ISSN 0120—5552 eISSN 2011—7531 Vol. 34, N° 2, 2018 Fecha de recepción: 26 de julio de 2017 Fecha de aceptación: 10 de octubre de 2017 DOI: http://dx.doi.org/10.14482/sun.34.2.610.73

artículo de reflexión / reflexion article

Sandra Elena Ramos Guajardo, Paula Ceballos Vásquez^{1 2}

¹Magíster en Enfermería mención Gestión del Cuidado. Académica Departamento de Enfermería, Universidad Católica del Maule. Talca, Chile. Fono: 56—71—2203462. Mail: sramos@ucm.cl

²Dra. en Enfermería. Académica Departamento de Enfermería, Universidad Católica del Maule. Talca, Chile. Fono: 56—71—2203462. Mail: pceballos@ucm.cl

Correspondence: Sandra Elena Ramos Guajardo, Departamento de Enfermería Avenida San Miguel N 3605, casilla 617, Talca, Chile. Phone: 56—71—2203462. Mail: sramos@ucm.cl

Abstract

The objective of this article is to reflect on the impact of emotional labor on care delivery to answer the question: How is emotional labor manifested in nursing professionals?. This bibliographical research was carried out on different data bases to develop the reflection and it was divided into three sections. Emotional labor was found to be present in nursing performance and, if professionals are not qualified or prepared to tackle this psychosocial risk, they may suffer from alterations in their health, such as saturation or exhaustion. Additionally, this may indirectly impact users and therefore affect the quality of the delivered care. Hence, it is an important topic for an optimal professional development either for the labor satisfaction or the suitable functioning of health organizations. Emotional labor is a complex construct, especially for health workers, and it may become a negative aspect for workers, users receiving care, and healthcare institutions, more precisely, in their accreditation processes.

Key words: Nursing; Occupational hazards; Emotions; Emotional intelligence (Source: DeCS).

Resumen

El objetivo del manuscrito es reflexionar sobre el impacto del trabajo emocional en la prestación de cuidados para responder a la pregunta: ¿Cómo se manifiesta el trabajo emocional en los profesionales de enfermería?. Se realizó una investigación bibliográfica sobre diferentes bases de datos para desarrollar la reflexión y dividirla en tres secciones. Se encontró que el trabajo emocional está presente en el desempeño de la enfermería y si no están calificados o preparados para enfrentar este riesgo psicosocial, pueden sufrir alteraciones en su salud, como la saturación o el agotamiento. Para agregar, esto puede impactar indirectamente a los usuarios y, por lo tanto, afectar la calidad de la atención brindada. Por lo tanto, es un tema importante para un desarrollo profesional óptimo, ya sea para la satisfacción laboral o el adecuado funcionamiento de las organizaciones de salud. Se puede llegar a la conclusión que el trabajo emocional es una construcción compleja, especialmente para los trabajadores de salud, y puede convertirse en un aspecto negativo para los trabajadores, usuarios que reciben atención en instituciones de salud, más precisamente, en sus procesos de acreditación.

Palabras clave: Enfermería; Riesgos laborales; Emociones Inteligencia emocional.

INTRODUCTION

Nursing is science and art: As a science, it comprises the inherent knowledge that makes this profession an area of expertise. As an art, it incorporates the essence of caring in a sensitive way and the creativity to achieve the established goals as well as helping the users receive care.

In general, these users are in vulnerability conditions, which demands nursing professionals to look after their needs. This may expose them to intense emotions and extreme situations such as death, violence, emergencies, among others, in addition to their role responsibilities. These professionals may be affected psychologically by such aspects and this may trigger the feeling of emotional labor (1). This may be perceived as something positive or negative, so it is a psycho—social aspect that may become a risk if it is not detected and treated on time. Additionally, it is a priority to establish limits so that emotional labor does not affect the quality of performance or the health of the worker.

Emotional labor is a construct that has only been developed in the last few decades, therefore its influence on nursing professionals has been studied in an incipient way (1—3). Thus, this article is conceived with the aim of reflecting on the effect of emotional labor on care delivery in order to respond to the question: How is emotional labor manifested in nursing professionals?

CONSTRUCTING EMOTIONAL LABOR

Some definitions of psychology are given with the purpose of understanding the functioning and concept of emotional labor. Experts point out that emotions and motivations are the two psychological processes in charge of the adaptation to both the internal and external environment demands. Both processes affect the rest of areas related to human functions such as attention, memory, thought, learning and behavior (4). Thus, understanding both processes, it can be said that nursing professionals, when performing their profession, confront both internal and external demands. The internal demands are related to their individual characteristics, which are pre—stablished by their own family and training; and the external demands are directly related to their working environment. Both generate a reaction to these stimuli; which is to care for each person with a unique treatment.

Defining another important term, emotional intelligence is the intelligence composed by intrapersonal intelligence (which refers to one's own knowledge) and interpersonal intelligence (referring to one's capability to read and understand other people's moods and motivations). Together, they determine the capability of managing one's life at a satisfactory level and give an account of the high or low competence to be aware of feelings such as enthusiasm, perseverance, impulse control, empathy and motivation (4). Therefore, it is postulated that nurses should have an adequate development of emotional intelligence, more specifically in terms of interpersonal intelligence, by the time they begin their education. This is a crucial aspect because empathy is a necessary skill for every nurse and knowing how to confront users' varied emotions is a challenge. Hence, reinforcing interpersonal intelligence is of great priority during training and so, providing tools for its development. Some experts postulate that developing emotional intelligence boosts a positive status related to work, and this has an impact on the quality of the assistance and on the health of the population receiving attention (5). Emotional health implies that there should be a responsible management of moods, emotions and their own and other people's feelings, recognizing and orienting them by taking into consideration values that are divided into four basic components: self—knowledge, self—control, empathy and assertiveness (4). Analyzing this definition, nurses have the responsibility to be healthy emotionally so that they can deliver holistic care of good quality. Thus, in the nursing profession, carrying out the technique to an impeccable standard is not enough to cover the great range of functions to be completed, perhaps, it is more important to deliver a humanized care related to an adequate emotional health (6). If the components of emotional intelligence are put into practice, it can be noted that each one plays a significant role in care delivery no matter which environment or place wher nurses perform their profession: Firstly, self—knowledge, which helps to recognize the reason for studying or picking a career in this profession, what inspires their behaviors, which are their values and believes, among other aspects; secondly, self—control, that should be present in every circumstance due to the hard situations which nurses may be exposed to such as conflicts with colleagues, with other professionals or collaborators and even with users; thirdly, empathy is another relevant aspect that many experts have described as an inherent element to this profession. If a nurse does not develop empathy, she or he cannot deliver a comprehensive care (7); and finally, assertiveness, which ensures a proper charge for users and better decision—making, considering the nurses' own physical and mental health when maintaining a balance between their personal and professional life. As it is made evident, emotional labor is a multidimensional construct which refers to expressing desirable emotions in an organizational environment which affect interactions with users and could have a negative impact on workers (8). Another author points out that emotional labor corresponds to psychological processes and to behaviors, conscious or automatic, which are derived from existing organizational norms about emotion expression, emotional experience or both. They also regulate interactions implicated in the performance of the position, facilitating the achievement of organizational goals related to emotion expression that, at the same time, are associated to the achievement of other symbolic or significant operational goals of a higher order (2). Thus, when referring to a nurses' job, it is clear that emotional labor is involved because there is a constant interaction with other human beings. In such scenario, emotions are constantly flowing, certain behaviors are desired only by the fact of being a nurse, and these emotions should be managed in response to what is desired from this profession and not always from their real expression (8).

Therefore, emotional labor is present in nursing, and in contrast with other professions, the interaction with third parties is not simple as there are users which are often in state of physical or mental vulnerability (9), and in general, these relations occur in places out of their usual environment, influenced by numerous factors. When nurses play their role, all of this makes them perceive higher levels of emotional labor, so it may become a negative aspect. Hence, for nursing, it is of a great priority to study the relationship between emotional labor and care.

EMOTIONAL LABOR AND ROLE RESPONSIBILITIES

It is well known that the development of this profession offers a cornucopia of possibilities, which is a positive aspect in today's working environment. Nonetheless, all these possibilities may be considered emotional labor triggers. For instance, in pediatric care, the focus and relevance of emotions is perhaps more significant since it is work in which one human being is absolutely dependent on another and affective bonds are a fundamental part in the care. Authors explain that the death of a child may be a situation experienced in different ways, due to bonds generated during care, and this may cause the learning of life skills (10). These stressful experiences are manifested in feelings that affect perception, cognition and behavior. As a result, occasionally, there may be responses, counter—responses and evasions, such as indifference, that prevent nurses from suffering and that may cause fatigue and exhaustion (11). Another work scenario in which emotional labor may be perceived is in the oncology department, where death is witnessed on a regular basis. Authors indicate that, in this department, training and preparation for confronting death is relevant for avoiding professional exhaustion (12).

For that reason, one of the factors that influence the perception of emotional labor is the working environment, and when it is healthy, it favors the improvement of emotions management. In that sense, experts point out that a good working environment helps the management of emotional demands and promotes the workers' welfare and loyalty (13). Therefore, employers should be in charge of encouraging and supporting healthy working environments and collaborating to the bettermentimprovement of job satisfaction and organizational performance.

As the presence of emotional labor is observed in nursing professionals, the relevance of providing future nurses with tools for boosting their performance and avoiding emotional labor is suggested. One of the proposals is that, during their education, they be trained to identify and control their emotions with the aim to strengthen their emotional intelligence and that with such tools, they will be able to do their professional tasks, putting in practice their best abilities. On one hand, experts highlight the fact that emotional skills should be taught using innovative methods, out of the formal classroom environment and in small groups, to carry out reflective teaching which is focused on the patient (14). On the other hand, the results of studies about emotional labor and emotional intelligence, and their relationship with work welfare and stress, also reaffirm the idea that emotional intelligence education should be included in nursing curricula. This may help in the mitigation of serious consequences attributed to high levels of emotional labor (15), which may have harmful effects.

EMOTIONAL LABOR CONSEQUENCES FOR NURSES

As previously mentioned, emotional labor may have effects on nurses' health. There are certain emotional and cognitive aspects related to the apparition of emotional imbalance and chronical stress that should be taken into account so that they are prevented in the future. Experts highlight the fact that, when a high emotional intelligence is perceived, the worker experiences less psychological demands when facing situations like death, excessive demands, stress, etc. In addition to this, having emotional clearance and higher skills to repair and differentiate their moods, allows nurses to generate higher levels of selfrealization (16). These results clarify that the personal variables on how to manage emotions and a good development of emotional intelligence trigger positive and protective effects for these workers.

Another consequence of emotional labor is labor dissatisfaction. Researchers proposed to prove the relation between the emotional intelligence perceived and job satisfaction by carrying out a study. One of the most relevant results in such study established that the element “emotional repair” is related to job satisfaction. Its definition is understood as the individual skills to manage negative emotions by substituting them when they are felt, for other emotions that make professionals feel better (17). So, it was proved evident that when emotional labor is confronted in a positive way, it is beneficial for workers and so, emotional repair is the key for emotional management.

Depressive symptoms are another consequence of emotional labor. Some experts detected that the more emotional labor is perceived, the more depressive symptoms are present, which in turn, affects the patients' safety and the quality of attention received (18). Consequently, the negative effects of emotional labor are varied, including professional exhaustion (19), depression (18), job discharge (20), among others, and in this respect, interventions become highly significant.

HOW TO CONFRONT EMOTIONAL LABOR

One of the strategies to face this labor problem would be to assure the efficient practice of the management of human resources by implementing high performance work systems (21). This means creating nursing teams with diverse capabilities, which can be strengthened and enhanced, and in turn, will mitigate the negative effects of emotional labor.

It is essential to create support programs for nursing professionals with the aim to reduce professional exhaustion and, therefore, improve job satisfaction (20). For instance, both individual and organizational strategies exist with the purpose of confronting emotional labor. When it comes to individual strategies, one thing to be mentioned is the spontaneous regulation process, which is manifested in the situations in which individual emotional experiences and expressions match organizational requirements. This way, individuals do not make additional efforts to regulate their emotional expression (2,22—23). Another strategy to be stated is deep action, in which, individuals employ different methods to generate emotional experiences compatible with emotional expressions according to pre—stablished norms. Additionally, the last individual strategy to be mentioned is superficial action, in which case, individuals reproduce emotional expressions without experiencing a concomitant emotion (24). This strategy may lead to emotional dissonance. On the other hand, in terms of organizational strategies, there are three that can be noted. First, institutions can carry out training related to emotional expression, especially in relation to the interactions with customers or users (2, 24). Secondly, organizations may carry out direct and indirect control strategies to supervise emotional labor patterns, as they are performed in the case of other work—related behavior aspects. This way, organizations monitor the compliance of expression norms by individuals under the supervision of superiors or by the utilization of real or simulation users and customers. To add, as a third point, the values and significance encasing organizational culture and socialization are fundamental elements which can define diverse situations and the relation that each individual has with them. Hence, organizational culture conditions the evaluation that individuals make of their working environment, therefore affecting their emotional experience (2, 25).

When analyzing these methods for confronting emotional labor, on one hand, individual learning should start from the professional education process, including curricular activities, emotions management and methods for facing future work demands. On the other hand, organizations should see emotional labor as an aspect to be considered during the beginning of the recruiting process, as well as including it in programs of constant training. Therefore, this will ensure an organizational culture which encourages team work and expression of emotions.

FINAL CONSIDERATIONS

It is known that emotional labor is a complex construct and it could become a negative aspect, for the worker, for the patients receiving care as well as for the companies. So, it becomes relevant to take the necessary actions to prevent it; improving the quality of the healthcare system and the performance and management of the organization.

Responding to the question “How is emotional labor manifested in nursing professionals?”. Firstly, the theoretical evidence demonstrates that emotional labor is inherent to the nursing profession, but this construct is scarcely approached as a subject during formation, and it is only visualized by nursing professionals once they begin their career. In such scenario, they find themselves confronted by challenges when carrying out tasks such as care delivery and responding to appropriate demands according to organizational considerations.

The empirical evidence shows that emotional labor is present in the working environment, but there are factors which have an influence both on individual and organizational aspects: for instance, the level of emotional intelligence, social support, place of performance, types of users, physical and psychological demands of the position, working environment, among others.

In order to tackle this problem, it is proposed that more qualitative research is carried out, applying diverse scales to measure emotional labor in all different nursing areas of expertise. This way, professionals have solid foundations to confront psycho—social risks and identify in a clearer way all factors and variables comprised. Nursing is a profession that involves interactions and relationships with other people, so managing emotional labor is of great importance to improve the care delivered to users and the nurses' occupational health.

Funding: Universidad Católica del Maule. Conflict of interests: None to declare.

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