Healthcare is in triage.

Something must be done to stop the bleeding – to find solutions for meaningful and sustainable treatment before it is too late. The emergency is recognised by all.

Healthcare is a highly demanding field, even at the best of times. However, the best of times is now a distant memory. The sector has been under sustained stress at every level, across all fields, and in every region of the world, since COVID-19 began.

As the memory of the pandemic begins to fade, the resulting impact of the trauma has proven harder to recover from. The ongoing stress of that season has led to prolonged strain that is driving hospitals and healthcare systems to the brink of collapse. We are not merely heading towards a global healthcare crisis, we are in it already.

In this context, healthcare workers (HCWs) are still required to manage themselves and engage professionally with others – colleagues, patients, and patients’ families – in the innately stressful dynamics of their day-to-day environment. It has become clear that the phrase “something must be done” applies as much to finding solutions for helping the human beings in the system, as it does to fixing the system itself. Indeed the two are inseparably linked.

Sector-specific areas of concern have arisen for HCWs in recent years. Among others, these include psychological well-being, burnout, staff retention and turnover (most importantly, in nursing). These work-related demands on HCWs at the individual level negatively impact whole institutions at the system level. The downstream impact of these factors on patient outcomes is undisputed.

Finding meaningful solutions to solve for these challenges will require a system-wide strategy – a treatment plan to bring healing to the wounds healthcare has sustained. Moreover, a sustainable treatment plan must effectively mitigate the harmful results of these psychosocial challenges in both the individual HCWs themselves, and the organisational dynamics that result when these human beings work together in the system.
A system-wide treatment plan must equip the human agents in the system with personal resources to manage themselves and their interactions with others more effectively. The competencies of Emotional Intelligence (EQ) have been shown to have a significant effect on building these resources.

EQ is the ability to effectively manage oneself and one’s interactions with others. EQ is a well-defined construct in social science, with a substantial history of academic study in real-world contexts.

The benefits of EQ have been observed and documented in a variety of industries, including the healthcare sector. Significant empirical evidence exists in favour of the positive impact on health outcomes when HCWs and leaders exhibit high EQ behaviours.

In short, increasing the emotional competencies of EQ at the individual agent level (frontline HCWs and leaders) has been conclusively shown to benefit the health of the system itself, and positively impact the ultimate beneficiaries of it.

This blue paper reviews the academic literature on EQ in healthcare and advocates for new pedagogies to effectively increase EQ levels in HCWs and systems. The research covered examines the positive impact of EQ on both agents and systems in relation to psychosocial concerns such as well-being, burnout, resilience, retention and turnover, organisational culture, patient outcomes, and ultimately the resulting financial impact of these factors. The paper argues that finding a sustainable EQ development methodology can serve as a treatment plan to equip HCWs and leaders with the internal resources necessary to prevent the collapse of healthcare systems.

These are bold hopes for a paper like this, but boldness is a necessity at this time.

The impact of COVID-19 on the global economy is long-lasting and undisputed. The devastation of the last few years has been widespread – impacting individuals and institutions at all levels.

Some sectors of the economy escaped the damage, or even thrived in the milieu, but many were hit inordinately hard and have struggled to recover.

The healthcare sector in particular has sustained some of the most grievous injuries, most pertinently in the psychological well-being of HCWs. Increased staff burnout has resulted in downstream operational strain on management, finance, ultimately impacting the quality of patient care.^1,2

Some of the early research during the pandemic around HCW burnout, counterintuitively, indicated an initial resilience in staff on the front lines. Those who were serving in the COVID-19 wards showed lower levels of burnout when compared to physicians not actively involved in fighting against the virus.³ The working hypothesis, at the time, was that a sense of meaningful contribution, and high levels of personal effectiveness, acted as a barrier to keep burnout at bay – for a time.* However, the sustained onslaught of trauma has since taken its toll.^4-7

The resulting impact on the sector, in terms of decreased psychological well-being, increased burnout, and higher staff turnover resulted in increased departmental strain that culminated as financial pressure at an institutional level. This reality has become a new normal – the unfortunate status quo of healthcare around the world, and the sector is scrambling to recoup.^2,7,8

The challenges in healthcare since the pandemic are numerous.

A global shortage of nurses seems to be the reality everywhere.^1,5,9

Nurse turnover is a real concern in most hospitals, and many nurses are leaving the industry altogether.^4,5
Howard Catton, co-author of a recent global report on the state of nursing has labelled the situation a global crisis.5 He goes on to say,

This mass exodus and forecasted shortage of medical staff puts further strain on the sector; an increase in absenteeism from burnout and the resulting increased dependency on locum staffing leads to financial pressure dramatically increasing within the system. Yet perhaps the greater impact will be felt in the undermining of organisational culture through the loss of meaningful relationships between HCWs on the front lines. The increasing reliance on short-term staffing stop-gaps prohibits the fostering of strong relationships necessary to create strong teams where safety and trust are held in the relationships that long-term co-workers create over time. Teams with strong relational capital collaborate more effectively to deliver the best patient care and achieve the outcomes desired. It is difficult to build a healthy culture with an ever-changing set of colleagues that differs from day to day. Furthermore, relying on a locum staff reduces the ability of frontline HCWs to build relationships with patients, further resulting in a lower quality of care.¹ As a result of these dynamics, hospitals and healthcare systems are deep in debt and losing money at an unprecedented rate.

In an attempt to stop the financial bleeding, many health systems have resorted to large-scale layoffs and restructuring efforts. These have had a negative impact on staff morale and have increased the psychosocial pressures within the healthcare system. As a result, patient care is compromised – undermining health outcomes in unprecedented ways.

Something must be done.

In the analogy of triage that is presented in this paper (with the health sector itself playing the role of the patient in the emergency department), medical executives find themselves in the role of the triage provider on the metaphorical frontline of the global healthcare crisis. They are tasked with diagnosing the issues. Furthermore, executives are also required to play the role of the physician to administer the treatment plan and prescribe the medication. They are needing to find effective new treatment solutions to meet the unprecedented new normal with new and effective strategies that mitigate the pressures. If they are unable to find successful treatment plans to attend to the numerous wounded elements of the system, their institutions are at risk of critical system failure at worst – death. Short of this extreme, when faced with an inability to maintain all the care services they have historically offered in their institutions, for the sake of survival difficult decisions will need to be made to shut down areas of care – amputation will be the last resort. Leaders are asking questions about their long-term sustainability to serve their communities; will they be able to provide the level and scope of care in the way they have historically been able to?^1,4

The current situation in healthcare is laid out in plain and clear terms by Mr Howard Catton. Serving as the CEO of the International Council of Nurses, Catton gives the following warning regarding the global healthcare crisis:

We can no longer afford to undervalue and underfund the nursing profession, not only for the sake of the health of nurses, but for the protection and sustainability of our entire global health system. Let’s be clear: we are not talking about stop-gap solutions, getting through the current pandemic, or even preparing for the next. We are talking about being able to address all the healthcare needs that have built up and been delayed since the onset of the pandemic. If we do not address all these present and urgent needs in a sustainable way over the next decade, the WHO’s ambition of Universal Health Coverage will be thwarted.^{6 (para 14)}

The time to act is now. But what is to be done?

Is there a simple or unified solution to these problems – a metaphorical treatment plan that executives can prescribe and administer to the system as a whole? Some say there is not, for instance, a group of health economists.

A project named the “1% Steps to Healthcare Reform” is a collaborative effort by 27 leading healthcare economists, from some of the leading universities in the United States.* They maintain that … “Reforming a $3.8 trillion [American] health system won’t involve a single change. There simply are no silver-bullet reforms that will transform the US health system.” ^{1 (para 2)}

Silver-bullet thinking loads all the individual pressures in the system onto one hope, and asks for unrealistic results. These academics are wise to be sceptical of such a proposition. Rather, their project is looking for ways to fix the system through many small steps, in the shape of numerous one percent reforms. To this end, they are writing a series of policies they recommend that health systems adopt and implement, to make incremental changes.

Their approach is reminiscent of the old African saying, “How do you eat an elephant? One bite at a time.” However, “one bite at a time” does not mean that only one mouth must do the biting. The time it takes to eat the whole elephant is largely a function of how many mouths are involved. When the elephant is a system-wide challenge, then a system-wide solution can include many mouths to contribute to the project of biting, chewing and swallowing, all at the same time.

Therefore, while silver-bullet thinking may be unrealistic in most cases, what if we were able to find another way to think of one unified solution – a different way to understand how to make numerous one percent changes, simultaneously? If we can find another way to approach the concept of a solution, then is there perhaps a way that executives in a health system might be able to take multiple one percent steps, but all within one simple strategic solution? There may be, but first we must find a more effective way to understand the idea of a solution.

This diagram illustrates the numerous connection points where both high and low levels of EQ have both positive and negative influence on factors within a health system, as discussed in this paper. The image illustrates the centrality of EQ in multiple areas of concern, and the repercussions of its influence through these factors on other dynamics within the system.

The sector-specific challenges facing healthcare right now are by no means new. Research has been conducted all around the world to explore how EQ helps individual HCWs and health systems to better serve the beneficiaries of their charters, and improve their outcomes. This section will explore EQ research across a number of areas of concern.

We will begin by looking at a high-level integrative literature review on the general impact that EQ has on various functions within nursing. This will help to form the outlines of a big-picture from which we will begin to explore more specific studies to fill in the details.

A 2009 literature review* exploring the link between EQ and nursing focused on four areas: the relationship between EQ and nursing education, nursing practice, clinical decision-making, and clinical leadership.¹¹ The authors conclude that EQ plays an important role in all four of these areas.

EQ was shown to positively affect the bio-psycho-social welfare of nurses, increasing their resilience. Higher EQ was also identified in the review as having a tangible impact on reducing stress, burnout, absenteeism and staff turnover. Furthermore, EQ was shown to protect workers from the natural effects of exhaustion and strain and enable them to more effectively operate within the context of those stressors.

Higher EQ was also linked to improved clinical decision-making, greater work engagement, higher job satisfaction and better performance.

Greater levels of EQ empowered HCWs to communicate more effectively and show compassion and empathy to patients and colleagues.

The ultimate benefit of higher EQ was seen in the holy grail of healthcare – patient outcomes. The authors conclude that higher EQ among nurses improves the quality of patient care, leading to better health outcomes.

The review ends with a recommendation that EQ training should be explicitly included in the early education of nurses, as well as in continuous professional development. We will return to the issue of EQ development later in the paper. Taking this literature review as a starting point the benefits of EQ on sector-specific concerns are worth exploring in more detail, to which we will now turn.

Burnout

Burnout, a growing concern the world over since the pandemic, has been identified as a particular danger for professionals with a job in healthcare – one that must be addressed to ensure the continuity of care for healthcare institutions.

Burnout rates in healthcare

HCWs have always been at higher risk of burnout than professionals in other fields.^4,12 Pre-pandemic, the World Health Organisation (WHO) estimated a prevalence of burnout in 13–27% of the general active population.¹³ However, burnout levels were already much higher amongst HCWs. One study with nursing aides in the same year (2018) reported burnout rates as high as 26–50%, twice the rate reported by the WHO in the general population. While nursing aides may be near the bottom of the medical hierarchy, increased burnout is also seen at the highest levels.

In a meta-analysis of 32 studies, it was found that the upper bound of burnout prevalence in neurosurgery residents was 67%, and 57% among attendings.¹⁴ Another study reported that 54% of advanced neurosurgery practitioners reported current burnout.¹²

Alongside these specific statistics mentioned in these few studies, it is poignant to recognise that higher levels of EQ in HCWs has consistently been shown in research from all around the world to decrease the risks of burnout, significantly, in all levels of the medical hierarchy.^13,15-21

We will now explore the positive impact of EQ on burnout.

Burnout factors and EQ

The three dimensions typically measured to determine levels of burnout syndrome are widely recognised as emotional exhaustion, depersonalisation, and a subjective sense of personal accomplishment.

Numerous studies have been conducted in recent years to determine the importance of EQ in reducing emotional exhaustion and depersonalisation, and its ability to increase a sense of personal accomplishment in nurses and physicians.

Results are by no means ambiguous – the tangible impact of higher EQ on reducing burnout and protecting HCWs from it, is positive and substantial.

A study in 2014 surveyed HCWs at all levels, from interns to doctors.¹⁵ * Their findings concluded that higher levels of EQ in HCWs reduced emotional exhaustion (10% variance), reduced depersonalization (3% variance), and increased a subjective sense of personal accomplishment (23% variance).

In a similar study in 2015, with 120 doctors and nurses in Romania, similar conclusions were reached. In this research, EQ was also shown to mitigate the effects of burnout syndrome. When HCWs are more emotionally intelligent they are more likely to feel a greater sense of personal accomplishment and have tools to effectively cope with the strain that leads others more quickly to emotional exhaustion and depersonalisation.¹⁶

The link between personal accomplishment was also clear.

Resilience, another trait associated with high EQ, is likewise a good protector against burnout. Researchers in Portugal, analysing burnout amongst doctors and nurses during the second wave of COVID-19, advocate that their findings offer not just knowledge about burnout, but knowledge on how to fight against it. They conclude that if we can reinforce and develop internal personal emotional resources in HCWs, before they encounter stress, it will greatly reduce the risk of burnout syndrome. ²⁰

Another study with 148 HCWs in a rehabilitation centre found a significant correlation between lower EQ scores and higher burnout scores. ²¹ The authors report that for every one unit increase in EQ, they noted a correlation of a 17-unit reduction in the score for burnout syndrome.

It is clear, from numerous studies, that higher levels of EQ have a significant impact on reducing the risk of burnout in multiple disciplines of healthcare.* Taken in harmony, these studies indicate that EQ should be recognised as an essential skill in HCWs, not just to protect themselves but to protect the systems in which they work, and the patients they serve.

Furthermore, EQ has also been shown to be an effective predictor of resilience amongst HCWs in the face of environmental stressors. The coping strategies that emotional competencies provide to HCWs serve as internal personal resources to fight against the threat of burnout.

One specific example of an EQ competency that helps protect against burnout is empathy. Counterintuitively, the skill of empathy has a profoundly positive effect on reducing burnout.

Burnout protection with empathy

In a study looking at burnout in staff at a mental health institution, it was found that empathy, far from contributing to burnout, actually protected HCWs from it. The more empathetic a HCW was, the lower the levels of burnout they experienced.¹⁸ * High empathy results in lower levels of burnout, greater job satisfaction and better relationships with patients.¹⁹

There is no shortage of academic literature on the positive effect of empathy in reducing burnout in HCWs (nurses in particular).

Burnout from poor well-being impacts patient outcomes

The link between high well-being in HCWs and desirable patient outcomes is clear.²² However, what is becoming ever clearer is the relationship between EQ levels and well-being.

HCWs without EQ carry the consequences of those deficient emotional competencies in the form of lower psychological well-being and deteriorating mental health. This in turn has deleterious effects on the quality of care these HCWs are able to give to their patients. Emotional exhaustion from job stressors (without the help of the internal emotional resources) manifests in poor job performance and a lower quality of patient care. Furthermore, this lack of EQ in HCWs results in conflict between colleagues and patients.^19,23 The price of burnout and reduced psychological well-being, therefore, is not only paid by the HCWs themselves, but by their colleagues and also the ultimate beneficiaries of the system – the patients themselves. This reality is observed widely.^19,24,25

It is no wonder then that numerous studies conclude that health systems must urgently and seriously consider training and development solutions for HCWs, to develop the competencies associated with EQ.^{12,13,17,19, 20, 26, 27}
The reason for these recommendations is not simply from a moral sense of organisational obligation – that employers should care for their staff – but for a far more tangible reason. As a result of reclassification of burnout in recent years, burnout has ‘institutional responsibility’ written all over it.

Burnout: an institutional responsibility

In 2019, in the 11th revised edition of the WHO International Classification of Diseases publication,²⁸ burnout was defined as an occupational phenomenon. ”Burnout refers specifically to phenomena in the occupational context and should not be applied to describe experiences in other areas of life.” ^{29 (par 4)}

The WHO does not define burnout as a disease or a medical condition.

This has strong implications for health systems and the leaders responsible within them. It calls for executives to be proactive in strategies to protect and promote the well-being of their staff.²¹ Being proactive means getting ahead of the problem – equipping HCWs with the skills required to navigate the challenges they will face in the sector.

In a systematic review of the connection between EQ and mindfulness practises the authors go so far as to say that, “EQ has been identified as a predictor of professional success” and they add, “The ability to manage emotions is a fundamental skill that should be developed by healthcare professionals as their work environment often entails a significant emotional burden.” ^{19 (p 2)} Sending HCWs into the field, without these fundamental skills and internal resources to handle the dynamics of the job (in an industry with twice the risk of burnout) is similar to sending them into a COVID-19 ward with no PPE; the individual HCW cannot be blamed when they suffer. The responsibility lies with the health systems themselves, and the leaders who serve in them. But what can institutions do to mitigate these burnout risks for their staff?

Strategies to equip HCWs with the competencies required to handle the dynamics of a career in healthcare cannot be left to the medical education system alone, they must form an integral part of the executive strategy for continuous professional development in health systems themselves.

We will return to the question of developing EQ competencies later in the paper, for now, we will continue exploring the impact of EQ in different dynamics of the healthcare sector. The next area of interest is leadership.

Leadership and EQ

The quality of leadership has an impact on all levels within an organisation. There is evidence for this across multiple sectors of the economy, and healthcare is by no means an exception.

When healthcare leaders are abusive it has a detrimental impact on the psychological well-being of HCWs, and increases their intention to quit. However, when leaders empower and equip those who report to them the benefits are felt across health systems, ultimately impacting on patient care and outcomes.³⁰

In a hospital environment, transformational leadership* has been shown to increase staff satisfaction and well-being, as well as decrease the overall stress and burnout levels among staff nurses.³⁰

But what does a transformational leader look like in healthcare? In short, it is a leader with high EQ that can unlock and draw out the best from those who report to them..

Leadership and EQ in healthcare

When individual HCWs can deliver service from a safe team where they can work effectively together and support each other, patient care improves.¹ The role of leadership in being able to shape and empower effective teams cannot be ignored. Emotionally intelligent leaders influence positively, and abusive leaders impact negatively.²⁷

In healthcare, high EQ in leaders results in better employee retention and higher quality of patient care and outcomes.¹⁹ This is illustrated in the findings from a study on leadership humility in a hospital setting.

Researchers, interested in understanding the relationship between burnout and the impact of leadership, explored the connection with two other variables, 1) employee engagement and 2) employee subjective well-being. Over 300 hospital employees were surveyed and it was found that the humility of the leader had a direct influence on the engagement and well-being of their followers.²¹

Drawing from Owens’ and Hekman’s Humble Leadership Framework,³¹ the authors of this study defined a humble leader as being one who:

The researchers concluded that humility in a leader is a crucial influencer of positive employee outcomes in hospital staff. Humble leaders energise and motivate their teams, while also providing them with resources to face difficult or uncertain situations, like occupational stressors that lead to burnout. When facing these situations HCWs with humble leaders recover more successfully and feel more supported. The psychological well-being of the staff also increases, decreasing their risk of burnout in the first place.

Furthermore, the results of humble leadership had a direct positive influence on employee engagement, with an explainable variance of 6.2%. In this study, a negative burnout variance of 4.4% was also observed from the impact of humble leaders on worker engagement, and a negative 4.9% of burnout variance is explained by the mitigating effect of humble leadership on an employee’s subjective well-being.

What do these results mean for us in our exploration of the impact of EQ in healthcare leaders? By all definitions of EQ (and the specific wording of survey questions in this study), this kind of humility in leadership is impossible without high levels of emotional maturity and EQ in the leaders themselves. To state it plainly, a humble leader, by Owens’ and Heckman’s definition, will necessarily have high levels of EQ. The two are tantamount to the same thing. Ultimately, in a pragmatic sense, leaders in the healthcare sector who exhibit EQ traits support their teams by bolstering their well-being and engagement at work, equipping team members with social resources to fight against the stressors of burnout.

There are multiple ways in which leaders with high EQ positively impact staff. One such example is a reduction in an important factor for staff retention, a nurse’s ‘intention to quit’.

Leadership impact on staff turnover

EQ in nursing managers has been found to have a positive impact on the frontline nurses themselves, and their retention within the system.

During the COVID-19 pandemic, a study was done with 921 HCWs in Quebec, Canada. Researchers examined the effects of work conditions and abusive leadership and how these factors impacted the psychological well-being of HCWs in a health system – specifically how their affected well-being influenced their intention to quit.²⁷

In summary, they assert that psychological well-being in HCWs is the fulcrum for the relationship between work conditions and staff intention to quit, but, importantly, the leadership dynamics play a key role in that employee well-being. When leaders are abusive, psychological well-being reduces, and turnover increases.

The researchers conclude with recommendations that hospitals put leadership development programmes in place to prevent the adoption of abusive leadership styles that will lead to increased turnover.

Ever since Daniel Goleman asserted that emotional competencies form up to 85% of leadership capability,³² it has long been accepted in the wider literature. In a study, looking at healthcare leadership competencies, researchers verified findings close to 60%. A correlational analysis of the data suggested a positive relationship between EQ competencies and leadership effectiveness. For each unit of increase in EQ, there was a 0.6 increase in overall healthcare leadership competence.³³

However, it is not merely emotional competency in leaders that affects nurse intention to quit or stay. The EQ of the nurses themselves plays a role. When nurses exhibit EQ traits it increases their intention to stay. This effect is amplified when the leaders share those competencies.

If this is true for planting trees, it is just as true for developing emotional competencies. Neither trees nor EQ will grow quickly, they both take time and intention.

With the projected global nursing shortage reaching 13 million nurses by 2030,⁵ it is imperative to mitigate or minimise the factors leading to nursing turnover and their exodus from the sector. It would have been most beneficial to develop EQ competencies in nurses and nurse leaders before the pandemic, the next best time is now. If healthcare can accomplish this mammoth task, the sector will begin to see a reduction in nurses leaving the field.

Furthermore, by retaining nurses, and increasing their EQ, hospitals and health systems will begin to see positive results in line with the ultimate goal of the healthcare system, patient outcomes, to which we will now turn.

High EQ in HCWs improves patient care and outcomes

In the UK, an integrative literature review included 22 studies between 1995 and 2017.* The authors explored the relationship between EQ in HCWs and caring behaviours.³⁴

There is also a clear connection between communication skills and EQ. Another study, comparing EQ levels in HCWs with subjective patient perspectives on their communication with those HCWs, surveyed 5 patients for each of the 108 HCWs who participated in the study.³⁵ The authors identified that HCWs with higher EQ levels, received better feedback scores from the patients surveyed. Furthermore, higher EQ also led to improved health outcomes.

In another study, more than 70% of the variance in the quality of communication was explained by EQ.³⁶

The implication is clear: by increasing the emotional competencies of HCWs, communication improves. With better communication, patient satisfaction improves, as well as patient care and safety.³⁷

When we look at this dynamic from the opposite angle, an interesting reality begins to emerge. A virtuous cycle created when patient safety improves. Increased patient safety impacts the culture of an organisation, which goes on to positively affect staff in terms of individual HCW well-being, which, as we have seen, has a direct influence on reducing burnout and turnover. Cultures of patient safety become powerful tools for a health system to reach its goals.

Cultures of patient safety become organisational tools for staff well-being

When organisations have a culture of patient safety it has a correlative effect on the well-being of the HCWs themselves, measured in terms of burnout levels.²²

A large cross-disciplinary study with 3232 HCWs in a Taiwanese healthcare system found that patient-safety culture was negatively related to staff burnout.* As patient safety cultures decreased, HCW burnout increased. The authors concluded that when a health system has a culture of patient safety it serves as an organisation-wide resource for better outcomes, amongst HCWs and teams.

One way to do this is to invest in the development of emotional competencies, triggering an upward spiral of improved well-being and patient safety.

With the precedent of a patient safety culture as an institution-wide resource, we will turn to exploring the wider implications of organisational culture as a resource to improve staff well-being and patient outcomes.

Cultures of trust improve patient safety

In an intervention to develop resiliency and well-being in a British hospital, 72 HCWs participated in an 8-week programme that combined self-led mindfulness techniques, and work-led lectures and interviews.²⁶ While the trial size was relatively small, the programme was intensive and the impact on work relationships and culture was significant.

The intervention resulted in a safer and more trusting environment for collaboration and working effectively together, yielding positive changes in day-to-day behaviour and social support within the HCW staff. Participants spoke of the results of the intervention, using phrases like, “We became more than colleagues.” The findings were published in the International Journal of Nursing Studies, and the article came with a strong recommendation from the authors that organisations must solve for the difficulty of running these kinds of interventions in the sector, where the operational contexts create difficulties to carve out the time necessary to run an intervention at scale.* The recommendation highlights a challenge that the sector faces – the feasibility and sustainability of EQ development using traditional approaches and methodologies.

Summary:
Literature review part one

We have surveyed the literature pertaining to the assessment of EQ levels in HCWs, the impact it has on numerous factors of concern. Two central themes have emerged:

1) Higher levels of EQ in HCWs and leaders impacts positively on all factors we have explored.
And,
2) Many of the researchers, following analysis of their data, make recommendations to run interventions that support HCWs and develop their EQ competencies. Doing so, they suggest, will provide internal resources to HCWs to better cope with the demanding dynamics of a career in healthcare. Furthermore, these interventions will improve the outcomes that healthcare systems need to address.

However, having high EQ, and being able to develop the EQ of HCWs are two different things. We will now turn to look to the literature around EQ development interventions, and their success in the sector.

Different development strategies and tools have been used in healthcare to build the competencies that will empower HCWs to thrive in the sector. Other strategies have been employed to support them in the stress and pressures of the environment. This section explores the research around these development and support interventions.

EQ-specific development interventions

While traditional EQ development programmes have proven effective, they are rare in healthcare. Not only is there a paucity of literature showcasing effective sector-specific EQ development interventions, where they do exist the trials usually include small sample sizes, as is seen in the study mentioned above.

In another small study, researchers in Israel monitored the improvement in EQ from training HCWs in a paediatric ward.³⁹ The trial group included 17 Physicians and 10 nurses who underwent an 18-month intervention. There was a significant increase in EQ levels across the group, ranging from roughly 4 to 6%.* Downstream impacts on patient satisfaction scores regarding the care of these physicians in the programme rose from a baseline of 4.4 to 4.7 after the intervention (p=0.03).

Although studies around EQ development with HCWs that have larger sample sizes can be found,* there is a reason that most EQ development interventions with more significant sample sizes in healthcare are usually run at a tertiary education level, with medical students. The operational dynamics in an education context are more favourable for traditional EQ development pedagogies. It is more feasible to create time and exposure by incorporating an EQ development programme into the educational structure of the medical training itself. By doing so, researchers have been more easily able to explore the impact of both EQ-specific and more generalised EQ-related interventions. In the next section we will turn to explore some of these EQ-related interventions.

EQ-related development interventions in healthcare

Beyond the EQ-specific development programmes mentioned above, other trials exist that aim to improve EQ-related skills like resilience and mindfulness. These interventions use EQ-related development practises to improve these skills. The effectiveness of these general interventions related to EQ yield similar results in reducing negative emotion, stress, and burnout.

Mindfulness-based interventions

Researchers in Norway ran a 6-year randomised control study looking at the longitudinal impact of a 7-week mindfulness training programme that was facilitated with a group of 288 medical and psychology students.^{41 †}
By first helping students to form mindfulness practises, the study focussed on how these practises led to adaptive coping mechanisms the students had access to, in the face of stress. These adaptive coping mechanisms in turn led to improved well-being.

The training ran for 7 weeks with an 1.5 hour session once a week, and a recommended 20–30 min of home-based mindfulness practice between sessions. The curriculum included teaching and experiential techniques focussed on self-acceptance, acceptance of thoughts and feelings, and exercises including phrases like “I am not my thoughts.” These and other techniques align with current models in psychology such as Acceptance and Commitment Therapy, and result in the strengthening of specific EQ competencies.

After the 7 weeks, participants underwent one full day of mindfulness practice. Over the next 6 years there were voluntary boosters the candidates could attend every 6 months.* At the end of the 6 year period, those who received the original training showed significant increase in well-being, as well as the prominent use of adaptive (problem-focussed) coping strategies, and a decrease in maladaptive (avoidance-focussed) coping strategies.

The results of a study like this illustrate the long-term benefit of training that helps individuals to build specific emotional skills that will be invaluable to achieve well-being in both their personal lives and at work. However, the time commitment in the 7 week intervention, using traditional pedagogies, is clearly not something that most healthcare institutions can easily fit into their operational structures and schedules.

Other mindfulness-based interventions have yielded similar results, as can be seen in meta-analyses on the subject.

Another form of EQ-related interventions that have yielded positive results in healthcare are resilience-based interventions.

Resilience interventions

A team of researchers did a systematic review looking at the effectiveness of interventions aimed at increasing resilience in HCWs.⁴⁴ They found that the majority of such interventions were successful. Their conclusions identified that resilience training among health professionals was an effective way to address stress in the workplace and reduce burnout. However, a crucial finding in their review was that the differentiating factors in intervention-effectiveness were duration and exposure. It is precisely these challenges of duration and exposure that make the traditional EQ interventions difficult to roll out in the healthcare sector.

Despite the difficulties, HCWs still require support to navigate the difficulties of a job in healthcare. As a result of the clear and present need to support their staff, particularly during the pandemic, many hospitals began to explore how they could care for their frontline staff in acute ways. For some this took the form of offering short reprieves while on shift, in the form of restorative breaks.

The significance of this recommendation is the direction it can provide in the search for appropriate EQ development pedagogies and tools – where long periods of time are impractical for training.

Combining short breaks and EQ development

Taken together – the proven power of EQ development in healthcare, along with the restorative benefit of short breaks or micro interventions – these two realities can be combined into effective new technology-based development tools to pioneer new ways of meeting both the acute and chronic needs that HCWs and health systems face. By using technology to create decentralised and asynchronous EQ development tools, HCWs are able to achieve both immediate relief as well as long-term development of the much needed EQ competencies that will sustain them in their work. Effective technology-based interventions are drip-fed in a way that enables self-led development by HCWs. EQ development interventions that use these tools can meet both the acute needs for support on the frontline, leveraging the power of short breaks to deliver “non-work activities”, to use the words of Nejati et al., in the review mentioned in the previous section.

Furthermore these tools offer HCWs a mechanism for maximum exposure to chronic development practises. By using technology to facilitate the practice of EQ techniques over time, HCWs can unlock the benefits of EQ long-term. It is these EQ techniques and practices, repeated in a sustainable way, that increases exposure (in bite-sized sessions) and enables HCWs to develop emotional competencies over time.

The success of this combination is shown in a study done at a private hospital in Brazil.⁴⁸ A total of 250 female employees underwent an 8 week trial using a mobile well-being app. The process included 4 classes per week that were made up of a brief theoretical portion and a 15-min guided practice. Periodic assessments measured the impact of the intervention. A control group of 240 employees underwent 4 assessments per week, to self-observe how they were feeling, but did no theory or guided exercises.

The process was rolled out completely digitally without any human interaction.

The study concluded that both the control group and the intervention group increased in general well-being, but only the intervention group increased in work-related well-being as well as a significant reduction in work-related and general stress.

Another study of a similar sort, using a short daily session on a mindfulness app, yielded comparable results.⁴⁹
The research on new technology tools and short self-led interventions paint a compelling picture for healthcare executives wishing to find ways to support their staff, and to do so sustainably and at scale.

Summary of key findings

The research literature surveyed in this paper shows that EQ is an important factor in healthcare outcomes – from individual HCWs on the frontline, to the leaders responsible for their contribution. Improved outcomes include higher levels of HCW well-being; strengthened cultures of collaboration and trust; improved communication; increased patient safety; as well as improved quality in clinical decision-making. Higher EQ also results in lower levels of HCW burnout; a decrease in nurse intention to quit, resulting in lower levels of staff turnover and fewer nurses leaving the industry. Furthermore, as a result of these changes, patient satisfaction and the improvement of health outcome is undisputed. Finally, the downstream financial impact from higher EQ is undeniable.

Measuring the importance of EQ with related outcomes is the important starting point, but developing it is the next step. So far this paper has explored a number of realities around EQ-specific and EQ-related development programmes. Interventions are effective in improving EQ in the sector. However, traditional EQ development methodologies have always been a challenge in healthcare. Synchronous face-to-face training requires time and space. This is costly and operationally impractical. As a result of these sector challenges, most studies done on the effectiveness of EQ training, while shown to be effective, are done with small sample sizes.

In spite of the challenges, the dire need for support remains – HCWs are strained to breaking and health systems need to find effective ways of supporting them. To that end, some hospitals have used measures such as short restorative breaks, and other tools, to acutely meet the need of reducing stress and burnout. These have been shown to be effective.

Tangential to the trend of short restorative breaks, new development pedagogies that rely on technology to deliver asynchronous, HCW-led, personal development, have also been shown to deliver value in a more scalable way. By combining the restorative power of short breaks, with the power of digital interventions at scale, there is new hope for methodologies that can offer system-wide intervention to yield meaningful change.

Towards new EQ tools for HCWs and health systems

As we have seen, the evidence is clear that EQ plays a critically vital role in the healthcare ecosystem. The plethora of social science research, both qualitative and quantitative, of which this paper only scratches the surface, illustrates the positive impact that developing EQ competencies can have in multiple domains and fields of healthcare.

Ultimately, the beneficial results of more EQ in the system will be passed on to the recipients of healthcare services, the patients themselves, via increased psychological well-being in the HCWs who care for them. However, new development pedagogies and training delivery tools must cater to the operational dynamics at play in health systems.

As we near the end of this paper, we will return to the two analogies offered at the start:

1) Healthcare requires a treatment plan to bring healing to the system itself, and

2) This treatment plan must come in the form of a system-wide solution, in the chemistry sense of the term.

If the researched benefits of EQ for HCWs and health systems is to be believed, then a solution to the healthcare crisis can be found within the health systems themselves – if those systems can be transformed into their own solutions with the necessary internal properties that will empower the agents to respond effectively to the factors that cause stress and strain within the system. Accomplishing this organisation-wide solution is the treatment plan that will be necessary to regain health and avert disaster in the sector.

As previously mentioned with the example of a saline solution, once the salt has been added to fresh water the properties of the water itself have changed, yielding different results when interacting with the environment it is in.

The changes are as follows:

1) Saltwater boils at a higher temperature, however,

2) Saltwater also reaches this higher boiling point more efficiently because it does so faster, requiring less energy to heat it to boiling point than fresh water does.

3) Saltwater also has a lower freezing point, maintaining its liquid form for longer, and at lower temperatures.

4) The buoyancy of a saline solution is different from freshwater as well, enabling it to interact differently with objects that are placed into it.

The challenge that executives face, therefore, is how to find appropriate EQ development strategies that are able to impact the systems at scale. Not to put too fine a point on it, but they need to find the right EQ ingredients that are able to effectively dissolve throughout the whole system. As we have seen in the research, this will be impossible to accomplish at scale with traditional EQ training approaches.

Face-to-face interventions, while effective, are costly and impractical. The time commitment alone makes them prohibitive, not to mention the exorbitant financial costs they incur to roll them out beyond the highest levels of leadership. In short, synchronous, face-to-face interventions are impractical, difficult to run, and financially prohibitive.²⁶

An appropriate approach, or treatment plan, must be found that impacts the system, within the parameters of the system, to change the properties of the system, throughout the system.

Appropriate use of EQ development digital technologies is one way to achieve this.

When people speak about EQ development I don’t think they are fully aware of the depth of growth opportunities that it unlocks.

My name is Lynette, I am a nursing manager and I oversee +200 nurses at a private hospital in South Africa.

In my experience with Mygrow, increasing EQ has enabled me to develop myself in a number of areas. I have appreciated the opportunity to understand my own perceptions of self, and then to compare those to how I am viewed by colleagues or subordinates.

The daily Mygrow droplets are short and powerful. They are fun and relatable, and easy to access via either a cell phone or a computer – thus ensuring accessibility. I have found that spending just 10 minutes a day focusing on myself is really powerful.

During COVID-19 so much time was spent coping with the pressures of caring for others that little or no time was spent caring for myself. The far-reaching effect was that we/staff focused on the negativity of the situation that we lost sight of living a life of gratitude and mindfulness. Burnout, absenteeism, fatigue and mental health issues became the order of the day for us in our hospital.

I recently conducted an exercise with the nurses at my hospital (using the principles that I have learned, and the skills I have developed from Mygrow). Through that exercise, we have managed to change staff attitudes about caring for ourselves, and for each other in simple ways, on a daily basis.

The spin-off of driving this initiative was an improvement in patient experience as indicated through patient discharge surveys. Secondly, we found that there has been a decrease in staff absenteeism and an improvement in overall staff well-being. I think it is true to say that the staff are happier. And they haven’t even done Mygrow yet! (This has just been from my own growth in the process, and how it is helping me lead better).

We are currently exploring how we can provide all our staff with the opportunity to use this app, starting with our unit managers, in order to sustain what I have initiated based on my learnings.

I fully believe that if we invest in developing our staff with the abilities that Mygrow helps to develop, they will provide skills to improve resilience and coping strategies that will enhance the mental strength and EQ of our nurses, enabling them to care for themselves and for others in a healthy manner. The Mygrow app provides such an opportunity.

For more information about Mygrow, please reach out to [email protected] or book a meeting directly.