LEARNING OBJECTIVES

Upon completion of this course, you will be able to:

• Identify characteristics of emotions.
• Describe the limbic system of the brain.
• Define emotions and their overall function.
• State the unique function of each of the primary emotions.
• Explain the management of primary emotions.
• Discuss "emotional intelligence."

What stirs our souls when we watch a glorious sunrise, depresses our mood when we suffer loss, enflames our passion when injustice prevails, or sickens our appetite when we see repulsive behavior? Emotions. But what are emotions? Where do they come from? Did we learn them or were they inborn? Are they the product of thought or something else? Can we manage them or are they unmanageable?

For centuries, prophets, poets, and philosophers have posed these questions, and for an equally long time these gurus offered convoluted explanations based on beliefs and conjectures. Modern-day psychologists and neurologists ask the same questions but use scientific research to understand the phenomena. Though recent studies reveal something about the anatomy and physiology of emotions, scholars have yet to agree on a single, comprehensive theory to explain the capacity of living creatures to experience and express this enigmatic thing we call an emotion (de Sousa, 2007).

This course addresses these issues, describes the generally accepted characteristics of emotions, identifies neurologic structures and functions involved in the production of emotions, offers a distinct model to explain the purpose and nature of the emotions, and suggests practical strategies healthcare professionals can use to manage the primary emotions.

CHARACTERISTICS OF EMOTIONS

Though scholars hold different views regarding the capacity to experience and express emotions, they agree on the following nine characteristics:

• Emotions are conscious phenomena—that is, people are aware of them.
• Emotions are more consistently demonstrated than other conscious states, such as fatigue.
• Emotions vary in several dimensions, such as intensity, type, and range.
• Emotions are reputed to be antagonists of objective, rational thought.
• Emotions play an indispensable role in determining the quality of life.
• Emotions contribute significantly when we define priorities in our lives.
• Emotions play a crucial role in the regulation of social life.
• Emotions protect us from excessively narrow rational thought.
• Emotions hold a central place in the teaching of ethical/moral behavior. (de Sousa, 2007)

THE LIMBIC SYSTEM

Neurologists have found that emotions are produced by a complex organization of the brain called the limbic system. "Limbic" comes from the Latin word limbus, meaning "edge" or "border," though its major structures are located in the center of the brain. The limbic system is the area of the brain that becomes active when humans experience emotions in the present or emotions associated with memory. The system influences the formation of memory and integrates emotional states with physical sensations (Bruce & Neary, 1995). The following structures and functions of the cerebral cortex and subcortex of the brain are included in the limbic system:

• Amygdala: signals the cortex about stimuli that regard fear and rewards
• Central nucleus of the amygdala: contains links to key brainstem areas that control autonomic functions
• Hippocampus: participates in the formation of long-term memories; it includes the parahippocampal gyrus, which plays a role in the formation of spatial memory
• Cingulate gyrus: regulates heart rate, blood pressure, and cognitive and attentional processing
• Fornicate gyrus: encompasses the cingulate, hippocampus, and parahippocampal gyrus
• Hypothalamus: regulates the autonomic nervous system by hormone production, affecting blood pressure, heart rate, hunger, thirst, sexual arousal, and the sleep-wake cycle
• Mammillary body: participates in the formation of memory
• Nucleus accumbens: participates in feelings of reward, pleasure, and addiction
• Orbitofrontal cortex: takes a vital part in decision making
• Thalamus: acts as the "relay station" to the cerebral cortex
• Pituitary gland: produces thyrotropin and adrenocorticotropin, activating the thyroid and adrenal systems (Bruce & Neary, 1995)

Using perceptions and thoughts, the structures of the brain's limbic system store and retrieve information from memory, generate emotions, and provide feedback about appropriate social behavior. However, identifying and naming these structures is just the beginning. We need to know much more in order to understand emotions. Specifically, we need to define what we mean by emotions, then learn their functions, numbers, qualities, intensities, and combinations. Most important, we need to learn how to manage our emotions.

WHAT ARE EMOTIONS?

Though there are as many definitions of an emotion as there are theorists, the one articulated by Robert Plutchik and his fellow researchers at Albert Einstein College of Medicine in New York City is widely accepted, builds on a broad base of research, and describes the steps of an exceedingly complex process. These investigators define an emotion as:

[An emotion is] a complex sequence of events having elements of cognitive appraisal, feelings, impulses to action, and overt behavior, all of which are designed to deal with a stimulus that triggers the chain in the first place and serves an adaptive function for survival. (Plutchik, 1980)

Primary Emotions

Plutchik (1980) identified eight primary emotions—four positive and four negative—in regard to the pleasure or displeasure they bring to the individual:

• Positive emotions: acceptance (love), anticipation (hope), surprise (shock), joy (happiness)
• Negative emotions: anger (wrath), fear (horror), disgust (revulsion), and sadness (sorrow)

Functions of Emotions

Lazarus affirmed that emotions have a useful purpose (function) and that purpose is to help the individual survive (1991). Eight such functions of emotions have been identified, including:

• Destruction of the enemy = anger
• Protection from harm = fear
• Reintegration to wholeness again = sadness/loss
• Rejection of whatever may be harmful = disgust
• Reproduction of the species = joy/happiness
• Incorporation of sustenance = acceptance
• Exploration of the environment for safety = anticipation/hope
• Orientation to an unexpected and possibly dangerous event = surprise/shock

An emotion is a chain reaction beginning with a stimulus event, followed by cognition (appraisal), then feeling, then impulse to act, and finally action. All of this occurs to increase the likelihood of survival. An individual:

1. Perceives a stimulus (hears, sees, smells, tastes, touches)
2. Appraises cognitively (thinks)
3. Experiences feelings (feels)
4. Has an impulse to action (considers or prepares for action)
5. Behaves (takes action)

These steps are illustrated as follows:

• Stimulus event: A burglar enters a store and approaches the clerk. He wears a mask, carries a gun, and says "This is a stick-up! Hand over your cash!"
• Perception: The clerk sees the mask and gun and hears what the burglar says.
• Cognition: The clerk thinks "This man is dangerous. He could hurt me."
• Feelings: The clerk feels intense fear.
• Impulses to action: The clerk wants to escape. Her heart beats rapidly. Epinephrine from the adrenal gland floods her circulatory system. She remembers the emergency button under the counter.
• Action: The clerk presses the emergency button, hoping help will come soon, then opens the cash drawer.
• Function: The emotion of fear serves a survival function, mobilizing the body to protect itself.

The table below shows an example of this chain reaction for each emotion.

EMOTIONS AS CHAIN REACTIONS

Stimulus Event	Cognition	Feeling	Behavior	Function
Source: Adapted from Plutchik, 1980.
Denial of need or want	Confrontation with denier	Anger (fury)	Lash out, attack, destroy	Destruction
Threat from enemy	Danger	Fear (fright)	Run/escape	Protection
Loss of loved one, self, others	Isolation, loneliness	Sadness (grief)	Cry for help, comfort	Reintegration
Sickening food or behavior	Nastiness, harmfulness	Disgust (revulsion)	Expel, vomit, turn from, vomit	Rejection
Introduction of a potential mate	Attraction, interest	Joy (happiness)	Sexual signaling	Reproduction
Unfamiliar, shocking event	Need to quickly appraise situation	Surprise (shock)	Stop: take in new information	Orientation
Event with an unknown future	Challenge	Anticipation (hope)	Mental mapping	Anticipation
Beneficial act of caring/kindness	Affiliation with nurturing other	Acceptance (love)	Holding, eating, grooming	Incorporation

Degrees of Intensity

In addition to their positive or negative polarity, emotions vary in degree of intensity, from mild to intense, as follows:

• annoyance → anger → rage
• boredom → disgust → loathing
• pensiveness → sadness → grief
• apprehension → fear → terror
• distraction → surprise → amazement
• pleasure → joy → ecstasy
• hopefulness → anticipation → vigilance
• toleration → acceptance → adoration

Combinations of Emotions

In addition to intensity, emotions often combine to form more complex emotions, such as:

• Sadness and surprise = disappointment
• Sadness, anger, fear = jealousy
• Sadness and disgust = remorse or guilt
• Disgust and anger = contempt or blame
• Fear and disgust = shame
• Fear and acceptance = submissiveness
• Fear and surprise = awe
• Joy and acceptance = love
• Anticipation and joy = optimism

Although emotions may be called positive or negative, in themselves they are neither good nor bad. Even so, the actions (behaviors) of people when they experience emotions may be harmful or helpful to themselves or others. For example, unmodulated joy may become mania, uncontrolled anger may beget violence and cruelty, unresolved sadness may lead to depression and suicide, and unfocused or inappropriate fear may become anxiety, phobia, and paranoia (Hamilton, 2008). For this reason, to live a balanced life people must learn to manage their emotions, accepting their reality but maintaining control of extreme expressions.

Management of Emotions

Emotions play a powerful role in the lives of individuals. Consider the capacity of anger to destroy, fear to protect, acceptance to nurture, disgust to repel, sorrow to enervate, hope to challenge, surprise to amaze, and joy to cheer! By understanding and managing these powerful capacities, people can achieve extraordinary personal goals or create great personal tragedy. We will look at each primary emotion, its definition, the stimulus events which produce it, thoughts people have as a result of the emotion, feelings they experience, the function of each emotion, its manifestations, behaviors, and strategies for management.

ANGER

Anger is an emotion designed to eliminate an obstacle to the satisfaction of an important need, such as striking down a barrier, defeating an opponent, or carrying out symbolic acts of destruction such as cursing or belittling another person.

ANGER

Stimulus Event	Anger occurs at times when people perceive an obstacle to be blocking something they need or want.
Thoughts (cognitions)	Individuals think about how they will eliminate the barrier to their desire.
Feelings	People feel annoyed, frustrated, angry, and full of rage.
Aim or Function	The function of anger is to eliminate or destroy an obstacle or overcome a barrier to a desire.
Manifestations of Anger	Grimacing, muscle tension, sympathetic nervous response.
Behaviors/Actions	Physical assault, verbal assault, passive-aggressive statements and actions.

Strategies for Managing Anger

COGNITIVE

Ask yourself: What is the obstacle? How powerful is it? Should I fight, take flight, or compromise? The rational-emotive approach (ABCDE) of Albert Ellis (1985) suggests that before individuals act they should carefully consider the emotion-triggering event, examine their belief about the event, and consider the consequences of various actions they might take.

The ABCDE of the rational-emotive approach is:

• Identify the activating event.
• Identify your belief about the event as well as the emotion related to the event.
• Consider the consequences.
• Discuss/debate various courses of action.
• Examine the effect of your action. (Ellis & Bernard, 1985)

For example:

• Activating event.   The driver of another automobile in the shopping mall rushes past Sam, taking the last remaining parking space.
• Belief.   Sam believes he deserves the space; he got there first and the other driver cheated him out of something that was rightfully his. He is angry.
• Consequences.   Sam considers how he can make the driver of the other vehicle relinquish the parking space.
• Discussion/debate.   Sam debates whether he should bump the offending vehicle, scream insults at the driver, or wait patiently for another parking space.
• Effect.   Sam examines the effect of each possible action. He concludes that it is best to let go of his anger and move on.

BEHAVIORAL

Research studies show that "letting it all out" escalates anger rather than decreasing it; therefore such action is not recommended (Travis, 1989). A more effective strategy uses a behavioral-cognitive strategy—wait, cognate, officiate—as demonstrated in the following example.

Example. When the driver of the other car rushes past Sam and takes the parking space, Sam waits. Sam thinks through (cognates) his options. Lastly, Sam officiates, deciding that confrontation may lead to harm for himself or his automobile. Sam takes a deep breath, looks away from the offending driver, shrugs his shoulders, and lets go of his anger.

CHEMICAL

When individuals are unable to use cognitive or behavioral strategies to manage anger, anti-anxiety (anxiolytic), sedating, or psychotropic drugs may be prescribed.

Management of Anger in Patients

People who are ill, in pain, and experiencing exceptional stress are more likely to express anger than those who are well and comfortable. It is no surprise, then, that healthcare professionals often encounter angry, hostile people. Some suggestions for response to verbal expressions of anger:

• Lower the volume of your voice and slow its pace.
• Acknowledge the person's anger, thereby showing respect.
• Ask what the person wants or needs and what is preventing him from obtaining it.
• Restate the problem until you have clearly identified it.
• Offer to seek a solution or to find someone who can do so.
• Demonstrate accurate empathy and genuineness.

When patients threaten aggressive physical behavior:

• Call for help.
• Protect yourself and others from harm. Remember, safety comes first.
• Maintain access to a door or other avenue of escape.
• Use calming verbal interactions as described above.
• Express your willingness to listen with genuineness and accurate empathy.

FEAR

Fear is a strong emotion intended to avoid harm and protect individuals. It is the opposite of anger, the purpose of which is to destroy.

FEAR

Stimulus Event	People perceive a threat of harm to themselves, their loved ones, or their property.
Thoughts (cognitions)	Individuals believe they and/or their property are in danger.
Feelings	People feel frightened, upset, and anxious.
Aim or Function	The function of fear is to protect individuals and help them escape danger and harmful forces.
Manifestation of Fear	Adrenal system floods the body with epinephrine and stress hormones, consequently the heart races, blood pressure rises, breathing quickens, liver releases glucose, digestion stops, skin chills, and blood diverts to muscles.
Behaviors/Actions	Individuals take defensive action (fight, flight, or withdrawal).

Strategies for Managing Fear

COGNITIVE

Ask yourself: Who is the enemy? How much threat is there? What will reduce the threat? Use the rational-emotive ABCDE approach:

• Activating event.   When Mary was 6 years old a large, overly friendly sheep dog ran up to her, pushing her over, and frightening her. Now 26 years of age, Mary has a panic attack whenever she sees or hears a dog barking. She is afraid to go out in public.
• Belief.   Mary believes all dogs are dangerous, no matter what breed or training.
• Consequences.   Mary is terrified by dogs of any size, number, breed, or training. Her fear limits her personal freedom. She does not want to be a prisoner in her own home. Rationally, Mary knows all dogs are not dangerous, but her fear persists.
• Discussion/debate.   Mary decides to seek professional help to overcome her unrealistic fear (phobia). She seeks desensitizing therapy in which she is gradually exposed to the object of her fear.
• Effect.   Desensitization therapy helps Mary reduce her fear of dogs to manageable levels. In addition, she learns to avoid places where off-leash dogs roam free.

BEHAVIORAL

Relaxation exercises and creation of a safe environment.

CHEMICAL

Anxiolytic drugs may be prescribed.

Management of Fear and Anxiety in Patients

Often patients are unfamiliar and fearful of hospitals and what goes on there. They may have seen gruesome pictures, heard or read horrific stories, or experienced painful procedures in hospitals. They know they are not in control of their person or property and, consequently, are afraid. Healthcare professionals can help reduce fear in patients by:

• Explaining and describing in advance planned test, treatments, or procedures.
• Speaking and behaving respectfully toward patients.
• Reduce stress-producing stimuli, such as sights, sounds, or extreme room temperatures.
• Identify yourself and others who are working with the patient.
• Stay with patients or provide some means for them to call for help.
• Give accurate empathy, unconditional positive regard, nonpossessive warmth, and genuineness.

SADNESS

Sadness is an emotion associated with the loss of someone or something of value to a person. It is the opposite emotion of joy, signaling a cry for help. The accompanying mild to moderate depression provides a time of healing.

SADNESS

Stimulus Events	Occasions when individuals suffer loss or damage to valued things or people.
Thoughts (cognitions)	People who are sad realize they are deprived of whatever is lost.
Feelings	Individuals feel pensive, sorrowful, alone, numb, and mild to moderate depression.
Aim or Function	The function of sadness is to provide a time of healing and reintegration.
Manifestations of Sadness	Withdrawal, depression, hopelessness, and reduced creativity.
Behaviors/Actions	Crying, tearfulness, lose of appetite, and avoidance of others.

Strategies for Managing Sadness

COGNITIVE

Recognize your loss, large or small. When loss is large and grief profound, schedule a time for "grief work." At first, this may be 30 to 60 minutes, two or three times a day. During this time allow yourself to weep and experience the loss. After each grieving period, return to activities not related to grief. Gradually, reduce the number and extent of planned grieving periods until those times are no longer needed. Use the ABCDE rational-emotive approach:

• Activating event.   Jane's husband of 51 years died after a brief illness. Until his death they had shared everything, reared three children, and never been apart except for brief periods.
• Belief.   Jane is overwhelmed by her loss. She does not believe she can live without her husband. Everything in her life seems surreal.
• Consequences.   Jane withdraws from all her normal social contacts and becomes more and more depressed. She walks around in a daze of confusion and pain.
• Discussion/debate.   The hospice nurse who attended her husband suggested Jane join a grief support group sponsored by the hospice agency. Jane was hesitant to expose her feelings to strangers but her daughter urged her to attend. Finally, Jane agreed to go to at least one meeting.
• Effect.   Jane was welcomed by the group and received comfort and support from its members. She decided to continue attending until she no longer felt the need.

BEHAVIORAL

Participate in a support group and share grief with sympathetic others. Perform grief work by repeatedly experiencing grief and sorrow and then letting go of sadness.

CHEMICAL

Antidepressants may be prescribed for chronic grief.

Management of Sadness in Patients

When patients suffer loss, healthcare professionals can provide genuineness, empathy, and nonpossessive warmth and, if appropriate, explain grief work and suggest counseling and participation in support groups.

DISGUST

Disgust is an emotion that arises from contact with something that is repulsive—physically, mentally, or morally. Disgust triggers rejection of an offensive object, idea, or person and is the opposite of acceptance.

DISGUST

Stimulus Event	People contact something that is physically, socially, or morally abhorrent to them, such as spoiled food, foul odors, promiscuity, and drunkenness.
Thoughts (cognitions)	The repulsive object or person is sickening and repugnant.
Feelings	Contempt, rejection, and repulsion.
Aim or Function	The function of disgust is to reject whatever is spoiled, foul, or offensive.
Manifestations of Disgust	Avoidance, disassociation, and expulsion.
Behaviors/Actions	Verbally or physically turning away or condemning a rejected object.

Strategies for Managing Disgust

COGNITIVE

Identify the disgusting object, idea, or person. Evaluate your judgments. Use ABCDE rational-emotive approach:

• Actuating event.   One month ago Sue, an RN and single mom, took a job in a surgeon's office. Carol, the office manager, adjusted Sue's work hours to meet her childcare needs. Soon after Sue began to work she noticed that Carol had many personal traits that disgusted her. The woman was annoyingly opinionated, and in addition she smacked her lips while eating, burped loudly, and expelled flatus without apology.
• Belief.   Sue thought Carol was both rude and gross.
• Consequences.   Because of her feelings about Carol, Sue avoided her as much as possible, but this was difficult in the small office. Sue felt antipathy toward Carol but she did not want to quit her job.
• Discussion/debate.   Sue decided to talk to Joyce, the other RN in the office. Joyce sympathized with Sue but said she believed Carol's behavior was due to low self-esteem coupled with inadequate socialization. Joyce suggested that Sue attempt to accept Carol as she is. Joyce also suggested that when Carol did something commendable, Sue should praise her for it.
• Effect.   Sue decided to look at Carol, not as a disgusting slob, but as a needy person with uncouth social manners. Eventually, Sue was able to accept Carol as a person, even though she could not accept her behavior.

BEHAVIORAL

Sue looked for opportunities to bolster Carol's self-esteem. The strategy seemed to help both Sue and Carol.

CHEMICAL

Medications to reduce disgust are not available.

Management of Disgust in Patients

When patients confide to a healthcare worker that they are disgusted with someone, individual, television personality, or athlete, the person:

• Listens closely to what patients see as the activating event.
• Ask patients to identify, if possible, beliefs behind their feeling of disgust.
• If appropriate, discuss the consequences of this belief.
• Show respect for patients, allowing them to evaluate effects of their rejection.

JOY (Happiness)

Joy is a transient emotion of pleasure, enthusiasm, action, and attainment of objectives. It is the opposite of sadness and loss. Many theorists liken joy to sexual excitement, creative activity, energy, and innovation.

JOY

Stimulus Event	These are times when people experience fulfillment, inspiration, and sexual attraction.
Cognition (thoughts)	Individuals experience self-actualization, recognition, and achievement.
Feelings	Energy, elation, sexuality, and pride in accomplishments.
Aim or Function	The function of joy is reproduction, fulfillment, and self-actualization.
Manifestations of Joy	Enthusiasm, creativity, energetic enterprise, and sexuality.
Behaviors/Actions	Sexual activities, dancing, singing, talking, inventing, and creating.

Strategies for Managing Joy

COGNITIVE

Recognize, acknowledge, and enjoy an expansive outlook on life and good energy level. Use the ABCDE approach:

• Activating event.   Ann woke up early; it was a beautiful morning and she felt wonderful. The night before she had a date with Tom, a senior at the liberal arts college where she was a junior, majoring in art. They had gone to Funny Girl, the spring musical. The words of one of the songs kept running through her head. The Fannie Brice character liked the feeling for Nicky Arnstein that was going through her, down her spine (Styne & Merrill, 1964). Like the song, Ann felt energetic, enthusiastic, and full of joy.
• Belief.   The future looked bright. She loved being with Tom and was quite sure he felt the same about her. She was doing well in all her courses and was pleased with her current project, a stylized metal sculpture of an athlete.
• Consequences.   Because of her joyful state of mind, Ann didn't get annoyed with her roommate, even when she found dirty dishes in the sink of their tiny kitchen. Instead, Ann hummed the tune from Funny Girl and cleaned up the mess.
• Discussion/debate.   Because she felt so good, Ann was tempted to take the day off, go shopping at the mall, go for a hike, and maybe ask Tom if he'd like to join her. Instead, Ann decides to use her energy to work on her sculpture.
• Effect.   Even though Ann's joyful elation lessened as the day progressed, her feeling of satisfaction continued as she worked on her project. Had her joy increased to a state of mania, Ann's judgment would have been impaired and she would not have been able to focus her energy productively.

BEHAVIORAL

Individuals channel their energy productively, modifying their behavior through reason.

CHEMICAL

When needed for hypomania or manic behavior, mood-stabilizing drugs may be necessary.

Management of Joy in Patients

It is important for healthcare professionals to monitor the mood of patients, noting whether they seem inappropriately elated and hyperactive or extremely withdrawn and depressed. In either case, the professional can enter into a conversation with such individuals about how they are feeling. When mania or depression is observed, it should be noted and reported to the attending physician.

ACCEPTANCE (Love)

Acceptance is the opposite of disgust and rejection. It is the emotion of incorporation and nurturance, It involves accepting a beneficial stimulus from the outside world, as in eating, grooming, mating, or affiliation with members of one's own social group (Plutchik, 1980).

ACCEPTANCE

Stimulus Event	These are time of nurturance, when people identify with others, caring for them as themselves.
Cognition (thoughts)	Individual acknowledges and recognizes others, both to give and receive.
Feelings	People feel warmth toward others and positive regard for one another.
Aim or Function	The function of acceptance is to confirm inclusion, assimilation, and merger—ultimately, as with all other emotions, for the survival of the species.
Manifestations of Acceptance	Embracing, recognizing, including, nurturing, eating, befriending.

Strategies for Managing Acceptance

COGNITIVE

Recognize feelings of positive regard and identification with another person or object and then use the ABCDEF approach:

• Activating event:   Amy gave birth to her third child, a boy she named Paul. This was the first boy in three generations on her side of the family and she was thrilled. Even so, Amy had difficulty bonding with the baby. He seemed like a stranger to her, a toy, something apart, not an extension of herself, as the girls had seemed. Amy decided not to breastfeed the baby and went back to work when he was 7 weeks old, happy to find a babysitter to care for him. One day Paul became acutely ill with a high fever and was admitted to the hospital. Amy took time off from work to stay with him in the hospital. Day and night she held him, fed him, and watched over him until he was well enough to come home. During that time Amy's attachment with her son changed. She began to identify with her little boy and to consider him her own.
• Belief:   Amy came to accept her baby boy as never before. Indeed, he became as dear to her as her own life.
• Consequences:   As a result of her experience of watching over and caring for her son, Amy was able to accept and embraced all three of her children as never before.
• Discussion/debate:   Before his illness, Amy had not bonded with her baby boy as she had with her girls. She needed to lose her discomfort with a helpless male infant and to identify with little boy as her own beloved child.
• Effect:   By recognizing her boy as unique, yet precious extensions of herself and her husband, Amy became a better parent to all three of her children.

BEHAVIORAL

Accepting people as they are, not as you want them to be, is accomplished by empathetic listening, genuineness, and identifying with them as fellow humans.

CHEMICAL

Acceptance of others nurtures both those who do the accepting and those who are accepted. For this reason, medications are not necessary.

Management of Acceptance in Patients

Because postpartum hospital stays are short, evaluation of bonding is difficult to quantify. However, if a mother wants to hold her baby, examine its tiny body, breastfeed, and spend time in an eye-to-eye, face-to-face (en face) position, initial attachment probably is occurring. If not, the nurse or other professionals may want to encourage activities that will foster bonding. In pediatric units, nurturance by parents may be indicated by their presence and behavior toward their children.

ANTICIPATION (Hope)

Anticipation is the emotion of investigation, exploration, and hope. It is the opposite of unexpected shock or surprise. When individuals anticipate and investigate circumstances, they are not caught off guard and are able to cope effectively with challenges to their survival (Plutchik, 1980).

ANTICIPATION

Stimulus Event	People experience anticipation when they are in unfamiliar territory and feel the need to explore and investigate a situation. These are times of excitement and challenge.
Cognition (thoughts)	Individuals think about potential goals and consequence; they investigate, explore, and anticipate end results.
Feelings	Anticipation is a feeling of hope and excitement, as well as slight fear and dread.
Aim and Function	The function of anticipation is exploration, mental mapping, and investigation about likely outcomes.
Manifestations of Anticipation	Alertness, excitement, curiosity.

Strategies for Managing Anticipation

COGNITIVE

Become aware of feelings, consider future possibilities. Use the ABCDE approach:

• Activating event.   Rich has an opportunity to buy some potentially valuable stock at below market price in a company with a solid earnings history. The seller has to raise money in a hurry and is willing to sell at a loss.
• Belief.   Rich believes he is getting a good deal and is quite sure he will profit.
• Consequences.   Rich decides to buy the stock and arranges to borrow the money.
• Discussion/debate.   Rich investigates the company, finds that the books look good. He decides to go ahead with the purchase.
• Effect.   Even though Rich thoroughly investigates the company, he knows there is some risk; nonetheless, he anticipates a handsome profit.

BEHAVIORAL

Use relaxation measures to guard against or reduce anxiety, including deep breathing, physical exercise, and meditation.

CHEMICAL

Anxiolytic medications may be prescribed if an individual becomes excessively anxious.

Management of Anticipation in Patients

When patients seek medical help, they may anticipate the worst or the best outcome. In either case, they can be taught relaxation measures to reduce anxiety and provide empathy, genuineness, and nonpossessive warmth.

SURPRISE (Startle, Astonishment)

The opposite of anticipation, surprise is an emotion of sudden shock, a response to new and unfamiliar stimuli, positive or negative. When startled, individuals must stop what they are doing, quickly reorient themselves, and take in information about the unexpected incident. When the stimulus has been evaluated, surprise usually changes quickly to another emotion, such as fear if the stimulus turns out to be dangerous, or joy if it turns out to be favorable.

SURPRISE

Stimulus Event	Something unexpected occurs or an unfamiliar person or animal intrudes in the environment.
Thoughts (cognition)	When such an unexpected event occurs, individuals tell themselves to exercise caution and evaluate the stimulus.
Feelings	Startle, shock, astonishment, arousal.
Aims and Function	The function of surprise is orientation, to allow people to pause and evaluate the environment.
Manifestations (behaviors)	Startle reaction, alertness, shock.

Strategies for Managing Surprise

COGNITIVE

Become aware of feelings, consider what may happen next. Use the ABCDE approach:

• Activating event.   Peggy, an LVN in a skilled nursing facility, was administering the evening medication from the medicine cart. She was at the end of a long, dimly lit hallway. Shortly after 9 p.m., a man came out of an empty room. He looked up and down the corridor, walked slowly toward her, showed a gun, and said, "Don't say a word! Put your narcotics in this bag. Do it now!" Peggy saw the gun and for about 10 seconds she froze in shock.
• Belief:   During the period of shock, Peggy evaluated the situation. She was in danger and needed help. Was anyone nearby?
• Consequences.   The period of shock gave her enough time to remember what the facility had taught her in an in-service class: Safety comes first! Loss of narcotics is nothing compared to loss of life.
• Discussion/debate.   Peggy fumbled, trying to open the locked narcotics drawer. The man moved closer, repeatedly poking the gun in her side. Her hands were shaking. It was difficult to think.
• Effect.   Peggy delayed as long as she dared. Just as she pulled open the drawer, a staff member came out of a nearby room. Peggy ducked toward the floor and called out the woman's name. When the robber saw another person, he escaped through a door that was about to be locked for the night.

BEHAVIORAL

Maintain control, take a deep breath, and exercise your best judgment whether the surprise turns out to bring joy, fear, or any other emotion.

CHEMICAL

Because the emotion of surprise lasts for such a brief time, medications are not an option.

Management of Surprise in Patients

Because of the brevity of surprise, the greater concern becomes the emotion that follows. For example, immediately after a physician tells a man he has a fatal disease, the patient experience shock and surprise. He may simply decide to deny the reality of the diagnosis or may immediately experience fear, anger, or some other emotion. Thus, it is especially important to give these individuals nonpossessive warmth, accurate empathy, genuineness, and unconditional positive regard (Rogers, 1961; Carkhoff, 1977).

EMOTIONAL INTELLIGENCE

As human beings, healthcare professionals experience the full range of emotions from sadness to joy, acceptance to disgust. They care for people who also possess a full range of emotions, but are suffering from a variety of stress-producing physical and psychological disorders. For this reason, nurses and other professionals need to possess what Daniel Goleman called "emotional intelligence (EI)" (1995). Goleman asserted that people with emotional intelligence possess three special capacities, self-awareness, self-discipline, and empathy:

• Self-awareness is the ability to identify ones own emotions.
• Self-discipline is the ability to manage ones life and ones emotions.
• Empathy is the ability to understand the emotions of others, to (figuratively) "walk in their shoes."

Indeed, all of these three capacities are the stuff of professional healthcare!

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Photograph © 2008 Jon Klein