INTRODUCTION

Nurses are exposed to stress on a daily basis: death situations, understaffing, high patient frequency and even physical or psychological violence⁽¹⁾. All these factors can contribute to the development of acute work-related stress which, over time, could become chronic, a situation that contributes to the development of Burnout syndrome. This situation was exacerbated to a large extent in the nursing profession during the Covid-19 pandemic⁽²⁾.

However, training in emotional intelligence (EI) mitigates stress and consequently improves effectiveness in nursing care⁽³⁾.

Therefore, emotional management helps to reinforce intrapersonal variables such as a positive self-concept ⁽⁴⁾, which is related to social skills. A social skill is “a behaviour or type of thinking that leads to resolving the social situation in an effective way that is acceptable to the subject and to their social context”⁽⁵⁾. The repertoire of social behaviours includes a number of skills such as: communication, empathy, conflict resolution and assertiveness⁽⁵⁾.

With regard to assertiveness, the person must assume a positive self-concept in order to be able to develop positive expectations of him/herself, reinforce his/her self-esteem and thus be able to say what he/she thinks in situations of disagreement or to ask for help when he/she needs it. All these abilities or skills are necessary in nursing practice in order to provide quality care.

Raut and Gupta's study⁽⁶⁾ concludes that personal introspection, such as self-reflection, can help improve EI. Therefore, the inclusion of content on managing emotions through EI will help nursing students in clinical practice to manage emotions appropriately during their training process and to continue in their subsequent professional development.

The overall objective of this study was centred on finding out how nursing students perceive management of their own emotions and how it has developed. This was done by identifying emotional situations in their clinical experience and their relationship with the skills of the nursing profession (empathy, self-concept, communication and procedural skills).

Other specific objectives included:

MATERIAL AND METHODS

RESULTS

Characteristics of the participants

The sample consisted of 85 fourth year nursing students who had rotated through the following departments: 21 students in the Emergency Department, 11 in the Intensive Care Unit (ICU), 27 in Oncology and 26 in Primary Care (PC). There were 79 female participants, with a mean age of 22.87±4.925 years.

Evolution of PEI of nursing students during clinical practice

At all three measurement points, the median values for emotional perception were 28, and for comprehension and regulation 29. All values are considered adequate.

In the non-parametric contrast with the Friedman test, no statistically significant differences were found in the three moments of the three dimensions of IEP: Perception (0.06), comprehension (0.74) and regulation (0.88).

When performing the same analysis in the different clinical contexts, it was found that the comprehension dimension in the Oncology area with a distribution of normal values, the ANOVA statistical test of repeated measures yielded a p-value: 0.048 of the Pillai Trace. Being less than 0.05 and the p-value: 0.738 of Mauchly's test of sphericity greater than 0.05, showing that the differences are statistically significant in the short and long term in the Oncology department.

Also, the Bonferroni test showed that there is a significant difference between the first and third moment (p-value: 0.032).

Figure 1. shows a slight increase in comprehension between the beginning and the end of the study.

Figure 1: Estimated marginal means of Comprehension. Oncology Group. 

Emotional situations and possible skills

Two main categories were identified (presence of skills and absence of skills), each of which includes two subcategories in the case of presence of skills, and three in the case of absence of skills.

Of the two main categories, the most frequent was the variable presence of skills, and the most representative subcategory was “empathy” (45.1%), followed by “self-concept” (24.4%). The variable “lack of skills” was the one least experienced by students, reflected in the subcategories: lack of competence (17.1%); relationship problems with professionals (7.3%); and relationship problems with the patient or family (6.1%) (Figure 2).

Figure 2: Conceptual map. 

Category 1. Presence of skills in nursing practice

Comprises emotional situations that are related to empathy and self-concept skills.

Subcategory 1. Empathy

The most representative skill in the sample was “empathy”, as rated by 37 students and identified in all clinical contexts assessed. Mayer and Salovey⁽¹⁰⁾⁾ argue that empathy includes aspects related to perceiving the emotions of others, as well as understanding them.

In oncology, the student felt sadness when communicating bad news to the patient; a poor prognosis (especially in young people); in the decision-making process of sedation; or when there was no farewell.

In contrast, in PC and in the emergency department, sadness manifested itself when the patient was in a situation of dependency.

With respect to identifying the emotions of others, students expressed sadness or grief, in Emergencies, Oncology and PC, in contrast to one case in ICU, in which the student expressed anguish.

In addition, cognitive empathy, the ability to understand that another is going through a difficult situation, the students put aside their own emotion to focus on helping the patient.

Subcategory 2. Self-concept

The “self-concept” in this study was rated by 20 students, seven of whom were doing their in-service training in oncology.

The concepts related to self-concept were: self-esteem and intrinsic motivation. Self-esteem was manifested in their perceived closeness to the patient; in their ability to work as a team; in their ability to cope with complicated situations in an autonomous manner; intrinsic motivation was found in cooperating in patient care and in their thinking about life in the face of death.

Category 2. Absence of skills in nursing practice

It was observed in problems of communication with professionals, patients, family members and in the lack of competence in complex situations.

Subcategory 1. Communication problems with professionals

This lack of skill was seen in six trainees from ICU and Emergencies, where anxiety was reflected in ICU trainees in tutorials during their evaluation.

Frustration was also observed in ICU and Emergencies when they did not receive the care they felt was appropriate for their learning process, as well as emotions such as anger, helplessness, rage and anxiety.

Subcategory 2. Communication problems with patients and/or family members

In Oncology (five students) a patient’s sadness or crying when receiving bad news created emotions of sadness, grief, helplessness and nervousness in students, which led them to doubt their competences.

In communication with family members, students felt anger, seeing a very demanding and insistent family member, and helplessness towards a family member after the death of a loved one, causing self-blame.

Subcategory 3. Lack of competence

In the emergency room, lack of competence was the most frequent subcategory, and in PC it was second only to empathy. The situations are different in the two contexts. In the case of the emergency department, a lack of competence in life-threatening situations was observed; in the PC department, it was seen in the skill in performing procedures.

PEI and nursing profession skills

Contingency coefficients were analysed in order to find out whether PEI and nursing profession skills had any degree of dependence on one another. In the Perception dimension, the value was 0.325 (p-value=0.275); in Comprehension it was 0.386 (p-value=0.069), indicating a marginally significant association; and in Regulation it was 0.247 (p-value=0.744). A tendency towards an association between emotional comprehension and nursing profession skills can be observed.

The levels of the IEP dimensions in each of the different categories related to emotional situations (nursing skills and lack of nursing skills) were also analysed.

The most frequent skill was empathy, accounting for 45.1% of the group. 29.3% reported adequate perception, 28.0% adequate comprehension and 36.6% adequate regulation.

Self-concept accounted for 23.2% of the group. 15.9% reported adequate perception, 15.9% adequate comprehension and 15.9% adequate regulation (Table 1).

Table 1: Contingency table for PEI and presence of nursing profession skills. 

In the lack of skills of the profession, 18.3% of the group reported a lack of competence. In this group, 8.5% reported adequate perception, 17.1% adequate comprehension and 14.6% adequate regulation.

The relationship with professionals was 7.3%. Of this group, 6.1% reported adequate perception, 3.7% adequate comprehension and 6.1% adequate regulation.

Finally, the lack of skill in the relationship with the patient or family member was 6.1%. In this group, 2.4% reported adequate perception, 4.9% adequate comprehension and 2.4% adequate regulation (Table 2).

Table 2: Table for PEI and absence of nursing profession skills. 

DISCUSSION

Emotional intelligence, according to Mayer and Salovey⁽¹⁰⁾ is a type of intelligence that involves the ability to monitor one's own emotions and those of others. Being able to discriminate between them and to use the information as a guide for thoughts and actions is important in nursing because of its positive effect on the health of the professional⁽³⁾, as well as on the quality of care provided by the nursing profession^(3,11).

This study involved students from the nursing degree programme who were doing their on-service training in emotionally charged departments such as Emergencies, ICU and Oncology, with the aim of finding out how they managed their own emotions. In addition, the PC department was added to detect whether the students presented this emotional burden and, if so, to identify whether there were differences with the previous departments.

There have been studies such as Foster et al.⁽¹²⁾ which have compared the evolution of EI in different nursing courses. As a finding, higher levels of EI were observed in the later years. This may indicate that the normal process of personal maturation of pupils contributes to better management of their emotions.

The aim of this study was to delve more deeply into the last academic year to verify whether there are differences in the PEI in different clinical practice contexts during the training of nursing students.

It was found that the participants presented an average of attention, comprehension and regulation of their emotions that was adequate. These results are in line with those reported in another study with nursing students⁽¹³⁾.

In addition, no differences in PEI dimensions were observed throughout the clinical practices in the total group.

However, when studying the clinical settings separately, the Oncology setting showed that the student's emotional comprehension did improve as time went on, with the most notable improvement at the end of the practice cycle.

The students, having more contact with cancer patients and their families, can experience more closely the difficult and complex situations that are experienced in this department. Establishing a therapeutic relationship and seeking to comprehend another person helps in better understanding one’s own emotions. This context can contribute to the development of students' EI. The finding coincides with the study carried out by Aradilla-Herrero et al.⁽¹⁴⁾although, in contrast to the present study, an increase was found in the emotional comprehension of third-year nursing students compared to previous years. The finding of the current research is that the improvement occurs in oncology students in a time interval corresponding to one cycle of clinical practice.

This study also found situations in clinical practice that have a high emotional impact on students, where it becomes clear if they have acquired professional skills or whether there are aspects to improve owing to a lack of any of them.

Empathy, from the point of view of the Salovey and Mayer model⁽¹⁵⁾, requires proper identification of emotional responses in other people (perception of emotion in others), and also involves attitudes and skills (ability to understand others).

One of the competencies of the nursing profession is to provide emotional support through empathy in situations such as when the patient is in danger or dying. In addition, empathy has a protective role against physical and emotional exhaustion⁽¹⁶⁾, related to EI⁽¹⁷⁾. Therefore, it is considered important to include it in students’ training through strategies for managing feelings.

Empathy is the most frequently occurring skill in all clinical settings, with the exception of the Emergencies group. It manifests itself as follows depending on the area:

The development of empathy does not necessarily amount to adequate management of emotions. Emotional identification is observed more in oncology during the communication of bad news, when implementing a sedation process to a patient and in situations where bereavement is foreseen, where student experienced emotions such as sadness or grief. The same is true for the study by McCloughen et al.⁽¹⁸⁾, where students faced with patients experiencing very intense emotions expressed emotions such as panic, anxiety or frustration, not knowing how to act; emotional comprehension was reflected in all groups, in particular when the professional felt comfortable, helpful⁽¹⁹⁾.

In the present study, a group of students paid little attention to their own emotions by way of denying conflict situations in order not to get involved, for fear of suffering. This group will need to do some work to improve their perception of their emotions, while those who paid too much attention to their emotions increased their anxiety levels. Many situations were related to the process of death. The study by Freitas et al. ⁽²⁰⁾ concludes that the lack of professional training in this process can lead to suffering in this group, thus affecting the quality of care provided to patients and their families.

Empathy leading to satisfaction⁽²¹⁾ is that which was observed in students who felt they helped the patient and/or family. They did a good job of managing their emotions by feeling satisfaction at having helped in a difficult situation by practising empathy.

This study examined another skill, namely the self-concept: “the self as known, on which the person works and which encompasses the ideas, judgements, images and beliefs that the subject has and makes of himself, including the images that others have of him, and even the image that he would like to be”⁽²²⁾.

Self-concept is a cognitive-affective organisation that influences behaviour⁽²³⁾ in this study, students’ own thoughts about being able to approach the patient, to work in a team and to be autonomous. This positive judgement of their own self-concept reinforced their self-esteem⁽²⁴⁾, as they felt pleasant emotions, a situation that helped boost their confidence and self-assurance.

In addition, intrinsic motivation related to the self-concept⁽²⁵⁾ was identified in situations where students collaborated with the rest of the team in patient care like any team member, and in which they reflected upon death, helping them understand that working as a team to achieve the best care for the patient and knowing how to act when the patient is at the end of their life allows them to better understand the profession, and to find meaning in their work at difficult times.

But deficits were also observed in the skills of certain competences, as well as in problems in the relationship with professionals and difficulties in the relationship with the patient or family member. The lack of this competence was found in the Emergency and PC departments. Students experienced fear and anxiety in certain procedures that are common stress factors in nursing students⁽²⁶⁾. When it came to managing their emotions, half of this group responded that they needed to improve their perception of their own emotions.

Another aspect of improvement found by the study was the relationship with professionals in the Emergency and ICU departments, a stress factor in nursing students⁽²⁶), a finding that was also observed here, as in the study by McCloughen et al.⁽¹⁸⁾

All the indicators studied point to the potential development of Burnout Syndrome, as these are specialities where chronic stress is predominant⁽²⁷⁾.

In the ICU and Emergencies, the problem of the relationship between students and professionals was found. It is therefore deemed necessary to better manage these situations with teachers.

It is also considered important to improve the relationship with patients or family members, especially in the Oncology department, owing to the difficulty of caring for patients at the end of their lives⁽²⁸⁾.

Another finding of this study is that a large part of the students expressed their intense emotion in situations related to empathy and self-concept, and in communication with the patient or family, considered a skill to be improved in emotional perception.

In all such situations, the central theme was death and dying, a common theme for health professionals⁽⁴⁾. The proximity of death prompts students to ask themselves how it affects them, and to seek the cause of their feelings, a situation that will help them to reflect on the reality of life, in which death is present. This is a pending task in nursing degree programmes.

In managing their emotions, students often focused on the problem (unpleasant emotion) and not on the search for a solution, since the unpleasant emotion persisted over time.

This study has certain limitations that are important to keep in mind. Firstly, when examining the evolution of PEI during a cycle of training with a group, we are restricted to the time frame of the cycle, which is an inherent limitation. Another limitation relates to the qualitative nature of the research, as only one question was asked. If a semi-structured interview had been conducted, we would have had the opportunity to collect information not only about the situation and the emotions experienced, but also about the strategies used to manage these emotions. In addition, we could have assessed the effectiveness of such strategies. This could have provided valuable tools for use in an EI training programme. It would certainly be fruitful to continue exploring this line of research in the future.

CONCLUSIONS

The most important conclusions are that death is the subject that most affects nursing students, and the most frequently used skill is empathy. If emotional comprehension has a certain tendency to be associated with the skills of the nursing profession, such comprehension will help nurses show more empathy to the sufferer and to know oneself better. Given that self-concept is the basis for working with patients who are at the end of their lives, it would be interesting and important to include EI as a nursing skill in end-of-life care in core subjects of the curricular programme of the nursing degree. And the setting of in-service training in Oncology could be an excellent place to put into practice what has been learned in class.