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The heart of art: Emotional intelligence in

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Nursing Inquiry 2004; 11(2): 91 98

Feature

The heart of the art: emotional

intelligence in nurse education

Blackwell Publishing, Ltd.

Dawn Freshwatera and Theodore Stickleyb

aInstitute of Health and Community Studies, Bournemouth University, Bournemouth, Dorset and bSchool of Nursing,
University of Nottingham, Nottingham, UK
Accepted for publication: 21 August 2003

FRESHWATER D. and STICKLEY T. J. Nursing Inquiry 2004; 11: 9198

The heart of the art: Emotional intelligence in nurse education
The concept of emotional intelligence has grown in popularity over the last two decades, generating interest both at a social
and a professional level. Concurrent developments in nursing relate to the recognition of the impact of self-awareness and
reflexive practice on the quality of the patient experience and the drive toward evidence-based patient centred models of care.
The move of nurse training into higher education heralded many changes and indeed challenges for the profession as a whole.
Traditionally, nurse education has been viewed as an essentialist education, the main emphasis being on fitness for practice
and the statutory competencies. However, the transfer into the academy confronts the very notion of what constitutes this
fitness for practice.
Many curricula now make reference in some way to the notion of an emotionally intelligent practitioner, one for whom theory,
practice and research are inextricably bound up with tacit and experiential knowledge. In this paper we argue that much of
what is described within curriculum documentation is little more than rhetoric when the surface is scratched. Further, we propose that some educationalists and practitioners have embraced the concept of emotional intelligence uncritically, and without
fully grasping the entirety of its meaning and application. We attempt to make explicit the manner in which emotional
intelligence can be more realistically and appropriately integrated into the profession and conclude by suggesting a model of
transformatory learning for nurse education.
Key words: emotion, emotional intelligence, nursing curriculum, reflection, reflective practice.

It is generally accepted that very little of our lives is governed

by logic alone. It is rather our emotional world that
motivates our decisions and actions. In recent years, breakthroughs in neuroscience have deepened the way in which
we understand emotions as a body state. Subsequently writers
have sought to popularise the concept of the emotions.
Goleman (1995), in his best selling book Emotional intelligence reminds us that we have two minds, a rational mind
that thinks, and an emotional mind that feels. Both however,

Correspondence: Dawn Freshwater, Professor of Mental Health and Primary

Care, Institute of Health and Community Studies, Bournemouth University,
Royal London House, Christchurch Road, Bournemouth, Dorset, UK.
E-mail: <dfreshwater@bournemouth.ac.uk>
2004 Blackwell Publishing Ltd

store memories and influence our responses, actions and

choices. Emotions hold independent views, have a mind of
their own, quite separate from that of the rational mind.
When we consider the significance of the emotions in everyday life, it is noteworthy how little we refer to them in the
busy-ness of our lives. As Freshwater and Robertson (2002)
comment, the emotions remain the Cinderella of our psyche.
The premise of this paper is that the rational mind and the
emotional mind need to be balanced partners; where this
relationship is harmonious, intellectual ability increases. So,
rather like Hegels (1971) notion of dialectical thinking, it is
important to draw together seemingly competing opposites
and emphasise the dialogue between them. Accordingly,
whilst the focus of this paper is on emotional intelligence, we
are mindful of the dialogue between this and other forms of
intelligence.

D Freshwater and T Stickley

The debate around the nature of intelligence has

been dominated by the scientific paradigm and superiority
afforded to the notion of IQ. It is not our intention to debate
the concept of IQ here, except to note that it is only one
proposed model of intelligence. Gardner (1983), for example, refutes the monolithic domination of measuring success
through IQ and purports seven varieties of intelligence that
we are all born with, these being: verbal and mathematical
logical alacrity; spacial capacity (as in art or architecture);
kinesthetic fluidity (as in sport); music; personal (as in
communication and interpersonal skills); charisma; intrapsychic ability (as in congruence and inner contentment
and containment).
We briefly return to these varieties of intelligence in our
discussion around nursing and nurse education, however,
we might at this point ask you to reflect on how these aspects
of intelligence inform and create the art and craft of any
practice discipline.

has gained extensive international recognition, having

been translated into 15 different languages. More recently
Bar-On has developed a 360-degree version of his test and
a youth version. Bar-Ons model contains five overall groupings, these being: interpersonal factors; intrapersonal factors; general mood and motivation; stress management;
adaptability.
Golemans (1995) own mixed model of emotional intelligence contrasts with that of Salovey and Mayer (1997), in
that he argues for the inclusion of a range of emotional
skills and personality traits, namely self-awareness, selfmanagement, social awareness and social skills. With regard
to definition, we conclude by stating that emotional intelligence is a core aptitude related to ones ability and capacity
to reason with ones emotions, especially in relation to
others.

EMOTIONAL INTELLIGENCE

Nurse education has often been viewed as an essentialist

education with the emphasis on producing an individual
that is fit for practice. Essentialist education by its very nature
moulds the student. In this sense, one could argue (and it
is a well-rehearsed debate) that nurse education with its
statutory competencies to meet is a training rather than an
education. Prior to Project 2000 courses in the UK, nurse
education was largely an apprenticeship model of training;
akin to the pretechnocratic model described by Bines and
Watson (1992). This model comprises the acquisition of skills
through on-the-job training with theoretical components
taught block or day release. The goal of traditional nurse
education has been to teach specific skills and knowledge in
order that students can reach a certain standard of behaviour, attitude and work as defined by the educational establishment and in the case of nursing in the UK, the United
Kingdom Central Council for Nurses, Midwives and Health
Visitors (now the NMC) and the National Boards for Nursing (now defunct). Thus the classroom has been dominated
by propositional knowledge and practical knowledge has
been the domain of the clinical environment. Propositional
knowledge can be described as textbook knowledge in which
a person builds up a bank of facts or theories about a subject
without necessarily having direct experience of the subject
(Burnard 1987; Rolfe 1998; Freshwater 1998a). Polanyi (1962),
Pring (1976) and Benner (1984) have referred to this way
of knowing as know that. From a nursing perspective, this
equates with the well-known and oft-quoted Barbara Carpers
(1978) scientific way of knowing and in critical theory it is
referred to as scientific or technical knowledge (Habermas
1972; Fay 1987).

Emotional intelligence (EI) can be described as being about

a set of non-cognitive abilities that influence the individuals
capacity to be successful in life. Although it is clear that EI
works synergistically with IQ to enhance overall performance, it is argued that EI can be measured and it can be
learned and it is this ability that differentiates exceptional
from mediocre ability and achievement.
As previously mentioned, the concept of emotional intelligence (EI) has been popularised by the authors Daniel
Goleman (1995) and Susie Orbach (1999). However the
origins of the term go back beyond the work of these well
known contemporary writers. Prior to the work of Goleman
and Orbach, several models of emotional intelligence were
being developed and refined, most notably the ability model
(Mayer and Kilpatrick 1994). Salovey and Mayers research
on the subject concluded that emotional intelligence is
an actual intelligence, in so much as it can be measured
through an ability test (Salovey and Mayer 1997).
This test, known as the MSCEIT (Mayer, Salovey, Caruso
Emotional Intelligence Test) was based on the ability model
of EI that comprises perceiving and identifying emotions;
assimilating and using emotions; understanding emotions
and managing emotions. These issues have been the subject
of recent neurobiological research (for example, Damasio 1995)
and continue to be of interest to psychologists (Bar-On and
Parker 2000), psychotherapists (Freshwater and Robertson
2002) and social scientists alike.
It was Bar-On, an Israeli psychologist, however, who
developed the first test of emotional intelligence that
92

NURSE EDUCATION

2004 Blackwell Publishing Ltd, Nursing Inquiry 11(2), 91 98

Emotional intelligence and education

The theory practice gap (again!)

The introduction of Project 2000 in the UK nursing programmes presented the opportunity to challenge traditional
nurse training and the split of theory and practice. Instead
models of education have shifted from the pretechnocratic
to the technocratic (Bines and Watson 1992). Both the pretechnocratic and technocratic approaches to nurse education and nursing practice are firmly based in Promethean
and Apollonian logic. Hence the curriculum development
models used have been closely aligned to the instrumentalist
ideology, liberal humanism (Pendleton 1991; Askew and
Carnell 1998) and the functionalist model of education
(Criticos 1993; Askew and Carnell 1998). From this viewpoint, the student is the inheritor of societys wisdom and
the manifestation of societys values. Anyone who has been
a patient in hospital or has had a sick relative will be grateful
for the instrumentalist ideology that has driven nurse curricula, for it is the teaching of a safe and competent performance of practical nursing skills that serves to protect the
general public. Patients also have the right to assume that
the type of care they receive is based upon sound evidence.
However, it could be argued that there is more to high quality
patient care than the safe and adequate completion of tasks.
Making informed decisions in clinical practice means
re-evaluating the relevance of a particular intervention for a
patient and learning from experience. and as Burnard (1987)
observes, a person may develop practical knowledge without
developing the appropriate propositional knowledge, for
example in the giving of an injection, and conversely a
person may develop propositional knowledge without ever
having developed the practical knowledge, an example of
this is often seen in the administration of cardio-pulmonary
resuscitation. Neither of these ways of learning feel particularly
holistic, rather, the theorypractice gap remains. It could be
argued that the bulk of nurse education has concerned itself
with propositional and practical knowledge (Freshwater 1998a).
Unfortunately, this has not usually occurred simultaneously.
Hence whilst there is no doubt that the curriculum
benefits from the explicit inclusion of propositional knowledge, the theorypractice gap continues, with propositional
knowledge being the concern of the academy and practical
knowledge coming from the clinical or ward area (Rolfe 1996).
Thus not only the students but also the patients are seen as
split entities. The functionalist model of education, instrumentalism and Apollonian logic have all been criticised for
being too mechanistic and failing to take a holistic approach
to the educational requirements of students, and in this case
the nurse and patient (Neville 1989; Pendleton 1991; Paris
1995; Askew and Carnell 1998; Randle 2002; Freshwater
2004 Blackwell Publishing Ltd, Nursing Inquiry 11(2), 9198

2002). Whilst the above approaches to teaching and

learning may appear to be relatively uncluttered, they are
incomplete. Learning is surface rather than deep (Entwistle and
Ramsden 1993), there is little, if any room for imagination,
the focus is on the parts rather than the whole (Okri 1997).
The role of the teacher when adopting this approach to
teaching is that of the expert, transmitting knowledge and
in the case of student nurses, training students in social and
psychomotor skills (Askew and Carnell 1998; Pendelton
1991). It is assumed that the student needs, and will respond
to, plenty of explanations of concepts and principles and
demonstrations of practical skills.
These models were perhaps appropriate for the traditional nurse syllabus conceived of by the General Nursing
Council, although the lack of emphasis on the experience of
the student could be contested as being one sided. Current
thinking in the advancement of nursing curricula is
influenced by critical social theory, reflexivity, narrativity
and feminist epistemology. Such theories are critical of
behaviourist approaches to teaching and the hierarchical
organisation of educational institutions (Osbourne 1996;
Rolfe et al. 2001; Randle 2002), espousing a more holistic
and mutual approach to teaching.

Balancing the rational and the emotional

Every nursing intervention is affected by the master aptitude
of emotional intelligence. It is not enough to attend merely
to the practical procedure without considering the human
recipient of the process. Whilst the rational mind may adequately attend to the necessary technical aspects of nursing
procedures, it is not the place of the rational mind to
intuitively sense the needs and emotions of the person at
the receiving end of care. As Perls (1973) reminds us, every
breath in every moment is significant. One sigh may be
communicating a lifetime of emotions. It is the emotionally
intelligent practitioner that hears the sigh, makes eye contact,
communicates understanding and demonstrates human
care (Freshwater 2003). Although this simple human contact may be easily taken for granted, it may, in the moment,
be of the most profound and potentially healing nature. An
education that ignores the value and development of the
emotions is one that denies the very heart of the art of nursing practice. By focusing entirely on the rational, we are in
danger of producing unbalanced practitioners. When teachers pay little or no attention to emotional development, they
fail to communicate with students the significance of human
relationships. It is not enough to simply impart communication skills because, by implication, communication becomes
another intervention similar to aseptic technique or giving
93

D Freshwater and T Stickley

an injection. Where communication skills training is separated

from the emotional content of human interaction, the
art of nursing is reduced to the science of the technician
(Freshwater 2003). Further, when emotional development is
neglected, the individual is denied the opportunity of fully
developing intellectually. Some are naturally more attuned
to emotional life through metaphor, simile, poetry, song,
dreams, myths and fable. These are all written, as Whyte (1997)
notes, in the hearts language. The emotionally intelligent
nurse is one who can work in harmony with thoughts and
feelings. Novelists, artists, psychotherapists may be more
adept at emotional intelligence as contact with their emotional world is critical to their work, it is also fundamental to
the act of caring, and as such the nursing curricula needs to
create space for the work of the heart.
It is argued that nursing is becoming more and more
technical at the expense of the human qualities of empathy,
love and compassion (see Stickley and Freshwater 2002)
What is nursing if it is not the provision of one human being
caring for another? Elsewhere we have argued for the
restoration of acknowledgement of the value of love in the
therapeutic relationship (Stickley and Freshwater 2002).
Within the current climate of evidence-based practice, clinical
outcomes and national standards, the value of human
relationships (which is not necessarily a measurable phenomena) and the associated emotion is lost. More importantly, of
what significance would a clinical outcome be without love?
We would argue therefore that love is a necessary component
of the nursepatient relationship and as such an emotionally
intelligent curriculum.
Many authors argue that to give and receive love is essential for being human, indeed it might be argued that love is
the most important experience of human existence (Fromm
1957; Rogers 1957; Maslow 1970). Psychological theories of
human development concur that unconditional love is vital
to the development of the individual. Humanistic theorists
focus on the role of authenticity, genuineness and empathic
understanding (Rogers 1957); psychoanalytic theorists concentrate on holding and containing in the development of
a true self (Winnicott 1971; Klein and Klein 1975), whilst
behavioural schools of thinking speak of positive reinforcement (Skinner 1958; Beck 1976). What all these theoretical
frameworks have in common is the general consensus that
love is fundamental to human experience. Furthermore,
some would argue that love heals (Siegel 1986; Sardello 1995).
The emotionally intelligent nurse is aware of her own need
for love, the need of love for her patients and the patients
own needs for receiving love. Whilst many nurses may deny
or neglect these needs, they will not go away. The ability
to give love (or what Rogers (1957) called unconditional
94

positive regard) whilst maintaining professional and social

boundaries may be the most therapeutic action a nurse can
commit. The balancing of the emotional and the rational
minds can provide a stable platform to develop the art of loving in the therapeutic relationship (Stickley and Freshwater
2002). However, the art of loving cannot be taught in a
propositional way, nevertheless, it can be modelled
through therapeutic relationships. If the teacher can communicate love to his/her students, then the students are more
likely to develop positive attitudes toward their patients.
Whilst the nursing literature includes much about the
therapeutic use of self, we would question the therapeutic
benefit of self when its own love needs are not fulfilled. Similarly, where nurses are not feeling supported and valued, their
practice will suffer. It is right and proper that all nurses have
access to clinical supervision (UKCC 1996), however, the
clinical supervision process needs to be more than the
monitoring of practice. Nurses are human beings with emotional and psychological needs, where these needs remain the
therapeutic benefit of their work could be questioned.
Effective clinical supervision can help to maintain the practitioners balance, and effectively facilitated reflective practice
will stimulate self awareness and personal growth, thus
transforming the life and practice of the individual.
The emphasis here however, is not on the specific
emotion of love, this is only one aspect of the emotional world.
We simply use this as an example to raise awareness of the
importance of a balanced approach to the practice, teaching
and learning, and indeed the research of nursing.
To refer back to our earlier point, an emotionally intelligent curriculum is not dominated by one understanding of
intelligence and knowledge, but recognises the value of a
complex and often unfathomable relationship between self
and intelligence. Such a movement is congruent with the
recent focus on the value of a patient-centred approach to
care, reflective practice, self awareness and therapeutic use
of self ( Ersser 1997; Freshwater 2002; Stickley and Freshwater
2002 and many others). We now turn our attention more
specifically to the role of emotional intelligence in nursing
and in nurse education.

EMOTIONAL INTELLIGENCE IN NURSING

It is impossible to describe the art and science of nursing
without referring to emotions, indeed nursing literature is
replete with reference to the emotional labour of nursing
(most notably the work of Isobel Menzies Lyth 1970, 1988).
More often writers have been working to rehabilitate the
emotions, once deemed to be inappropriate in nursing,
back into the nursepatient relationship (Stickley and
2004 Blackwell Publishing Ltd, Nursing Inquiry 11(2), 91 98

Emotional intelligence and education

Freshwater 2002). Nurses, in their professional life, clearly

work consistently with human emotion, whether this be
through pain, discomfort, sadness, relief or hope. Evans and
Allen (2002) and Cadman and Brewer (2001), along with
other writers, contend that the ability to manage our emotional life, while interpreting other peoples is a prerequisite
skill for any caring profession. Indeed, it could be argued
that the advent of patient- and relationship - centred care
(see, for example, McMahon and Pearson 1998 and Freshwater 2002) represents an explicit acceptance of these longdebated concerns. That the practitioner should be able to
develop an empathic relationship in order to execute her
role is now well documented and forms the basis of many
nursing theories (Peplau 1992; Newman 1994; Parse 1997;
Parker 2002), who, whilst not necessarily engaging in the
same language, argue for emotional competence.
Bellack (1999), for example, contends that nurses are
required to develop emotional competence if they are to be
successful in their working environment. Arguing that nurse
education fails in the important domain of the emotions,
Bellack (1999) calls for nurse educators to examine the role
of emotional learning and competencies within the curricula.
The role of nurse education in supporting this development
is as yet unclear, although it would appear from the
literature that there are some initiatives that specifically aim
to explore the link between emotional intelligence and
the nursing curricula (Bellack 1999; Cadman and Brewer
2001; Evans and Allen 2002). Whilst Evans and Allen (2002)
attend to these concerns in a rather descriptive paper, they
nevertheless contend that:
The inclusion of emotional intelligence in the curriculum
empowers students to manage situations that may be highly
charged emotionally. If they are able to deal with their own
feelings well then they will be able to deal with others confidently, competently and safely (42).

Cadman and Brewer (2001), in their sensitively written paper

on recruitment in nursing, explore the research relating to
the development of empathic resonance. Concluding that
nurses are unable to demonstrate high levels of empathy, they
point out the direct relationship between levels of empathy
and beneficial client outcomes. Whilst these last two issues
are obviously of significance to the current debate, we cannot
do justice to them in this paper, however, we feel that they
need to be addressed in some detail within the nursing sphere.

EMOTIONAL INTELLIGENCE AND NURSE

EDUCATION
Evans and Allen (2002) state that integrating emotional intelligence into the curriculum provides nurses with a greater
2004 Blackwell Publishing Ltd, Nursing Inquiry 11(2), 9198

opportunity to understand themselves and the way in which

they create relationships with others. That this impacts upon
the therapeutic relationship and subsequently on the patients
illness experience is indisputable. However, this process of
self-inquiry may not always be a comfortable or ordered one.
In order to bring into the cognitive domain that which
ordinarily resides in the precognitive the practitioner needs
to engage in a reflective learning that moves beyond, but
includes, the level of propositional and practical knowledge,
to a place of deep learning (Greenwood 1998). The rhythm
of movement between deep and surface learning, when
managed through the process of critical reflection, creates a
learning situation that is transformatory, both for the learner
and for the learners practice. Freshwater (2002) notes that:
Transformatory learning not only enables the student to
learn, and to learn how to learn, but also facilitates the
process of transformation in that learning (84). However, it is
not a mechanistic approach to education that can be taught
through a prescriptive model, rather it is an approach that
is experienced in a unique and individual encounter with
both the interpersonal and intrapersonal aspects of oneself.

DISCUSSION
Nurse education, in its rush to embed factors relating to
emotional intelligence such as self-awareness, therapeutic
use of self and critical reflection is guilty of creating mechanistic models, or worse still transplanting models from other
disciplines uncritically. The purpose of providing an education that stimulates an inquiry into the world of the emotions
is to safely bring into current awareness a knowledge of
that which is ordinarily unknown and, at times, unspeakable.
This requires that teachers are in intimate contact with their
own emotions and are able to facilitate learning in the other
from a position of self-knowledge. However, as several
authors have commented, nurse teachers themselves have
low levels of self-awareness and emotional intelligence (Randle
2002; Freshwater 2002). Further, the preferred mode of
teaching is also called into question; the traditional didactic
transference of knowledge is now, more than ever, being
challenged, with the use of art, poetry, dance, drama, music
in the classroom slowly being encouraged in nursing curricula. These expressive modalities can penetrate in an instant
the heart of the learning, more importantly, they help to distinguish the concepts of care and caring from the notion of
treatment and cure.
Frank (1991) differentiates care from treatment. Treatment is a technical routine that could ultimately be performed by a robot. Care is that which is communicated by
the words and actions of an understanding and empathic
95

D Freshwater and T Stickley

human being concerned for the other upon whom they

administer treatment. Just as our supermarket cashiers have
now been trained to welcome each shopper with a Hello,
we automatically sense the ones for whom this is a meaningless chore and welcome the same greeting from the cashier
who makes eye contact and obviously welcomes the chance
for human contact. This trend in customer service is a
recognised sociological issue and labelled McDonaldisation
by Ritzer (1996). One might question, to what extent is
nursing, and other health-related disciplines becoming
McDonaldised? In this age of managed care, success is
measured by efficiency and cost reduction. Whilst legislators
use the language of care, what appears to matter most to
those in power is the efficiency of productivity. In the process
of MacDonaldising the nursing profession, we are in danger
of inviting the notion of care the very act upon which the
profession is established to leave the room. For any of us
who have been on the receiving end of hospital care, we know
only too well the demoralising effects of treatment without
care. Similarly, we recognise and appreciate the treatment
with care that makes the experience of being a patient all
the more bearable. Without care we are treated as objects,
we lose our sense of our own purpose, we become victims
of a dehumanising system as we seek out the smile and care
from the nurse who attends to us. We seek for anything to
restore our sense of personhood and dignity.
If at the hands of health-care, people become demoralised, nurses have the singular opportunity to engage in the
re-moralising of their patients. This simple but profound
activity requires self-awareness of the highest order but
demands little more than human care demonstrated by
empathic understanding. This kind of understanding does
not come about by professional culture or practical osmosis,
empathic understanding can be developed through a continued emphasis on emotional intelligence, facilitated not
just through nurse education, but also through practice and
research
So, what would a curriculum look like that had emotional intelligence at its heart? Whilst we do not wish to prescribe a curriculum model of emotional intelligence here, it
is fitting that we mention elements of what has proved a
transformatory learning process for us (Freshwater 1998b).
Thus we suggest that an emotionally intelligent curriculum
would include:
reflective learning experiences;
supportive supervision and mentorship;
modelling;
opportunities for working creatively with the arts and
humanities;
focus on developing self and dialogic relationships;
96

developing empathy;
a commitment to emotional competency.
Some approaches to experiential learning to be found in an
emotionally intelligent curriculum may include:
forum theatre;
self inquiry;
narrative;
reflective discussion and writing;
art, drama, music, film and poetry;
practising listening skills, both in the classroom and in
practice;
the use of video for observation and feedback;
service user involvement in the planning and delivery of
the course.
Rather than an addendum to the nursing curricula,
emotional intelligence needs to be firmly placed at the core.
For this to be effectively integrated much work needs to be
undertaken to support the highly stressed, often underpaid and
disillusioned teachers who themselves are not only removed
from the caring environment, but also find their own working environment uncaring thus paralleling the processes
that practitioners encounter in their clinical settings. This is
rather like being trapped within a hermeneutic circle and
having no space to reflect on the escape routes. Whilst we
realise that emotional intelligence is not a panacea for all the
ills of nursing and nursing education, we firmly believe that
it is at the heart of learning to care, both for oneself and
others, and as such deserves to be examined in more depth.
Finally, we wish to return to our earlier point that both
the rational and emotional dimensions are essential to
intellectual functioning and indeed to healthcare practices.
Whilst it may appear that we have, in the main, concentrated
our attention on the emotional dimension within the paper,
the very act of putting the paper together is a rational act
driven by emotions such as passion, love and anger. The
focus of the paper has been on the prevailing professional
discourse that tends to devalue emotional intelligence, preferring instead abstract knowledge. We would like to reiterate
here that emotional intelligence and rational intelligence are
interdependent. As such, curriculum designers are tasked
with developing educational strategies that promote stronger
links between the two domains, responding to such questions
as how can educators, practitioners and researchers work within
the current context of underrecruitment and evidence-based
practice to sustain reflective practice and emotional learning.

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