Nurse Education Today 35 (2015) 510–517

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Review

Emotional intelligence education in pre-registration nursing programmes: An integrative review Kim Foster a,⁎, Andrea McCloughen b,1, Cynthia Delgado c,d,2, Claudia Kefalas d,3, Emily Harkness e a

Faculty of Health, Disciplines of Nursing & Midwifery, PO Locked Bag 1, University of Canberra, ACT 2601, Australia Sydney Nursing School, University of Sydney, 88 Mallett Street, Camperdown, NSW 2006, Australia Sydney Nursing School, The University of Sydney, 88 Mallett Street, Camperdown, NSW 2050, Australia d Royal Prince Alfred Hospital, Sydney Local Health District, P.O. Box M50, Missenden Road, Camperdown, NSW 2050, Australia e School of Psychology, University of Sydney, NSW 2006, Australia b c

a r t i c l e

i n f o

Article history: Accepted 17 November 2014 Keywords: Emotional intelligence Emotional labour Nurse education Curriculum Pre-registration

s u m m a r y Objective: To investigate the state of knowledge on emotional intelligence (EI) education in pre-registration nursing programmes. Design: Integrative literature review. Data sources: CINAHL, Medline, Scopus, ERIC, and Web of Knowledge electronic databases were searched for abstracts published in English between 1992–2014. Review methods: Data extraction and constant comparative analysis of 17 articles. Results: Three categories were identified: Constructs of emotional intelligence; emotional intelligence curricula components; and strategies for emotional intelligence education. Conclusions: A wide range of emotional intelligence constructs were found, with a predominance of trait-based constructs. A variety of strategies to enhance students' emotional intelligence skills were identified, but limited curricula components and frameworks reported in the literature. An ability-based model for curricula and learning and teaching approaches is recommended. © 2014 Published by Elsevier Ltd.

Background The ability to establish therapeutic relationships and to communicate effectively with patients, families, and colleagues are essential standards for competent registered nurses (Nursing and Midwifery Board of Australia, 2006; UK Nursing and Midwifery Council, 2008). These relational abilities are vital as nursing practice involves complex care for people who are emotionally vulnerable due to physical or mental illness. The significance of human relationships in nursing (Freshwater and Stickley, 2004), and the critical importance of skilled nursing care which addresses patients' emotional and physical needs, are evidenced by recent healthcare reports (e.g. Francis, 2013) calling for nurse education with an increased focus on developing students' compassion and caring.

⁎ Corresponding author at: Faculty of Health, Locked Bag 1, University of Canberra, ACT 2601, Australia. Tel.: +61 2 6201 5131; fax: +61 2 6201 5128. E-mail addresses: [email protected] (K. Foster), [email protected] (A. McCloughen), [email protected] (C. Delgado), [email protected] (C. Kefalas), [email protected] (E. Harkness). 1 Tel.: +61 2 91144085; fax: +61 2 93510679. 2 Tel.: +61 2 9114 4080; fax: +61 2 9351 0649. 3 Tel.: +61 2 9515 8714.

http://dx.doi.org/10.1016/j.nedt.2014.11.009 0260-6917/© 2014 Published by Elsevier Ltd.

In order to meet patients' and families' emotional needs effectively during the health/illness journey nurses engage in caring practices of managing their own and others' emotions. This emotional labour, or work, involves induction and/or suppression of emotion; the purpose of which is to sustain an outer appearance that makes others feel safe and cared for (Hochschild, 1983). Theodosius (2008) identifies three types of emotional labour (EL) in nursing: Instrumental EL involves the use of interpersonal skills while carrying out a clinical procedure in order to make the process more comfortable and to minimise patient distress. Therapeutic EL involves listening to and encouraging expression of patient/family feelings with the intention to establish an interpersonal relationship and promote emotional wellbeing. The final type is Collegial; the interpersonal relationships and communication between nurses and within the interdisciplinary team which has the purpose of processing important information and facilitating effective nursing care. Emotional labour calls upon the use of personal and interpersonal skills or ‘intelligences’ (McQueen, 2004). Leading theorists have defined emotional intelligence (EI) as an intelligence comprising the ability to perceive emotions, integrate emotions to facilitate thinking, understand emotions, and to regulate or manage emotions to promote personal growth (Mayer and Salovey, 1997). EI has, however, been variously defined and understood. The credibility of the construct has been challenged due to the array of conceptual perspectives and definitions.

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Researchers have identified two main EI conceptual models; one based on abilities, the other on personality traits (Roberts et al., 2010a). The ability-based model views EI as a form of information-processing and is considered the most conceptually and empirically valid (Roberts et al., 2010a, 2010b). The ability model is grounded in the work of Mayer and colleagues. Their four factor or branch model involves a hierarchy of abilities starting with emotional perception (accurately perceiving emotions in self and others); emotional facilitation (using emotions to facilitate tasks); emotional understanding (understanding the relationship between emotions and situations); and emotional management (regulation of own and others' emotions) (Mayer et al., 2003). From an educational perspective, the concept of EI as abilitybased is salient as it presumes that EI can be learnt, and EI abilities can be taught (Foster and McKenzie, 2012). The trait-based EI model, on the other hand, includes a mix of competencies and personality traits such as assertiveness, stress management, self-awareness, and social awareness (Bar-On, 1997; Goleman, 1998). Key proponents of this approach, Bar-On (1997) and Goleman (1998) have constructed self-report measures based on these conceptual underpinnings. Goleman's (1995) model encompasses a range of emotional skills and personality traits and includes two types of competencies: emotional and personal. Emotional competencies include selfawareness, self-regulation and motivation, whereas social competencies comprise of empathy and social skills. Accordingly, while these competencies are grounded in possessing the trait of EI, individuals must learn and develop the associated skills to be effective in the workplace and enhance professional behaviour. Because of the mixture of characteristics attributed to EI in the trait-based model however, it is a heterogeneous construct (Gignac, 2010a) which has been critiqued for having substantial overlap with personality. Due to its self-report measurement, there is also potential limited personal insight and/or faking of higher scores (Roberts et al., 2010a). Despite the lack of consensus on the EI construct, over the past decade there has been a growing body of international literature investigating pre-registration nursing students' levels of emotional intelligence (Benson et al., 2010; Namdar et al., 2008; Por et al., 2011; Rankin, 2013). These studies have used EI measures based on a range of EI constructs, with little consistency in measurement. While findings identify that EI is negatively correlated with stress management, practice performance, academic performance, and retention for nursing students (Por et al., 2011; Rankin, 2013), there is limited ability to make comparisons between studies due to the heterogenous measurement of EI. Given the substantial emotion work entailed in nursing practice, there is a need to develop students' EI capacity during pre-registration education. Internationally, numerous calls have been made, primarily by mental health academics, for inclusion of EI education in preregistration programmes (e.g. Freshwater and Stickley, 2004; Hurley, 2008; Hurley and Rankin, 2008). Due to the varying theoretical understandings of EI, however, there is lack of consensus on the construct in nursing (Bulmer Smith et al., 2009), and little systematic examination of EI education in pre-registration curricula. Preliminary scoping of the literature revealed minimal review of EI nurse education. As part of a broader review of EI in nursing, McQueen (2004) argued that while EI has been acknowledged as relevant to nursing curricula, it was yet to be a requirement of nursing programmes. She recommended selfawareness, self-regulation and social skills as key skills to be incorporated in curricula, and that teaching methods and key learning outcomes relevant to EI needed to be explicit. This is consistent with Bulmer Smith et al. (2009), who concur that EI needs to be overt in curricula and concluded it was important to identify whether curricula included emotional knowledge and skills as EI could influence the quality of student learning and critical thinking, and their ability to make ethical decisions and use evidence in practice. Nurses acknowledge how important EI capabilities such as self and other emotion awareness and management are to effectively perform

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their work (Hurley, 2013), and recognise the need for adequate preparation to maintain their emotional wellbeing in practice (Rose and Glass, 2010). Due to the mounting imperative to include EI education in pre-registration nursing programmes, and the lack of substantial review of EI education, the present study sought to extend understandings of EI preparation of the nursing workforce and investigate EI education in pre-registration nursing programmes. Aim and Questions Aim To investigate and synthesise the state of knowledge on emotional intelligence education in pre-registration nursing. Questions 1. What theoretical constructs of emotional intelligence are evident in pre-registration nurse education literature? 2. What emotional intelligence components are considered important to include in pre-registration nursing curricula? 3. What emotional intelligence educational strategies have been proposed and/or developed for pre-registration nursing curricula? Method Whittemore and Knafl's (2005) integrative review methodology was used to guide the review and ensure a systematic and rigorous process was followed. Integrative review method is inclusive of empirical and/or theoretical literature, and aims to synthesise findings in order to provide greater understanding of an issue. Data Sources CINAHL, Medline, Scopus, ERIC, and Web of Knowledge electronic databases were searched for abstracts (Table 1). Inclusion and Exclusion Criteria Peer-reviewed research or discussion papers focusing on education for EI in the context of pre-registration nursing programmes, published in English between 1992 and 2014, were included. Literature reviews and grey literature were excluded. Papers that addressed EI education for postgraduate nursing or registered nurses, or did not have EI as the central focus, were excluded. Empirical research investigating or measuring nursing students' emotional intelligence (EI) were also excluded as the focus of the review was on how students were being educated for EI, rather than on students' levels of EI. Table 1 Search terms. Concept

Subject headings

Text words

Emotional intelligence: AND

Emotional intelligence OR Emotional competence OR Self-competence OR Self-competence Nursing

Emotional intelligence OR Emotional competenc* OR Self competenc* OR Self-competenc* Nurs*

Education OR Students OR

Educat* OR Student* OR Health occupations OR Pre-nursing OR Curricul*

Nurse: AND Education:

Limit to English language and years 1992 to 2014. *Define.

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Screening

Constructs of Emotional Intelligence

Titles and abstracts of 305 records were initially reviewed against the inclusion/exclusion criteria. Full texts of retained articles were read and screened and reference lists were hand searched, resulting in 17 relevant articles for review (Fig. 1).

A range of EI constructs and definitions were referred to. The primary EI theorists were Goleman (15/17 papers), Salovey and Mayer (11/17) and Bar-On (6/17). A summary of the theories and main constructs are in Table 2. Goleman's (1998) definition of EI was quoted by two authors (Harrison and Fopma-Loy, 2010; Roberts, 2010) as “the capacity for recognising our own feelings and those of others, for monitoring ourselves, and for managing emotions in ourselves and in our relationships” (Goleman, 1998; p. 317). Most commonly, however, Goleman's EI concept was briefly outlined as comprising a range of emotional skills and personality traits involving personal and social competence (e.g. Bellack et al., 2001; Wasylko and Stickley, 2003). Specific aspects of these competencies were expanded on by several authors. Cadman and Brewer (2001) and Harrison and Fopma-Loy (2010) referred to Goleman's (1995) domains of self-awareness (emotional awareness, accurate self-assessment, and high self-esteem/self-confidence); self-regulation and motivation (emotional self-control, flexibility in managing change/adaptability, optimism, innovation and initiative); social awareness (encompassing empathy, organisational awareness and service) and relationship management/social skills (inspiration, influence, persuasiveness, conflict management and leadership skills). There was variation in the terms and language used to describe Goleman's model of EI competencies and qualities. Bellack (1999) and Hurley (2008) outlined personal competence as comprising self-confidence, self-awareness/knowing one's strengths and limits, self-control of emotions, trustworthiness, flexibility, adaptability/being comfortable with new ideas or change, initiative, drive, commitment, optimism, accountability and drive to be one's best. Qualities of social

Analysis Constant comparison method was used to guide data analysis (Patton, 2002). Data were extracted and coded for the 3 review questions. In an iterative comparison and contrast process within and across articles, key concepts and meaning units relevant to each question were grouped. In a final process of comparison and integration, relevant elements were synthesised into an integrated summary (Whittemore and Knafl, 2005). Key words and constructs were also counted in order to gain an understanding of the contextual use and emphasis of content in the articles (Hsieh and Shannon, 2005). Results The review included 17 published articles from 1992–2014. These were mainly discussion/opinion papers (15/17); two papers reported primary research studies. Authors were predominantly from the United Kingdom (11/17) and six authors had written more than one article. Over half the articles (10/17) addressed EI in the context of mental health pre-registration nursing; the remainder focused on pre-registration nursing generally. Findings are categorised according to the three review questions.

Fig. 1. Search and Screening.

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Table 2 Terms used to describe primary theories of emotional intelligence. Author

Goleman Personal competence: –Motivation –Self-awareness –Self-regulation Social Competence: –Empathy –Social skills –Emotional competence

Bellack (1999) Bellack et al (2001) Brewer and Cadman (2000) Cadman and Brewer (2001) Evans and Allen (2002) Freshwater (2004) Freshwater and Stickley (2004) Harrison and Fopma-Loy (2010) Hurley (2008) Hurley and Rankin (2008) MacCulloch (1999) Por et al. (2011) Proctor and Welbourn (2002) Roberts (2010) Stickley (2003) Wasylko and Stickley (2003) Wilson and Carryer (2008)

√ √ √ √ √ √ √ √ √ √ √ √ √ √ √

competence were described as interest and concern for others, recognising and responding to customer needs, valuing diversity, political awareness, effective listening, communication, leadership, influencing and inspiring others, cooperating and collaborating with others, managing change, and resolving conflict (Bellack, 1999; Hurley, 2008). Roberts (2010) referred to high self-esteem, self-motivation and conflict management as examples of Goleman's EI components. Across papers, ‘emotional intelligence’ was used alongside and interchangeably with ‘emotional competence’, ‘emotional literacy’, ‘emotional labour’ and ‘countertransference’. ‘Emotional competence’ was particularly used when describing whether and how EI could be learned or developed. Harrison and Fopma-Loy (2010) discussed that emotional competence has its basis in EI, but is a learned capacity which leads to excellent work performance. Wilson and Carryer (2008) identified emotional competence as the product of life experience and professional experience. Notably, they were critical of the interchangeable use of the various terms, and MacCulloch (1999) acknowledged that the terms EI and emotional competence were not synonymous. Salovey and Mayer's (1990) construct of EI (11/17 papers), was identified as a type of social intelligence involving the ability to monitor own and others' emotions, to discriminate among them, and to use the information to guide one's thinking and actions. Roberts (2010) explained that for Salovey and Mayer (1990), EI is a mutually beneficial interdependence between emotion states and ability to think, learn and adapt to the environment. The four hierarchical branches of EI ability were identified: 1) perceive emotion — through nonverbal behaviour, 2) use emotion to facilitate cognition 3) understand emotions by analysis and prediction and 4) manage, regulate and reflect upon emotions in the context of other personality characteristics (Hurley and Rankin, 2008; Hurley, 2008; Roberts, 2010). The importance of this construct of EI to guide decision making and behaviour was emphasised by several authors (Brewer and Cadman, 2000; Cadman and Brewer, 2001; Por et al, 2011; Harrison and Fopma-Loy, 2010). Salovey and Mayer's model was recognised as highlighting the cognitive components of emotional intelligence, in line with the tradition of standard intelligence (Por et al., 2011). Bar-On's (1997) model of EI was highlighted in six papers and components of the model including intrapersonal and interpersonal factors,

Salovey & Mayer Intelligence –Ability to perceive emotion –Understand emotions –Use emotion to facilitate cognition –Manage, regulate and reflect upon emotions

Bar-On Intrapersonal Interpersonal –Adaptability –Stress-management –General mood/motivation

√ √ √ √ √

√ √ √ √

√ √

√ √ √

√ √



adaptability, stress management and general mood/motivation factors, were specifically addressed in four papers (Freshwater and Stickley, 2004; Freshwater, 2004; Hurley, 2008; Hurley and Rankin, 2008; Por et al., 2011; Roberts, 2010). Intrapersonal EI encompasses emotional self-awareness, assertiveness, self-regard, self-actualisation and independence; interpersonal EI comprises empathy, interpersonal relationships and social responsibility; adaptability relates to problem solving, reality testing and flexibility; stress management includes stress tolerance and impulse control (Hurley and Rankin, 2008; Hurley, 2008). When compared to Goleman's, Bar-On's model is a mixed approach (Por et al., 2011) where EI encompasses a range of personality traits, social skills and work related competencies (Roberts, 2010). These include empathy, high self-esteem, self-motivation, self-control, self-awareness, conflict management and adeptness in relationships (Por et al., 2011; Roberts, 2010). Other theorists on interpersonal communication and related aspects of emotional wellbeing were also referred to in order to substantiate or elaborate on EI. Examples include Gardner's (5/17) construct of multiple intelligences, Heron's (2/17) emphasis on the impact of unresolved personal distress in the quality of interactions with clients, and Orbach's (2/17) term ‘emotional literacy’. In the main (12/17), the eclectic nature of the various EI theories was neither discussed nor critiqued. Hurley (2008) however, noted the lack of agreement and clarity about whether EI was a construct of competencies or personality characteristics. He concluded that the major EI theorists (Goleman, 1995; Salovey and Mayer, 1990; Bar-On, 1997) were not only attempting to define a universally accepted construct, but also trying to provide the language to describe the construct, placing different emphasis on its defining aspects. Harrison and Fopma-Loy (2010) and Por et al (2011) acknowledged there were ‘ability’ models such as Salovey and Mayer (1990) which differed from mixed models, such as Goleman (1995) and Bar-On (1997), while Freshwater and Stickley (2004) and Roberts (2010) acknowledged that the models contrasted with one another. Emotional Intelligence Curricula Components Components of EI considered important to incorporate into preregistration programme curricula for nurses were outlined by most authors (15/17) (Table 3). These were highlighted as standard qualities

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Table 3 Components of Emotional Intelligence for Inclusion in Curricula. Author Bellack (1999) Bellack et al (2001) Brewer and Cadman (2000) Cadman and Brewer (2001) Evans and Allen (2002) Freshwater and Stickley (2004) Harrison and Fopma-Loy (2010) Hurley (2008) MacCulloch (1999) Por et al (2011) Proctor and Welbourn (2002) Stickley (2003) Wasylko and Stickley (2003) Wilson and Carryer (2008)

Self-awareness/ reflective practice

Self/emotion regulation

Commitment/motivation/ personal growth

√ √

√ √ √ √

√ √ √ √ √ √ √ √ √

√ √ √ √

Empathy/responsiveness

Communication/ interpersonal skills

√ √ √ √

√ √ √

√ √ √







√ √

√ √ √



necessary for effective nursing practice, and included: self-awareness and reflection, self-management, social awareness, relationship management, ability to maintain professional and social boundaries and balance emotion, and rational thinking in order to effectively make decisions. Specific aspects of Goleman's EI framework identified as important for nursing education and curricula (6/17) were personal competence including self-awareness, self-regulation and motivation, and social competence including empathy and social skills (Bellack et al., 2001; Brewer and Cadman, 2000; Harrison and Fopma-Loy, 2010; Hurley and Rankin, 2008; Roberts, 2010). Additionally, Goleman's five domains of reflective practice; exploration of self and other's emotional responses, continuing personal and professional growth, feedback to aid understanding of self and others, and development of micro skills, were promoted as providing a foundation for establishing high-level therapeutic communication skills (Proctor and Welbourn, 2002). The importance of including components of EI aligned with Goleman's framework, although he was not specifically cited, were outlined in a further five papers (Evans and Allen, 2002; Freshwater and Stickley, 2004; Por et al., 2011; Stickley, 2003; Wasylko and Stickley, 2003). Hurley (2008) argued that within the context of EI, and mental health nursing specifically, curricula require a clear identification of requisite abilities students should exit with. Drawing from professional reviews and user-based research, a range of shared EI values that should be embedded into curriculum were recommended: empathy for self and others, responsiveness, unstated morality, communication, relatedness, reflection, awareness and self-management (Hurley, 2008). Freshwater and Stickley (2004) and Bellack (1999) also contended nursing curricula should not be dominated by one understanding of knowledge and intelligence, but needs to manage a balance of the rational and emotional and recognise the merit of the complex relationship between self and intelligence. They saw a need to embed factors related to self-awareness, therapeutic use of self and reflective practice into curricula that stimulates inquiry into the world of emotions and focuses on transformatory learning (Freshwater and Stickley, 2004). At the same time, initiative, organisational skills, teamwork abilities, customer orientation and self-responsibility were also important to the development of students' EI (Bellack, 1999). The ability to preserve personal and professional boundaries while still maintaining empathic communication with patients was acknowledged as an important skill (Freshwater and Stickley, 2004) and as a specific target for pre-registration curricula (Wasylko and Stickley, 2003). MacCulloch (1999) highlighted the importance of enhancing awareness of transference and countertransference, and Heron's (1990) components of emotional competence, as areas to be developed in students. Wilson and Carryer (2008) identified themes of effective communication, recognising and regulating own emotions and reactions, recognising others' emotions, and personal development.

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Emotional decision making/reasoning

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In addition to outlining essential EI curricula components, a few authors identified that pre-registration students should possess specific EI-related qualities upon entering nursing. They contended this could reduce attrition rates (Cadman and Brewer, 2001) while also providing candidates with formative evaluation directing them to the relevance of EI and areas for self-development (Hurley, 2008). Brewer and Cadman (2000) and Cadman and Brewer (2001) identified that students should possess a balance of divergent, lateral thinking ability, and convergent, logical thinking ability, while Hurley (2008) proposed that empathy, self-awareness, stress coping, and relating could be measured during nursing education. Strategies for Emotional Intelligence Education Strategies for EI education in pre-registration curricula were highlighted in all papers, with many referring to multiple strategies (Table 4). These included EI self-assessment, reflection activities, modelling of EI behaviours and development of empathy. Three papers outlined programmes with strategies that had been designed and implemented to enhance EI skills. These all drew heavily on Goleman's EI model. Bellack et al. (2001) used Goleman's (1998) EI framework to provide the structure for operationalising leadership that aimed to enhance beginning leadership competencies in students. Leadership was defined as a broad competency that embraced managing self and relationships with others. Self-assessment of EI and leadership competencies and subsequent interpretation of results were used by nursing faculty and clinical partners as a starting point to redevelop curriculum with an emphasis on improving these competencies in graduates (Bellack et al., 2001). Harrison and Fopma-Loy (2010) developed and tested a series of student reflective journal prompts, designed to stimulate reflection and discussion around 18 EI competencies related to Goleman et al.'s (2002) domains of self and social awareness and self and relationship management. The prompts were effective in assisting students to progressively build selected EI competencies. Prompts focused on essential competencies identified as: emotional self-awareness and accurate self-assessment, emotional self-control, developing others' abilities and conflict management (Harrison and Fopma-Loy, 2010, p. 646). Proctor and Welbourn (2002) drew on Hochschild's (1983) concept of EL and Mayer and Salovey (1997) and Goleman's (1995) constructs of EI when developing a communication module aimed at enhancing nursing students' therapeutic communication and emotional awareness skills using an experiential and reflective process. Experimental tasks (exploration of own emotional issues and understanding of psychological/emotional roadblocks) incorporating activities to practice skills, video demonstration of therapeutic communication, peer assessment, reflective processes and continuous feedback were used to develop students' effective therapeutic skills incorporating aspects of EI.

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Table 4 Emotional intelligence education strategies proposed for curricula. Author

Bellack (1999) Bellack et al. (2001) Brewer and Cadman (2000) Cadman and Brewer (2001) Evans and Allen (2002) Freshwater (2004) Freshwater and Stickley (2004) Harrison and Fopma-Loy (2010) Hurley and Rankin (2008) Hurley (2008) MacCulloch (1999) Por et al. (2011) Proctor and Welbourn (2002) Roberts (2010) Stickley (2003) Wasylko and Stickley (2003) Wilson and Carryer (2008)

Reflective learning/. enquiry-based learning

Reflection activities/ support/personal growth/counselling

√ √ √ √

Teachers to model EI skills

Experiential/role play/theatre/ art/poetry

Service user involvement

√ √ √

√ √

Assessment of EI/ self-assessment & feedback

√ √ √ √ √ √ √ √ √



Transparency of EI skills expectations √

√ √ √ √ √







√ √

√ √

√ √ √

√ √

Students reported that the module enhanced their insight and awareness of emotional processes (Proctor and Welbourn, 2002). Strategies that promoted self-awareness and personal growth, and incorporated aspects of supervision/support from others, were most commonly recommended (12/17 papers). For example Por et al. (2011) identified students' need for adequate support structures such as clinical supervision while on clinical placement to assist with recognising and managing their emotional responses. MacCulloch (1999) pointed out the need for professional support via mentoring, peer self-help groups and role development supervision, to achieve emotional competence and effective communication. The next most recommended strategies were reflective learning or enquiry-based learning (7/17) and experiential learning (7/17). Brewer and Cadman (2000) recommended dividing students into reflective groups and questioning aspects of practice within a collective learning experience where students shared their ‘clinical’ stories. Experiential learning specifically incorporated reflective discussion and writing, skills practise and role play, video for observation and feedback, and incorporation of art, drama, music, film and poetry (Freshwater and Stickley, 2004). Ongoing assessment of EI competencies (6/17), including selfassessment by teachers (Bellack, 1999) and students (Brewer and Cadman, 2000), and modelling of EI behaviours and empathy by teachers (6/17) were also identified as important components for curricula. Three papers referred to the merit of including health consumers in planning curriculum and having them in co-facilitation roles in the classroom (e.g. Hurley and Rankin, 2008), and the need to provide clear goals and to have transparency around expectations for EI competencies (2/17). While the challenges of incorporating EI into nursing curricula were widely acknowledged, two papers (Bellack, 1999; Wilson and Carryer, 2008) specifically highlighted the difficulty of developing students' EI competency due to time and resource constraints. While not a strategy for inclusion in curricula, screening of potential students so that only those with high EI are admitted into programmes was recommended. Discussion This review has analysed and synthesised the published literature on emotional intelligence (EI) education in pre-registration nursing. The reviewed literature was from three countries only (UK, USA, NZ). This may reflect EI as a western construct and/or the drive of individual academics to embed EI within curricula. The predominance of UK-based mental health authors also appears to reflect the pre-registration nursing programme pathways in the UK, which include mental health. Given

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the increasing measurement and reporting of EI in pre-registration students across countries however, there is a concomitant need for development of EI-specific curricula and broad-based reporting of the pedagogy and curricula within which students' EI is being assessed. Reviewed articles were primarily discursive or opinion pieces, with only two primary research papers. The lack of empirical evidence on EI curricula development and implementation can be understood to reflect the emergent nature of the EI construct in nursing education and more widely. The review covered the period from the 1990s when the EI construct was emerging in the broader literature (Salovey and Grewal, 2005) and when Goleman's (1995) work was being popularised in world media. It is not surprising that this model was initially taken up widely in nurse education. In respect to the theoretical constructs of EI evident in preregistration literature (Review Q.1), the eclectic collection of EI theories found in the reviewed articles, and predominant use of trait-based or mixed EI constructs, critiqued in the wider literature as heterogenous (Gignac, 2010a) and as less conceptually and empirically robust than the ability-based model (Roberts et al, 2010a, 2010b), raises several issues. These include a lack of EI construct clarity taught in nursing programmes; with subsequent implications for development of EI knowledge and skills in students, and for empirical measurement of students' EI over the course of programmes. The review findings indicate a need for greater consensus on EI as a construct in nurse education, and for more consistent use of an empirically validated construct. Without clear construct definition, it will be difficult to develop relevant educational approaches that address students' need to recognise and manage effectively their own and other's emotions in the context of healthcare. In respect to the EI components considered important for preregistration curricula (Review Q.2), these were articulated clearly within the included papers. However, as per Q.1 findings, future curricula will need to include components consistent with the EI framework (eg. Mayer & Salovey (1997) ability model) used to guide the curriculum, rather than a diverse group of components based on various EI constructs. In respect to EI educational strategies for pre-registration nursing programmes (Review Q.3), while an eclectic range of strategies to enhance students' EI were proposed by authors, there was a paucity (n = 3) of EI-specific modules or approaches developed and tested for inclusion in curricula. These findings further highlight the emergent nature of EI nurse education. Continued calls for screening of EI as part of selection criteria for student admission into pre-registration nursing programmes (Cadman and Brewer, 2001; Brewer and Cadman, 2000; Wilson and Carryer, 2008) also warrant careful consideration. Although this strategy may address the need for emotionally intelligent students it does not take into

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account the validity and variance across EI measures. As EI abilities can be strengthened through education (Foster and McKenzie, 2012), this strategy also does not take into consideration the impact that EI nurse education can have on building students' EI abilities. As an alternative, we recommend students are screened for EI as part of recruitment, but not necessarily excluded based on their results. Formative assessments relating to EI abilities throughout the programme can help develop students' knowledge and skills in personal and interpersonal emotion awareness and management, and can form part of requirements for passing specific units/subjects within the programme. Conclusion As a way forward for EI nurse education, we recommend that EI be explicitly included as a construct on which to scaffold EI theory and abilities throughout pre-registration programmes, and as a core ability outcome expectation for pre-registration nursing students. We contend that emotional intelligence and emotional labour can be understood as threshold concepts, or learning thresholds (Meyer and Land, 2003), which form the basis for mastery of personal and interpersonal emotion management in nursing practice, and provide an opportunity for students to develop new ways of thinking about and practising effective interpersonal communication. From a theoretical standpoint the EI ability construct can be used as an organising heuristic or framework (Salovey and Grewal, 2005) which includes personal and interpersonal skills relating to emotion work and provides a validated conceptual basis from which to develop and scaffold curricula components, and to subsequently measure students' EI ability. There are a range of developed EI resources and components relating to healthcare, including those reported in this review. Roberts et al. (2010b) for example, provide an overview of measures, resources, and learning and teaching approaches relevant to the ability model that could be used to inform the development of EI curricula. Based on the findings of this review, a summary of recommendations for EI education in pre-registration nursing curricula is outlined (Table 5). These include educational strategies such as arts-based learning approaches combined with conventional approaches, which can provide more diverse opportunities for students to engage with learning about Table 5 Summary recommendations for emotional intelligence nurse education. EI construct for curricula Ability-based model (e.g.. Mayer and Salovey, 1997) Learning & teaching theory & curricula

Student EI screening & assessment

EI skill & ability measures Educational strategies

Learning approaches, e.g.: –Transformative learning –Social learning theory –Enquiry-based learning Consider 4 stage hierarchical model of EI as framework for learning & teaching. Scaffold content progressively through curricula EI-specific learning outcomes and graduate attributes in curriculum documents Screen for EI as part of programme admission process Screen regularly throughout programme (e.g. at end of each year and/or end of programme) Peer and self-assessment of EI abilities Formative assessment of EI abilities (e.g. self-emotion management) in written, audiovisual &/or clinical assessments e.g. MSCEIT (Mayer et al. (2003)) GENOS (Gignac (2010b)) Self-awareness, self-management, & interpersonal communication as foundation skills for EI Explicit education on emotional labour & emotional intelligence theory & science Mixture of arts-based and conventional learning approaches (see Table 3 for examples) Multimedia & online EI education in addition to classroom teaching Include healthcare consumers & family in curricula development & co-teaching

emotions and develop their capacity for the art of interpersonal interactions (Freshwater and Stickley, 2004). Further, the inclusion of healthcare consumers/patients and family in curriculum development and coteaching can increase the relevance of EI education, support the development of students' empathy, and improve students' communication skills through in-situ educational interactions (Hurley, 2008). In order to build a robust evidence base for EI education, there is a need for comprehensive evaluation and reporting of newly developed EI curricula and components that includes key stakeholder perspectives (i.e. students, academic & clinical staff, patients and family, & health services). To conclude, EI education and preparation of students at preregistration level have significant implications for registered nurses' emotional welfare, workplace performance, and patient care. EI has been found to have significant positive effects on registered nurses' wellbeing and job stress (Karimi et al., 2014), and is a key strategy to improve nursing retention and reduce the substantial negative impacts of issues such as workplace bullying (Bennett and Sawatzky, 2013). Nurses' empathy, however, can decrease with age, which is problematic for a caring profession (Harper and Jones-Schenk, 2012). Subsequent to pre-registration EI education, there is a concomitant need for continuing education in EI for registered nurses, and inclusion of EI education in postgraduate nursing programmes.

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Emotional intelligence education in pre-registration nursing programmes: an integrative review.

To investigate the state of knowledge on emotional intelligence (EI) education in pre-registration nursing programmes...
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