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OPINION

'Complex emotional intelligence is essential and can be taught'

  • 10 Comments

A friend was reflecting recently on witnessing what she described as inspirational nursing.

She was talking about accompanying a nurse who was working with a dying patient and his wife.

The patient had explained how he wanted to spend his last few days and how he wanted to avoid medication. As his pain grew, his wife of some 50 years became uncertain. Staying true to his request seemed overwhelmingly important. It was about honouring him and them; it was the last act of protectiveness, of love. However, seeing the excruciating pain was tearing her apart.

That level of dismay, confusion and fear must come out somewhere, so it came out at the nurse. Well not so much at the nurse as near the nurse. If it was at anything, it was at the universe or god or cancer or life, but it manifested itself as rage and involved howling at the moon.

You can read the webchat transcript about emotional intelligence with Mark Radcliffe here

The nurse, it seems, stayed present. She did not make any excuses to leave nor did she try to distract the woman from her pain. She did not, because she was focused and generous, try to “boundary” the language or limit the outpouring of emotion. Nor did she try any magic words that might ameliorate the woman’s feelings.

My friend said the nurse managed to “hold” the woman without touching her. This may sound a little vague and ill defined for these dot-to-dot days. It makes sense, I think, to suggest the nurse “sensed” her way through what was probably one of the defining moments in the life of the woman in front of her.

As it was, the woman decided that she wanted her husband to have more pain relief. She felt that, had he been able to express a wish, he would wish for less pain and she also decided she was not willing to live with the sense that she was causing him pain by keeping a promise. He died peacefully and she expressed relief that she had held his hand as he did so.

I know the problem with talking about such brilliant nursing is that one can use it as an example to support any position you like. You could say: ‘“They don’t make them like that any more.” Or: “You see, you can’t teach that sort of ability - it comes from within.”

In both cases you would, in my view, be wrong. First, the nurse in question was a student and my friend was her mentor.

Second, I think you can teach it. I think it is hard, it requires a lot of time, will and a collective commitment to the value of emotional intelligence and a willingness to review our own sense of moral action - but I think it can be taught. You may not necessarily be able to teach it to everyone, and I certainly don’t think once it has been “taught” you can consider it to be another skill like having a good injection technique. Complex abilities - particularly those that are integrated with our own humanity - require revisiting, reinvigorating, re-energising.

Perhaps I’m wrong. Perhaps the “good and intuitive” nurse is made in the womb rather than in the world. And we mainly need to keep teaching ourselves to be technically adept and policy aware to reclaim the nursing profession from the shadow of Mid Staffs and the recent Care Quality Commission report. But I doubt it.

Sooner or later, we are going to have to address the fact that the best of nursing requires complex emotional intelligence and, unless we start to focus on how to promote, protect and extend that quality, the wise and inspirational nurse will become little more than a myth.

Mark Radcliffe is a senior lecturer and author of Gabriel’s Angel.

  • 10 Comments

Readers' comments (10)

  • michael stone

    'The patient had explained how he wanted to spend his last few days and how he wanted to avoid medication. As his pain grew, his wife of some 50 years became uncertain.'

    'Feelings' around death are horribly complex. But English LAW is very clear - patients make their own decisions, and can make them in advance of predicted mental incapacity.

    Sad as it is, this should have been discussed with the patient. While he was mentally capable, he alone decides how much pain to accept, before requesting pain relief. And he really SHOULD have been asked 'if you are incapable, but apparently in pain, do you want pain relief ?'.

    I am much more interested, in whether sedation on request should always be supplied to dying patients who request it, because they find their 'condition of living' intolerable.

    But the issue of pain relief for mentally capable patients is NOT a moral/ethical one - under English law, the patient has to ask for and accept pain relief (or accept ti if it is offered without his asking). And it gets VERY complicated, when patients become mentally incapable - something I have been debating with 'all and sundry' for 2 years.

    I think your 'emotional intelligence' could possibly be taught - but I do not believe that anyone not in the wife's position, and who has never been in her position, can be 'taught how the wife feels'.

    And I will add a comment. 'Death and dying' does, as you point out, 'tend to tear people apart'. The NHS should NOT be making that tearing worse, by behaving inappropriately when people are dying, or have just died. Some CPR/VoD policies and protocols, make the tearing worse: peculiar, for a 'healing' organisation !

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  • michael stone

    Mark, I am still not 100% certain of exactly what ‘emotional intelligence is’ – I have so far, not had the time to track down your paper and read it.
    But as for ‘racism’ and ‘systemic racism’, is the concept of ‘systemic emotional intelligence’ valid ?
    I have been discussing ‘the rules for death/dying’ for a couple of years with ‘the NHS’ (and trying, largely unsuccessfully, to discover what nurses believe the law is for ‘death and dying’ to feed into those discussions, is why I became involved with the NT ‘site) and I asked for some opinions from two married friends, who between them have lost 3 parents during the last couple of years. This is something they wrote in an e-mail to me:

    ‘Finally, based on some of our recent experiences with our mothers and now with Pam's father, society and its systems are not ready to accept that there is a time when people are ready to die and that they should be allowed to in the most humane manner possible. Talking about such a topic still appears to be very much taboo. As Pam has said several times recently, including to medical professionals: "We treat animals at the end of their lives better than we treat humans".’

    Now, this ‘unsatisfactory experience of death – too much suffering going on’ is obviously why there is a lobby for assisted-suicide to be legalised.

    Does the presence of this level of ‘suffering of the dying’, indicate a lack of ‘systemic emotional intelligence’ ?

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  • michael stone

    I think I was confused - it seems it was not a reference to a separate article, but to the piece above.

    So, I'm still a bit unsure about this 'emotional intelligence' area - but I am willing to say, that most people, including nurses, simply do not understand the sheer complexity, and individuality, of 'feelings around dying and death'.

    And I do think, there is an age/proximity factor - I do think you 'understand' differently when your own parents die and you are 50-ish, as opposed to when you are in your 20s and your parents are healthy and in their middle age. And, presumably 'death looks different again' when you yourself, are in your 80s, at least for many people.

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  • Michael Stone

    Daniel Goleman coined the phrase 'emotional intelligence' and describes it in his best selling books on the subject available in most bookshops.

    His theory is useful for everyday life and has been adopted in management and leadership and in many professions such as nursing and psychology and his books such as Goleman, D. 'Working with Emotional Intelligence' are often required reading on management and professional training courses.

    Goleman, D. (1995). Emotional intelligence. New York: Bantam Books.

    Goleman, D. 'Working with Emotional Intelligence'

    Theories from many of the psychologists such as Carl Rogers and the concept of 'holding' somebody in emotional crisis are also of great value in nursing and coping with others in different situations. Other theories include those of Bowlby and Aaron Beck as well as transactional analysis.

    You fail to recognise that a great number of nurses and other health care workers are highly trained and have a wealth of experience in the care and needs of dying patients and you repeatedly cite instances where things have gone wrong as happens in every type of service. Perhaps you should examine some of the hospice movements and palliative care for example.
    In acute hospital settings sadly this is not always the case and patients and their relatives may be failed for a very wide variety of reasons.

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  • michael stone

    Anonymous | 7-Nov-2011 10:40 pm


    'You fail to recognise that a great number of nurses and other health care workers are highly trained and have a wealth of experience in the care and needs of dying patients and you repeatedly cite instances where things have gone wrong as happens in every type of service'

    No. I DON'T 'fail to recognise' the things you mention. I am just acutely aware that the use of personal experience 'to make judgements about the behaviour of others' is very tricky.

    And, as a 'rule of thumb', when something is already pretty good, you learn more by looking at what still goes wrong, than by saying 'it usually goes right'. And if staff are as expert as you say, things ought to be 'pretty good'. When did you last read of an investigation, into a good landing by an airliner !

    But I do not believe that all staff - especially many of the staff who are involved in EoLC for patients who are in their own homes - possess the levels of 'expertise' you imply: and furthermore, many paramedics agree with me, as do various other people.

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  • "But I do not believe that all staff - especially many of the staff who are involved in EoLC for patients who are in their own homes - possess the levels of 'expertise' you imply: and furthermore, many paramedics agree with me, as do various other people."

    my experience is on acute medical hospital wards, and not in the community, where with so many urgent demands, change overs of staff and the time this requires to hand over and report, administrative duties, often inadequate staffing levels at particular times of the day, and in some cases all the time, there is not always time for nurses experienced in this area to exercise their highly developed knowledge and skills to the full for each individual patient. Unfortunately an acute hospital ward is not the ideal place for the end of life but it is not always planned and sometimes, according to the circumstances, there is little choice.

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  • michael stone

    Anonymous | 7-Nov-2011 10:40 pm



    I have located, and quickly scanned, a business book about EI, by Jill Dann. I am told in the 'definition of EI part', that to be highly developed our EI requires us:

    * to stop and think
    * to control our impulses
    * to use our innate intuition
    * to be authentic with ourselves and others
    * to manage our fears in leading nothers effectively

    Also, on page 174 of her book under 'Stages in Conflict' we read:

    'Conflicts at work often take time to develop. They come about from our perceptions of other people or of situations, and those are typically based on our experience built up over a period of time'.

    Now, my main concern is EoLC at home, and CPA/CPR in particular. With an emphasis on mis-representation of the law, witihn current clinical guidance. And one of the problems, is that a relative's own emotions and behaviour, will be very strongly influeneced by his or her own previous life experiences, and by what he or she knows or has been told. At home, GPs and DNs do not usually talk to relatives enough, to be aware of a relative's previous life experiences, and often do not tell relatives enough about things such as prognoses. To complicate matters, patients and relatives can, and do, talk to each other, while they are alone - or a relative can talk to a GP, when no DN is present. Etc. There is an inevitable time-lag, between these discussions happening, and anyone who was not directly involved, learning of them. And those discussions cannot be 'fully covered' in patient notes. Throw in the fact that everyone is concentrating on the person who is dying, and that CPA 'comes as a shock at some level', and 'either is or isn't an emergency', plus the relative sees only that single 'dying and death' so tends to assume it is normal/typical, but professionals see many, and therefore 'have a concept of a typical death', and you have a very complicated situation.

    My position is pretty simple, for my EoLC and CPA/CPR discussion. Firstly, the 'information base tends to become so fragmented between different individuals, and 'reactions to CPA/death are so truly complex and weird', that nobody should even attempt 'to get into the mind of a just-bereaved person''. So I don't like:

    * to use our innate intuition

    because professional 'experience built up over a period of time' could be innappropriate, when applied to a situation which you might be mis-interpreting: the wrong experience, is worse than useless, and leads to very bad decision-making. The wrong type of experience - ie experience which is being applied out-of-context, to the 'wrong' situation - does make experts chose worse options, than having no expertise/experience at all would lead to be chosen.

    And for this particular article, it started with 'should pain relief be provided for the husband ?' as the problem, which elicited this example of good emotional intelligence re the wife. But we have law (and equivalent medical ethics) about 'should pain relief be provided': the law is based on 'it is the patient's decision', so, as I have already commented, the husband SHOULD have been asked 'if you lose mental capacity, and appear to still be in pain, should we give you pain relief ?'. And if all nurses, etc, are as expert as you tell me they are, they should have known that ! And asked him ! If he had made his choice clear, the wife would not have been troubled by having to work out 'would he want pain releif ?'. She might still have been 'suffering' if he had indicated he did not want pain relief even if he became mentally incapable but still appeared to be in pain, but the law is very clear here: his decision is the one which counts, for refusals of offered treatment.

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  • michael stone

    Anonymous | 8-Nov-2011 1:17 pm

    I had pre-prepared my post above. It appears to me, that your short post, and my lengthy post, seem to actually agree about some of the complications of EoLC at home (but I think I mentioned rather more of them). But I have a lot of evidence that as a group clinicians simply do not understand the Mental Capacity Act, even Palliative Care Consultants and very possibly even the group who publish the high-level DH-spinsored guidance for things such as Advance Decisions. An opinion I share with a nurse who is also a senior lecturer at a university, and who teaches the legal aspects of nursing, to her student nurses - we both agree that clinical understanding of the MCA is pretty awful !

    As the DH wishes for many more patients to be allowed to die at home (and there is some suggestion the number could be two or three times as many would prefer to die at home, as currently do die at home) this needs to be sorted out !

    Are you the anonymous of 7-Nov-2011 10:40 pm ?

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  • Mark, thankyou for that piece. I've been in so many situations as you describe, probably as has every other nurse in the land. I wasn't aware of the nature of 'holding' someone without touching them until I did a counselling course. I absolutely agree that this can be taught and learned, and yet not everyone will be able to develop it to the same extent, as with most things. It certainly wasn't taught in my training except the theories, but I'm not sure it could have been either. It really does necessitate good mentoring and support, as you say, in the nursing environment rather than just hoping for the best.
    The other thing that strikes me is the regular and heartwrenching mismatch of what seems right, in terms right vs wrong, and doing the best we can in very difficult circumstances. The older I've got, the more 'messy' it all seems and less definite or certain, except from the NMC of course!
    I don't see how that will change either until humanity is valued as much as the pounds and pence.

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  • michael stone

    Anonymous | 8-Nov-2011 4:58 pm

    'The older I've got, the more 'messy' it all seems and less definite or certain, except from the NMC of course!
    I don't see how that will change either until humanity is valued as much as the pounds and pence.'

    Very perceptive comment, about 'almost everything': the older you get, or the more you think about things, the more 'messy and complex' things become. So guidance starts to look very flawed, to many people - yet to those who 'understand less', the guidance is 'a set of rules'.

    With more experience and knowledge, comes an understanding of 'the bits I find problematic, and realise I don't entirely understand'.

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