RESEARCH ARTICLES

Emotional labor and emotion management in oncology health care teams: a qualitative study

Carla Carvalho^I; Ema Barata^II; Pedro Parreira^III; Denize Cristina de Oliveira^IV

^ISchool of Psychology and Education Sciences, University of Coimbra. Portugal. E-mail: cms.carvalho@gmail.com
^IISchool of Psychology and Education Sciences, University of Coimbra. Portugal. E-mail: emamartinsb@yahoo.com
^IIISuperior Nursing School of Coimbra. Portugal. E-mail: parreira@esenfc.pt
^IVPhD, Professor, School of Nursing, State University of Rio de Janeiro, Rio de Janeiro, Brazil. E-mail: dcouerj@gmail.com

ABSTRACT

Representations of cancer tend to be negative because of anxiety, fear, pain and loss, and the uncertainty of diagnosis, treatment and follow-up. Cancer hospitals have particular characteristics in terms of emotional states generated there, which affect the health professionals, patients and relatives who interact in them. The study objectives were to understand individual perceptions, mental representations and attributes relating to management of emotions at work. Using a qualitative methodology, six health care professionals from three professional groups at the Francisco Gentil Portuguese Institute of Oncology, in Coimbra, Portugal, were interviewed in 2008, and content analysis echnique was applied. The results show that raising levels of awareness about emotional states, combined with quality support and appropriate activities, can contribute to caregivers' well-being and quality of life. It was concluded that the results can inform the implementation of solutions to support health professionals' emotional self-regulation.

Keywords: Emotional labor; display rules; emotion regulation strategy; emotional exhaustion.

INTRODUCTION

The cancer hospital setting exhibits particular characteristics concerning the emotional states of both healthcare providers and patients. The social representations of cancer care are extremely negative as a result of the anxiety and fear, pain and loss, and the living conditions associated with a cancer diagnosis and its treatment^1-3. In addition to technical care, patients and their relatives might also require emotional support, which could be provided by the healthcare professional with whom they interact^4-6. The quality of such support and a broad awareness of emotional states might be relevant to the appropriate management of emotions by healthcare providers⁷, particularly concerning the perception of confidence and professionalism, improvements in their professional performance and job satisfaction, the establishment and/or maintenance of a stable and quiet environment, emotional control/regulation, the reduction of emotional stress, maintaining the self-esteem of both healthcare providers and patients, and global improvements in organisational performance.

The aim of the present study was to understand the individual perceptions and mental representations of and the attributes associated with the management of emotions in the workplace.

LITERATURE REVIEW

In their working lives, many professionals are required to confront situations and scenarios that impose substantial emotional demands and stress; this is certainly the case for healthcare providers, particularly those who tend to cancer patients. Their work recurrently compels them to confront pain, suffering, and losses under circumstances that have substantial effects on the management of their and their patients' emotions⁸. Clearly, such professionals are exposed to a wide variety of psychosocial factors in the workplace, from the risks and stressors common to all caregivers to the emotional demands derived from excessive work, problems in their interpersonal relationships with patients, co-workers, and supervisors, the need to perform multiple tasks under time pressure, and a lack of control over the planning of their own work^9,10. The combination of work-related contingencies and emotions, affects, and feelings of anxiety, anguish, fear, and uncertainty might interfere, to a greater or lesser extent, with the lives and professional performance of healthcare providers in the hospital setting¹¹. Those professionals need to cope with many different psychophysiological states at various stages, from medical visits to diagnoses, surgical procedures, postoperative periods, and treatments. Under such conditions, their emerging feelings exhibit a broad scope of modulations with respect to intensity, frequency, duration, and variety.

Instances of cancer also have substantial impacts on patients, who must undergo very difficult situations that might affect their self-image, cause feelings of uncertainty, disappointment, revolt, and anger, and induce changes in their patterns of social relationships, depressive symptoms, and regressive behaviour^12,13, as they consecutively face a diagnosis of disease, its treatment, and secondary physical effects. The reactions exhibited by individuals suffering from cancer unavoidably render them difficult patients⁸, who induce feelings of anger, absence, empathy, and depersonalisation in their healthcare providers^14,15. Some patients go as far as to demand over-engagement from their healthcare providers, primarily as a function of the latter's past experience¹⁶. For those reasons, it is crucial for healthcare professionals to become able to manage these types of situations by establishing an appropriate balance between the distance required to conserve their objectivity in action and the proximity necessary for the patient to perceive a supportive relationship with his or her provider¹⁷.

After many years of work in the cancer care setting, our primary hypothesis is that gathering knowledge on the emotional context in which healthcare providers perform their work, as well as their self-perceptions of how they cope with emotions, might allow for the development of supportive and monitoring strategies with the potential to improve their personal and professional performance and, finally, their wellbeing and efficacy.

METHODS

The present study adopted a qualitative, phenomenological approach using interviews and the content analysis technique ¹⁸ to organise, encode, categorise, analyse, and make inferences from the collected data. Six healthcare professionals from an oncology service were interviewed; that number was selected on the basis of the staff organisation at that service, which includes three types of professionals, namely, healthcare assistants, nurses, and doctors. The interviews were conducted in 2008 at Francisco Gentil Portuguese Institute of Oncology of Coimbra, Coimbra, Portugal. The inclusion criteria were as follows: professional category; more than six years of professional experience; gender variety; and the ability to serve as a professional reference for the corresponding function.

The interviews were conducted on an individual basis based on a script we designed to achieve the aims of the study. Thus, the interviews investigated the participants' recognition of emotions, emotional states, and emotional stress within the organisational context, their reflections on the possible relationship between emotional stress and professional performance as well as those between emotion management and individual, staff, and organisational performance. Participants were identified by the letter "I" (interviewee) and a number (e.g., I1, I2, I3, I4, I5) to protect their anonymity. The average length of the interviews was approximately 51 minutes, and we had a total of five hours and 11 minutes of recorded statements.

The content analysis was performed following the methodology of the authors regarded as a reference in this field^18-21. For the purpose of categorisation, the structure of the analysis comprised dimensions and concepts. Categorisation was based on the theoretical framework, and the recording units were classified as a function of their orientation and attributed to a concept and a dimension. In addition, we also accounted for the possibility that the orientation of the discourse would exhibit a tendency for the recording units to converge on a positive, favourable sense, characterised by approximation/concordance, or conversely, on a negative, unfavourable sense, characterised by detachment/discordance.

The analysis was performed in several steps, including an initial reading of all interview transcripts with the aim of grouping responses according to common themes and the detection of individual particularities. The rule of exhaustiveness compels one to consider all of the elements of a corpus, and for that reason, all of the interviews were considered for categorisation and content comparison according to a matrix of analysis^18,21.

Three dimensions were considered for proper content analysis: emotions, emotional stress, and emotion management. As expected, the interviewees made quantitatively different contributions to the content.

Regarding ethical considerations, we asked the institution for formal authorisation to conduct the study. The participants were informed of the aims of the study and that interview content would be analysed for scientific purposes. They were further informed that their rights of self-determination, intimacy, anonymity, and confidentiality were ensured. After they consented to have the interviews recorded, the recorder remained visible throughout the interviews.

RESULTS AND DISCUSSION

The main results, based on the counting of recording units (RUs) and a content analysis organised according to the three dimensions of interest are described in Figure 1.

FIGURE 1: Matrix of simple results relative to the concepts extracted from content analysis, Coimbra, Portugal, 2008.

Emotion management, emotional stress, and emotions

Nearly half of RUs corresponded to the dimension of emotion management (49.60%), which is unsurprising, as all of the interviewees had substantial working experience that allowed them to make valid and feasible proposals, as Figure 1 reflects. Additionally, the relative weight of the RUs corresponding to emotional stress was significant (36.76%). Concerning the dimension of emotions, the largest number of RUs indicated the interviewees' need to illustrate the experiences they had undergone; however, the overall difficulty they experienced in defining emotions was remarkable (13.64%), as Figure 1 indicates. The observation that the lowest number of RUs corresponded to the emotional dimension might be attributable to the difficulty the interviewees experienced in conceptualising them.

Regarding the professional context of the study, the categorisation corroborated some of the stated expectations²² concerning the set of features associated with emotional states.

The establishment of emotional states is based on neurophysiological and biochemical phenomena as well as on factors related to an individual's personality. The interviewees' narratives included explicit references to that relationship, as they not only frequently admitted that individual differences represent the true basis of numerous complex emotional situations but also clearly identified the organic consequences of the emotions experienced in the work environment. References to "the psychological factor", changes in behaviours and attitudes, and individual differences were common and may be illustrated by the following statements:

[...] the psychological factor is the heaviest one because we incorporate the idea that disease might be healed, but it's too heavy a load, something very complicated, and it's hard to witness people suffering over long periods of time […] until they die. (I4)

In my case, my sleep pattern was seriously altered, but that started after my first experience with death. (I1)

Uncertainty distinguishes between anxiety and fear. Work at a cancer hospital is characterised by the instability of the patients' health and unpredictable events, which give rise to strong dynamics in workers' emotional states. The fear of being unable to cope with the most complex situations or the most painful personal and family contexts might be a source of substantial anxiety for healthcare assistants. That aspect can be represented in the following statements:

[...] I remember this one patient with coronary disease, his condition was pretty much stable […] and even had chances of surviving […] He had a cardiac arrest; it could not be remedied, and […] he died. (I3)

Fear, I mean, not something physical, a fear of not being able to overcome that situation, those doubts, [… ] that wall, [and achieve] that goal. (I4)

Positive and negative expectations are enmeshed with the orientation of care as well as with the establishment of strategies to cope with emotional states. Working at a hospital is fraught with expectations resulting from service norms, performance assessments, medical protocols, therapeutics, and treatments. In addition, all of the personal and professional expectations derived from the individual's professional and life experience and projected onto the workplace also play a role. Taking those factors into account, we were able to establish that the interviewees recurrently employ strategies to cope with their emotional states, namely, accommodation, a focus on technical features, and abstraction.

I remember this 16-year-old kid, who was admitted to the service, we were bathing him, the nurse and me, and he asked him, 'So, Daniel, what do you want to be when you grow up?' He turned to the nurse and said: 'I won't get there, why are you asking me that?' (I5)

The perception of wellbeing involves cognitive and affective processes (learning, memory, rationalisation, and emotional processes). The self-perception of wellbeing is a subjective process shaped by affective and cognitive components. In the present study, particular context-related features are liable to shape this assessment as a function of the impact of the emotional states. Although the interventions performed by doctors, nurses, and healthcare assistants are perfectly defined, and for that reason might be subjected to objective assessment, caring for cancer patients also includes a significant interpersonal and supportive component that is difficult to assess via standards.

Then, sometimes you get to think: 'Today I worked like a dog, but it seems I did nothing'. But at the end of the day, when you pass by and someone says, 'Well, madam, nurse, till tomorrow! We'll wait for you here!' So, maybe I did […] perhaps I actually did something but didn't realise. (I3)

It is possible to observe a relationship between emotion management and the levels of individual, group, and organisational performance. All of the interviewees demonstrated an awareness of the existence of a relationship between emotion management and the various levels of performance in the cancer hospital organisation, namely, improved conflict management, a better professional atmosphere, gains in performance, improved interpersonal relationships, and greater consistency in goal-centred work.

Yes, I think. Because, you know, if we get to manage emotions so that everybody feels fine, right? Without conflict, misunderstanding, I believe that if I'm OK with someone, with anyone I'm with, our work will be better. (I3)

Not because of the patient's recognition as such, but because of the social and organisational recognition, which actually is no better. But I believe that […] I mean, to invest in the relationship and to have well-defined goals relative to what truly matters and that might truly result in better provision of care, that was important. (I6)

We must be well, so that we might help one another; if we're not well, we can't give the best of us to others […] (I1)

Interpersonal communication is deeply affected by the expressive and behavioural features of emotions. Professional performance in cancer care is highly relational and demanding with respect to communication. Communication involves technicians, patients, and their relatives within a network characterised by complex relationships, situations, and emotions. On various occasions, the interviewees reported that interpersonal communication is influenced by emotional states:

Because, as there's little communication, and some systematically believe they're better than the others and that their ideas are the ones that should be carried out, that stuff sometimes gives rise to conflict, even between professional categories. It's not about people within the same category. Things should be organised better. (I5)

I think that, although I believe that emotions have much to do with personal stuff, with one's personality […], the true essence, to me, is the relationship. (I3)

Strong emotional experiences might be associated with deep existential questions related to the meaning of life and the reformulation of one's life trajectory. This aspect could be discerned in the interviewees' narratives, as some among them had substantial professional experience and previously worked at other services or hospitals. Their personal experience led the interviewees to call their ability to adapt to the specific demands of their actual or intended job into question, as shown below:

Yes. When I was there [paediatric service] I had to cope with very difficult situations. What I want more in life is to become a mom, but while I was working at the paediatric service, I'd say: I don't want to. It was a major emotional fight in terms of feelings, because on the one hand, that was and still is what I want most, but I saw so much stuff that I got so scared […] (I4)

An awareness of one's emotional states and identifying the attitudes associated with them might provide grounds for the development of valid strategies to cope with emotional stress. Our decision to select professionals with significant experience meant that they were able to identify strategies to cope with emotional stress while accounting for the emotional load to which they are exposed on a daily basis. The following examples emphasise systematisation, rigour, a goal-centred approach, and the organisation of work:

One of the things that I believe might help us […] is things being truly well organised. Having good group dynamics and people knowing what they have to do and for what purpose they are there. (I1)

[...] others spoke about the need to go out, play a sport, dance, and listen to music. From the perspective of the development of strategies, the need to promote active dialogue and sharing at various levels was mentioned with an eye to the definition and division of tasks, assessment of situations, training, and individual and staff support according to the perceived needs. (I4)

Someone the professionals could talk to, go and talk about their problems, or about a situation at the workplace, a misunderstanding with a colleague, or the boss, or a patient, you know… go there and check: perhaps I'm the one who's not well? Or is it the other person who's not well? To try and help […} I believe that was good. (I2)

Working at a cancer hospital might give rise to emotions associated with specific situations and are thus somewhat expectable. In this regard, the interviewees mentioned the following emotions: sadness, fear, anguish, joy, patience, calm, balance, sensitiveness, affectivity, love, happiness, revolt, pity, anxiety, emotiveness, shock, and tragedy.

The nature of such terms allows us to expect that emotions are doubtless integral components of human and organisational life²³. In another sense, we also observed that affective dimensions affect organisational behaviour²⁴ as a function of the influence that emotions exert on interactions^22-24. We were able to establish that the interviewees recognised the potential psychological effects that emotions have on human beings at the individual (wellbeing), group (interactions), and organisational (performance) levels²⁵. The interviewees reported that emotional states interfere with the atmosphere, interpersonal relationships, career decision-making, commitment, and motivation at work²⁶. Regarding the management of emotions, as the interviewees did not report being aware of any formal institutional mechanism for regulating emotions, we expected to observe instances of informal regulation^27-29. We noted that such informal regulation was primarily based on personal experience or internal control of interactions among the staff and with patients and their relatives.

In the present study, the expression of emotions considered desirable for organisations during professional interactions and in interpersonal relationships in the professional context acquired particular meanings as a function of the institutional context, i.e., a cancer hospital. Emotions are expressed within a complex context of interactions and critical decisions, in which vital variables play a major role. As a result, the term "desirable emotions" is attributed to emotions that are controlled by either surface acting or deep acting, and the nature of these emotions is often quite different from that of the emotions actually experienced and reflects attempts to stabilise the atmosphere in which one interacts with patients, their relatives, and other professionals. An example is provided by the following transcript:

It has a negative impact because, when we aren't well, we must make a lot of effort to pretend to the patient that we're well. We have to put a mask on because we must look well to the patient, even when we are not; we can't let the patient notice because, if we do, he's ill, he's suffering, and we're sad and showing […] it would make the patient's discomfort worse. (I3)

In the present study, we recognised four means of regulating emotions²⁷, which account for the interaction among emotional, cognitive, and behavioural features: 1) neutralisation, whereby the appearance or increase of emotions is prevented; 2) buffering, which consists of the distribution of emotions across compartments so as not to hinder the performance of on-going activities; 3) the recommendation of socially acceptable means of expression; and 4) normalisation, whereby emotions are reframed in a manner amenable to conserve the status quo.

After analysing the results based on the relevant features of a theoretical model that allows emotions to be described in the terms of frequency, duration, intensity, and dissonance³⁰, we noticed that the frequency and intensity of emotional states can exhibit significant variation, their duration can be quite long, thereby having substantial consequences for an individual's life and giving rise to deep existential questions, and these emotions are often dissonant due to individuals masking or replacing feelings regarded as negative.

Over time, the emotional labour demanded from healthcare providers in the cancer hospital setting might result in poor individual and organisational performance; however, this could be remedied by implementing strategic interventions at the individual, group, and organisational levels.

The intervention strategies at the individual level involve the acquisition and development of emotion management skills, such as taking brief pauses at work, establishing real and feasible goals, and developing self-control techniques and strategies for active adaptation^31,32,33. In this regard, enhanced empathetic skills and attempts to understand the impact that cancer has on patients represent potential coping strategies ¹¹, provided that they are accompanied by an increase in the healthcare professionals' awareness of their own emotional states.

At the group level, actively seeking social support from colleagues and supervisors in the workplace is liable to induce changes in negative attitudes and behaviours in interactions with others, reduce emotional exhaustion, and increase the feeling of self-accomplishment at work^32,34.

At the organisational level, prevention programmes and strategies intended to improve the organisational environment and atmosphere are of the utmost importance³⁵ and include recruitment and selection programmes that make it possible to identify professionals with emotion expression styles that are the most well suited to organisational norms concerning communication with the general public and interactions with patients; anticipatory socialisation programmes; emotion management training programmes; increased autonomy in the workplace; the promotion of active employee participation in decision-making; improvements in the quality of the physical environment in the workplace; the reallocation of tasks to reduce work overload; and access to specialists to assist healthcare professionals (e.g., psychologists, therapists, emotion management support offices) ^{8,32,33,35,36}.

CONCLUSIONS

The results of the present study provided a broader understanding of its subject and have the potential to stimulate the creativity of researchers in formulating working hypotheses concerning professional settings that require high levels of emotional labour.

Given the emotional labour demanded from healthcare providers in a cancer hospital setting, it is likely that the individual, as well as organisational, results will deteriorate over time. However, such issues might be controlled or even reversed by implementing diversified intervention strategies at the individual, group, and organisational levels.

The actions that we provide at these various levels might contribute to improved perceptions of confidence and professionalism, employees' professional performance and job satisfaction, the establishment and/or maintenance of a stable and quiet environment, a reduction in emotional stress, the maintenance of the self-esteem of both healthcare providers and patients, and global improvements in organisational performance.

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