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Theheartofart:Emotionalintelligenceinnurseeducation

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© 2004 Blackwell Publishing Ltd

Nursing Inquiry 2004; 11(2): 91–98

F e a t u r e

Blackwell Publishing, Ltd.

The heart of the art: emotionalintelligence in nurse education

Dawn Freshwatera and Theodore Stickleyb

aInstitute of Health and Community Studies, Bournemouth University, Bournemouth, Dorset and bSchool of Nursing , University of Nottingham, Nottingham, UK

Accepted for publication: 21 August 2003

FRESHWATER D. and STICKLEY T. J. Nursing Inquiry 2004; 11: 91–98The heart of the art: Emotional intelligence in nurse educationThe concept of emotional intelligence has grown in popularity over the last two decades, generating interest both at a socialand a professional level. Concurrent developments in nursing relate to the recognition of the impact of self-awareness andreflexive practice on the quality of the patient experience and the drive toward evidence-based patient centred models of care.The move of nurse training into higher education heralded many changes and indeed challenges for the profession as a whole.Traditionally, nurse education has been viewed as an essentialist education, the main emphasis being on fitness for practiceand the statutory competencies. However, the transfer into the academy confronts the very notion of what constitutes thisfitness for practice.

Many curricula now make reference in some way to the notion of an emotionally intelligent practitioner, one for whom theory,practice and research are inextricably bound up with tacit and experiential knowledge. In this paper we argue that much ofwhat is described within curriculum documentation is little more than rhetoric when the surface is scratched. Further, we pro-pose that some educationalists and practitioners have embraced the concept of emotional intelligence uncritically, and withoutfully grasping the entirety of its meaning and application. We attempt to make explicit the manner in which emotionalintelligence can be more realistically and appropriately integrated into the profession and conclude by suggesting a model oftransformatory learning for nurse education.

Key words: emotion, emotional intelligence, nursing curriculum, reflection, reflective practice.

It is generally accepted that very little of our lives is governedby logic alone. It is rather our emotional world thatmotivates our decisions and actions. In recent years, break-throughs in neuroscience have deepened the way in whichwe understand emotions as a body state. Subsequently writershave sought to popularise the concept of the emotions.Goleman (1995), in his best selling book ‘Emotional intelli-gence’ reminds us that we have two minds, a rational mindthat thinks, and an emotional mind that feels. Both however,

store memories and influence our responses, actions andchoices. Emotions hold independent views, have a mind oftheir own, quite separate from that of the rational mind.When we consider the significance of the emotions in every-day life, it is noteworthy how little we refer to them in thebusy-ness of our lives. As Freshwater and Robertson (2002)comment, the emotions remain the Cinderella of our psyche.The premise of this paper is that the rational mind and theemotional mind need to be balanced partners; where thisrelationship is harmonious, intellectual ability increases. So,rather like Hegel’s (1971) notion of dialectical thinking, it isimportant to draw together seemingly competing oppositesand emphasise the dialogue between them. Accordingly,whilst the focus of this paper is on emotional intelligence, weare mindful of the dialogue between this and other forms ofintelligence.

Correspondence: Dawn Freshwater, Professor of Mental Health and PrimaryCare, Institute of Health and Community Studies, Bournemouth University,Royal London House, Christchurch Road, Bournemouth, Dorset, UK .E-mail: <dfreshwater@bournemouth.ac.uk>

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The debate around the nature of intelligence hasbeen dominated by the scientific paradigm and superiorityafforded to the notion of IQ. It is not our intention to debatethe concept of IQ here, except to note that it is only oneproposed model of intelligence. Gardner (1983), for exam-ple, refutes the monolithic domination of measuring successthrough IQ and purports seven varieties of intelligence thatwe are all born with, these being: verbal and mathematicallogical alacrity; spacial capacity (as in art or architecture);kinesthetic fluidity (as in sport); music; personal (as incommunication and interpersonal skills); charisma; intra-psychic ability (as in congruence and inner contentmentand containment).

We briefly return to these varieties of intelligence in ourdiscussion around nursing and nurse education, however,we might at this point ask you to reflect on how these aspectsof intelligence inform and create the art and craft of anypractice discipline.

EMOTIONAL INTELLIGENCE

Emotional intelligence (EI) can be described as being abouta set of non-cognitive abilities that influence the individual’scapacity to be successful in life. Although it is clear that EIworks synergistically with IQ to enhance overall perform-ance, it is argued that EI can be measured and it can belearned and it is this ability that differentiates exceptionalfrom mediocre ability and achievement.

As previously mentioned, the concept of emotional intel-ligence (EI) has been popularised by the authors DanielGoleman (1995) and Susie Orbach (1999). However theorigins of the term go back beyond the work of these wellknown contemporary writers. Prior to the work of Golemanand Orbach, several models of emotional intelligence werebeing developed and refined, most notably the ability model(Mayer and Kilpatrick 1994). Salovey and Mayer’s researchon the subject concluded that emotional intelligence isan actual intelligence, in so much as it can be measuredthrough an ability test (Salovey and Mayer 1997).

This test, known as the MSCEIT (Mayer, Salovey, CarusoEmotional Intelligence Test) was based on the ability modelof EI that comprises perceiving and identifying emotions;assimilating and using emotions; understanding emotionsand managing emotions. These issues have been the subjectof recent neurobiological research (for example, Damasio 1995)and continue to be of interest to psychologists (Bar-On andParker 2000), psychotherapists (Freshwater and Robertson2002) and social scientists alike.

It was Bar-On, an Israeli psychologist, however, whodeveloped the first test of emotional intelligence that

has gained extensive international recognition, havingbeen translated into 15 different languages. More recentlyBar-On has developed a 360-degree version of his test anda youth version. Bar-On’s model contains five overall group-ings, these being: interpersonal factors; intrapersonal fac-tors; general mood and motivation; stress management;adaptability.

Goleman’s (1995) own mixed model of emotional intel-ligence contrasts with that of Salovey and Mayer (1997), inthat he argues for the inclusion of a range of emotionalskills and personality traits, namely self-awareness, self-management, social awareness and social skills. With regardto definition, we conclude by stating that emotional intelli-gence is a core aptitude related to one’s ability and capacityto reason with one’s emotions, especially in relation toothers.

NURSE EDUCATION

Nurse education has often been viewed as an essentialisteducation with the emphasis on producing an individualthat is fit for practice. Essentialist education by its very naturemoulds the student. In this sense, one could argue (and itis a well-rehearsed debate) that nurse education with itsstatutory competencies to meet is a training rather than aneducation. Prior to Project 2000 courses in the UK, nurseeducation was largely an apprenticeship model of training;akin to the pretechnocratic model described by Bines andWatson (1992). This model comprises the acquisition of skillsthrough on-the-job training with theoretical componentstaught block or day release. The goal of traditional nurseeducation has been to teach specific skills and knowledge inorder that students can reach a certain standard of behav-iour, attitude and work as defined by the educational estab-lishment and in the case of nursing in the UK, the UnitedKingdom Central Council for Nurses, Midwives and HealthVisitors (now the NMC) and the National Boards for Nurs-ing (now defunct). Thus the classroom has been dominatedby propositional knowledge and practical knowledge hasbeen the domain of the clinical environment. Propositionalknowledge can be described as textbook knowledge in whicha person builds up a bank of facts or theories about a subjectwithout necessarily having direct experience of the subject(Burnard 1987; Rolfe 1998; Freshwater 1998a). Polanyi (1962),Pring (1976) and Benner (1984) have referred to this wayof knowing as ‘know that’. From a nursing perspective, thisequates with the well-known and oft-quoted Barbara Carper’s(1978) scientific way of knowing and in critical theory it isreferred to as scientific or technical knowledge (Habermas1972; Fay 1987).

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The theory–practice gap (again!)

The introduction of Project 2000 in the UK nursing pro-grammes presented the opportunity to challenge traditionalnurse training and the split of theory and practice. Insteadmodels of education have shifted from the pretechnocraticto the technocratic (Bines and Watson 1992). Both the pre-technocratic and technocratic approaches to nurse educa-tion and nursing practice are firmly based in Prometheanand Apollonian logic. Hence the curriculum developmentmodels used have been closely aligned to the instrumentalistideology, liberal humanism (Pendleton 1991; Askew andCarnell 1998) and the functionalist model of education(Criticos 1993; Askew and Carnell 1998). From this view-point, the student is the inheritor of society’s wisdom andthe manifestation of society’s values. Anyone who has beena patient in hospital or has had a sick relative will be gratefulfor the instrumentalist ideology that has driven nurse cur-ricula, for it is the teaching of a safe and competent perform-ance of practical nursing skills that serves to protect thegeneral public. Patients also have the right to assume thatthe type of care they receive is based upon sound evidence.However, it could be argued that there is more to high qualitypatient care than the safe and adequate completion of tasks.

Making informed decisions in clinical practice meansre-evaluating the relevance of a particular intervention for apatient and learning from experience. and as Burnard (1987)observes, a person may develop practical knowledge withoutdeveloping the appropriate propositional knowledge, forexample in the giving of an injection, and conversely aperson may develop propositional knowledge without everhaving developed the practical knowledge, an example ofthis is often seen in the administration of cardio-pulmonaryresuscitation. Neither of these ways of learning feel particularlyholistic, rather, the theory–practice gap remains. It could beargued that the bulk of nurse education has concerned itselfwith propositional and practical knowledge (Freshwater 1998a).Unfortunately, this has not usually occurred simultaneously.

Hence whilst there is no doubt that the curriculumbenefits from the explicit inclusion of propositional knowl-edge, the theory–practice gap continues, with propositionalknowledge being the concern of the academy and practicalknowledge coming from the clinical or ward area (Rolfe 1996).Thus not only the students but also the patients are seen assplit entities. The functionalist model of education, instru-mentalism and Apollonian logic have all been criticised forbeing too mechanistic and failing to take a holistic approachto the educational requirements of students, and in this casethe nurse and patient (Neville 1989; Pendleton 1991; Paris1995; Askew and Carnell 1998; Randle 2002; Freshwater

2002). Whilst the above approaches to teaching andlearning may appear to be relatively uncluttered, they areincomplete. Learning is surface rather than deep (Entwistle andRamsden 1993), there is little, if any room for imagination,the focus is on the parts rather than the whole (Okri 1997).The role of the teacher when adopting this approach toteaching is that of the expert, transmitting knowledge andin the case of student nurses, training students in social andpsychomotor skills (Askew and Carnell 1998; Pendelton1991). It is assumed that the student needs, and will respondto, plenty of explanations of concepts and principles anddemonstrations of practical skills.

These models were perhaps appropriate for the tradi-tional nurse syllabus conceived of by the General NursingCouncil, although the lack of emphasis on the experience ofthe student could be contested as being one sided. Currentthinking in the advancement of nursing curricula isinfluenced by critical social theory, reflexivity, narrativityand feminist epistemology. Such theories are critical ofbehaviourist approaches to teaching and the hierarchicalorganisation of educational institutions (Osbourne 1996;Rolfe et al. 2001; Randle 2002), espousing a more holisticand mutual approach to teaching.

Balancing the rational and the emotional

Every nursing intervention is affected by the master aptitudeof emotional intelligence. It is not enough to attend merelyto the practical procedure without considering the humanrecipient of the process. Whilst the rational mind may ade-quately attend to the necessary technical aspects of nursingprocedures, it is not the place of the rational mind tointuitively sense the needs and emotions of the person atthe receiving end of care. As Perls (1973) reminds us, everybreath in every moment is significant. One sigh may becommunicating a lifetime of emotions. It is the emotionallyintelligent practitioner that hears the sigh, makes eye contact,communicates understanding and demonstrates humancare (Freshwater 2003). Although this simple human con-tact may be easily taken for granted, it may, in the moment,be of the most profound and potentially healing nature. Aneducation that ignores the value and development of theemotions is one that denies the very heart of the art of nurs-ing practice. By focusing entirely on the rational, we are indanger of producing unbalanced practitioners. When teach-ers pay little or no attention to emotional development, theyfail to communicate with students the significance of humanrelationships. It is not enough to simply impart ‘communi-cation skills’ because, by implication, communication becomesanother intervention similar to aseptic technique or giving

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an injection. Where communication skills training is separatedfrom the emotional content of human interaction, theart of nursing is reduced to the science of the technician(Freshwater 2003). Further, when emotional development isneglected, the individual is denied the opportunity of fullydeveloping intellectually. Some are naturally more attunedto emotional life through metaphor, simile, poetry, song,dreams, myths and fable. These are all written, as Whyte (1997)notes, in the heart’s language. The emotionally intelligentnurse is one who can work in harmony with thoughts andfeelings. Novelists, artists, psychotherapists may be moreadept at emotional intelligence as contact with their emo-tional world is critical to their work, it is also fundamental tothe act of caring, and as such the nursing curricula needs tocreate space for the work of the heart.

It is argued that nursing is becoming more and moretechnical at the expense of the human qualities of empathy,love and compassion (see Stickley and Freshwater 2002)What is nursing if it is not the provision of one human beingcaring for another? Elsewhere we have argued for therestoration of acknowledgement of the value of love in thetherapeutic relationship (Stickley and Freshwater 2002).Within the current climate of evidence-based practice, clinicaloutcomes and national standards, the value of humanrelationships (which is not necessarily a measurable phenom-ena) and the associated emotion is lost. More importantly, ofwhat significance would a clinical outcome be without love?We would argue therefore that love is a necessary componentof the nurse–patient relationship and as such an emotionallyintelligent curriculum.

Many authors argue that to give and receive love is essen-tial for being human, indeed it might be argued that love isthe most important experience of human existence (Fromm1957; Rogers 1957; Maslow 1970). Psychological theories ofhuman development concur that unconditional love is vitalto the development of the individual. Humanistic theoristsfocus on the role of authenticity, genuineness and empathicunderstanding (Rogers 1957); psychoanalytic theorists con-centrate on holding and containing in the development ofa true self (Winnicott 1971; Klein and Klein 1975), whilstbehavioural schools of thinking speak of positive reinforce-ment (Skinner 1958; Beck 1976). What all these theoreticalframeworks have in common is the general consensus thatlove is fundamental to human experience. Furthermore,some would argue that love heals (Siegel 1986; Sardello 1995).

The emotionally intelligent nurse is aware of her own needfor love, the need of love for her patients and the patient’sown needs for receiving love. Whilst many nurses may denyor neglect these needs, they will not go away. The abilityto give love (or what Rogers (1957) called unconditional

positive regard) whilst maintaining professional and socialboundaries may be the most therapeutic action a nurse cancommit. The balancing of the emotional and the rationalminds can provide a stable platform to develop the art of lov-ing in the therapeutic relationship (Stickley and Freshwater2002). However, the art of loving cannot be taught in apropositional way, nevertheless, it can be modelledthrough therapeutic relationships. If the teacher can commu-nicate love to his/her students, then the students are morelikely to develop positive attitudes toward their patients.Whilst the nursing literature includes much about thetherapeutic use of self, we would question the therapeuticbenefit of self when its own love needs are not fulfilled. Simi-larly, where nurses are not feeling supported and valued, theirpractice will suffer. It is right and proper that all nurses haveaccess to clinical supervision (UKCC 1996), however, theclinical supervision process needs to be more than themonitoring of practice. Nurses are human beings with emo-tional and psychological needs, where these needs remain thetherapeutic benefit of their work could be questioned.Effective clinical supervision can help to maintain the practi-tioner’s balance, and effectively facilitated reflective practicewill stimulate self awareness and personal growth, thustransforming the life and practice of the individual.

The emphasis here however, is not on the specificemotion of love, this is only one aspect of the emotional world.We simply use this as an example to raise awareness of theimportance of a balanced approach to the practice, teachingand learning, and indeed the research of nursing.

To refer back to our earlier point, an emotionally intelli-gent curriculum is not dominated by one understanding ofintelligence and knowledge, but recognises the value of acomplex and often unfathomable relationship between selfand intelligence. Such a movement is congruent with therecent focus on the value of a patient-centred approach tocare, reflective practice, self awareness and therapeutic useof self ( Ersser 1997; Freshwater 2002; Stickley and Freshwater2002 and many others). We now turn our attention morespecifically to the role of emotional intelligence in nursingand in nurse education.

EMOTIONAL INTELLIGENCE IN NURSING

It is impossible to describe the art and science of nursingwithout referring to emotions, indeed nursing literature isreplete with reference to the emotional labour of nursing(most notably the work of Isobel Menzies Lyth 1970, 1988).More often writers have been working to rehabilitate theemotions, once deemed to be inappropriate in nursing,back into the nurse–patient relationship (Stickley and

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Freshwater 2002). Nurses, in their professional life, clearlywork consistently with human emotion, whether this bethrough pain, discomfort, sadness, relief or hope. Evans andAllen (2002) and Cadman and Brewer (2001), along withother writers, contend that the ability to manage our emo-tional life, while interpreting other people’s is a prerequisiteskill for any caring profession. Indeed, it could be arguedthat the advent of patient- and relationship-centred care(see, for example, McMahon and Pearson 1998 and Fresh-water 2002) represents an explicit acceptance of these long-debated concerns. That the practitioner should be able todevelop an empathic relationship in order to execute herrole is now well documented and forms the basis of manynursing theories (Peplau 1992; Newman 1994; Parse 1997;Parker 2002), who, whilst not necessarily engaging in thesame language, argue for emotional competence.

Bellack (1999), for example, contends that nurses arerequired to develop emotional competence if they are to besuccessful in their working environment. Arguing that nurseeducation fails in the important domain of the emotions,Bellack (1999) calls for nurse educators to examine the roleof emotional learning and competencies within the curricula.The role of nurse education in supporting this developmentis as yet unclear, although it would appear from theliterature that there are some initiatives that specifically aimto explore the link between emotional intelligence andthe nursing curricula (Bellack 1999; Cadman and Brewer2001; Evans and Allen 2002). Whilst Evans and Allen (2002)attend to these concerns in a rather descriptive paper, theynevertheless contend that:

The inclusion of emotional intelligence in the curriculumempowers students to manage situations that may be highlycharged emotionally. If they are able to deal with their ownfeelings well then they will be able to deal with others con-fidently, competently and safely (42).

Cadman and Brewer (2001), in their sensitively written paperon recruitment in nursing, explore the research relating tothe development of empathic resonance. Concluding thatnurses are unable to demonstrate high levels of empathy, theypoint out the direct relationship between levels of empathyand beneficial client outcomes. Whilst these last two issuesare obviously of significance to the current debate, we cannotdo justice to them in this paper, however, we feel that theyneed to be addressed in some detail within the nursing sphere.

EMOTIONAL INTELLIGENCE AND NURSE EDUCATION

Evans and Allen (2002) state that integrating emotional intelli-gence into the curriculum provides nurses with a greater

opportunity to understand themselves and the way in whichthey create relationships with others. That this impacts uponthe therapeutic relationship and subsequently on the patient’sillness experience is indisputable. However, this process ofself-inquiry may not always be a comfortable or ordered one.In order to bring into the cognitive domain that whichordinarily resides in the precognitive the practitioner needsto engage in a reflective learning that moves beyond, butincludes, the level of propositional and practical knowledge,to a place of deep learning (Greenwood 1998). The rhythmof movement between deep and surface learning, whenmanaged through the process of critical reflection, creates alearning situation that is transformatory, both for the learnerand for the learners practice. Freshwater (2002) notes that:‘Transformatory learning not only enables the student tolearn, and to learn how to learn, but also facilitates theprocess of transformation in that learning’ (84). However, it isnot a mechanistic approach to education that can be taughtthrough a prescriptive model, rather it is an approach thatis experienced in a unique and individual encounter withboth the interpersonal and intrapersonal aspects of oneself.

DISCUSSION

Nurse education, in its rush to embed factors relating toemotional intelligence such as self-awareness, therapeuticuse of self and critical reflection is guilty of creating mechan-istic models, or worse still transplanting models from otherdisciplines uncritically. The purpose of providing an educa-tion that stimulates an inquiry into the world of the emotionsis to safely bring into current awareness a knowledge ofthat which is ordinarily unknown and, at times, unspeakable.This requires that teachers are in intimate contact with theirown emotions and are able to facilitate learning in the otherfrom a position of self-knowledge. However, as severalauthors have commented, nurse teachers themselves havelow levels of self-awareness and emotional intelligence (Randle2002; Freshwater 2002). Further, the preferred mode ofteaching is also called into question; the traditional didactictransference of knowledge is now, more than ever, beingchallenged, with the use of art, poetry, dance, drama, musicin the classroom slowly being encouraged in nursing curri-cula. These expressive modalities can penetrate in an instantthe heart of the learning, more importantly, they help to dis-tinguish the concepts of care and caring from the notion oftreatment and cure.

Frank (1991) differentiates care from treatment. Treat-ment is a technical routine that could ultimately be per-formed by a robot. Care is that which is communicated bythe words and actions of an understanding and empathic

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human being concerned for the other upon whom theyadminister treatment. Just as our supermarket cashiers havenow been trained to welcome each shopper with a ‘Hello’,we automatically sense the ones for whom this is a meaning-less chore and welcome the same greeting from the cashierwho makes eye contact and obviously welcomes the chancefor human contact. This trend in customer service is arecognised sociological issue and labelled McDonaldisationby Ritzer (1996). One might question, to what extent isnursing, and other health-related disciplines becomingMcDonaldised? In this age of managed care, success ismeasured by efficiency and cost reduction. Whilst legislatorsuse the language of care, what appears to matter most tothose in power is the efficiency of productivity. In the processof MacDonaldising the nursing profession, we are in dangerof inviting the notion of care — the very act upon which theprofession is established — to leave the room. For any of uswho have been on the receiving end of hospital care, we knowonly too well the demoralising effects of treatment withoutcare. Similarly, we recognise and appreciate the treatmentwith care that makes the experience of being a patient allthe more bearable. Without care we are treated as objects,we lose our sense of our own purpose, we become victimsof a dehumanising system as we seek out the smile and carefrom the nurse who attends to us. We seek for anything torestore our sense of personhood and dignity.

If at the hands of health-care, people become demoral-ised, nurses have the singular opportunity to engage in there-moralising of their patients. This simple but profoundactivity requires self-awareness of the highest order butdemands little more than human care demonstrated byempathic understanding. This kind of understanding doesnot come about by professional culture or practical osmosis,empathic understanding can be developed through a con-tinued emphasis on emotional intelligence, facilitated notjust through nurse education, but also through practice andresearch

So, what would a curriculum look like that had emo-tional intelligence at its heart? Whilst we do not wish to pre-scribe a curriculum model of emotional intelligence here, itis fitting that we mention elements of what has proved atransformatory learning process for us (Freshwater 1998b).Thus we suggest that an emotionally intelligent curriculumwould include:• reflective learning experiences;• supportive supervision and mentorship;• modelling;• opportunities for working creatively with the arts and

humanities;• focus on developing self and dialogic relationships;

• developing empathy;• a commitment to emotional competency.Some approaches to experiential learning to be found in anemotionally intelligent curriculum may include:• forum theatre;• self inquiry;• narrative;• reflective discussion and writing;• art, drama, music, film and poetry;• practising listening skills, both in the classroom and in

practice;• the use of video for observation and feedback;• service user involvement in the planning and delivery of

the course.Rather than an addendum to the nursing curricula,

emotional intelligence needs to be firmly placed at the core.For this to be effectively integrated much work needs to beundertaken to support the highly stressed, often underpaid anddisillusioned teachers who themselves are not only removedfrom the caring environment, but also find their own work-ing environment uncaring — thus paralleling the processesthat practitioners encounter in their clinical settings. This israther like being trapped within a hermeneutic circle andhaving no space to reflect on the escape routes. Whilst werealise that emotional intelligence is not a panacea for all theills of nursing and nursing education, we firmly believe thatit is at the heart of learning to care, both for oneself andothers, and as such deserves to be examined in more depth.

Finally, we wish to return to our earlier point that boththe rational and emotional dimensions are essential tointellectual functioning and indeed to healthcare practices.Whilst it may appear that we have, in the main, concentratedour attention on the emotional dimension within the paper,the very act of putting the paper together is a rational actdriven by emotions such as passion, love and anger. Thefocus of the paper has been on the prevailing professionaldiscourse that tends to devalue emotional intelligence, pre-ferring instead abstract knowledge. We would like to reiteratehere that emotional intelligence and rational intelligence areinterdependent. As such, curriculum designers are taskedwith developing educational strategies that promote strongerlinks between the two domains, responding to such questionsas how can educators, practitioners and researchers work withinthe current context of underrecruitment and evidence-basedpractice to sustain reflective practice and emotional learning.

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