Effective healthcare organisations must have strong leadership at every level from the board to the ward (The King's Fund, 2012). However, the Francis report (Department of Health (DH), 2013) identified a breakdown in leadership behaviours as one of the reasons for the service failures that arose in Mid Staffordshire NHS Foundation Trust. Furthermore, it was noted that the hospital's leaders had passed behaviours to their staff that were more concerned with hitting targets than caring for patients.
Nurse leaders play a core role in providing high-quality patient care and services (The King's Fund, 2012). Emotional intelligence (EI) is said to be central to effective leadership in the NHS and a foundation of outstanding care quality (Carragher and Gormley, 2017). Understanding the intricacies of characteristics that enhance leadership should therefore be a goal of any healthcare organisation.
Background
There are several conceptual definitions of EI (Salovey and Mayer, 1990; Goleman, 1995; Bar-On, 1997), which share similar theoretical foundations, including the ability to monitor one's own and others' feelings and emotions to predict and nurture interpersonal effectiveness and guide behaviour (Mansel, 2017). In response to the Francis report (DH, 2013), the NHS Leadership Model (NHS Leadership Academy, 2013) recognises that personal qualities such as self-confidence, self-control and self-awareness, which are core competencies within EI, are part of the foundation of effective leadership.
The underpinning theory, developed from research by Storey and Holti (2013:6), states that an effective leader should use ‘soft intelligence’ rather than ‘hierarchical imposed targets’ and should listen, validate and engage with positive and negative emotions. The emotional abilities of ‘perceiving emotion, facilitating thought using emotion, understanding emotions and managing emotions’ make up the four-branch model of the ability-based model (Mayer et al, 2016:294), which is the exemplar (Elfenbein and MacCann, 2017).
Research regarding EI and healthcare has focused on the following in undergraduate nursing students: leadership (Duygulu et al, 2011); academic performance (Fernandez et al, 2012); curriculum (Codier and Odell, 2014; Foster et al, 2015; Carragher and Gormley, 2017). Codier (2015) and Rankin (2013) emphasised the importance of using EI screening as part of the admissions process. The new Nursing and Midwifery Council (2018) standards of proficiency acknowledge the importance of EI for registered nurses. EI capabilities are valuable to nursing and considered to be important for effective nursing leadership (Akerjordet and Severinsson 2008; Feather, 2009).
In the current context of healthcare delivery, the quality and effectiveness of services are becoming more important than ever as they develop against a rapidly changing and increasingly complex background. While leading the provision of changing healthcare services, nurses are expected to effectively communicate with those they are serving and to positively affect and influence them. During this process, nurses should get to know and understand themselves as well as the emotions and thoughts of the individuals they care for and interact with, and exhibit appropriate behaviours. However, there are limited empirical studies of EI among nursing professionals to support this, despite putative links between EI and the quality of care, which is core to organisational success in any healthcare body.
The literature on leaderships suggests that the unconscious emotional activity of leaders can be related to followers through leadership behaviour, which is based on how they perceive the world and react (George, 2000; Macaleer and Shannon 2002; Rao, 2006; Smith and Hughey, 2006). In a healthcare environment, it is desirable to identify a leadership model that leads to a long-term relationship between leaders and followers. The association between EI and specific leadership styles has received academic attention, predominately focused on the transformational leadership style (Harms and Credé, 2010).
A positive related link between EI and leadership ability has been described (Jin et al, 2008; Parker and Sorensen, 2008; Harms and Credé, 2010; Cavazotte et al, 2012; Lopez-Zafra et al, 2012). The need to enhance leadership capabilities with traits or characteristics associated with EI is a paramount consideration for the success of any organisation.
In high-risk industries, leadership is acknowledged to be an essential characteristic of safety management (Zohar, 2000). Leadership in health care is no different from other areas where safety is crucial. In Safety First (DH, 2006) the predominant message was about strengthening leadership to make patients safe. Patient safety should never be assumed; it requires the constant attention of leaders and continual support of the workforce. Without that risk grows. Engaged followers work more effectively and more productively, which leads to better outcomes for patients and the organisation (West et al, 2011). However, engaging followers is a significant leadership challenge, particularly in a working context with increased demand on nurses.
Therefore, it is logical to explore and understand the depth and breadth of nurse leaders' lived experience. Interpretive phenomenological analysis (IPA) is particularly useful to analyse emotional intelligence in leaders because it focuses on participants' perceptions of their experiences and how they attribute meaning to these (Smith, 2004; Prins, 2006; Smith and Eatough, 2006).
Study aims
The purpose of this IPA analysis study was to explore EI in nurse leadership.
Objectives
Design
To address the gap in qualitative studies on this topic, the study used IPA (Smith and Osborn, 2003; Smith et al, 2009). This approach to qualitative research involves exploring and understanding the lived experience of a specified phenomenon (Smith and Osborn, 2003). It considers the complex, multivariate nature of individuals and social influences (Creswell, 2008; Smith et al, 2009) and focuses on participants' perceptions of their experiences and their attribution of meanings (Smith, 2004; Prins, 2006; Smith and Eatough, 2006). This methodology offers a unique insight into EI competencies that might otherwise be missed in structured surveys or research and is well suited for accessing tacit, taken-for-granted, intuitive understanding of an experience (Tracy, 2013).
It is argued that qualitative research is too impressionistic and subjective, with findings relying on researchers' often unsystematic views about what is significant and important (Bryman and Bell, 2015). However, the strength of IPA lies in drawing on experiences to achieve a better understanding of how people think and of their individual behaviour. IPA is also interpretative, and engages with ‘double hermeneutics’, in which the researcher is trying to make sense of the participant who is attempting to make sense of their experiences (Smith and Osborn, 2003; Smith et al, 2009). It was this philosophy that guided every stage of the research process from the choice of setting to the process of analysis.
Participant selection
Various sample sizes have been used for IPA, typically from one to 15 (Bramley and Eatough, 2005); there is no ‘right’ sample size (Smith and Eatough, 2006). It is said that the difficulties in analysis of large data sets may result in the loss of ‘potentially subtle inflections of meaning’ (Collins and Nicolson, 2002:626), and exploring data in depth from large samples can lead to superficial understanding (Smith and Osborn, 2003). A consensus towards the use of smaller sample sizes has emerged (Smith, 2004; Reid et al, 2005), with five or six participants being recommended as a reasonable sample size (Smith and Osborn, 2003).
This study sample consisted of registered band 7 sisters/charge nurses/team managers; all were experienced senior nurses who were responsible for a clinical area, including the leadership of staff and delivery of patient care. Participants were invited from a list of ward/team nurse leaders provided by the head of mental health services and the head of nursing in a health board in south Wales. An email invitation was issued to potential participants (n=37) detailing the nature, purpose and process of the study. Five nurse leaders volunteered to take part. All five were women, four were aged 50-59 years and one was within the 40-49-year age bracket. They had a combined total of 81 years of experience as nurse leaders. In line with IPA, this sample was chosen as a defined group for whom the focus of the study had relevance and significance (Bryman, 2012).
Data collection
Semistructured interviews
Semistructured interviews were carried out, audiorecorded, transcribed verbatim, then analysed using IPA as outlined in Box 1 (Biggerstaff and Thompson, 2008). With semistructured interviews, it is helpful to prepare an interview plan. This was used purely as a guide to facilitate the natural flow of conversation because it was important to follow the participants' unanticipated and unprompted accounts rather than getting answers to specific questions asked in a sequence (Smith et al, 2009). The first author adopted the usual approach in IPA, using a prompt sheet to guide the semistructured interviews.
Data analysis
Transcripts were coded according to Biggerstaff and Thompson's (2008) analysis stages (Box 1).
Ethical considerations
Ethical approval was given by Swansea University's College of Human and Health Sciences' ethics committee. Permission was given by the health board where the study was conducted. All nurse leaders received information about the aim of the study and on how it was proposed that results would be disseminated; confidentiality was assured, as was participants' right to withdraw at any time.
Participant interviews were carried out in a private location at times convenient to the nurses.
Rigour
In IPA studies, the analysis considers the interpretation of one researcher and does not seek to find a single answer or validity, but rather a coherent and authentic account that is attentive to the words of the participants (Pringle et al, 2011). The use of a reflective diary by the first author assisted in supporting the decisions taken in the research process. It is recognised that IPA is subjective as a qualitative research approach because it is improbable that two researchers analysing the same data will arrive at precisely the same clusters and themes. According to Smith and Osborn (2008), the value of IPA is that the findings are attuned to issues that could be usefully explored in existing literature. The intention of this study was not to generalise results but to gain a deeper understanding of experiences from the perspectives of the participants (Maykut and Morehouse, 1994). However, the first author acknowledges that their own position as a healthcare professional and academic may have influenced interpretation of the findings and collation of themes.
Findings
The main themes that emerged from the analysis are presented in Table 1.
| Clusters | Subthemes |
|---|---|
| Sensing others: the empathic leader |
|
| Experiencing the affected sense of self |
|
| Strategies employed to build the team |
|
| Reading the flux of the organisation |
|
Sensing others: the empathic leader
The data suggest that empathy is an inherent expectation and should be a characteristic of all health professionals. Empathy is a connection and is about letting people know they matter. The emotional connection allows nurse leaders to be mindful of what staff and patients are experiencing. Empathy is therefore paramount to great leadership.
Understanding the feelings of others
Accurately reading emotions is an essential process in being aware of the feelings of others (Arora et al, 2010). The nurse leaders in this study were clear that their role involved supporting colleagues through an awareness of what they were thinking and feeling.
‘Because you do have to tune in to everybody's needs and be empathetic about what is going on in their lives and that kind of thing. Again, the strong points, if you are going to develop them in a strong productive way, you have to be tuned into those things.’
Empathy is an attitude of life that can be used to attempt to approach someone, to communicate and to understand others' experiences and feelings (Halpern, 2003). In this case, empathy was valued as part of a relational approach to leadership. It is interesting here that the distinction between leadership and management was not made explicit by the participants but was implicit in their comments.
‘Some do talk about their feelings and you appreciate that, but you can also keep an eye on them and just tell them, “well, look, you know where I am, I am here, just let me know”, and, once they know that, that makes a difference … It's the relationship you develop with them.’
This comment suggests that empathy, as a component of EI, develops over time, which is in line with the idea that this is a relational issue.
Cultivating the skills and values that people require to care compassionately and effectively
This emerged throughout all interviews as a core theme. It was clear that intrinsic aspects of role satisfaction were related to the emotional engagement in caring.
‘If they [staff] are happy, they tend to look after people with a lighter heart and it's not a chore; it's, you know, caring is one of those professions where it's in us, you nurture, you want them [patients] to get better.’
The idea that EI and its components could be developed actively in colleagues emerged during the analysis.
‘An awareness. You can nurture it in somebody. If you can pick up that somebody is showing these tendencies, that they can come [and] tell you, “look something is not right with so and so this morning, keep an eye, see if you can have a word with them later”.’
This shows that a degree of compassion for colleagues is required for teamworking and speaks to the context of care.
Perception of the lack of empathy from others
According to Goleman et al (2013), empathetic people are outstanding at recognising and meeting the needs of followers. However, two participants perceived a lack of empathy from senior managers:
‘You want to take people with you and you care for your team and my manager and manager above. That I can't fault, they are both excellent, but [when] you go beyond that there does not seem to be that empathy, does not seem to be that caring.’
It was clear that these aspects of EI were viewed as desirable by colleagues.
‘People in more senior positions don't realise how important it is to acknowledge other people's part in the process and make them feel that they are doing a good job.’
The lack of perceived empathy from senior leaders could be down to the absence of personal contact and leading from a distance. This was interpreted by the first author as a need for greater collaboration between senior managers and nurse leaders, because a display of empathy makes people feel valued and understood as individuals (Kellett et al, 2006).
Experiencing the affected sense of self
An understanding of the world people live in provides a rich source of ideas and avenues for comprehending and exploring their lived experience, which in turn informs and deepens our understanding of reality (Smith et al, 2009).
Feeling overburdened
Chalmers Mill (2010) suggested that there should be a positive correlation between leaders' hard demands (tasks) and soft skills (empathy and understanding of the development needs of their staff). However, due to workplace pressures/demands/competing priorities, staff appear to be losing out on completing personal development reviews, reflective practice and other opportunities to develop their careers:
‘Time is a huge issue—enough time to do everything. All these audits to do: 9-10 every month we have to do, and every 3 months another four on top of that.’
This seems to indicate that the administrative workload associated with a leadership role could restrict the manifestation and expression of EI.
West and Dawson (2012) examined engagement scores in an NHS staff survey and found that appraisals proved to be a significant factor in predicting employee engagement. Furthermore, patient satisfaction was significantly higher in trusts with higher levels of employee engagement.
‘If you are going to be a leader, you have to have time to be a leader really. Time, I think, is a big problem. You are always pushed for time and, of course, as always, if someone wants something, it is always your staff who actually do without, as you drop that to deal with someone else, you know, because someone needs these numbers by today.’
This is illustrated by The King's Fund (2013), in its report on patient-centred leadership, which was published after the Francis report (DH, 2013). The King's Fund found that 51% of nurse leaders, when asked what they considered to be the biggest barrier to improving care quality, stated ‘time and/or resources’.
‘I do try and meet up with them [the team] regularly and just see how things are going. But it is hard because it means that if you do that you have to put something else to one side. The time I have to spend data collecting, I feel like a glorified admin—I can't do supervision as often as I would like. The staff are losing out because I have to crunch numbers or pull this together or pull that together.’
This is an example of the dominant NHS leadership style known as ‘pacesetting’ (Ham, 2014), characterised by setting demanding targets, leading from the front and collaborating little—and is a consequence of the health service focusing on process targets. Nurse leaders related their experience of their managers as being more focused on the delivery of targets than engaging with patients and staff.
‘I don't think senior managers understand the pressure team leaders [are under] at the moment to produce all this data collection; most of the pressure comes from above really. It's about massive amounts of auditing, data collection you have to report on, which takes you away from actually driving the service forward. And that is hugely frustrating.’
According to The King's Fund (2012), a growing body of research shows that the NHS needs to depart from the command and control, target-driven approach. Time is identified as a barrier to employing EI in healthcare leadership. There appears a tendency to carry out urgent tasks at the expense of those that are highly important.
Awareness of feeling stressed and anxious
Effective leadership places huge demands on the shoulders of one person. According to Van Rooy and Viswesvaran (2004), the effects of emotions and work in general are understudied. This study identified that all participants experienced negative emotions because of workload pressure. Stress and anxiety in the workplace can be related to a number of factors, not the least being the ability to manage the impact of the role on the self.
‘I have been off on periods of stress as I have bottled things up.’
It is interesting to see that the participant here allocates blame for the stress to herself and her lack of effective coping mechanisms, rather than on other factors that might be affecting her response.
‘I was on leave last week and I didn't sleep Sunday night thinking … Oh! What am I going into tomorrow morning.’
Again, the stress of the job is evident, and it extends into other aspects of life. The participants noted that operational and cultural factors may affect EI and their experiences in leadership roles.
‘There is always a blame culture going on and it is always someone else's fault and that goes through the whole organisation, and it does not matter what they say, you can't get away from that, it's true—it is there. I think that makes people anxious and I think they are not going to get supported if something goes wrong, they are going to be blamed.’
Research in higher education indicates the lack of EI in leaders is the root cause of stress and conflicts in the workplace (Smith and Hughey, 2006). All participants in this study reported having negative feelings associated with organisational pressures and the perceived lack of support for their demanding leadership positions. This may affect their ability to manifest EI and use it in their roles.
Strategies employed to build the team
According to Goleman et al (2013), teamwork goes beyond mere work obligations, which was evident from the data collected. Informal rewards in recognition of a job well done and saying thank you were identified. These relate to the following themes of positive feedback, gathering people together, reading the flux of the organisation, leading from a distance and poor staffing levels.
Positive feedback
Positive feedback was seen as a means of supporting and motivating colleagues and addressing the culture within the clinical setting. Being able to recognise the need to offer staff rewards of some kind is clearly a component of reading the mood of the staff and using EI to foster a supportive culture.
‘Well done. So good feedback is very important.’
Feedback is viewed positively.
‘And I know that I am forthcoming with praise quite a lot in the meetings. Loads of praise. I don't agree with criticisms either.’
The association of praise and positivity with the leadership role may be linked to leaders’ awareness of needing to manage people's experiences within the clinical team.
Gathering people together
Cultivating social connections as a simple act of gathering around the table helps builds bonds. Social connectedness has been shown to increase happiness and a sense of belonging (Mauss et al, 2011).
‘Another thing I like to do to encourage people, is every so often have a team breakfast and I will bring in nice things to eat … a reward for hard work.’
Again, this demonstrates an awareness of the need to generate a positive working environment.
‘I brought food in the other week because we had a particular, heavy couple of weeks.’
The underlying operational issues that bring about these working conditions need addressing; major changes take significant amounts of time. It is clear that elements of managing staff feelings and experiences are related to their perception of leadership, which suggests that EI is about more than addressing issues when employees have problems. This is evident in the following theme.
Reading the flux of the organisation
The participants were all politically astute and understood the political forces at this time of austerity. Nevertheless, the lack of perceived support they received was apparent.
Leading from a distance
‘Managers are leading from a distance. People who manage the managers don't do walkabouts enough’.
Walkabouts are beneficial, and there have been calls for health boards to do more to exercise clear and visible leadership to improve the quality of care their organisations provide (DH, 2013).
‘Quite often, you don't see anyone from the top until something has gone wrong. You're the one who is carrying the can—you're the one who's held to account.’
This speaks to the two-way process of EI—as something that benefits both the team and the leaders. Working in a punitive culture can be difficult.
‘When something goes wrong, they come down like a ton of bricks. It would be nice to see them once a year—people do respond to it, it means a lot, you know, and it is supporting the leaders as well.’
The NHS Modernisation Board's annual report 2000/2001 (DH, 2002) acknowledged that senior management in the health services must increase their contact with frontline staff to improve service delivery and effect change. Despite this, the Francis report (DH, 2013) detailed some of the worst failings in care that followed a lack of clear and visible leadership.
Poor staffing levels
It is difficult to maintain professional standards because of time constraints and being under-resourced. The Francis report explicitly stated that poor staffing levels at Mid Staffordshire led to poor quality care (DH, 2013), and participants in this study agreed:
‘I think you need more nurses as well. Nurses become paperwork heavy and, if people are sitting writing up this, that or the other, really time has been taken away from the patient.’
This speaks to the impact on practitioners as well as patients.
‘As a manager, I was there with the rest of them, feeding people, bathing people because we did not have the staff on the floor. Where is the quality of care?’
Two participants reported being included in ward nurse numbers because of employee shortages, which took time from their leadership roles. This finding supports the Royal College of Nursing's (RCN, 2009) investigation into the pressure placed on ward leaders and suggests that there may be scope to consider how such demands would affect EI.
Discussion
It is evident that EI is a complex, bidirectional phenomenon or quality that requires leaders to manage the self while supporting and managing others. Empathy is regarded as an inherent trait of EI (Austin et al, 2005). Empathy, expressed in terms of joy, sorrow, excitement, misery, pain and confusion in health care, enables practitioners and patients to work together (LeCompte, 2000). EI in nurse leadership seems to be the buffer between the frontline workforce and the organisational factors that affect their roles, but this appears to place a considerable burden on nurse leaders.
The NHS Leadership Academy, in Towards a New Model of Leadership for the NHS, stressed that leaders in a healthcare setting should seek to help create a climate that facilitates positive emotional attributes such as compassion, commitment, empathy and optimism (Storey and Holti, 2013). The findings of this study support this, demonstrating a critical role for empathy, part of the ‘social awareness’ of EI (Goleman et al, 2013).
Empathy is paramount to great leadership and management in health care for at least three reasons. First, the ‘increasing use of teams’, described by Goleman as ‘cauldrons of bubbling emotions’; second, the ‘rapid pace of globalization’ (growth and development in healthcare with miscommunications readily leading to misunderstandings); and, third, the ‘growing need to retain talent’ (Goleman, 1998). It is clear from this study that operational and staffing factors require a skilful management of the workforce, which in turn requires sensitivity and EI.
The NHS Leadership Model (NHS Leadership Academy, 2013) recognises that personal qualities such as self-confidence, self-control, self-knowledge, personal reflection, resilience, determination and self-awareness are elements of the foundation of effective leadership. This study echoes this and highlights that self-awareness, as a component of EI, is a bidirectional quality that strengthens leadership. According to Goleman et al (2013), characteristics of a self-aware individual include emotional self-awareness, accurate self-assessment and self-confidence. The nurses in this study appear to use EI to mediate between the organisation and the workforce in the light of factors that are not easy to change. The personal impact of working in this way needs further exploration.
One foundation of effective leadership is the development of a deeper awareness of your own self through reflective practice. Being insightful about emotions and their influence on management decisions and practice lends to the development of the characteristics of self-awareness (Salovey and Mayer, 1990). It is clear that the participants in this study exhibited a good degree of self-awareness, but only in relation to the impact of their roles, particularly in terms of stress levels. It would seem that the use of EI requires a certain degree of resilience towards a multiplicity of organisational factors affecting staff, and the drain on nurse leaders needs further investigation.
Good leadership is about having not only exceptionally high levels of self-awareness, but also the ability to apply this knowledge in practice. The organisational factors that impede this may be addressed more proactively if leaders are able to use EI, because it promotes the growth of reflection on, and awareness of, influences that can affect leadership in health care. Channelling this into team building seems important to relationships between self, team and environment, and has suggested how practitioners can consciously work with this triadic relationship.
Although it is no surprise that working conditions and stress emerged as a theme, the expression of core values of EI was also important for these leaders. This echoes other research, such as that by Slaski and Cartwright (2002), who reported significantly lower stress and distress, higher morale, improved perceived quality of working life and significantly better health in managers who had high levels of EI. It was evident that the narratives of nurse leaders’ lived experiences in this study reflected some core values of EI within their leadership roles.
However, significant difficulties identified around time, pressure and poor staffing levels appear to suppress their potential in achieving emotionally intelligent leadership. This study supports the views of the RCN (2009) and Ham (2014) that pressure and competing priorities had a detrimental effect on effective leadership, suggesting that changes in the context of nursing are also required to ensure that organisations can optimise the potential of their resources. Most importantly, nurse leaders should take advantage of the great power of emotions and their role in EI to positively influence followers to achieve excellent patient care.
The findings of this study supports the findings reported over the decades and, in response to many NHS failings of the perceived lack of support for nurse leaders by senior managers, highlight the need for a less hierarchical approach to managing healthcare organisations. EI is important not only for the success of individuals in a healthcare organisation but also as individuals rise through leadership positions and, crucially, it appears to affect care quality. It may mean that EI is a critical factor for developing effective leadership in health care, and it becomes more significant in the higher levels of an organisational hierarchy. The key challenge is to develop leaders within health care with the right values who will implement a culture of emotionally intelligent caring. Aspiring leaders should consider improving levels of EI competencies, which can be intentionally learnt by those who are willing to learn and continuously work on them, which would in turn enhance leadership effectiveness (Zakariasen and Zakariasen Victoroff, 2012).
The ability to manage and read emotions is an important skill for any health professional and has the potential to enhance patient care. This study adds to the limited body of knowledge on EI in nurse leadership. However, further research and different methodological approaches are required to achieve a deeper understanding of how EI is linked to nurse leaders, followers and patient care, and organisations themselves should prioritise action to overcome barriers to effective expression of nurse leadership. The time and resources spent in this manner are likely to result in greater efficiency and longer term savings in the use of resources. At the same time, barriers between the staff who work at the coalface and those in leadership positions must be eroded.
High-achieving individuals often demonstrate high intelligence, strong personality types and high EI. Their personal, social and organisational effectiveness is often strongly influenced by their self-awareness and social awareness as a foundation for their skill and ability to manage themselves and others in all types of situations and circumstances. It is vital therefore to educate the nurse leaders of the future in developing and using EI in their leadership roles, and in addressing the structural and cultural aspects of leadership practice, including outmoded expressions of hierarchical position, to ensure that the positive qualities of EI can be expressed by all staff regardless of the context of care.
Limitations
The authors acknowledge that leadership success is more complicated than a single dimension such as EI. Because the sample was small and purposive, the results of this study may not be generalisable beyond the population from which the sample was drawn, and caution should be applied to avoid overgeneralising beyond the study location (Bryman, 2012). This study used a sample of nurse leaders and may have included more motivated individuals from within the profession, which may have skewed the thematic findings.
Conclusion
There are two dimensions to the conclusions and recommendations that arise from this study. First, in terms of policy, the most significant finding is that there are significant professional challenges identified by leaders in relation to time, pressure and poor staffing levels. These factors appear to suppress their potential to become more effective leaders by using EI. This study has supported the views of the RCN (2009) and the Ham (2014), which note that pressure and competing priorities have a detrimental impact on effective leadership. Policies should reflect the value of the emotional dimensions of leadership and should allocate sufficient time and resources to staff engagement and activities that could enhance their ability to develop and actualise EI in their professional life. An urgent review of data collection requirements and targets imposed on nurse leaders should be carried out. Organisations, policymakers and nurse leaders must work together to empower nurse leaders to apply EI in health care.
Second, in relation to practice, it is clear that, before nurse leaders can even start to discuss EI or improve it, greater understanding is needed of the term and its meanings, and of how its dimensions may be implicit in existing behaviours and attributes. Despite the lack of familiarity with the concept of EI in the nurse leaders interviewed, it was evident in the narrative of their lived experiences that they were able to reflect some of the core values of EI within their leadership roles, even when they did not define these as EI. Senior managers should increase their visibility in the clinical area with more frequent walkabouts to listen to staff issues and be empathetic to staff needs.
The authors conclude that nurse leaders should take advantage of the power of emotions and their role in EI to positively influence followers within health care to achieve excellent patient care. In addition, they should provide feedback on operational issues that impact on the experience of the workforce, and explore the ways in which they use intrinsic and extrinsic rewards to improve their ability to manage their teams.
The following key elements appear to be essential to ensuring emotionally intelligent nurse leadership: understanding the concept of EI in healthcare leadership; recognising that this will enhance nurse-leadership approaches; placing a high priority on overcoming barriers to effective nurse leadership; committing time and resources to making it happen; ensuring the support of senior management through their demonstration of presence; and visible and emotionally intelligent leadership at all levels of the organisational hierarchy.
A recognition of the bidirectional nature of EI and the dual-facing role of nurse leaders, at the intersection of the wider body of staff and the higher levels of the organisation, and their perception of their role as mediating between these two elements, would enable future work to address how to optimise EI in leadership while continuing to use it as a tool for service quality improvement.