Patient safety is one of the most important challenges to nursing practice in the United States. The 1999 Institute of Medicine (IOM) report To Err Is Human: Building a Safer Health System revealed that up to 100,000 deaths were associated with medical errors each year.1 Much attention has since focused on improving patient safety. Despite these efforts, researchers at the Johns Hopkins University School of Medicine estimated that there are about 250,000 error-related deaths annually in the United States, making medical errors the third-leading cause of death.2 Because there is no systemic way to measure the incidence of death due to medical errors—death certificates do not list errors as a cause of death—the authors conclude that their estimate understates the scope of the problem.2
In a Joint Commission report of sentinel events that occurred between 2004 and 2015, errors in communication were a frequent root cause.3 The link between communication and errors has been discussed widely among nurses since publication of the IOM report,1 and some communication practices, such as those used by nurses during shift changes, have been examined more closely. However, there has been insufficient focus on the development of specific skills that could help nurses to “error proof” communication in the health care setting.
In this article, we propose that emotional intelligence—which refers to a person's ability to recognize and manage both her or his emotions and the emotions of others—may offer such a skill set. Although the relationship between emotional intelligence ability and patient safety has not yet been studied, research supports the relationship between safety and emotional intelligence in other fields; for example, in the construction industry.4 We will introduce the concept of emotional intelligence and focus on findings that suggest emotional intelligence abilities may influence individual performance, interpersonal relationships, and team function in ways that make patients safer. These findings will be discussed in the context of the Quality and Safety Education for Nurses (QSEN) project's competency standards5, 6—six statements modeled on the core competencies for all health care professionals that were included in the 2003 IOM report Health Professions Education: A Bridge to Quality.7 The QSEN competencies focus on patient-centered care, teamwork and collaboration, evidence-based practice, quality improvement, safety, and informatics.5, 6 Begun in 2005, the QSEN project is a collaborative effort by nurse leaders to integrate these QSEN competencies into undergraduate and graduate nursing education programs in order to ensure new nurses receive and attain “the knowledge, skills, and attitudes… necessary to continuously improve the quality and safety of the healthcare systems within which they work.”8
EMOTIONAL INTELLIGENCE IN THE WORKPLACE
An operational definition of emotional intelligence ability used widely in health care research was formulated by pioneers John D. Mayer and Peter Salovey, who described emotional intelligence in four parts: (1) the ability to correctly identify emotions in self and others; (2) the ability to use emotions to facilitate reasoning; (3) the ability to understand emotions; and (4) the ability to manage emotions in oneself and in emotional situations.9
Since its emergence as a concept more than 20 years ago, emotional intelligence ability has been acknowledged as a crucial skill set for success in the workplace. An industry white paper published in 2012 summarizes two decades of information about the impact of emotional intelligence ability in organizations, coming to this conclusion: “A clear body of evidence shows that Emotional Intelligence (EI), more than knowledge, technical skills or traditional measures of intelligence, determines individual effectiveness and successful business outcomes. This foundational competency differentiates high performers and propels leaders and organisations to higher and more sustainable levels of success.”10
A literature review of nursing emotional intelligence was done in 2007, focusing on emotional intelligence in nurse leaders.11 By that time, a foundation of hundreds of research studies on other professions had demonstrated clear evidence of the relationship between emotional intelligence ability and important workforce and workplace elements, such as performance,12, 13 leadership effectiveness,14, 15 teamwork,16, 17 and positive customer satisfaction.18 Subsequent research in nursing and other health care disciplines validated many of these findings within health care settings.11, 19-21
For the purposes of this article, specific categories of skills outlined in the prelicensure and graduate QSEN competencies5, 6 will be used to offer examples of the relationship between this research and the skills necessary to ensure patient safety.
Certain elements of patient-centered care—such as clinical performance, communication in the therapeutic relationship, and compassionate care—are themes that appear throughout QSEN's corresponding competency for both prelicensure- and graduate-level education. The relationship between these elements and emotional intelligence skills suggests that patients may be safer when cared for by nurses with higher emotional intelligence.
Clinical nursing performance. It makes sense that if a nurse's clinical performance is excellent, the care she or he provides will be patient focused and safe. Research clearly demonstrates that the level of clinical performance correlates with measured emotional intelligence in nurses.19, 20, 22, 23 Emotional intelligence also correlates with the caring behaviors of nurses as well as patients’ perceptions of being cared for.24, 25 Other variables that may reflect quality (effective and safe) patient-centered care, such as customer satisfaction and positive clinical outcomes, have also been correlated with emotional intelligence ability in nurses.26 Other “indirect” influences on the quality of patient care, such as the retention of nurses,20 nurse engagement,20, 27 and job satisfaction,28 have also been demonstrated to correlate with measured emotional intelligence ability.
Communication in therapeutic relationships. Two aspects of the therapeutic relationship—information gathering and the experience of being cared for—can impact safety. Safe health care depends on accurate information, most of which is transferred from patient to care provider during interviews and other verbal interactions. Inaccurate or incomplete information can lead to serious errors. Thus, a therapeutic relationship characterized by clear and accurate communication can improve care and prevent errors. This is particularly important as it ensures the appropriateness and completeness of patient care data, on which safe and appropriate care are predicated. Because of the correlation between communication ability and emotional intelligence ability,29 the development of emotional intelligence ability may support complete and accurate data collection, thus enhancing patient safety.
To prevent the omission or misinterpretation of health care data, nurses must be able to accurately assess their own bias, fatigue, and stress levels as well as the influence of emotional factors, such as conflict or hostility, in the work environment. This is especially important as nurses are increasingly facing heavier workloads, administrative system pressures, and nonclinical demands—all of which may increase the potential for errors. Emotional intelligence ability can positively influence information transfer between nurses and patients within the therapeutic relationship, as illustrated by this typical hospital scene: a nurse is interviewing a patient and entering data in a bedside computer console. By staring at the console, or even having her or his back turned to the patient, this nurse is not tuned into the patient's nonverbal emotional cues that indicate if the patient is uncomfortable, anxious, or withholding information. A nurse who has emotional intelligence skills may have a greater chance of identifying these emotional cues by making eye contact, checking and validating the emotions she or he perceives, and following up to make sure the information gathered is complete and accurate.
Compassionate care. A patient's perception of being cared for also correlates with nurses’ measured emotional intelligence.25 The experience of being cared for may be physically therapeutic, and its impact on the therapeutic relationship is also important. When a patient feels cared for emotionally, she or he may be more likely to have trust, confidence, and agency in the care relationship. Patients or family members who feel cared for, in turn, may be more apt to identify what isn't working and inclined to confront a potentially risky staff performance. This makes the care safer. Emotional intelligence may provide a framework for identifying core competencies that improve patient safety.
TEAMWORK AND COLLABORATION
Emotional intelligence ability can be an important factor in team communication and conflict resolution.
Team performance. Emotional intelligence ability correlates with team performance.21, 30 Because the quality of teamwork directly affects both the effectiveness and the quality of patient care,31 this finding is highly significant. When teams are communicating well, members express information succinctly and openly. This is particularly important in interdisciplinary teams. Patient care has the best opportunity to be safe and error-free when members of these teams communicate effectively. When this is not the case, the negative effects of conflict between team members in the clinical setting may result in a higher risk environment. If a nurse or physician bullies novice nurses, or clinical staff engage in hazing or scapegoating, it seems likely that team communication—and, indirectly, patient safety—will be affected. This association has not been studied and calls for further research.
Team conflict management. Emotional intelligence in nurses correlates with positive conflict resolution skills,32 and measured emotional intelligence ability in teams has been found to correlate with positive conflict management in these teams.33 When conflict in a team is managed constructively, issues are confronted and resolved more effectively. Relationships within the team are not only maintained but also grow with the positive experience of successful conflict resolution. There is less energy and distraction from conflict that can negatively affect patient care. Nurses who experience dysfunctional teams, handicapped by mistrust and conflict or poor interpersonal relationships, are likely to feel that collaboration is compromised.34 Although this has not been a focus of nursing research, work team emotional intelligence skills have been found to increase job site safety in the construction industry.4
Both the organizational fear of and response to medical errors can activate a climate of finger pointing, territorial defensiveness, and blame. In organizations where this highly emotional issue is acknowledged and “no blame” approaches are adopted, patients are likely to be safer. This kind of organizational culture can enable those working within it to quickly identify risk potential, discover error events, analyze dynamics effectively, and, with each analysis, strengthen the culture of safety and error prevention.
This approach requires effective communication, interdisciplinary team proficiency, and the ability to resolve conflict positively, all of which can be supported by emotional intelligence abilities. For example, if those attending a root-cause analysis meeting focusing on the evaluation of a serious sentinel event use the four main emotional intelligence abilities, members would identify emotions correctly (everyone is feeling guilty about her or his part in this error), use emotions to reason (thinking and feeling their way through difficult issues), understand emotions (such as the role of anger and defensiveness in guilt), and manage emotions (preventing the distraction of guilt and blame from important problem solving).
IMPLICATIONS FOR PRACTICE
With the staggering number of patient fatalities each year resulting from medical errors, and because most of these errors involve faulty communication, it is essential that we identify skills that support accurate communication and information transfer, optimum patient-centered care, team function, and patient safety. The effect of emotional intelligence ability on performance, therapeutic relationships, conflict management, team effectiveness, and the culture of safety at an organization suggests that having this ability may provide just such competencies. Although there is no current research on emotional intelligence and patient safety, we have previously suggested a model of the relationship between emotional intelligence, communication, and patient safety that describes the mediating effect of emotional intelligence ability in institutional error reduction.35
Recommendations for practice include the incorporation of emotional intelligence skills into nursing education, specifically as they are used in interpersonal communication, interviewing, teamwork, leadership development, and conflict resolution. Emotional intelligence research in nursing that is focused on patient safety—and the link between specific skills and clinical outcomes—is recommended.
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