sometimes referred to as EI, or emotional quotient (EQ), as a differentiated construct is made up of the personal-emotional-social components of general intelligence. By contrast, EQ generally refers to a quantification of skills in practice, and in particular to measures of emotional intelligence captured by commonly used psychological assessment instruments.

In practice leaders can only get things done by working with and through others. At all levels, leaders set the EI culture in their enterprise and this culture directly impacts patient relationships, staff morale, turnover, and relationships with colleagues.

Poor application of EI in healthcare settings specifically will harm the organization’s reputation, its patient care, and increase staff turnover, all of which can impact financial health. Clearly EI is a foundational skill that is a pre-requisite for good leadership in healthcare situations.

EI skills are essential tools for healthcare leaders since they enable groups to advance interests that serve the team. These skills are crucial because healthcare is rarely delivered in isolation of the rest of a team. Emotional Intelligence is a strong tool for building bridges and alliances and, importantly, for repairing those relationships when they are damaged. Leaders in healthcare and public health must realize the challenging nature of distributing scarce resources in difficult times: relationships can become frayed due to internal competition for those resources, recognition, or opportunity.

While EI skills might not be innate, they can be developed, learned and taught. When engaging in leadership development of healthcare leaders, regardless of the discipline, basing skill development on both a theoretical and practical basis of EI skills is crucial (Pagnini 2009). Two components should be taken into consideration: the development program itself, with the elements of skill development incorporated, and the desire of the participant to learn and grow.

For EI self-improvement in our work, the foci are personal competence and social competence. Personal competence is characterized by a broad range of abilities, including how one perceives and expresses oneself, makes decisions and manages stress. In our construction of development programs and coaching these basic skills serve as the foundation for social competence, which itself is comprised of social awareness and relationship management.

This model is the foundation for leadership skills development work with healthcare and other leaders. This model has been inspired by and adapted from the research of Goleman, Bar-On, Stein, and others (Figure 1).

1. Personal competence
Personal competence is the foundation of EI and is characterized by knowing, understanding and expressing oneself. In many ways these skills successively build on one another, with skills in self-perception being necessary for those in self-expression, and those serving as a basis for stress management. Stress management, itself helps lay the groundwork for skills in decision making. In this way, our model is a “stacked” one, in which some skills create leverage points for the development of others.

a. Self-Perception – is an essential component required for effective EI skill development and consists of:

• Self-regard – is “the ability to respect and accept (one) self as basically good” and that one has strengths and weaknesses. The ability to maintain respect for oneself and to identify with ethically grounded principles and values while facing the common difficulties of life, or even failing at some of them, is key to maintaining integrity of self, personal identity, and a feeling of self-confidence.

• Emotional Self-awareness – is the ability to understand how one is feeling and why. It further allows one to grasp the nuance of emotions and the potential “impacts they have on the thoughts and actions of oneself and others”. Understanding how one personally feels may help one to effectively support oneself and then be able to support others through difficult times.

• Self-actualization – is “the ability to lead a rich and meaningful life”, and an enjoyable life, through the willingness to persistently strive to improve oneself towards the maximum development of one’s abilities and talents. One can develop this ability through learning new skills (related or unrelated to clinical practice or administration) or through engaging in selfless activities that benefit others. Many find such personal fulfilment and meaning through volunteer, charity, or medical mission work.

b. Self-Expression – is the second core area of Personal Competence and contains three elements:

• Emotional Expression – is a constructive expression of emotions based in an ability to openly convey one’s feelings both verbally and non-verbally. The basic ability to perceive these emotions undergirds the ability to give expression to them. Poor skills in emotional expression leave one with either unexpressed or inappropriately expressed feelings, which can lead to isolation, disengagement, anger or unfounded anxiety.

• Assertiveness – is the ability to openly communicate feelings, beliefs, and thoughts and defend personal rights and values in a socially acceptable, non-destructive, non-offensive manner, and to maintain the ability to do so even if the stance taken is not necessarily admired or accepted by others as the norm. When done appropriately, assertiveness allows individuals to respectfully disagree with others and helps in the defense of deeply held beliefs without resorting to subterfuge. However, when assertiveness is misused individuals may be seen as blunt, abrasive, intimidating, and alienating.

• Independence – is being self-controlled and self-directed in one’s actions. Freedom from emotional dependency is central to independence, as is the ability to autonomously engage in decision making, planning and daily tasks.

c. Stress Management Skills – is characterized by the ability to weather difficult situations without becoming overwhelmed. As with the other dimensions of EI it also contains three sub-components:

• Optimism – is an indicator of one’s positive attitude and outlook on life. It is related to remaining resilient and hopeful despite occasional setbacks, and characterized by the ability to weather difficult situations without becoming overwhelmed. Optimism in the face of stress greatly facilitates learning from mistakes and is positively associated with success, both for the individual and for the group. Optimistic people are sure of themselves in most circumstances; believe they can stay on top of difficult situations through their ability to handle even upsetting problems.

• Stress tolerance – is the ability to withstand adverse events and stressful situations without falling apart by actively and positively coping with stress. Another term for stress tolerance is “resilience”. This method of coping can lead to burnout and failure to deliver on objectives, a major cause of derailment. Indecisiveness can also result from poor EI skill development in this area.

• Flexibility – is the ability to adjust one’s thoughts, emotions, and behavior to dynamic circumstances that are unpredictable or unfamiliar. Being able to see a situation objectively, as described below in reality testing, is related to the ability to capitalize on this EI skill of flexibility. This ability requires a keen flexibility of the mind. Additionally, flexibility allows the iterative process of seeing and embarking on a defined course, re-assessing its effectiveness, and re-directing beliefs and feelings in the light of data accordingly and as necessary.

d. Decision Making – is the fourth core area of Personal Competence, containing three sub elements:

• Reality Testing – is the capacity to remain objective by seeing things as they really are. The ability to recognize when emotions or personal bias can cause one to be less objective is key to this EI construct as well. This skill includes one’s ability to accurately and objectively “size up” a situation. Increased reality testing proficiency requires taking a step back from situations and refraining from making judgments about them, yet still confronting the truth and facts that are evident. Effective reality testing can include observing others by their actions and words, and considering the perspectives, needs, biases and beliefs that motivate them.

• Impulse Control – is the ability to resist or delay an impulse, drive or temptation to act. It involves managing a temptation, halting an angry or aggressive outburst, or avoiding a hostile or irresponsible behavior. Examples of poor impulse control include angry outbursts, emotional tempers, insensitive statements, vindictiveness, passive aggressiveness, incivility, or uncontrolled passions: these examples are hallmarks of poor emotional intelligence. Low impulse control can have serious implications for organizational culture and productivity.

• Problem Solving – is “the ability to find solutions to problems in situations where emotions are involved”. It involves generating and implementing potentially effective solutions that take into account how emotions impact decision making. Problem solving has seven steps, including identifying that a problem exists and gathering the necessary information about that problem (both subjectively and objectively). Subsequently, a list of solutions assessment/ analysis) are generated, and then the alternatives are evaluated. The next steps involve choosing an optimal solution and then implementing it (planning), followed by assessing the outcome.

2. Social competence
Social competence is a complex of social awareness and relationship management that allows a healthcare leader to understand the emotional tenor of her or his group, to communicate effectively and compassionately with members of the group, and to solicit input from them. The ability of healthcare leaders to manage relationships is crucial to their capacity to create impact in their organizations and communities—and for providers, with their patients.

a. Social Awareness – is the ability to understand the social networks and unspoken norms of a group, often through attending to both verbal and non-verbal cues. It is appreciating a group’s values and culture and considering the motivations, allegiances and stakeholders which affect others. Well-developed EI in this arena allows one to speak with tact and empathy, implementing skills in cultural competence and cultural elasticity. Skills in social awareness allow one to ask for the perspectives of others while listening attentively and non-judgmentally.

• Empathy – A subcomponent of Social Awareness that bridges to Relationship Management is empathy, which is the ability to recognize, understand, and appreciate the way others feel. Lack of empathy can cause a lack of trust from others or lack of confidence in the ability to confide in the leader.

• Interpersonal relationship –is also an EI skill that bridges the gap between Social Awareness and Relationship Management, and exists within the larger domain of Social Competence. This component is based on developing and maintaining mutually satisfying relationships that are characterized by trust and compassion.

b. Relationship Management – is the pinnacle of our EI pyramid: as the most sophisticated of the EI skills it relies heavily on the hierarchy of skills upon which it is built (Figure 1). In relationship management, one attends to and nurtures interactions with others to create an environment where group behavior can be directed towards a positive course and/or effectively meet difficult challenges. The ability to manage relationships fosters information sharing and creativity. Cultivating a positive emotional tone among the team, creating a safe environment where ideas can be shared non-judgmentally, and supporting members while fostering their cooperation will likewise further one’s relationship management skills and so improve team performance.

• Social Responsibility – reflects behaviors of willingly contributing to society, to one’s social groups, and generally to the welfare of others. It includes acting responsibly, having a social consciousness and showing concern for the greater community.

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