Index de Enfermeria

Revista INDEX DE ENFERMERIA (Edici�n digital) ISSN:1699-5988 v24n4 9899e

INSTRUMENTS

Acting techniques and emotional intelligence of healthcare professionals. Transformational learning

Esther Solsona de la Serna,^1,2 Jordi Pujol,³ Salvador Llistar,⁴ Elena Barbera,¹ Nuria Giménez^5-7
¹Universitat Oberta de Catalunya (UOC). ²Estudio Nancy Tuñón/Jordi Oliver para la Formación del Actor. ³Corporación Fisiogestión, Servicio de Rehabilitación Domiciliaria, Punterapèutic Centre de Fisioteràpia, Escola Universitària Gimbernat, Universitat Autònoma de Barcelona. ⁴Fundació Vallparadís y Fundació l'Espluga, Fundación para la investigación MútuaTerrassa, Universitat de Barcelona. ⁵Unidad de Investigación, Fundación para la investigación MútuaTerrassa, Universitat de Barcelona. ⁶Grupo de comunicación de la Sociedad Catalana de Medicina de Familia (CAMFiC). ⁷Laboratorio de Toxicología, Universitat Autònoma de Barcelona, Catalunya

Manuscript received by 16.7.2014
Manuscript accepted by 28.8.2014

Index de Enfermería [Index Enferm] 2015; 24(4): 240-244

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Abstract

The task of the healthcare professionals is a combination of science and art, knowledge and technical resources coupled with emotional intelligence. Aim: To know, through acting training techniques that enhance the development of emotional intelligence, the opinion of the professionals working in healthcare centers and their reflections on their experience. Methods: From 2008 to 2013, a multidisciplinary team conducted fifteen editions of a training course on how to recognize and manage one's emotions. The experience was assessed using mixed methods: qualitative (reflexive essays) and quantitative methods (satisfaction questionnaire, 1-to-10 scale). Results: A total of 231 professionals participated: 26% were nurses, 6% physicians, and 68% auxiliary nurses. The reflexive essays of the participants reflected their satisfaction and their perception of having re-discovered resources and natural abilities to promote communication and professional and personal growth. The average rating for satisfaction was 9.75 points. Conclusions: The training was perceived as effective. The participants were enthusiastic towards the experience that combined a environment to express their emotions appropriately together with guided acting training techniques.
Key-words: Communication/ Emotional intelligence/ Empathy/ Professional competence/ Health personnel/ Nurses.

Introduction

    The main purpose of health and social centers, regardless of their level of care and the professionals who work in them, is to care, support and improve the health of the population, providing the best health care resources available. To achieve this goal, health professionals, not only use their knowledge and clinical skills, but also all their professional skills, including ethical values, experience and a wide range of abilities related to emotional intelligence, such as empathy and communication skills. It is accepted that quality health care includes science and art simultaneously¹ and therefore requires an appropriate combination of scientific knowledge, technical means, creative and communicative skills of their professionals.² In fact, the many benefits of good communication with patients are well known,^3,4 but mastering these skills and dedicating the required time on a daily basis still entails a challenge.⁵
    In general, professionals value positively the opportunity to be trained, and courses related to the development of communication skills are often among the most requested.⁶ Training opportunities to meet this kind of demand are varied and include various teaching methods,⁷ including particularly artistic disciplines. These educational experiences characteristically deviate from the theoretical realm of classical training and build knowledge through personal experience.^1,8,9 This type of training, still pioneer in our country, is best known in the English-speaking world, especially when it is part of the theory of transformational learning and includes theatrical techniques with actors/teachers.¹⁰ Education focused on transformational learning involves people acting out a fact or a problem experienced which they evaluate critically. The teacher's role is to promote critical thinking, pose challenges, promote autonomous decision-making and encourage reflection on practice. It aims to lead the learner towards actively interpreting and giving meaning to their experience, the strategies used to address the situation and to integrate this new interpretation to their cognitive system transforming their own practice.¹¹
    This article aims to describe an educational intervention designed to strengthen and unite the skills related to emotional intelligence, as well as to collect the reflections, opinions and satisfaction of participating professionals.

Methodology

    Between 2008 and 2013, a multidisciplinary team designed and delivered fifteen editions of a course based on a transformational educational approach using acting training methodology. In each issue, between 12 and 18 people received 24 hours training (four sessions of six hours, once a week).
    A mixed design was used to evaluate the perception and satisfaction of participants using qualitative and quantitative methodology. Qualitative data were obtained by requesting a written reflection on their personal learning experience. Quantitative data were obtained from the standard questionnaire used in MútuaTerrassa to assess the opinion and overall satisfaction with the training. Confidentiality was guaranteed.
    This transversal and voluntary training was addressed to the 706 professionals of MútuaTerrassa of the twenty socio-healthcare centers (including, besides pure socio-healthcare, geriatric care centers, mental health and care for the intellectually disabled). All in all, they serve a dependent population of 1,295 people in three provinces and twelve locations: Barcelona (L'Ametlla del Vallès, Badalona, Barcelona city, El Prat de Llobregat, Sant Cugat del Vallès, Sant Feliu de Llobregat, Sant Just Desvern, Sabadell and Terrassa), Girona (Tossa de Mar) and Tarragona (Cambrils, Mora la Nova).
    The course was based on 16 exercises that focused on the experience and guided reflection in intrapersonal areas (self-knowledge) and interpersonal (relations) (Table 1). The exercises impelled participants to use their emotional intelligence, understood as the ability to recognize their own and other people's emotions and the ability to channel them properly. Intrapersonal intelligence emerges from managing skills of self-awareness (ability to know what we are feeling), emotional regulation and its externalization, as well as the ability to motivate oneself and others. Likewise, interpersonal intelligence is held in empathy ("mental and emotional ability to identify with another's feeling", as defined by the Royal Spanish Academy)¹² and social skills.
    All exercises resorted to the kinetic experience to familiarize participants with the body potential as a transmitter of information. Occasionally, participants were deprived of sight and speech to raise awareness of other personal resources, such as intense listening, information acquired through touch and communication by the emission of non-verbal sounds (resources often used by the users of the socio-healthcare centers to express their needs). Other exercises addressed the information conveyed and received by a simple look.
    Speech was used to build awareness in the shared reflection with the group guided by teachers (feedback). Exercises should be taken into consideration as being significant as a personal experience, but only got their real value as a "tool" (Table 2) to be discussed and analyzed in this context (Table 3).
    Similarly, drama techniques (role play of 4-6 people) set in health care situations were also used. Participants-actors role-played two versions of the event: the real one and the desired one.

Table 1
Table 1. Emotional Intelligence: Intrapersonal and interpersonal skills
covered in class
Table 2
Table 2. Seven tools for stress management
Table 3
Table 3. Course objectives

    The effectiveness of the exercises depended on the ability of spontaneous response of the participants. The "wow factor" was considered as an essential element of learning, so confidentiality was requested. Moreover, in performing the exercises, they were given only the essential guidelines, so that each participant had to explore in situ its own resources to develop the proposed activities.
    For the analysis of reflective essays of participants on their perception of the experience, qualitative methodology was used, as this enables researchers to work with the hypothesis that "nothing is trivial and everything has the potential to be a clue that could reveal a greater understanding of the subject matter".¹³ Two researchers independently reviewed the writings, codified the main ideas and organized them by category. Subsequently, all authors participated in reorganizing the topics and developing the narrative summary and tables where the best comments of the participants were reproduced.
    Regarding the statistical tests used, the reliability of the questionnaire was assessed by Cronbach ? and descriptive statistics. The qualitative variables were expressed as n and percentages and quantitative variables as mean. SPSS version 17.0 was used. (SPSS Inc., Chicago, IL, USA).
    This study was approved by MútuaTerrassa Ethics Committee for Clinical Research.

Results

     A total of 33% of professionals working in health and social centers in MútuaTerrassa (n = 231) participated in the study: 94% were women (n = 217) with a mean age of 38 years. By professional category, 26% were registered nurses or other related postgraduate studies (n = 60), 6% consultants and other graduates (n = 15), and 68% nursing and clinical assistants, monitors, social workers, and administrative staff (n = 156).
    The perception of the participants on the training received was assessed by analyzing their reflective essays, which expressed satisfaction and perception of rediscovering natural resources and skills that promote effective communication and professional and personal development. The reflections were grouped into two groups: "Self-knowledge" and "empathic and communication skills in professional practice" (Table 4).
    The writings highlighted the positive assessment on ethical issues involved in the relationship between patients and professionals. Subjectively, the participants expressed greater compassion and attention to the needs of the patients. This was achieved by integrating their personal and professional skills, enabling them to interact without being protected behind attitudes that distance themselves from the emotional experience of the people they serve. Among the skills that most strongly became part of their conscious resources, further to transformational learning, they mentioned active listening and non-verbal language. They reported how this learning process in integrating their own values and resources, contributed to increase their self esteem and enrich their relationships.
    The professionals expressed satisfaction and gratitude for the opportunity to participate in the experience. They also said they had discovered or deepened skills and resources they already had and now benefited by consciously using them. They also showed satisfaction with the effectiveness of the methods used as shown in their comments ("The course was great; congratulations to the company for supporting it", "It was a dose of optimism"), as well as in the institutional questionnaire. In this questionnaire, the participants rated the overall satisfaction, on average, with 9.8 points (Table 5). The Cronbach a coefficient was 0.854.
    Subsequently, directors of healthcare centers highlighted the increased team cohesion among professionals who had received this training even when they participated in different editions. Hence, they proposed new courses to delve deeper into this line of work.

Table 4

Table 4. Participants reflections

Table 5

Table 5. Results of the standard satisfaction questionnaire on the course given. Scale 1-10

Discussion

    This study shows the satisfaction of healthcare professionals to explore their emotional intelligence skills through creative activities that allow them to connect with their emotions and express them appropriately in the context of a safe setting. Theatrical interpretation techniques were the training tools for emotional education of healthcare professionals and to enhance their awareness of professional ethics. "Invisible" skills enhanced during the course have a positive impact on patients and professionals, though its worth is not always recognized.¹⁴
    It should be noted that strictly speaking, most of the exercises were not specifically theatrical as they missed the essential element defining the scenic fact: the audience. The learning process was based upon two main cornerstones: personal experience taking place during exercise (provided both as impulses and conditioned learning); and further reflection (focused on the analysis of the decisions taken during the experience). This verbal reflection, which was shared by all participants, was guided by teachers, influenced by group dynamics and the relationships established during the exercise performed. Thus, through a transformational teaching methodology focused on practice and reflection, the training aimed at working on resources that facilitated the awareness of one's own emotions to manage them as key opportunity; as well as to communicate effectively both verbally and nonverbally, assertively express themselves and building self-esteem.
    In the context of professionals working in socio-healthcare centers, which serve mainly elderly patients with chronic diseases and disabilities, it is possible that a daily challenge consists in keeping an adequate and balanced emotional involvement to provide quality care. Knowing their own emotional intelligence skills such as self-awareness, social awareness and empathy facilitate this task. Self-consciousness allows to address the intense emotions that sometimes seize patients (fear, sadness and others) and can vent (sometimes with anger) on the professionals who serve them. Knowing how to manage one's emotions enables the professional to channel these situations. Social awareness contributes to active and reflective listening as well as interpreting nonverbal communication. Likewise, empathy enables professionals to perceive the patient's feelings, recognize and validate them, facilitating a relationship based on trust, which can therefore improve the therapeutic effectiveness.¹⁵ It is important in this sense to be aware that this ability is not exempt from the possibility of being misunderstood and associated with excessive emotional implications and unwanted effects.^3,16 In addition, the perception of empathy is variable and can be evaluated differently by patients and healthcare professionals.^17,18 Taking care of these aspects, together with the validation of emotions, improves patient cooperation and general attention.^3,19
    Another benefit of the course was a greater feeling of team cohesion among those professionals involved. Professionals often evaluated positively the opportunity to establish social relationships with peers, being it a known factor that contributes to professionals' satisfaction.²⁰ The collaboration of participants was also highlighted, who aware of the strategic nature of the "wow factor" for the proper development of the course, respected the request for confidentiality and did not transmit information to colleagues who participated in later editions.
    Among the limitations of this study, we noted that after reviewing the measuring instruments mostly used, as the Jefferson scale of empathy or the interpersonal reactivity index, among others, none of the questionnaires completely met our goals. So qualitative methodology was chosen for this first approach to the experience of professionals, albeit with a mixed qualitative and quantitative design when systematically collected.
    Moreover, since the point of view of the experience of communication differs between health professionals and patients,¹⁸ it is interesting to analyze simultaneously if after an intervention of this kind, the perception of beneficial effects of the professionals is also shared by the patients they serve.
    Another well-known aspect is that many healthcare professionals state that, altruist and humanitarian reasons are among the main reasons for choosing their profession as well as their dedication and commitment to people, and that this social vocation is its driving force. However, compassion, even being sincere, not always achieves the goal of helping others, and thus it is currently accepted as possible and beneficial to teach and learn skills of emotional intelligence.^1,2 Nonetheless, this training is still a pending issue, both in undergraduate and graduate curricula, and it is not yet given due prominence as it should given their positive impact on satisfaction and quality of care received by patients.⁸ Occasionally, implementing empathy at work is confronted with difficulties in providing more time to patients and with the need to revise the value system of healthcare.⁴ This misalignment supports the need for a new paradigm to reformulate how society deals with disease, disability and death²¹ and altogether opens far-reaching philosophical reflections that were often also raised by participants in the course.^22,23 By training emotional intelligence skills, however, professionals feel better endowed to deal with these or other adverse conditions and protect the quality of the relationship with the patient.
    In fact we might ask ourselves: why asking professionals to leave their comfort zone and encourage them to break their defenses to become another and feel fragile? Why taking them, for example, to their future as the elderly person (as proposed in one of the exercises of the course) if not for some to discover (or remember) that their most powerful motivation, standing out the daily difficulty is to treat patients as they would like to be treated themselves in the future? The answer to these questions is that by setting participants in the place of the essential vulnerability of human beings, most rediscover their own essential strength. Given the above, professionals were satisfied with the skills learned and consider developing them throughout their career and live them as a real source of motivation and enthusiasm. They also stressed the strong sense of pride and vocation to the chosen profession.
    In short, theatrical interpretation techniques, properly guided, were perceived as effective for transformational learning in emotional intelligence of health professionals by allowing them to connect with their own emotions and appropriately express them in a safe environment. Besides expressing their satisfaction, participants also showed their enthusiasm and interest in this type of training.

Acknowledgements

Our thanks to Patricia Vigués for correcting the English version of abstract and translating the manuscript. We also thank all professionals MútuaTerrassa socio-healthcare centers, and especially Mireia Boté for their collaboration in this study. Finally, we show our gratitude to all patients treated at these centers who we would like, somehow, to have brought some benefit.

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