Perspective Chapter: Emotional Labour – Understanding and Responding to the Emotional Challenges of Nursing

Abstract

The purpose of this chapter is to consider the emotional labour of nursing. The chapter explores the context of caring in nursing and the resulting need for nurses to engage in emotional labour. There is an overview of the origins of the term, emotional labour, before consideration of emotional labour in the context of nursing. The sources of emotional labour in nursing are covered alongside the impact of engaging in emotional labour on individual nurses, the service users they deliver care to, as well as the organisation and wider social impact. Strategies designed to support nurses and to respond to the emotional challenges of nursing are also explored.

1. Introduction

It is suggested that caring is an innately human quality and one that people demonstrate toward each other through altruistic acts or feelings of concern for another person [1]. Nursing is a profession which is characterised by care and care giving is an essential feature of the nursing role. Despite the increasing complexity of modern healthcare with changes in technology, medicine and expansion of nursing roles, this has not eroded the over-riding concern of providing care.

In nursing caring occurs through two domains. Firstly, it is a noun that refers to the act of caring for people when they are unable to care for themselves. Secondly is through the adjective of being a caring nurse, which is displayed through certain actions, namely those that show compassion kindness and concern. Whilst caring is not unique to nursing it has often been considered a key quality and feature of the role and there is both an onus on the nurse to perform their nursing duties in a caring manner but also on the discipline in its wider sense to foster this, This places emphasis on employing and regulatory bodies to develop the evidence base of the caring profession and to provide the requisite mechanisms through education, training and organisational practices to achieve it [1].

In nursing, caring involves being there for the patient and/or their family in what ever way is needed at the time and in the particular context. Thus, the context of providing care is complex and presents the nurse with a wide range of situations and diverse people to provide care for. This can include caring for people at different stages of the life course; those who have specific vulnerabilities and in birth and death, meaning nurses can provide care at some of the happiest and most difficult times. To do this, the nurse must draw on a wide range of skills to be able to adapt to the needs of individual patients and situations with the aim of caring and showing a caring attitude at the centre of this work [1].

Whilst many nurses join the profession to provide high quality care, the demands and complexity of the nursing role can provide a barrier to this and can have impacts both on the quality of the care delivered but also on the nurses delivering it. The increasing demands on nurses have become a key global concern and in recent years there has been recognition that countries across the globe need to do more to retain staff and to attract nurses to the profession. It is known that nurse retention is a key concern globally and many newly qualified and experienced staff are leaving the profession citing lower levels of job satisfaction, working conditions such as workload, stress and burnout, as key factors [2]. This context is known to influence recruitment and impact on the extent to which nursing is considered a desirable profession. On this basis some of the approaches recommended globally are to focus on improving the context in which nurses work and placing emphasis on support for their physical and emotional well-being, which is the focus of this chapter.

2. Emotional labour

In 1983 Hochschild [3] introduced the term emotional labour and this then generated both interest and research into this subject which focused on the impact of work on individuals at an emotional level and also the organisational structure and social relations of service jobs [4].

Hochschild [3] drew on Marxist theory that considered not only the fairness of using and paying human beings as instruments in the context of the profits made by factory owners but also focused on the human cost to the individual. Drawing a parallel between the Marxist and modern context Hochshild [3] explored the relationship between emotions that are really felt and those that are acted out for the benefit of others, using the example of commercial airlines where flight attendants were actively recruited based on their potential to project a desired company image and were then further trained to treat passengers in a certain way and to act out the idealised notion of Southern American charm and hospitality. They were expected to always smile and the connection between their smiles and the travel experience were a key focus of marketing strategies. Thus, the smile is considered an asset which reflects the company’s disposition and sells a product and experience to consumers. The impact of this on the flight attends was significant and Hochschild’s work revealed that the commercialisation and professionalisation of flight attendants work where they were trained to adopt a set of behaviours and working practices, which included the performance of smiling and creating a calm and warm atmosphere for passengers produced an emotional impact on them [3]. This resulted in feelings of insincerity, feeling their behaviour was contrived, with a need to suppress or what Hochschild called transmutation of their own feelings in order to sustain a particular outward image in the context of their working life, producing tensions between real and performed behaviours where seeming to love the job becomes part of the job [3].

Essentially, Hochschild’s work suggests flight attendants sell their personal emotions in the labour market, as if they were a product [3]. Some flight attendants reported a deep tensions, where the process of deep acting was so stressful, they overidentified with their work and found it difficult to relax and switch off from the artificially created elation at the end of a shift but also experienced a blurring of the boundaries between their personal and professionals selves, thus becoming more at risk of stress and burnout.

In exploring the work of the flight attendant Hochschild noted that the role involved physical labour in terms of the activities associated with providing catering to passengers but also an emotional aspect relating to the mental challenges associated with caring for the passengers, looking after their safety, their comfort and providing them with a cheery and calm atmosphere. This combination of the physical and the mental is what Hochschild combined to define as emotional labour [3].

Hochschild made an important link between emotional labour and gender and suggested that emotional work and emotional labour were expressly tied to women’s work and were illustrative of wider social structures that reflect social status and power [5]. Historically this connected to the role of women being homemakers and responsible for caring for children, and the resulting financial dependence on men, as well as enduring social norms relating to the belief that women are naturally more caring than men. Such social norms are manifest in the role of women in the workforce where historically they have predominantly occupied professions considered to be caring, such as nursing.

2.1 Emotional labour in nursing

Hochschild never applied the concept of emotional labour to nursing but acknowledged the application of it to professions other than flight attendants should three features of their work be met:

1. the role requires face to face or voice to voice interaction with the public.

2. there is a need for the worker to produce an emotional state.

3. there is a role of the employer through the provision of training and supervision to exercise a degree of control over the emotional activities of employees [3]. On this basis it is not surprising that her work has been applied to healthcare and in particular, nursing.

There is a clear parallel between Hochschild’s assertion that emotional labour is connected to women’s work and the historical development of the nursing profession, particularly the prototype for more contemporary nursing, Florence Nightingale, who is the archetypal caring female [6]. Despite the contemporary overarching narrative and reality that globally more nurses are female, men do actually have a long history in nursing that is somewhat lost to the last 200 years [7]. Indeed, Kearns and Mahon highlight many historical examples of men providing nursing care dating back to 250 BC when the first nursing school started in India where only men were considered pure enough to become nurses. By the mid-1800s as men fought and died in wars including the Crimean and American Civil wars among others, more women became nurses. Alongside this, there was an increasingly gender based division of labour which produced a context where the social concept of care became increasingly feminised and men in caring professions were considered deviant or unable to get a man’s job and accompanied by the devaluing of caring and the ensuant low pay, more men were forced to seek work in occupations with higher status and better pay to provide for their families [7]. Despite this there are global efforts now to encourage men to join nursing, particularly to address the global shortfall in the nursing workforce and importantly it is recognised that men who do enter nursing, do so for the same reasons as women – to provide care. As such, it is important to understand the impact of providing care on all nurses regardless of gender to recruit and retain staff and support them to deliver high quality care to patients.

Smith 1992 was arguably one of the first to specifically identify the relevance of emotional labour to nursing and in particular to nursing students and the way they were trained [8]. In 1991 and 1992 she travelled to California to study under Hochschild in order to apply the concept to nursing. Smith wanted to explore the perception of nurses as being intrinsically caring and apply this to the context of nurse training. She asserted that in a similar way to how Hochschild uncovered that flight attendants were recruited for their personal characteristics, this also occurs in nursing where candidates who display a friendly and caring attitude are actively selected [8]. This is reflected in the approach adopted in some countries, such as England, where a values-based recruitment framework has been introduced in the National Health Service which aims to recruit the best people with personal values that align with that of the organisation [9]. Whilst recruiting those with caring qualities is important, Smith notes that the process of nurse training is designed to shape these qualities and the nursing students’ identity to develop them into that of the professional and dedicated nurse who portrays the nursing image through their physical appearance and the emotional labour invested in their role [8]. Part of nurse training embeds in staff a sense of professional duty to follow organisational emotion-display rules and develop strategies to manage their emotions.

Nursing is a complex profession and the day-to-day activities involved in nursing are often both physically and emotionally demanding. These include but are not limited to the increasing organisational and professional regulatory demands placed on nurses, the exposure to the chronic and acute conditions of patients, as well as births, deaths and traumatic events experienced by their patients. It is also recognised that nurses experience physical and verbal abuse within the context of their working life given the complex nature of patients they provide care to but also some nurses experience negative interactions with peers and reported bullying from superiors [10]. These all require some form of cognitive and emotional response by the nurse, essentially, emotional labour.

It is asserted that there are two broad strategies employed by service workers, including nurses, in engaging with emotional labour. These are surface acting and deep acting [3]. Surface acting is the suppression of internally felt emotions driven by the need to adhere to organisational or occupationally desired emotions. So here, this results in hiding or faking emotions and displaying outward behaviours such as smiling, which are not consistent with the emotions they are truly feeling [11]. Deep acting is where the individual engages in or tries to experience emotional expressions which are consistent with the emotions they feel or the desired emotions. So here, this involves work on inner feelings and effort to try and regulate emotions, for example, trying to stir up a feeling we wish we had or trying to block a feeling we wish we did not. The drivers of this emotional labour are produced by organisational and professional regulatory guidelines but are also influenced by social norms, personality traits and situational factors such as the intensity of work and the interaction with service users [11].

2.2 Consequences of emotional labour

The negative consequences of emotional labour in nursing are wide ranging but can produce both a physical and emotional impact. These include emotional dissonance, burnout, compassion fatigue, secondary and post-traumatic stress and vicarious trauma [12].

2.2.1 Emotional dissonance

It is thought that because surface acting requires the suppression of internal feelings, this results in an emotional dissonance which can impact on the emotional wellbeing of the individual as well as job satisfaction and commitment [10]. Emotional dissonance, which has been mentioned previously in this chapter, is perhaps one of the most common negative consequences of emotional labour and is produced by the tension associated with feeling emotions but because of professional constraints being unable to express them and consequently being required to act in a way that makes the individual feel they are unauthentic, thus posing a challenge to the person’s sense of self [13].

2.2.2 Burnout

The term burnout was introduced by Freudenenberger in 1974 [14] when he observed a loss of motivation and reduced commitment among volunteers who were working at a mental health clinic. Burnout is a response to excessive stress at work and is characterised by feelings of emotional and physical exhaustion. Burnout develops over time through exposure to prolonged, excessive chronic stress which has either not been successfully identified and/or managed [15]. Maslach [16] suggests that burnout is connected to a number of risk factors or dimensions and in cases where burnout presents, it is usually connected to at least one of the six dimensions of working life, shown in Table 1.

Dimension	Reason for increased risk of burnout
Workload	If workloads and the demands of work are excessive and recovery from these demands cannot be achieved.
Control	If employees have or do not believe they have sufficient control over the resources needed to complete their job.
Reward	Where employees receive or perceive they receive too little reward for their work. These rewards may be monetary but also include other rewards such as social rewards and a sense of pride in their work.
Community	Where employees doe nor feel they have positive connections with peers, senior colleagues and that there is an absence of social support.
Fairness	Where there is actual or perceived unfairness, which may include inequity of workload or financial remuneration for work.
Values	Where employees feel their job forces them to act against their own values or when they experience conflict between the organisation’s values.

Table 1.

Dimensions of burnout (based on the work of Maslach) [16].

Whilst Maslach views burnout as being work related [16] others such as Shirom [17] refer to it as a process which may include both work and personal related circumstances that place excessive and cumulative demands on the individual. Burnout is known to impact on mental health and may lead to depression and anxiety and feelings of physical exhaustion, as well as increasing the risk of substance misuse and suicide [18]. Burnout often impacts on job satisfaction and has been cited as a key reason for staff in health and social care leaving their jobs. Equally, it is important to note that for staff experiencing burnout there are likely to be consequences for care delivery in terms of reduced quality of care and errors [19].

Burnout is often considered an occupational hazard for nurses, and it is known that the number of staff working in health and social care, particularly nurses are reporting burnout more frequently [15, 20]. Reflecting the dimensions highlighted in Table 1, workload is often a key factor, and this is connected to and a driver of vacancies in the sector. Alongside this, the intensity of workload is a factor where chronic and sustained workload pressures increase risk brought about by staffing levels as well as the increased demands on nurses in terms of providing care to increasingly complex patients, for example, during the global pandemic [20].

When nurses experience burnout there can be variation in how this manifests, but it is thought that for many there is an impact on physical and emotional well-being, and that this can include feelings of physical and emotional exhaustion, a sense of cynicism about one’s work and feelings of moral distress brought about by a sense that they are not delivering the quality of care they would like to [15].

2.2.3 Compassion fatigue

Compassion is often considered an essential aspect of nursing care and refers to the sense of connection to another person’s suffering. It is positioned as being a hallmark of good nursing and is thought to enhance care delivery and ensure that patients are treated with comfort, dignity and respect [21].

Initially described by Johnson [22] compassion fatigue is viewed as emotional, physical and psychological exhaustion induced by work-related stress. It is often associated with burnout and is thought to be a process which originates as compassion discomfort before progressing to compassion stress and ultimately culminates in compassion fatigue [23]. Whilst this implies that compassion fatigue is the result of experiencing many traumatic events over a prolonged period of time, there is also evidence that it can arise from the experience of caring for one individual or from a single event [24]. It is thought that when nurses reach the point of compassion fatigue it is extremely unlikely that compassion will be fully recovered and as such, it is not surprising that this is one of the most commonly cited reasons globally for nurses leaving the profession, which has partly contributed to an expected global shortage of 7.6 million nurses by 2030 [25].

In recent years compassion fatigue has been a key concern in nursing given the impact it has on the individual as well as employers and the wider discipline, At the individual level some of the impact is similar to the symptoms of burnout in terms of the negative effect on physical and emotional well-being where those affected may suffer from insomnia, exhaustion, depression as well as poor judgement, and failure to nurture. Research [26] also highlights the impact on patient care where compassion fatigue can lead to poor nurse–patient relationships, reduced quality of care and increased likelihood of complaints. This is felt at the organisational level and is compounded by the cost of reduced productivity, high staff turnover and difficulties in attracting new staff into nursing. Whilst employees in many sectors report experiencing burnout, it is thought that compassion fatigue is unique to those involved in caring or providing emotional support to others and is triggered by the need to use empathy and emotional energy; in other words, emotional labour.

2.2.4 Post-traumatic and secondary traumatic stress

Post-traumatic stress or Complex Post Traumatic Stress Disorder (PTSD; C-PTSD) is a mental health condition which is the result of the individual experience an event that they find highly traumatic. These traumatic events can include terrorist attacks, street violence and sexual assault. The severity of the condition varies from person to person but for some the condition can be crippling and can mean they are unable to return to their previous state of mind.

Whilst PTSD is a relatively well-known condition, there is increasing awareness of the impact of secondary trauma on individuals. This describes the impact of indirect exposure or experience of a traumatic event. As mentioned earlier in this chapter, the daily working lives of nurses often involve caring for patients during difficult times and it is known that providing this care and listening to the firsthand accounts of patients who have encountered trauma can be a traumatic and emotionally challenging experience for nurses [27]. Equally, as outlined earlier, emotional labour and both surface and deep acting are often required as nurses provide care and support and try to understand what the patient has experienced. One of the factors that compounds both identification and intervention for staff experiencing secondary trauma is the wider social narrative that assumes nurses should expect and be equipped to deal with working in this context. This can impact on ability to seek and receive support.

2.2.5 Vicarious trauma

Burnout, compassion fatigue and vicarious trauma are often referred to collectively, they are theoretically distinct. Burnout, described previously in this chapter, is a psychological strain resulting from difficult conditions and can result in emotional exhaustion, decreased motivation, low mood and delivery of poor care but it is unlikely to alter core internal belief systems. Compassion fatigue is also a reaction to the work environment and like burnout can produce similar consequences. However, vicarious trauma is thought to more closely resemble a primary traumatic response, as experienced in PTSD and C-PTSD. This can have sustained impacts on self, trust, safety and regulation [28], and therefore, this should be prioritised as a concern for nurses.

Vicarious trauma is considered with the impact on professionals who support those who have experienced trauma. It refers to the undesirable outcomes associated with this work, resulting from listing to and observing the effects of trauma from those who have received, as well as reviewing case files and evidence and being involved in providing a response, in relation to providing care and nursing intervention (Office for Victims of Crime). It is also known that clinicians may experience moral distress which can result from ethical conflicts, sometimes resulting from their own beliefs, values, and attitudes, and also from institutional limitations on the extent of care they can provide [28].

Vicarious trauma is a product of the therapeutic relationship, whereby the ability to provide empathic care to the patient produces harm to the nurse. Whilst there is a risk of experiencing vicarious trauma generally in nursing, it is thought that some settings are more likely to increase the risk. These include, but are not limited to, settings such as emergency departments, mental health services, substance misuse services, hospices, veteran services and sexual assault services. Here, the increased risk is related to levels of exposure to people who have experience trauma.

2.2.6 Additional risk factors for the individual

Alongside the consequences of emotional labour already described, there are also some individual risk factors which are thought to contribute to poor mental health and well-being. These include some of the six dimensions Maslach [16] refers to, particularly perceived and actual workload and levels of autonomy staff hold to carry out their duties. Other risks include working patterns, which is a key concern in nursing, particularly in view of the need for shift rotation in many nursing roles. There is some evidence to suggest that working shifts in itself is a potential risk, but this can be compounded by shift length, the pattern of shifts and also how the individual has control over their shift pattern and the fit with their personal circumstances [29]. Frequency and length of breaks are also a factor as well as organisational issues such as staffing levels, the quality of relationships with peers and leaders and the wider culture within the organisation.

Staff who have pre-existing mental health problems are at increased risk of negative effects associated with emotional labour as well as those with lower levels of resilience and personal support [19]. There is also evidence that staff from minority ethnic backgrounds are generally at greater risk of poor mental health [19].

2.2.7 Positive consequences of emotional labour

It must be noted that whilst emotional labour is a central feature of nursing, there are wide ranging benefits to the individual nurse of providing high quality, compassionate care. Indeed, empathic interactions with service users can bring about a feeling of pride and personal accomplishment, as well as having a motivational and energising impact on the individual’s work [19]. Equally, it is suggested that nurses who work with those who have experienced trauma are sometimes protected from negative outcomes on their emotional well-being. This can be accounted for by the sense of care they provide, but also by the policies and protocols which govern practice in these complex areas and wider organisational support, which will be explored later in this chapter.

As mentioned previously, nurses are often drawn to the profession due to a desire to make a difference in the lives of their patients and are recruited on the basis of showing caring and compassionate qualities. This may explain why many nurses actually flourish when they know they are providing support to patients during their time of need. Sacco and Copel [28] refer to this as compassion satisfaction and this allows the care giver to cope with the negative aspects of their work.

2.2.8 Consequences for the organisation and profession

The negative consequences of emotional labour can have significant implications for employers in terms of staff absences, staff attrition and the delivery of poorer care, which can lead to litigation, as outlined previously. Also of great concern is the global nursing workforce shortage which produces difficult working conditions and therefore, is a key contributory factor to the mental well-being of staff.

A recent report suggests that prior to the global Covid-19 pandemic there was an international shortfall of 5.9 million nurses and many of these shortages are concentrated in low and lower-middle income countries [20]. To address this shortfall and the expected future workforce changes, it is suggested that in the next ten years 13 million additional nurses will be needed. It is accepted that the global Covid-19 pandemic has worsened the global shortage of nurses and that this has increased some of the issues outlined already in this chapter, particularly burnout, compassion fatigue and moral injury. In view of this there is a need for all countries globally to review their workforce needs and put in place measures to try to address not only retention but also desire to join the profession.

It is suggested that poor workforce planning in many countries has not only produced the significant staff shortages outlined in this chapter but has also impacted on skill mix and created a context where working conditions are not attractive to potential or existing staff [2]. Poor salary is also reported as a key factor and in recent years this has been compounded by the cost-of-living crisis facing many countries. This means that some nurses seek employment outside of the health sector in jobs with comparable salaries but less stress and better work-life balance [30].

Clearly, addressing workforce shortages and skill-mix are not straightforward and the solutions are not instant given the time it takes to train nurses, but what is key, is to retain the current workforce and support existing nurses to thrive.

2.3 Responding to emotional labour

Understanding the impact on those who experience emotional labour as part of their work is vital and this can help inform strategies to address any negative consequences. These strategies include activities at organisational and individual level.

2.3.1 Supporting staff wellbeing

It is known that in high stress environments supportive work environments can positively impact on physical mental health and well-being and also improve individual and team performance. Some of the key ways to support staff well-being include making time for team-based activities which can be in the form of formal meetings as well as more informal events. Given the changes to working conditions for many staff, particularly since the global Covid-19 pandemic it is important that staff who work from home in a hybrid way, as well as those who work alone are included in these. It is thought that good peer relationships improve morale but also create an environment where colleagues can identify any changes in behaviour and provide peer support when needed. It also provides an opportunity for colleagues to talk and share coping strategies or identify sources of support if needed.

Organisations need to provide mechanisms to support staff to look after their general health and well-being and this includes the provision of preventative services, including immunisation, as well as access to occupational health services [22]. It is also necessary to try to improve safe staffing levels and create working patterns and cultures that support staff and help them to thrive; this includes access to continuing professional development and supportive leadership. Where senior leaders are shown to care about their staff, this has a positive impact on staff morale but also helps leaders to identify and address actual and potential issues.

In some countries, England, for example, safe spaces have been created in some clinical areas, referred to as wobble rooms [31]. These spaces provide somewhere staff can go for a short break to have time out from the clinical area or to have a few moments with a colleague to share worries, experiences or just sit quietly. The idea behind the introduction of these spaces is to create a culture where it is acceptable for staff to express their emotions and feelings and also to receive support.

Clinical supervision has been used widely in nursing and provides a safe space where staff can talk about critical incidents or their experiences. However, given some of the challenges nurses face in relation to shift work and short staffing, this can be difficult to access. Similarly, education and training are thought to help in terms of raising awareness about physical and emotional well-being and ways to engage in self-care and access support. However, the pressures nurses face in terms of busy and demanding roles can impact on ability to access these resources.

Whilst there is a clear organisational role in creating a positive working environment, it is important for staff to look after themselves. This can include taking care of physical health by eating well and exercising, as well as having regular time off. This will also have an effect on emotional well-being. This chapter has outlined the role of nurses in providing compassionate care, and this should also apply to caring for themselves. Neff [32] refers to the concept of self-compassion, which refers to the way in which we treat ourselves. Neff suggests we should recognise that we are human and not be too hard on ourselves [32]. In doing this, nurses can become less critical and judgmental but also more resilient.

3. Conclusion

This chapter has introduced the context of caring in nursing and the need to engage in emotional labour within everyday nursing practice. Emotional labour requires surface and deep acting and can bring about positive and negative consequences for the individual. The negative consequences are of key concern in terms of the impact on the individual nurse, where a range of issues including burnout and compassion fatigue may manifest. These can bring about situations that compromise the delivery of high-quality care and are a key contributor to the current global nursing workforce, which compounds the situation further. Whilst addressing nursing workforce issues cannot be achieved quickly, this chapter has highlighted some of the strategies that may help to support nurses and address some of the negative consequences of engaging in emotional labour in order to not only retain them in the profession but to support them to enjoy their work and to deliver high quality nursing care.

Conflict of interest

The author declares no conflict of interest.