In 1999, the Institute of Medicine (IOM) released a report that pinpointed medical error as the cause of 100,000 hospital patient deaths annually (Kohn, Corrigan, & Donaldson, 1999). The report highlighted the decentralization and fragmentation of care in an increasingly complex health care delivery system as an important component of medical error (Kohn et al., 1999; Ouslander, Bonner, Herndon, & Schutes, 2014; Romano, Segal, & Pollack, 2015). Over the past 20 years, complexity of health care delivery has continued to increase (Romano et al., 2015). Despite countless quality and safety initiatives, preventable patient harm remains a major issue (National Patient Safety Foundation, 2015).
Health care educators in all disciplines, including advanced practice registered nurse (APRN) educators, have integrated quality and safety education into foundational professional competencies to immerse students in safe practice from the beginning of their professional career (American Association of Colleges of Nursing [AACN], 2011, 2012; Nasca, Weiss, & Bagian, 2014; Stoller, Taylor, & Farver, 2013). Despite much attention focused on patient quality and safety since the 1999 IOM report was published, there has been little sustained improvement (Federico, 2015). Exposing students in health care disciplines to the importance of quality and safety early on in professional education seems to have not had the effect on patient harm that was expected. Perhaps awareness of the issue and education about how to resolve it are not sufficient.
One factor has remained constant over the past 20 years: the decentralization and fragmentation of care in a complex health care delivery system. Decentralization and care fragmentation are not solely related to care delivery itself; rather, they also are related to the complex network of interpersonal relationships within which care is delivered. The practice of nursing on all levels is grounded in interpersonal relationships, including APRN education (D'Antonio, Beeber, Sills, & Naegle, 2014). APRNs are positioned on interprofessional teams such that they can interact across the health care system, bridging potential interpersonal communication gaps and facilitating relationships (Weller, Boyd, & Cumin, 2014). Delivery of safe, quality care in many ways relies on APRNs' demonstration of leadership, communication, and teamwork (AACN, 2011, 2012; Barnsteiner et al., 2013).
Emotional intelligence (EI), described as the ability to perceive, understand, manage, and use emotions in self and others, comprises a key factor in interpersonal relationships that are inherent in actualizing leadership, communication, and team-work in health care (Fernández-Berrocal, Extremera, Lopes, & Ruiz-Aranda, 2014). Fundamentally, the science of nursing is inextricably bound to the transformative power of interpersonal relationships (D'Antonio et al., 2014). Although health care delivery remains dependent on interpersonal relationships, the various health care disciplines have not yet fully embraced integrating EI into health professions' education (Flowers, Thomas-Squance, Braini-Rodriguez, & Yancey, 2014). This article outlines specific EI competencies and explores how EI competencies support and align with APRN educational competencies. Nurse educators may then use strategies such as reflective journaling to enhance EI in support of APRN competencies.
Emotional Intelligence Competencies
After decades of research on noncognitive intelligence, Salovey and Mayer created the term emotional intelligence in 1990 to describe people who possess self-awareness and social awareness and use this ability in decision making (Cherniss, 2010). Goleman's book Emotional Intelligence in 1995 proposed EI to leaders in business, social sciences, and educators as a way to quantify individual intangibles outside of the classic measures of intelligence, such as the Intelligence Quotient, that lead to success (Cotler et al., 2017; Grant, 2013; Johnson & Blanchard, 2016; Lanciano & Curci, 2015; Terziyan & Kaikova, 2015). Early on, a philosophical debate divided experts on whether EI is an ability (skill or proficiency) or a trait (inherent quality); however, many proposed that EI is composed of both (Ackley, 2016). For the purposes of this discussion, EI is considered an inherent quality that can be both measured like an ability and enhanced by incorporating particular strategies, either individually or within an education setting such as APRN curricula.
EI consists of four dimensions: self-awareness, which is the ability to identify one's emotions; self-management, described as the ability to use one's emotions for reasoning and problem solving; social awareness, which is the ability to understand others' emotions; and relationship management, the ability to effectively manage emotions in self and others for the purpose of what could be called teamwork (Codier & Codier, 2017). Each dimension's competencies are listed in Table 1. These dimensions are divided into personal competence, which consists of skills related to self-awareness and self-management, and social competence, which involves social awareness and relationship management skills (Table 1) (Stoller et al., 2013). Self-awareness and self-management skills are typically well formed prior to mastery of the social competence elements because accurate self-assessment is foundational to expression of social competence (Cherniss & Goleman, 2001). Accurate self-assessment supports critical thinking and clinical judgment, which are expected hallmarks of APRN professional practice (Niu, Behar-Horenstein, & Garvan, 2013).
Emotional Intelligence Competencies
In addition to supporting the personal competencies' attributes of self-assessment and self-management, research supports associations between EI and characteristics of leadership, communication, and teamwork in business settings (Terziyan & Kaikova, 2015; Maqbool, Sudong, Manzoor, & Rashid, 2017). The success of EI in business has caught the attention of health care disciplines such as medicine, pharmacy, and behavioral health, which are incorporating EI competencies into professional education (Bowe & Jones, 2017; Flowers et al., 2014; Haight et al., 2017; Heckemann, Schols, & Halfens, 2015; Johnson & Blanchard, 2016; Schutte, Palanisamy, & McFarlane, 2016). APRN leadership, communication, and teamwork competencies use the EI social competencies within social awareness and relationship management (Table 2) (Almost et al., 2016; Lanciano & Curci, 2015; Mikolajczak & Van Bellegem, 2017). Faculty developing APRN curricula seek to incorporate the professional competencies of the Graduate Quality and Safety Education for Nurses (QSEN) core competencies (AACN, 2012) and The Essentials of Master's Education in Nursing (AACN, 2011) to meet regulatory guidelines, as outlined in Table 2. Aligning EI competencies with foundational APRN competencies has the potential to further strengthen APRNs' leadership, communication, and teamwork skills. By aligning EI competencies with APRN competencies as demonstrated in the matrix provided in Table 3, APRN educators have a roadmap to use the significant body of EI research for application in APRN education.
Advanced Practice Registered Nursing Education Competencies
Leadership, Communication, and Teamwork Matrix for Advanced Practice RNs (APRNs) and Emotional Intelligence (EI) Competencies
APRN and EI Competencies
The APRN Essentials of Master's Education in Nursing (AACN, 2011) competencies were updated, and QSEN competencies (AACN, 2012) were integrated into APRN curricula in response to the 2010 IOM's consensus report on the Future of Nursing (Barnsteiner et al., 2013). EI-related competencies are applicable across the gamut of QSEN competencies and master's Essentials. The QSEN competencies specifically detail the requisite nursing knowledge, skills, and attitudes necessary for each competency (Barnsteiner et al., 2013; Gerard, Kazer, Babington, & Quell, 2014). The classic nursing knowledge, skills, and attitudes of APRN Essentials' competencies mimics Boyatzis's (2009) description of EI competencies, requiring knowledge, action, and intent. Examples of how QSEN competencies and master's Essentials competencies intersect with EI competencies are provided in the matrix in Table 3. Advanced critical thinking and clinical judgment, the foundation of competent APRN practice, differentiates APRN practice from other levels of nursing practice (Hamric, Hanson, Tracy, & O'Grady, 2014). Nursing as a profession has always been grounded in critical thinking and application of clinical judgment; advanced nursing practice requires even higher levels of knowledge, action, and intent to support the requisite leadership, communication, and teamwork competencies outlined in APRN education competencies. By cross-walking APRN competencies with EI competencies as suggested in the matrix provided, APRN educators can more easily incorporate these competencies. Additionally, by framing EI as a set of traits and abilities, EI can be measured and studied empirically. Using ability-based EI instruments such as the Mayer-Salovey-Caruso Emotional Intelligence Test (MSCEIT) allows educators and researchers to measure interventions designed to enhance EI (Brackett & Salovey, 2006).
Many instruments used to measure EI are self-reported or self-assessed measures (Snowden, Watson, Stenhouse, & Hale, 2015). Although experts differ philosophically on whether EI is an ability or a trait (Ackley, 2016), the two original researchers, Salovey and Mayer, have always characterized EI as an ability (Brackett & Salovey, 2006). The MSCEIT is an online 141-item instrument that measures four branches, outlined as the ability to perceive emotion, use emotion to facilitate thought, understand emotions, and manage emotions. This test is divided among eight kinds of tasks, representing two for each branch, and takes approximately 30 to 40 minutes to complete. The results include seven scores: one for each branch, two area scores, and a total EI score that measure a participant's skill in each of the four branches. Considering EI an ability allows measurement of an intervention's effects on EI. Therefore, the ability-oriented instrument MSCEIT is recommended to measure APRN students' EI (Brackett & Salovey, 2006).
APRN competencies such as QSEN patient-centered care and master's Essential VI health policy and advocacy (AACN, 2012) align with leadership ability. The EI competency empathy is a competency of EI social awareness and is a quality necessary to provide the QSEN competency, patient-centered care, and the master's Essential VI, health policy and advocacy (AACN, 2012). Patient advocacy has been a fundamental tenet of nursing practice since time immemorial. APRNs demonstrate leadership in patient-centered care by actively advocating for and promoting organizational policies that enhance patient empowerment. To empower others, APRNs must first demonstrate cognitive empathy (i.e., ability to understand another's perspective) and empathic concern (i.e., ability to sense what others need) (Goleman, Boyatzis, & McKee, 2013). These EI competencies, mastered during APRN education, should enhance leadership skills in practice. Organizational awareness, a competency of EI social awareness, and influence and change catalyst, EI competencies of relationship management, are detailed in master's Essential II, organizational and systems leadership (AACN, 2011). To be organizationally effective, the APRN must demonstrate influence and inspirational leadership—elements of EI social competency relationship management. This position is well documented in business literature (Maqbool et al., 2017). Inspirational leaders are also creative and can be powerful change catalysts as changes are inevitable in organizations committed to continuous quality improvement. If EI social awareness competencies of empathy and organizational awareness and EI relationship management competencies of influence, inspirational leadership, and change catalyst are enhanced during APRN education, demonstration of commensurate APRN educational competencies may be enhanced.
In 2016, The Joint Commission determined that the root cause of most sentinel events continues to be miscommunication (The Joint Commission, 2016). Miscommunication can stem from patients having a primary team of internal medicine providers and also having consultants in cardiology, pulmonology, or infectious disease, for example. In addition to specialty disciplines, the complexity of the health care team creates opportunities for miscommunication across the roles and responsibilities of physicians, APRNs, physician assistants, pharmacists, RNs, laboratory technicians, sonographers, radiology technicians, and various other ancillary personnel. Health care delivery within these roles involves a series of information handoffs on multiple levels, resulting in further opportunities for communication failures. Studies have shown that higher EI is directly associated with greater communication skill (Cherry, Fletcher, & O'Sullivan, 2014; Lee & Gu, 2013). This association supports master's Essentials III and VI that specifically elucidate APRNs' responsibility to communicate, collaborate, and consult with other health care professionals (AACN, 2011). These competencies also support the QSEN competencies of quality improvement and safety (AACN, 2012). APRNs who use the EI social competency skills of empathy (social awareness domain) and building bonds and conflict management (relationship management domain) demonstrate how EI supports communication within the health care team.
In many current health care models, especially acute care, fragmentation of care increases due to the number of providers interacting on all levels as described previously (Ouslander et al., 2014). APRNs are best suited to connect across the roles within the health care team and to interact with various interprofessional providers and capitalize on interpersonal relationships. The APRN has the responsibility to be the communication hub on multidisciplinary teams, effectively communicating information to and from the patient, the nursing staff, ancillary providers, and physician staff. The EI self-management competencies of transparency fosters trust and honest communication, serving to increase the relationship management competency of influence and thereby reduce fragmentation of care with better communication.
Leadership and patient-engaged teamwork among the various disciplines are key factors in establishing a culture of safety within health care facilities. Nursing executives, hospital administrators, and physician colleagues must partner with APRNs to establish a functional culture of safety within their health care organizations (Chassin & Loeb, 2013). Accurate information sharing comprises one component of safe care delivery—how information is shared is another. The QSEN competency of teamwork and collaboration describes the APRN role as one that fosters open and honest communication, mutual respect, and shared decision making (AACN, 2012)—all qualities actualized within the EI self-management competencies of transparency and adaptability, the relationship management competency of developing others, and building bonds. Master's Essential II states that APRNs must also understand that “promotion of high quality and safe patient care” is key to good working relationships among interdisciplinary teams (AACN, 2011, p. 4), actualized within the EI relationship management competencies of building bonds, conflict management, and teamwork and collaboration.
Patient safety initiatives focus on preemptive harm prevention strategies instead of individual error review (Gandhi, Berwick, & Shojana, 2016). An APRN leader who has mastered the EI relationship management competency of change catalyst will have the skills to guide multidisciplinary teams toward these organizational goals. APRNs must be able to “communicate, collaborate, and consult” with other team members to promote safe quality care according to master's Essential VII Interprofessional Collaboration (AACN, 2011, p. 5). The QSEN competency of teamwork and collaboration and master's Essential VII are actualized within the EI relationship management competencies of teamwork and collaboration, building bonds, and conflict management. Studies investigating EI in business identified EI relationship management competencies as essential to high-functioning teams (Maqbool et al., 2017). A study on disaster-management teams' use of EI recognized the specific relationship management competencies of teamwork and collaboration and building bonds and the EI self-management competency of adaptability as key to successful disaster drills (Wilkinson, 2015). Educators in all health care disciplines, not just APRN educators, have the opportunity to integrate EI into their curricula to expose future team members to the fundamentals of safe, quality practice and teamwork (Boland, Scott, Kim, White, & Adams, 2016; Carney et al., 2016; Sherwood & Zomorodi, 2014).
Enhancing EI to Improve APRN Competencies
This review has already linked EI to APRN competencies. Thus, enhancing EI will enhance APRN competencies. Although a detailed exploration of strategies to enhance EI in nursing curricula is beyond the scope of this review, a brief discussion of potential methods to incorporate EI into reflective learning is warranted. Clinical experiences are the foundation of APRN curricula, and reflective learning is a strategy frequently used to translate these experiences into empirical understanding. Reflective learning supports advanced critical thinking and clinical judgment (Bussard, 2015; Garrity, 2013; Ruiz-López et al., 2015; Silvia, Valerio, & Lorenza, 2013). Reflection, according to Mezirow's transformative learning theory (Kitchenham, 2008), allows the student to find meaning in experience. Journaling provides an avenue to revisit an experience, reflect, and reframe the experience in context of new knowledge (Harrison & Fopma-Loy, 2010; Reed, 2015; Silvia et al., 2013). Strategies such as reflective journaling, online clinical conferencing, or blogging can be used to assist with APRN students' processing of clinical experiences (Berkstresser, 2016; Garrity, 2013; Gordon, 2017; Harrison & Fopma-Loy, 2010; Montenery et al., 2013; Naber & Wyatt, 2014; Raterink, 2016; Reed & Edmunds, 2015; Ruiz-López et al., 2015). Reflective journaling is by far the most commonly practiced strategy; however, most research has been undertaken in undergraduate nursing education. Research relating EI competencies to APRN competencies and incorporating EI-based prompts to guide APRN student reflective journaling is an area that merits further study.
Health care complexity and fragmentation can be positively affected by highly EI competent APRNs. These leaders are uniquely positioned to connect the complex health care team and simplify its inherent intricacies. EI competencies help actualize APRN graduate education competencies as outlined by AACN's (2011, 2012) QSEN competencies and The Essentials of Master's Education in Nursing. Incorporating content to master EI competencies within APRN curricula could strengthen APRN educational competencies. Integration of EI competencies within the curricula can promote APRN students' professional development, as well as enhance leadership, communication, and teamwork skills necessary to excel in the ever-changing health care delivery landscape. Furthermore, existing instruments, such as the ability-based MSCEIT, provide an evidentiary foundation for assessing the success of teaching EI competencies to APRN students. A well-educated and emotionally intelligent APRN graduate can enhance cooperation in multidisciplinary teams, promote better communication, and demonstrate APRN leadership to improve patient outcomes. APRN educators must be educated on how to use learning strategies such as reflective journaling, online clinical conferencing, and shared blogs that are designed to enhance EI. These intentional efforts will foster emotionally intelligent APRNs that can impact the future of health care.
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Emotional Intelligence Competenciesa
|Personal Competencies||Social Competencies|
| Emotional self-awareness|| Empathy|
| Accurate self-assessment|| Organizational awareness|
| Self-confidence|| Service|
| Emotional self-control|| Inspirational leadership|
| Transparency|| Influence|
| Adaptability|| Developing others|
| Achievement|| Change catalyst|
| Initiative|| Conflict management|
| Optimism|| Building bonds|
| Teamwork and collaboration|
Advanced Practice Registered Nursing Education Competencies
|QSEN Competencies||Essentials of Master's Education in Nursing|
|Quality improvement||I. Background for practice from science and humanities|
|Safety||II. Organizational and systems leadership|
|Teamwork and collaboration||III. Quality improvement and safety|
|Patient-centered care||IV. Translating and integrating scholarship into practice|
|Evidence-based practice||V. Informatics and healthcare technologies|
|Informatics||VI. Health policy and advocacy|
|VII. Interprofessional collaboration for improving patient and population health outcomes|
|VIII. Clinical prevention and population health for improving health|
|IX. Master's-level nursing practice|
Leadership, Communication, and Teamwork Matrix for Advanced Practice RNs (APRNs) and Emotional Intelligence (EI) Competencies
|ARPN competencies: QSEN patient-centered care; master's Essential health policy and advocacy||ARPN competencies: QSEN quality improvement, safety; master's Essentials quality improvement and safety, health policy and advocacy||ARPN competencies: QSEN teamwork and collaboration; master's Essentials organizational and systems leadership, interprofessional collaboration|
|EI competencies: empathy, emotional self-control, initiative, service||EI competencies: empathy, building bonds, conflict management||EI competencies: transparency, adaptability, developing others, building bonds, conflict management, emotional self-awareness and teamwork and collaboration|
|APRN competencies: master's Essential organizational and systems leadership||ARPN competencies: QSEN patient-centered care, informatics; master's Essential informatics and health care technologies||ARPN competencies: QSEN evidence-based practice; master's Essential translating and integrating scholarship into practice|
|EI competencies: organizational awareness, influence, change catalyst, influence, inspirational leadership, self-confidence, optimism||EI competencies: transparency, influence, achievement||EI competencies: building bonds, adaptability, achievement|