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Self-awareness, self-regulation, consideration of others, and managing relationships are key concepts in leadership across disciplines and for self-regulation. Biblical leadership through Old and New Testament scriptures provides illustrations within a Christian viewpoint.

Learning Outcomes

Upon successful completion of this module, you will be able to:

Discuss effective use of emotions among Biblical leaders in scripture.

Reflect upon leadership skills needed based upon career aspirations.

Identify personal emotional intelligence and develop an improvement plan.

New studies of the brain show that leaders can improve group performance by
understanding the biology of empathy. by Daniel Goleman and Richard Boyatzis
and the Biology of
IN 1998, ONE OF US, DANIEL GOLEMAN, published in these pages
his first article on emotional intelligence and leadership. The
response to “What Makes a Leader?” was enthusiastic. People throughout and beyond the business community started
talking about the vital role that empathy and self-knowledge
play in effective leadership. The concept of emotional intelligence continues to occupy a prominent space in the leadership literature and in everyday coaching practices. But in
the past five years, research in the emerging field of social
neuroscience – the study of what happens in the brain while
people interact – is beginning to reveal subtle new truths
about what makes a good leader.
Jean-François Podevin
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Social Intelligence and the Biology of Leadership
but their inability to get along socially on the job was profesThe salient discovery is that certain things leaders do – spesionally self-defeating.
cifically, exhibit empathy and become attuned to others’
What’s new about our definition of social intelligence is
moods – literally affect both their own brain chemistry and
its biological underpinning, which we will explore in the folthat of their followers. Indeed, researchers have found that the
lowing pages. Drawing on the work of neuroscientists, our
leader-follower dynamic is not a case of two (or more) indeown research and consulting endeavors, and the findings of
pendent brains reacting consciously or unconsciously to each
researchers affiliated with the Consortium for Research on
other. Rather, the individual minds become, in a sense, fused
Emotional Intelligence in Organizations, we will show you
into a single system. We believe that great leaders are those
how to translate newly acquired knowledge about mirror neuwhose behavior powerfully leverages the system of brain inrons, spindle cells, and oscillators into practical, socially intelterconnectedness. We place them on the opposite end of the
ligent behaviors that can reinforce the neural links between
neural continuum from people with serious social disorders,
you and your followers.
such as autism or Asperger’s syndrome, that are characterized
by underdevelopment in the areas of the brain associated
with social interactions. If we are correct, it follows that a
Followers Mirror Their Leaders – Literally
potent way of becoming a better leader is to find authentic
Perhaps the most stunning recent discovery in behavioral neucontexts in which to learn the kinds of social behavior that
roscience is the identification of mirror neurons in widely disreinforce the brain’s social circuitry. Leading effectively is, in
persed areas of the brain. Italian neuroscientists found them
other words, less about mastering
by accident while monitoring a particusituations – or even mastering solar cell in a monkey’s brain that fired only
cial skill sets – than about developwhen the monkey raised its arm. One day
ing a genuine interest in and talent
a lab assistant lifted an ice cream cone
for fostering positive feelings in the
to his own mouth and triggered a reacpeople whose cooperation and suption in the monkey’s cell. It was the first
port you need.
evidence that the brain is peppered with
The notion that effective leaderneurons that mimic, or mirror, what
ship is about having powerful social
another being does. This previously uncircuits in the brain has prompted
known class of brain cells operates as
us to extend our concept of emoneural Wi-Fi, allowing us to navigate our
People often ask whether gender
tional intelligence, which we had
social world. When we consciously or undifferences factor into the social intelgrounded in theories of individual
detect someone else’s emoligence skills needed for outstanding
psychology. A more relationshiptions
their actions, our mirror
leadership. The answer is yes and no.
based construct for assessing leadneurons
those emotions. ColIt’s true that women tend, on average,
ership is social intelligence, which
create an instant
to be better than men at immediately
we define as a set of interpersonal
sensing other people’s emotions,
competencies built on specific neuMirror neurons have particular imporwhereas men tend to have more
ral circuits (and related endocrine
in organizations, because leaders’
social confidence, at least in work setsystems) that inspire others to be
and actions prompt followers
tings. However, gender differences
those feelings and deeds. The
in social intelligence that are dramatic
The idea that leaders need social
activating neural circuitry in
in the general population are all but
skills is not new, of course. In 1920,
brains can be very powerful.
absent among the most successful
Columbia University psychologist
study, our colleague Marie
Edward Thorndike pointed out that
observed two groups: One
When the University of Toledo’s
“the best mechanic in a factory may
performance feedback
Margaret Hopkins studied several
fail as a foreman for lack of social
positive emotional
hundred executives from a major
intelligence.” More recently, our colsignals
and smiles; the
bank, she found gender differences in
league Claudio Fernández-Aráoz
feedback that
social intelligence in the overall group
found in an analysis of new C-level
frowns and
but not between the most effective
executives that those who had been
men and the most effective women.
hired for their self-discipline, drive,
Ruth Malloy of the Hay Group uncovand intellect were sometimes later
states of the two groups, the people who
ered a similar pattern in her study of
fired for lacking basic social skills. In
received positive feedback accomCEOs of international companies.
other words, the people Fernándezpanied
by negative emotional signals
Gender, clearly, is not neural destiny.
Aráoz studied had smarts in spades,
reported feeling worse about their per-
Do Women
Have Stronger
Social Circuits
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formance than did the participants who had received goodnatured negative feedback. In effect, the delivery was more
important than the message itself. And everybody knows that
when people feel better, they perform better. So, if leaders
hope to get the best out of their people, they should continue
to be demanding but in ways that foster a positive mood in
their teams. The old carrot-and-stick approach alone doesn’t
make neural sense; traditional incentive systems are simply
not enough to get the best performance from followers.
Here’s an example of what does work. It turns out that
there’s a subset of mirror neurons whose only job is to detect other people’s smiles and laughter, prompting smiles and
laughter in return. A boss who is self-controlled and humorless
will rarely engage those neurons in his team members, but a
boss who laughs and sets an easygoing tone puts those neurons to work, triggering spontaneous laughter and knitting
his team together in the process. A bonded group is one that
performs well, as our colleague Fabio Sala has shown in his
research. He found that top-performing leaders elicited laughter from their subordinates three times as often, on average,
as did midperforming leaders. Being in a good mood, other
research finds, helps people take in information effectively
and respond nimbly and creatively. In other words, laughter
is serious business.
It certainly made a difference at one university-based hospital in Boston. Two doctors we’ll call Dr. Burke and Dr. Humboldt were in contention for the post of CEO of the corporation that ran this hospital and others. Both of them headed
up departments, were superb physicians, and had published
many widely cited research articles in prestigious medical
journals. But the two had very different personalities. Burke
was intense, task focused, and impersonal. He was a relentless perfectionist with a combative tone that kept his staff
continually on edge. Humboldt was no less demanding, but
he was very approachable, even playful, in relating to staff,
colleagues, and patients. Observers noted that people smiled
and teased one another – and even spoke their minds – more
in Humboldt’s department than in Burke’s. Prized talent often
ended up leaving Burke’s department; in contrast, outstanding
folks gravitated to Humboldt’s warmer working climate. Recognizing Humboldt’s socially intelligent leadership style, the
hospital corporation’s board picked him as the new CEO.
The “Finely Attuned” Leader
Great executives often talk about leading from the gut. Indeed,
having good instincts is widely recognized as an advantage for
a leader in any context, whether in reading the mood of one’s
organization or in conducting a delicate negotiation with the
competition. Leadership scholars characterize this talent as an
ability to recognize patterns, usually born of extensive experience. Their advice: Trust your gut, but get lots of input as you
make decisions. That’s sound practice, of course, but managers
don’t always have the time to consult dozens of people.
Findings in neuroscience suggest that this approach is probably too cautious. Intuition, too, is in the brain, produced in
part by a class of neurons called spindle cells because of their
shape. They have a body size about four times that of other
brain cells, with an extra-long branch to make attaching to
other cells easier and transmitting thoughts and feelings
to them quicker. This ultrarapid connection of emotions, beliefs, and judgments creates what behavioral scientists call our
social guidance system. Spindle cells trigger neural networks
that come into play whenever we have to choose the best response among many – even for a task as routine as prioritizing
a to-do list. These cells also help us gauge whether someone is
trustworthy and right (or wrong) for a job. Within one-twentieth of a second, our spindle cells fire with information about
how we feel about that person; such “thin-slice” judgments
can be very accurate, as follow-up metrics reveal. Therefore,
leaders should not fear to act on those
provided that they are also
Watch an interview
with Daniel Goleman
Such attunement is literally physiat goleman.hbr.org.
cal. Followers of an effective leader
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Social Intelligence and the Biology of Leadership
experience rapport with her – or what we and our colleague Annie McKee call “resonance.” Much of this feeling
arises unconsciously, thanks to mirror neurons and spindlecell circuitry. But another class of neurons is also involved:
Oscillators coordinate people physically by regulating how and
when their bodies move together. You can see oscillators in action when you watch people about to kiss; their movements
look like a dance, one body responding to the other seamlessly.
The same dynamic occurs when two cellists play together. Not
only do they hit their notes in unison, but thanks to oscillators, the two musicians’ right brain hemispheres are more
closely coordinated than are the left and right sides of their
individual brains.
Firing Up Your Social Neurons
The firing of social neurons is evident all around us. We once
analyzed a video of Herb Kelleher, a cofounder and former
CEO of Southwest Airlines, strolling down the corridors of
Love Field in Dallas, the airline’s hub. We could practically see
him activate the mirror neurons, oscillators, and other social
circuitry in each person he encountered. He offered beaming smiles, shook hands with customers as he told them how
much he appreciated their business, hugged employees as he
thanked them for their good work. And he got back exactly
what he gave. Typical was the flight attendant whose face lit
up when she unexpectedly encountered her boss. “Oh, my
honey!” she blurted, brimming with warmth, and gave him a
Are You a
Socially Intelligent
To measure an executive’s social intelligence
and help him or her develop a plan for improving it, we have a specialist administer our
behavioral assessment tool, the Emotional
and Social Competency Inventory. It is a 360degree evaluation instrument by which bosses,
peers, direct reports, clients, and sometimes
even family members assess a leader according to seven social intelligence qualities.
We came up with these seven by integrating
our existing emotional intelligence framework
with data assembled by our colleagues at the
Hay Group, who used hard metrics to capture
the behavior of top-performing leaders at hundreds of corporations over two decades. Listed
here are each of the qualities, followed by some
of the questions we use to assess them.
big hug. She later explained, “Everyone just feels like family
with him.”
Unfortunately, it’s not easy to turn yourself into a Herb
Kelleher or a Dr. Humboldt if you’re not one already. We know
of no clear-cut methods to strengthen mirror neurons, spindle
cells, and oscillators; they activate by the thousands per second
during any encounter, and their precise firing patterns remain
elusive. What’s more, self-conscious attempts to display social
intelligence can often backfire. When you make an intentional
effort to coordinate movements with another person, it is
not only oscillators that fire. In such situations the brain uses
other, less adept circuitry to initiate and guide movements; as
a result, the interaction feels forced.
The only way to develop your social circuitry effectively is
to undertake the hard work of changing your behavior (see
“Primal Leadership: The Hidden Driver of Great Performance,”
our December 2001 HBR article with Annie McKee). Companies interested in leadership development need to begin
by assessing the willingness of individuals to enter a change
program. Eager candidates should first develop a personal vision for change and then undergo a thorough diagnostic assessment, akin to a medical workup, to identify areas of social
weakness and strength. Armed with the feedback, the aspiring
leader can be trained in specific areas where developing better social skills will have the greatest payoff. The training can
range from rehearsing better ways of interacting and trying
them out at every opportunity, to being shadowed by a coach
Do you understand
Do you listen
attentively and think
what motivates
other people, even
those from different
about how others feel?
Are you attuned to
others’ moods?
Are you sensitive to
others’ needs?
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and then debriefed about what he observes, to learning directly from a role model. The options are many, but the road
to success is always tough.
How to Become Socially Smarter
To see what social intelligence training involves, consider the
case of a top executive we’ll call Janice. She had been hired as
a marketing manager by a Fortune 500 company because of
her business expertise, outstanding track record as a strategic
thinker and planner, reputation as a straight talker, and ability to anticipate business issues that were crucial for meeting
goals. Within her first six months on the job, however, Janice
was floundering; other executives saw her as aggressive and
opinionated, lacking in political astuteness, and careless about
what she said and to whom, especially higher-ups.
To save this promising leader, Janice’s boss called in Kathleen Cavallo, an organizational psychologist and senior consultant with the Hay Group, who immediately put Janice through
a 360-degree evaluation. Her direct reports, peers, and managers gave Janice low ratings on empathy, service orientation,
adaptability, and managing conflicts. Cavallo learned more
by having confidential conversations with the people who
worked most closely with Janice. Their complaints focused
on her failure to establish rapport with people or even notice
their reactions. The bottom line: Janice was adept neither
at reading the social norms of a group nor at recognizing
people’s emotional cues when she violated those norms. Even
Do you appreciate
the culture and
values of the group
or organization?
Do you persuade
others by engaging
them in discussion
and appealing to their
Do you understand
social networks and
know their unspoken
more dangerous, Janice did not realize she was being too blunt
in managing upward. When she had a strong difference of
opinion with a manager, she did not sense when to back off.
Her “let’s get it all on the table and mix it up” approach was
threatening her job; top management was getting fed up.
When Cavallo presented this performance feedback as a
wake-up call to Janice, she was of course shaken to discover
that her job might be in danger. What upset her more, though,
was the realization that she was not having her desired impact on other people. Cavallo initiated coaching sessions in
which Janice would describe notable successes and failures
from her day. The more time Janice spent reviewing these
incidents, the better she became at recognizing the difference
between expressing an idea with conviction and acting like a
pit bull. She began to anticipate how people might react to
her in a meeting or during a negative performance review; she
rehearsed more-astute ways to present her opinions; and she
developed a personal vision for change. Such mental preparation activates the social circuitry of the brain, strengthening
the neural connections you need to act effectively; that’s why
Olympic athletes put hundreds of hours into mental review
of their moves.
At one point, Cavallo asked Janice to name a leader in her
organization who had excellent social intelligence skills. Janice identified a veteran senior manager who was masterly both
in the art of the critique and at expressing disagreement in
meetings without damaging relationships. She asked him to
Do you coach and
mentor others with
compassion and
personally invest
time and energy in
Do you get support
from key people?
Do you articulate
Do you solicit input
a compelling vision,
build group pride,
and foster a positive
emotional tone?
from everyone on
the team?
Do you lead by
Do you provide
feedback that people
find helpful for
their professional
bringing out the
best in people?
Do you support
all team members
and encourage
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Social Intelligence and the Biology of Leadership
Opinion surveys conducted with Janice’s staff before and after
help coach her, and she switched to a job where she could
Cavallo’s second round of coaching documented dramatic inwork with him – a post she held for two years. Janice was
creases in their emotional commitment and intention to stay
lucky to find a mentor who believed that part of a leader’s
in the organization. Janice and the staff also delivered a 6%
job is to develop human capital. Many bosses would rather
increase in annual sales, and after another successful year she
manage around a problem employee than help her get better.
was made president of a multibillion-dollar unit. Companies
Janice’s new boss took her on because he recognized her other
can clearly benefit a lot from putting people through the kind
strengths as invaluable, and his gut told him that Janice could
of program Janice completed.
improve with guidance.
Before meetings, Janice’s mentor coached her on how to express her viewpoint about contentious issues and how to
Hard Metrics of Social Intelligence
talk to higher-ups, and he modeled for her the art of perforOur research over the past decade has confirmed that there
mance feedback. By observing him day in and day out, Janice
is a large performance gap between socially intelligent and
learned to affirm people even as she challenged their posisocially unintelligent leaders. At a major national bank, for
tions or critiqued their performance. Spending time with a
example, we found that levels of an executive’s social inliving, breathing model of effective behavior provides the
telligence competencies predicted yearly performance
perfect stimulation for our mirror neurons, which allow us to
appraisals more powerfully than did the emotional intellidirectly experience, internalize, and ultimately emulate what
gence competencies of self-awareness and self-management.
we observe.
(For a brief explanation of our assessment tool, which
Janice’s transformation was genuine and comprehensive.
focuses on seven dimensions, see the exhibit “Are You
In a sense, she went in one person and came out another. If
a Socially Intelligent Leader?”)
you think about it, that’s an important
lesson from neuroscience: Because our
behavior creates and develops neural
networks, we are not necessarily prisoners of our genes and our early childhood experiences. Leaders can change if,
like Janice, they are ready to put in the
effort. As she progressed in her training,
When people are under stress,
scientists want to study the highest
the social behaviors she was learning
surges in the stress hormones
levels of stress hormones, they
became more like second nature to her.
adrenaline and cortisol strongly
simulate a job interview in which an
In scientific terms, Janice was strengthaffect their reasoning and cognition.
applicant receives intense face-toening her social circuits through pracAt low levels, cortisol facilitates
face criticism – an analogue of a
tice. And as others responded to her,
thinking and other mental functions,
boss’s tearing apart a subordinate’s
their brains connected with hers more
so well-timed pressure to perform
performance. Researchers likewise
profoundly and effectively, thereby reand targeted critiques of subordifind that when someone who is very
inforcing Janice’s circuits in a virtuous
nates certainly have their place.
important to a person expresses
circle. The upshot: Janice went from beWhen a leader’s demands become
contempt or disgust toward him, his
ing on the verge of dismissal to getting
too great for a subordinate to handle,
stress circuitry triggers an explosion
promoted to a position two levels up.
however, soaring cortisol levels and
of stress hormones and a spike
A few years later, some members of
an added hard kick of adrenaline can
in heart rate by 30 to 40 beats per
Janice’s staff left the company because
paralyze the mind’s critical abilities.
minute. Then, because of the interthey were not happy – so she asked CaAttention fixates on the threat from
personal dynamic of mirror neurons
vallo to come back. Cavallo discovered
the boss rather than the work at
and oscillators, the tension spreads
that although Janice had mastered the
hand; memory, planning, and creativto other people. Before you know
ability to communicate and connect
ity go out the window. People fall
it, the destructive emotions have inwith management and peers, she still
back on old habits, no matter how
fected an entire group and inhibited
sometimes missed cues from her direct
unsuitable those are for addressing
its performance.
reports when they tried to signal their
new challenges.
Leaders are themselves not imfrustration. With more help from CaPoorly delivered criticism and
mune to the contagion of stress. All
vallo, Janice was able to turn the situdisplays of anger by leaders are
the more reason they should take
ation around by refocusing her attencommon triggers of hormonal
the time to understand the biology
tion on her staff’s emotional needs and
surges. In fact, when laboratory
of their emotions.
fine-tuning her communication style.
The Chemistry of
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The way to develop your social circuitry is to
undertake the hard work of changing your behavior.
Social intelligence turns out to be especially important in
crisis situations. Consider the experience of workers at a large
Canadian provincial health care system that had gone through
drastic cutbacks and a reorganization. Internal surveys revealed that the frontline workers had become frustrated that
they were no longer able to give their patients a high level
of care. Notably, workers whose leaders scored low in social
intelligence reported unmet patient-care needs at three times
the rate – and emotional exhaustion at four times the rate – of
their colleagues who had supportive leaders. At the same time,
nurses with socially intelligent bosses reported good emotional health and an enhanced ability to care for their patients,
even during the stress of layoffs (see the sidebar “The Chemistry of Stress”). These results should be compulsory reading
for the boards of companies in crisis. Such boards typically
favor expertise over social intelligence when selecting someone to guide the institution through tough times. A crisis manager needs both.
Thomas Cheney
As we explore the discoveries of neuroscience, we are struck
by how closely the best psychological theories of development
map to the newly charted hardwiring of the brain. Back in
the 1950s, for example, British pediatrician and psychoanalyst
D.W. Winnicott was advocating for play as a way to accelerate
children’s learning. Similarly, British physician and psychoana-
lyst John Bowlby emphasized the importance of providing a
secure base from which people can strive toward goals, take
risks without unwarranted fear, and freely explore new possibilities. Hard-bitten executives may consider it absurdly indulgent and financially untenable to concern themselves with
such theories in a world where bottom-line performance is the
yardstick of success. But as new ways of scientifically measuring human development start to bear out these theories and
link them directly with performance, the so-called soft side of
business begins to look not so soft after all.
Daniel Goleman (contact@danielgoleman.info) is a cochair-
man of the Consortium for Research on Emotional Intelligence
in Organizations, which is based at Rutgers University’s Graduate School of Applied and Professional Psychology in Piscataway,
New Jersey. He is the author of Social Intelligence: The New
Science of Human Relationships (Bantam, 2006). Richard
Boyatzis (richard.boyatzis@case.edu) is the H.R. Horvitz Chair
of Family Business and a professor in the departments of organizational behavior, psychology, and cognitive science at Case
Western Reserve University in Cleveland. He is a coauthor, with
Annie McKee and Frances Johnston, of Becoming a Resonant
Leader (Harvard Business Press, 2008).
Reprint R0809E
To order, see page 139.
“So, what makes you think you’d fit in?”
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Building Innovative Nurse Leaders at the Point of Care
I s E m o t i o n a l In t e l l i g e n c e a n
I m p o r t a n t Tr a i t f o r N u r s e
M a n a g e r s a n d Le a d e r s ?
Stephen D. Krau, PhD, RN, CNE
Consulting Editor
It has been suggested by Tyczkowski and colleagues1 that stress and lack of support
for the role of nurse managers are among the reasons that less than 12.5% of nurses
aspire to leadership roles. 1 They suggest that the trait of resiliency enables one to
adapt to adversity, and tension is integral to an effective nurse manager and is a predictor of a manager’s success. As health care becomes more complex and continues
to evolve, the skills, knowledge, and behaviors of nurse managers must also evolve.
This evolution is accompanied by an increase in stress among nurse managers.
Emotional Intelligence (EI) is a means to enhance psychological resiliency to ameliorate
stressors as high levels of EI have been shown to enhance transformational leadership
style, which contributes to the provision and support of a positive and effective work
EI embodies the ability to identify and regulate one’s own emotions as well as the
emotions of others. The notion of EI includes the 3 following basic skills: (1)
Emotional awareness, which is the ability to identify one’s own emotions, while
discriminating among variant emotions; (2) the ability to utilize those emotions in order
to apply them to charges such as thinking and problem solving; and (3) the ability to
manage those emotions, which includes regulating one’s own emotions and helping
others regulate their emotions. EI is sometimes referred to as “Emotional Quotient”
(EQ), which holds wide interest and has been used in the interview processes of several
well-known companies. The theory is that persons with higher levels of EI make better
coworkers and/or make more effective leaders. In addition, EI is a skill that can be
honed through training, journaling, and counseling. Persons with high levels of EI are
conscious of their own emotional states and are also attuned to the emotions others
experience. The ability to see how emotional sensitivity to emotional signals from
Nurs Clin N Am 55 (2020) xiii–xiv
0029-6465/20/ª 2019 Published by Elsevier Inc.
within and from the professional environment could make one a better leader.
Although a gold standard for the measurement of EI has yet to be identified, there
are many tools that have been developed to measure EI. One tool used to measure
EQ is the Bar-on EQ-I survey tool, which has recently been used in a study by
Tyczkowski and colleagues.1
One leadership style that is often considered desirable in the ever-changing health
care milieu is transformational leadership. This form of leadership relates to resiliency
among nurse leaders as well as those they manage. As attrition and burnout are common elements in many health care settings, there is evidence to suggest that transformational leadership is significantly related to increased satisfaction, increased staff
well-being, decreased burnout, and decreased overall stress in staff nurses.3
Transformational leadership is a leadership style in which nurse leaders encourage,
inspire, and motivate nurses to innovate and create change that will help grow and
structure the future success of the health care institution. The basis of transformational
leadership includes individualized consideration, intellectual stimulation, inspirational
motivation, and idealized influence. Whereas there are other styles of leadership,
transformational leadership has particular implications for the ever-changing and
stressful health care system. Numerous studies have shown a positive correlation
among staff that works with leaders who have been identified as transformational
leaders.1 The study by Tycyzkowski and colleagues1 shows results congruent to
many studies that there is a “significant positive relationship between EI factors and
transformational leadership style.”1(p.177)
The results of the evidence related to EI and transformational leadership support the
need to recruit, educate, and keep topmost performing leaders and managers in
nursing. If not a part of the initial interview, EI assessment and development can be
a part of the manager’s career trajectory. Because EI can be learned, it would be
worthwhile for health care systems to provide training and counseling to nursing
leaders and managers as well as nurses who are potential nurse leaders.
Stephen D. Krau, PhD, RN, CNE
Vanderbilt University School of Nursing
6809 Highland Park Drive
Nashville, TN 37205, USA
E-mail address:
1. Tyczkowski B, Vandenbouten C, Reilly J, et al. Emotional Intelligence (EI) and
nursing leadership styles among nurse managers. Nurs Admin Q 2015;39(2):
2. Barling J, Slater F, Kelloway K. Transformational leadership and emotional intelligence: an exploratory study. Leadersh Organ Dev J 2000;21:157–61.
3. Weberg D. Transformational leadership and staff retention: an evidence review
with implications for healthcare systems. Nurs Admin Q 2010;34(3):246–58.
‘It’s the relationship you develop with
them’: emotional intelligence in nurse
leadership. A qualitative study
Beryl Mansel and Alys Einion
Aim: to investigate emotional intelligence (EI) and its relationship to nursing
leadership. Background: strong, effective leadership is core to organisational
competency and significantly influences care quality. EI is the ability to
understand one’s own feelings and to assess and respond to the feelings of
others. It is linked to self-awareness, self-management, social awareness and
social skills, all of which are vital in leadership roles. However, insufficient
research explores EI in nursing leadership from the perspective of nurse
leaders. Design: a qualitative study employed interpretive phenomenological
analysis methods, using a purposive sample of band 7 sisters/charge
nurses/team managers (n=5) from one Welsh health board. Semistructured
interviews were recorded and analysed in four stages. Findings: four clusters
of themes were identified, each with two to three subthemes. These were:
sensing others—the empathetic leader; experiencing the affected sense
of self; strategies employed to build the team; and reading the flux of the
organisation. Conclusion: although the nurse leaders were unfamiliar with
the concept of EI, their narratives reflected some core values of EI. However,
significant barriers around time, pressure and staffing levels impeded their
potential to use EI to become more effective leaders. Nurse leaders should
harness the power of emotions to influence others to achieve excellent care.
Key words: Emotional intelligence â–  Nurse leadership â–  Relationships
â–  Organisational behaviour â–  Interpretive phenomenological analysis
ffective 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
Beryl Mansel, Senior Lecturer, Swansea University,
Alys Einion, Associate Professor, Swansea University
Accepted for publication: August 2019
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.
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
British Journal of Nursing, 2019, Vol 28, No 21
© 2019 MA Healthcare Ltd
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
© 2019 MA Healthcare Ltd
The purpose of this IPA analysis study was to explore EI in
nurse leadership.
â– â–  To explore and understand how nurse leaders make meaning
or sense of their own emotional intelligence capabilities
â– â–  To explore how nurse leaders perceived or demonstrated
the essence of qualities and behaviours related to EI within
their leadership roles
â– â–  To explore the potential value of EI in nurse leadership, and
barriers to its realisation, within the current context of NHS
â– â–  To identify recommendations for future research, education
or training in relation to EI.
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).
British Journal of Nursing, 2019, Vol 28, No 21 1401
The following criteria were applied as rooted within a
phenomenological hermeneutic tradition:
â– â–  Stage 1: first encounter with the text
â– â–  Stage 2: preliminary themes identified
â– â–  Stage 3: grouping themes together as clusters
â– â–  Stage 4: tabulating themes in a summary table
Source: Biggerstaff and Thompson, 2008
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.
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.
The main themes that emerged from the analysis are presented
in Table 1.
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.’
Participant 1
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.’
Participant 2
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.’
Participant 4
British Journal of Nursing, 2019, Vol 28, No 21
© 2019 MA Healthcare Ltd
Box 1. Analytical model applied
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”.’
Participant 2
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.’
Participant 4
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.’
Participant 5
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).
‘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.’
Participant 3
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.’
Participant 2
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.’
Participant 4
Table 1. Main themes
Sensing others: the empathic
â– â–  Understanding the needs of others
â– â–  Cultivating the skills and values that people require
to care compassionately and effectively
© 2019 MA Healthcare Ltd
â– â–  Perception of a lack of empathy from others
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:
Experiencing the affected
sense of self
â– â–  Feeling overburdened
â– â–  Awareness of feeling stressed and anxious
â– â–  A state of mind (feeling)
Strategies employed to build
the team
â– â–  Positive feedback
Reading the flux of the
â– â–  Leading from a distance
â– â–  Gathering people together
â– â–  Poor staffing levels
British Journal of Nursing, 2019, Vol 28, No 21 1403
‘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.’
Participant 4
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.’
Participant 2
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.’
Participant 3
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.’
Participant 1
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.’
Participant 5
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.’
Participant 1
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.’
Participant 5
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.’
Participant 3
British Journal of Nursing, 2019, Vol 28, No 21
© 2019 MA Healthcare Ltd
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.
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
Participant 5
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.’
Participant 2
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.’
Participant 1
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.
© 2019 MA Healthcare Ltd
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.’
Participant 5
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?’
Participant 2
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.
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 selfconfidence.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
British Journal of Nursing, 2019, Vol 28, No 21 1405
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.
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.
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
British Journal of Nursing, 2019, Vol 28, No 21
© 2019 MA Healthcare Ltd
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
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. BJN
Declaration of interest: none
© 2019 MA Healthcare Ltd
Acknowledgement: the first author would like to thank her
dissertation supervisor, Professor John Gammon of Swansea
University, for his guidance and support in undertaking this research
study for submission in fulfilment of the MSc in Healthcare
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CPD reflective questions
â– â–  After reading this article, identify the leadership styles that are synonymous with emotional intelligence
â– â–  What strategies can you utilise to build your own self-awareness?
â– â–  Consider your skills and reflect on which competencies within the emotional intelligence mixed model you
Have an idea for BJN?
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Self-reflection: Relationship Building in
Patients With Excess Weight
Karla K. Giese, DNP, FNP-BC
Obesity or excess weight is a well-documented health problem. Obesity bias is prevalent in society, and
literature suggests obesity bias exists among health care providers. This article addresses the bias and
stigmatization associated with weight and outlines ethical principles for nurse practitioners caring for
vulnerable populations such as the obese. Self-reflection, a key method to address potential provider obesity
bias, is outlined through use of the Johns Model for Structured Reflection.
Keywords: cultural safety, ethical principles, Johns Model for Structured Reflection, obesity bias
Ó 2016 Elsevier, Inc. All rights reserved.
urse practitioner (NP) clinicians are in a
unique position to hear sensitive details of
an individual’s life, including those surrounding weight. Many patients encountered in
primary and specialty care are frustrated with their
weight and would benefit from interventions offered
by the health care team. Weight, however, can be a
difficult topic to discuss during appointments for a
variety of reasons—including patient and health care
provider factors. Patient-related factors include worry
about blame, privacy, socioeconomic constraints
(food, exercise facilities/equipment, medication/
co-pay costs), and insufficient social support.1,2 Time
constraints, clinician skepticism, clinician confidence
relating to diagnosis and management, and even
personal bias against those with obesity are
contributing health care provider factors.3,4 The lack
of an established therapeutic caring-trusting
relationship could also significantly affect an NP’s
ability to effectively intervene.
Given the prevalence of overweight and obesity
among industrialized countries, health care providers
must become comfortable offering weight-related
assistance. The purpose of this report is to discuss clinician self-reflection regarding attitudes, acceptance, and
comfort caring for individuals with obesity or excess
weight, and the related ethical underpinnings specifically related to the nursing profession. Assessing and
understanding values and beliefs that manifest as attitudes is a start toward change. Ultimately, as clinician
insights are discovered, and tensions addressed through
reflection, the development of a therapeutic caringtrusting relationship can begin. Once an individual
patient perceives authentic caring, then the evidenceinformed interventions, as outlined in obesity clinical
guidelines, can begin.5
Physical comorbidities associated with obesity are
well documented and include cardiovascular disease;
endometrial, pancreatic, kidney, breast, and colon
cancers; type 2 diabetes; osteoarthritis; asthma; gall
bladder disease; chronic back pain; and liver steatosis.6,7 Psychologically, obesity, with its related body
image disturbance, is associated with reduced selfesteem, shame, and depression.8-11
In addition to personal physical and psychological
manifestations, individuals with obesity often experience social stigmatization and bias from
others.1,12,13 Such stigmatization and bias is present in
the media, health care settings, seating environments,
terminology used, and even in the professional
literature.12-16 The American Psychological
Association and American Medical Association
writing styles are now recommending a “people first”
approach to journal writing, in addition to avoiding
terminology consistent with victimization—such as
“suffering from.”17,18 Qualitative research by
Wadden and Didie found that, although no term
depicting excess weight is highly desirable among
obese individuals, “weight” was the term most
positively accepted.19 Unfortunately, “weight” alone
The Journal for Nurse Practitioners – JNP
lacks specificity. Therefore, “excess, or excessive
weight,” a term found to be neutral in Wadden and
Didie’s study, is adopted herein for this study.19
By virtue of the potential for stigmatization and bias,
in addition to increased risk for poor long-term health
associated with excess weight, persons with excessive
weight could be considered a vulnerable population.
Garcel et al. defined vulnerable populations as groups
or individuals “who, due to a wide variety of factors,
are at a greater risk for poor health status and health
care access.”20(p7) In addition, they outline the
convergence of a variety of factors in an individual’s
life such as physical, mental, and/or social factors,
whereby altered health status along one dimension
contributes to altered health status in the others.20
Thus, excessive weight could be a major factor in
several coexisting biopsychosocial vulnerabilities.
Caring for and commitment to vulnerable populations are central concepts in nursing.21 Such care
is emphasized in the recently revised American
Nursing Association (ANA) Code of Ethics whereby
the nurse, which includes all levels of professional
nursing, is in a nonnegotiable position to practice in a
manner respecting the “inherent dignity, worth, and
unique attributes of every person.”21 Promotion of
social justice, another tenet within the ANA Code of
Ethics, dealing with the “marginalized.exploited,
and voiceless” is another parallel concept that can
be applied to individuals with excess weight due to
the tendency toward social isolation.21
Ethical care is universally important to all vulnerable
or marginalized populations—whether related to excess
weight or another situation. Recent international
professional nursing literature has also addressed these
concepts. Developed in New Zealand, the concept of
culturally safe care addresses the power imbalances
between clinicians and patients, particularly vulnerable
or marginalized persons.22 New Zealand’s nursing
council specifically states that a nurse’s practice is unsafe
if it “demeans or disempowers.the well-being of an
individual.”23 The council also promotes the process of
self-reflection as part of this culturally safe, ethical
nursing care.23 A power imbalance can exist when the
NP, especially if of normal weight, holds position over
the vulnerable patient with excessive weight. This
The Journal for Nurse Practitioners – JNP
circumstance deserves acknowledgment and
subsequent reflection.
Patients have a right to unbiased care. Dr. Peter
Attia bravely began a social media dialogue as a
provider with an excess weight bias.24 Attia discussed
a personal struggle with contempt toward a woman
requiring an amputation due to complications of
diabetes.24 Excessive weight, as is often the case, was
a factor contributing to the patient’s uncontrolled
diabetes. Attia assumed the patient’s excessive weight
was related to overindulgence with food and lack
of physical activity, and subsequently assigned the
patient blame for the pending amputation.24 During
a meaningful reflection, Attia recalled earlier training
in medical research whereby the challenge was to
question all assumptions.24 Then, in a transformative
moment, he challenged himself against making
assumptions regarding the etiology of a patient’s
excess weight, and instead pledged to provide such
patients with the same compassionate care as
individuals of normal weight.24
Dr. Attia’s example illustrates how clinician bias
interferes with respect and appreciation for an individual’s worth or unique attributes. In such cases,
authentic caring is compromised and the individual
is demeaned. Therefore, an important first step in the
process of caring for persons with excessive weight
gain is self-reflection.
The practice of self-reflection is imperative in developing compassion toward all vulnerable populations,
including those with excessive weight gain. British
reflective practice expert, Christopher Johns, defines
reflection as “being mindful of self, either within or
after an experience.in order to confront, understand,
and move towards resolving contradiction between
one’s vision and actual practice.”25 Johns has drawn
a distinction between describing a situation versus
reflecting upon the same. A description is defined as
“the raw data of experience,” whereas reflection
goes beyond the facts, helping a committed nurse
“counter negative qualities.associated with
defensiveness.resistance and ignorance,” and
experience transformative insight, which could
ultimately improve the nurse-patient therapeutic
Volume 12, Issue 1, January 2016
The Model for Structured Reflection (MSR)
involves 5 phases, as described by Johns25:
1. Preparatory phase: Bringing the mind home.
2. Descriptive phase: Focusing on describing an
experience, including affirmation and problematic aspects.
3. Reflective phase: The participant wrestles with
the following questions:
What issues are significant to pay attention
How were others feeling and why did they
feel that way?
How was I feeling and what made me feel
that way?
What was I trying to achieve and did I
respond effectively?
What were the consequences of my actions
for the patient, others, and myself?
To what extent did I act for the best and in
tune with my values?
What knowledge did or might have
informed me?
How does this situation connect with previous experiences?
What assumptions govern my practice and
what factors influence the way I feel, think,
and respond to the particular situation?
4. Anticipatory phase: Participant reflects on the
following questions:
How might I reframe the situation to
respond more effectively?
What would be the consequences of
responding differently for the patient, others,
and myself?
What factors might constrain me responding
in new ways?
How do I now feel about this experience?
5. Insight phase:
What insights have I gained?
Using the MSR as outlined above, the NP would
find a quiet area with minimal distractions to focus on
the situation—perhaps thinking of a recent patient
encounter with excessive weight as a primary presenting problem or comorbidity. As a patient enters
the NP’s care are unwelcoming environmental cues
present—such as limited capacity scales, normal or
large adult blood pressure cuffs as opposed to thigh
cuffs, or chairs with side arms present making seating
difficult? What was the NP feeling about the situation involving a patient with excessive weight, and
what were the contributing factors behind those
feelings? Could past personal, family, or professional
experiences or even bias be present? Did the nursepatient encounter honor the inherent worth and
unique attributes of the patient? Could there be a
power imbalance present—especially if the NP is of
normal weight? Can the patient trust that the NP
truly cares? Does the NP desire a caring relationship
with the patient with excess weight? Honest
acknowledgment of feelings and openness to reflection upon nursing’s professional code of ethics may
assist the nurse in learning to respond more
compassionately. Compassionate nursing care calls
for an environment in which the patient feels
comfortable discussing sensitive personal details.
Patients with excessive weight deserve compassionate
care from NPs in a manner that is consistent with
the ANA’s Code of Ethics. Self-reflection by the NP
clinician, employing the MSR, can be utilized to
acquire insights into the experience of caring for
patients with excessive weight. Although the goal
is compassionate, culturally safe care, it must be
acknowledged that not every clinician is open to
change. The MSR, however, can assist NPs in
uncovering new ways of responding in a manner in
which the clinician’s words, demeanor, and associated nonverbal cues suggest openness, true care, and
compassion consistent with professional nursing
practice. Once an individual with excessive weight
perceives a true sense of care and acceptance, a
trusting nurse-patient relationship can be established
and the treatment for excess weight can begin.
1. Puhl RM, Heuer CA. The stigma of obesity: a review and update. Obesity.
2. Mauro M, Taylor V, Wharton S, Sharma A. Barriers to obesity treatment. Eur J
Intern Med. 2008;19(3):173-180.
3. Brown I. Nurses’ attitudes towards adult patients who are obese: literature
review. J Adv Nurs. 2006;53(2):221-232.
4. Gunther S, Guo F, Sinfield P, Rogers S, Baker R. Barriers and enablers to
managing obesity in general practice: a practical approach for use in
implementation activities. Qual Prim Care. 2012;20(2):93-103.
5. Jensen MD, Ryan DH, Apovian CM. 2013 AHA/ACC/TOS guideline for the
management of overweight and obesity in adults. J Am Coll Cardiol.
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