The Impact of Emotional Intelligence on Essential Aspects of Functioning of Patients with Chronic Kidney Disease
Creators: name: Magdalena, Lech
name: Adrian, Lech
name: Niemczyk Stanisław
name: Lubas Arkadiusz
Publisher: name: Zenodo
Year: 2020
Subjects: emotional intelligence, haemodialysis, quality of life, depression, acceptance of illness

description: <strong>Introduction</strong><br> <br> The term emotional intelligence (EI) denotes the capability of individuals to properly recognize, judge and express emotions. Two models of emotional intelligence are distinguished: the ability model and the mixed model. The first model – scientific – was developed by Salovey and Mayer (1990). It assumes that it is a set of the individual’s abilities to process emotions. The mixed models by Goleman (1997) and by Bar-On (1997) make the term emotional intelligence also include personal traits that are not abilities (Knopp, 2006). Goleman distinguishes five elements of EI: recognizing and monitoring one’s own emotions (self-awareness and self-regulation), motivating, awareness of, and managing other people’s emotions (Goleman, 1997). According to Bar-On, EI includes fifteen components divided into 5 groups:1 – intrapersonal competences, 2 – interpersonal competences, 3 – adaptability, 4 – competences related to coping with stress, 5 – components related to the general mood and sense of happiness (Bar-on, 2001). In 2001, Ciarrochi <em>et al</em>. created a model of the potential impact of emotional intelligence on the life of an individual (Carriochi et al., 2001). It reveals that patients with low levels of EI do not cope well with stress and poorly adapt to a new situation. Currently, there have been many further studies published confirming the relationship between EI and different aspects of human life. Emotional intelligence allows for development of the relations constituting support in difficult situations(Parihar,2015). It also allows to rational judgment, quick crisis resolution and protects against long-term stress. All of that reduce risk of the depression. Emotional intelligence also promotes acceptance of changing environmental conditions(DuPlooy,2017). Disease acceptance and improvement of the emotional condition contribute to mental comfort and improvement of the quality of life. This study aimed to assess the level of emotional intelligence in patients with CKD, its impact on the development of depression, quality of life, and acceptance of illness. <br> <strong>Materials and Methods</strong> <br> Two hundred individuals were invited for participation in the study (84 F, 116 M, 61 ±12 years): 160 patients with CKD, stage G4-G5 from one haemodialysis unit with a nephrology OPD, and 40 healthy persons constituting a control group (Table 1). Depending on the stage of the illness and length of the dialysis treatment, the persons investigated were qualified for five groups of 40 people each: Group 1 – control group, healthy people; Group 2 –patients with CKD in a pre-dialysis period (BD), stage G4-G5; Group 3 –patients haemodialysed (HD) &lt; 1 year; Group 4 - HD 1-5 years and Group 5 - HD &gt;5 years. The inclusion criteria were: the age ≥ 18 years, free consent to participate, diagnosed CKD, stage G4-G5 (Groups 2-5). The rules excluding from the study include uncompensated cardiac insufficiency, severe medical conditions (e.g., fever, pain), no permission for participation in the study. The study obtained the consent of the local Bioethical Committee. All the persons examined were informed about the rules and purpose of the study. They consented to their participation in the study. In the study we used the diagnostic poll method with the use of the following questionnaires:<br> Two-dimension inventory of emotional intelligence (DINEMO) – The questionnaire assesses basic components of emotional intelligence, including OTHERS scale – the ability to recognize, understand and respect emotions of other people, i.e., interpersonal emotional intelligence (IEEI) and SELF scale – the ability to recognize, understand, respect and express one’s own emotions, i.e., intrapersonal emotional intelligence (IAEI) (Matczak et al., 2011). DINEMO consists of 33 items containing descriptions of different situations - the source of emotions. Each of them has four variants of possible answers. Four types of responses are linked to each situation, and the person surveyed chooses this reaction, which he/she considers most typical of him/her. The general score is calculated by summing up the points obtained for 33 questions. The minimum is 0, and maximum - 33 points. Two questions are shared by both scales, so the final score is not a sum of the points obtained from the scales OTHERS and SELF. Reliability measured by Cronbach’s alpha (α) for the SELF scale was between 0.44 and 0.66 for different age groups and for OTHERS scale – from 0.64 to 0.82, and the total score from 0.61 to 0.81. Acceptance of Illness Scale (AIS) – It consists of 8 statements describing the negative consequences of poor health related to limitations caused by the disease. The answers are scored on a 5-step scale where 1 is “I definitely agree”– meaning poor acceptance of illness and 5 – “I definitely disagree” – indicating high acceptance of illness. The score ranges from 8 to 40. A higher score is proof of better acceptance of illness and better adjustment to it. A score above 30 means high or complete acceptance of illness. A score below 20 proves no or low acceptance of illness (Juczynski,2006). Reliability measured by Cronbach’s α equals 0.85. <br> Kidney Disease Quality of Life Short-Form (KDQOL-SF) –It is is a self-report instrument comprised of 36 items of a general health nature as eight scales: physical functioning (10 items), role-physical (four items), pain (two items), generalhealth perception (five items), energy/fatigue (fouritems), social function (two items), role-emotional(three items) and emotional well-being (five items).In addition to these generic items, 43 items specific to kidney disease complete the survey. These make up the 11 scales: symptoms/problems (12 items),effects of kidney disease (eight items), burden ofkidney disease (four items), work status (twoitems), cognitive function (three items), quality ofsocial interaction (three items), sexual function(two items), sleep (four items), social support (twoitems), dialysis staff encouragement (two items)and patient satisfaction (one item). The score ranges from 0 to 100, higher score is proof of better HRQOL. Reliability measured by Cronbach’s α equals 0.70. Beck Depression Inventory (BDI) – serves as an assessment of depression symptoms in adults and adolescents above 13 years of age (Beck et al., 1961). It consists of 21 multiple-choice questions that respondents answer by choosing 1 of 4 possible options. Each response is assigned a value from 0 to 3, which corresponds to depression severity in a given area (among others, mood, interests, appetite, sleep quality). The reliability measured by Cronbach’s α is 0.91. <em>The author-prepared questionnaire </em><em> - It was created for the needs of this study to collect socio-demographic (age, gender, education, professional activity</em>, place of residence, stimulants) and clinical <em>(the time which elapsed from the first dialysis treatment</em>, number of taken medications, comorbidities) data. <br> <em><strong>Statistics</strong></em><br> The PQ Stat 1.6.8 statistical package was used for carrying out statistical analysis. Average values of quantitative and qualitative variables were presented as the mean with standard deviation or the medians with minimum and maximum values. The Mann-Whitney U test was used to check the differences between the two groups. If more than two groups were compared, the Kruskal-Wallis (ANOVA) test with the post-hoc Dunn-Bonferroni test were performed. Interdependencies between the variables assuming continuous values were checked by calculating the Pearson’s correlation coefficient (for variables with normal distributions) or Spearman’s rank correlation coefficient. A multi-factor backward stepwise regression was carried out to assess the independent relationship between EI and selected factors. The value of p&lt; 0.05 was considered statistically significant. <br> <em><strong>Results</strong></em><br> <br> <em> The average IEEI score was higher than that for IAEI (9.92 ±2.88 vs. 5.50 ±2.02; p&lt; 0.001) (Figure 1).</em>Women were characterized by higher interpersonal abilities than men (10.62 <em>±</em> 3.26 vs. 9.52 <em>±</em>2.60; p= 0.011) (Figure 2). The IAEI value significantly correlated with the stage of treatment, i.e., the progress of <em>CKD (r= 0.26; p&lt; 0.001). </em>Patients who started dialysis demonstrated a much lower IAEI level than patients in the pre-dialysis period and healthy persons. No such correlation was found for IEEI. <br> Table 1. Characteristics of selected socio-demographic and clinical factors. Figure 1. Emotional intelligence levels in patients at subsequent stages of CKD treatment. Figure 2: Comparison of the EI levels in women and men. <br> <br> Patients with low levels of emotional intelligence were more prone to depression (IAEI r= -0.28; p&lt; 0.001; IEEI r= -0.27; p&lt; 0.001). No relationship was found between EI and propensity for nicotine and alcohol addiction . The relationship between emotional intelligence and the quality of life was statistically significant (Table 2). IEEI positively correlated with support from the dialysis unit workers (r= 0.21; p= 0.02) and better quality of sleep (r= 0.2; p= 0.01). On the other hand, higher IAEI was related to higher awareness of the disease impact (r= 0.26; p&lt; 0.001), its severity (r= 0.21; p&lt; 0.007) and a stronger sense of pain (r= 0.29; p&lt; 0.001). It was also related to better cognitive (r= 0.25; p&lt; 0.001), social (r= 0.32; p&lt; 0.001) and physical (r= 0.29; p&lt; 0.001) functioning. <br> <br> Table 2. Correlation between emotional intelligence and selected aspects of quality of life.<br> <br> <em>No relationship was found between the disease acceptance and emotional intelligence (IAEI r= 0.44; p= 0.633, IEEI r= 0.145; p= 0.113). </em> <em> An analysis of multi-factor backward stepwise regression including disease progression, depression level</em>, general assessment of the quality of life and results of its sub-scales, i.e., support from the dialysis unit workers, sleep quality, awareness of the disease impact, disease severity, sense of pain, cognitive, social and physical functioning revealed that the <em>disease progression (R<sup>2</sup>= 0.25; p&lt; 0.001) and the depression intensity (R<sup>2</sup>= 0.25; p= 0.049) </em>independently affected<em> IAIE. Moreover, sleep quality (R<sup>2</sup>= 0.09; p&lt; 0.001), depression intensity (R<sup>2</sup>= 0.08; p&lt; 0.001) and social functioning (R<sup>2</sup>= 0.09; p= 0.014) were the only factors independently modified the IEEI value.</em> <em><strong>Discussion</strong></em><br> For the first time in the available literature, our study showed an independent relationship between emotional intelligence and the quality of sleep, depression intensity, and social functioning of patients with chronic kidney disease. While CKD progression significantly and independently deteriorates EI in its intrapersonal aspect, it did not influence IEEI. The results obtained let us state that in the early stages of treatment when the disease is less intense, the people examined are most motivated, aware of their resources, and able to use their emotions constructively. The progress of the disease, limitations it entails, medical procedures, repeated dialyzes, and consecutive hospital stays generate strong, long-lasting stress, which has a negative effect on the most important component of emotional intelligence, i.e., ability to regulate emotions. Our study also shows that patients with CKD are not focused on themselves and their experiences. The level of interpersonal intelligence was significantly higher than that of intrapersonal intelligence and did not depend on the stage of the disease. This implies that despite their disease progression, patients are interested in building relationships with other people. In this respect, women have better competences than men. The differences between genders in the field of EI have also been confirmed by other studies where it was stated that women are more emotional, more emotionally expressive, and they often base their adjustment strategies on these features (Petrides, 2000;Bogucki, 2010; Matczak et al., 2005; Baruah,2016;Katyal,2017). The role women play in the evolution of humanity (mother) is not without significance here as it requires sensitivity to non-verbal signals of emotional states (Knop,2006). Reports from the field of neuropsychology and neuroimaging showed that EI positively correlates with the volume and density of grey matter in the areas responsible for emotional reactions (the ventromedial prefrontal cortex) (Damasio, 1996;Tan et al., 2014). Not only does EI facilitate recognition of one’s own and other people’s emotions, but also the choice of an adequate reaction and strategy of coping with stress, which reduces the risk of depression (Bogucki, 2010; Fernandez-Berrocal, 2006). This is confirmed by our study in which both IAIE and IEEI were independently correlated with the degree of depression assessed on the BDI basis. A partial explanation of this correlation is the fact that for the depression development predisposes some personal traits which compose the mixed model of EI. Irrespective of disease progression, the relationship between depression and EI can be the basis for implementing activities aiming to improve the quality of life of patients with CKD, e.g., through the active increase of EI (Figure 3).<br> <br> Figure 3. EI impact on indicators of good functioning of patients with CKD. The relationship between EI and mental well-being was demonstrated in many studies [Brackett et al., 2004; Brackett et al., 2006; Schutte et al.,2011; Anjum et al., 2017]. In her work, Gregajtys proved the influence of EI on the objective assessment of the quality of life of patients with CKD [Gregrajtys, 2002]. On the other hand, in the research by Shahnavazi <em>et al</em>., a 6-month program aiming to educate in the field of EI contributed to a marked improvement in the quality of life of haemodialysis patients (Shahnavazi et al., 2008). High emotional intelligence affects appropriate assessment, regulation, and utilization of emotions helps in solving problems effectively. It also facilitates establishing interpersonal relations and getting social support, which causes that people less often experience negative emotions but assess their quality of life more positively. In our study high IEEI significantly correlated with support from the dialysis unit workers and was independently related to better sleep quality. These findings comply with earlier reports (Emert et al., 2017;Bavafa et al., 2019;Schartz et al., 2013; McGlinchey et al.,2011). The research by Bavafa <em>et al</em>. also showed that EI correlated with sleep quality and, additionally, with sleep disorders. No correlation was found with the length of sleep (Bavafa et al., 2019). On the other hand, the research by Schwarz <em>et al</em>. showed that sleep restriction was related to reduced facial expression in response to emotional stimulation (Schartz et al., 2013). Our study did not find any relationship between EI and acceptance of illness by patients with CKD. Yet, the research results concerning this aspect of EI are inconclusive. The work by Sasin <em>et al</em>. shows that all EI components correlated with the acceptance of illness in patients with alopecia areata (Sasin, 2009). On the other hand, the research by Basińska <em>et al</em>. revealed that EI as a whole was not an indicator of illness acceptance in patients with psoriasis; in fact, only one factor was such an indicator, namely, using emotions in thinking and actions, which is an EI component (Basinska et al., 2012). Moreover, it was noted that in the mild course of illness, EI helped with its acceptance, but when the course was complicated, its supporting role in the acceptance of illness decreased. In their research Cha <em>et al</em>. demonstrated that a high EI indicator protected against suicidal thoughts and tendencies (Cha et al., 2009). Suspicions that people with low emotional intelligence are more vulnerable to the influence of other people and hence the risk of dependence seem justified. However, this hypothesis has not been confirmed in our study.<br> Despite promising results, our study had some limitations. Firstly, our research was carried out using the blind questionnaire method without the possibility of data verification. Secondly, aiming to compare results for several equal groups limited the group size. Probably other studies performed in bigger groups could be helpful in the development of additional variables independently related to the level of emotional intelligence, and therefore they would increase possibilities of improving quality of life in patients with CKD. <br> <strong>Conclusions</strong><br> Emotional intelligence, especially in its intrapersonal aspect, deteriorates together with CKD progression. In view of the independent relationship between illness progression and depression intensity and sleep quality, the implementation of actions aiming to improve emotional intelligence can contribute to better health and quality of life in these patients. The complex character of dependencies and a series of determinants related to CKD progression necessitate continuation of research regarding the role of emotional intelligence in improving the quality of life of individuals with this illness.<br> <br> <strong>Limitations</strong><br> The presented research has some limitations. We used self report questionnaires that present the problems of being subject to patients' biases in self-image and self-evaluations and this could be especially true for dimensions such as depression symptoms and quality of life, so it would be necessary to use conversation analysis or semi-structured interviews for future studies. This is an important limitation to be mentioned. Moreover, authors did not assess trait emotional intelligence, which is a relevant dimension related to emotional intelligence. Future studies are indeed needed to deepen the interplay between the dimensions assessed in the authors’ study and trait EI, as it is particularly relevant in the context of renal patients. <strong>Acknowledgments</strong><br> We would like to thank all the participants of this study.<br> <br> <strong>Disclosure statement</strong> The authors declare that they have no competing interests. <strong>Funding </strong><br> This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.<br> <br> <strong>ORCID</strong> Lech Magd