Emotional Labor among Taiwanese Nurses

Background: Nursing staff is important health manpower in hospital. In order to provide a good quality of care to patients, nurses are indispensable. However, emotional labor may cause physical and psychological pressure on nurses and then affect the patient care. The study aims to investigate the correlations among the nurses’ status of emotional labor in order to suggest practical methods for their management, prevention, and reduction. Methods: This study was cross-sectional research design. A convenience sampling was used in a medical center located in Southern Taiwan. In this study, questionnaires such as demographic information, Emotional Labor Scale were distributed to 919 nurses. Results: The results showed nurses had high emotional labor (M=88, SD= 10.5). Age (r?.09, p?.01), and year of nursing experience (r?.10, p?.01), educational level (F?2.59, p=.05), work unit (F?6.48, p?.01?), and work shift (F?3.48, p?.01) was found to have positive and significant correlation with emotional labor. Discussion and Conclusions: The study results suggested that in order to improve the quality of medical service, nursing administrators should pay more attention to how to manage emotional relief and adaptation working stress, and improve health such as regularly exercise and so on.


Background and Significance
With the change of social pattern, service industry has become the mainstream in this economic society. In service industry, the quality of service and the feelings of customers are emphasized. Providing good quality of services to clients can increase the satisfaction of clients, establish a good image for the organization, and promote organizational efficiency. Thus, the frontline workers are often required to control, regulate, even suppress their emotion in order to provide good quality of service to the customer. This process of modifying emotion to accord with organizations' rules and guidelines is called as emotional labor (EL).
According to Hochschild's theory [1], a job requires EL when it involves the following: 1. making voice or facial contact with the public; 2. producing an emotional state in the client or customer; and 3. working for an employer that has the opportunity to control workers' emotional displays. In the health care profession, the nursing is grouped under the profession with highly EL. Nurses provide the services to the patients, and it is necessary to disguise or suppress their true feelings during the heavy working time. They are often required to maintain good attitudes and emotions to provide professional services. Any situation (including emotion) that is felt during working time often affects, directly or indirectly, their physical, mental, and behavioral state.
EL is a multidimensional and complex concept, which has been explored across vary disciplines for couple decades since the sociologist Arlie [1] provides the first definition of emotional labor as 'the management of feeling to create a publicly observable facial and bodily display' (p. 7). According to Hochschild's theory, EL is the process by which workers have to manage their feelings in order to accord with organizations' rules and guidelines to produce 'the proper state of mind in others … the sense of being cared for in a convivial and safe place' [1]. Therefore, EL may involve enhancing, faking or suppressing emotions to modify emotional expression. Based on an interactionist model of emotion, Morris et al. [2] defined EL as 'the effort, planning and control needed to express organizationally desired emotion during interpersonal transactions' (p. 987). From interactionist perspective, people comprehend emotions through their understanding of the social environment in which the emotions are experienced. Therefore, emotional experience and expression can be and often are subject to external direction, enhancement, and suppression.
According to Morris et al. [2], which focused on the level of planning, control, and skill that are required to present appropriate emotional display in organizational settings, the EL construct was conceptualized along four dimensions: frequency of appropriate emotional display, attentiveness to required display rules, variety of emotions to be displayed, and emotional dissonance.
Frequency of appropriate emotional display: Clients are more likely to do business with an organization which established affective bonds of liking, trust, and respect with the clients through employee behavior [3]. Therefore, the organization would demand the employees for regulated displays of emotion. Obviously, frequency of emotional display is an important indicator of EL. The more often a work role requires appropriate emotional displays, the greater EL of the worker will be.
Attentiveness to required display rules: It is always needed psychological energy and physical effort when the employee pay attention to display appropriate emotion the organization demanded. Therefore, the more attentiveness to display rules required, the more EL will cause. However, Attentiveness to display rules required consists of both the duration of emotional display and the intensity of emotional display. Duration of emotional display. The level of effort required for emotional displays depends on the duration of emotional display. Cordes et al. [4] reported that longer interactions with clients are associated with higher levels of burnout. The longer duration of emotional display is, the more effort and emotional labor requires. Intensity of emotional display. How strongly or with what magnitude an emotion is experienced or expressed also affect the level of EL. According to [1], in order to display appropriate emotions at work, employees sometimes must hide or fake felt emotions (surface acting) or try to experience the desired emotion (deep acting). For deep acting, the employees must actively invoke thoughts, images, and memories to induce the associated emotion [5]. Besides, emotional intensity often is difficult to fake. Therefore, the greater deep acting to be displayed, the greater effort requires.
Variety of emotions to be displayed: Due to various situations, clients, or timings, service providers may need to alter the kinds of emotions expressed to fit specific situational contexts. they have to expend huge amount of psychological energy in more active planning and conscious monitoring of their behavior. Therefore, the greater the variety of emotions to be displayed, the greater the EL will be.
Emotional dissonance: Emotional dissonance occurs when the emotional expression required to be displayed in organizations conflicts with the inner or real feelings. When the real feelings conflict with organizationally required emotions, greater control, skill, and attentive action will be needed. Thus, the greater the EL will be.
Since Hochschild extended her research on Delta flight attendants, in which she claimed that EL has negative psychological consequences, most researchers have studied the effect of EL on workers and found more negative outcomes, such as stress, emotional exhaustion/ burnout [6][7][8][9][10][11] turnover intentions [12][13][14][15], and impaired well-being [16][17][18]. However, some studies showed that the consequences of EL included positive and negative. In their meta-analysis of three decades of research on the costs and benefits of emotional labor, Hülsheger et al. [19] found that there were significantly positive relationships among surface acting, impaired well-being, and worse job attitudes, and a slightly significantly negative relationship between surface acting performance outcomes. In contrast, deep acting showed a weakly negative relationship with impaired wellbeing and worse job attitudes but a significantly positive relationship with emotional performance and customer satisfaction. Badolamenti et al [20], in their systematic review of 27 research on the EL of nursing profession, found that there were two main families of EL consequences: positive and negative. The negative consequences included emotional dissonance, worker dissatisfaction, worsening memory performance, emotional exhaustion, depersonalization. The positive consequences included organizational consequences such as better performance and quality of care, and individual consequences such as better wellbeing, job satisfaction, or self-efficacy when nurses' EL engages with patients at a personal level.

Design and Sample
In this study, a cross sectional research design was used from a medical center in Southern Taiwan. A convenience sampling frame was used to request participation by nurses. Registered nurses employed within a medical center were provided with a questionnaire at their place of employment. Data were collected from direct-care nurses except nurse managers with administrated work and new nurses with less than 3 months nursing experiences. The available Page 2 of 4 survey sample was 1048 registered nurses; 919 of them completed the questionnaires. The response rate was 87.6%.

Research Questions
The research questions addressed in this study were: 1. What are current Taiwanese nurses' emotional labor? 2. What factors are likely to influence nurses' emotional labor in this sample?

Instruments Emotional Labor Scale
The Emotional Labor Scale (ELS), developed by [21], is a 24 items, self-reported instrument developed to measure emotional labor. All items are anchored by a 5-point Likert scale where 1= strongly disagree and 5= strongly agree. All items are presented positively and scores are summed with a possible range of 24-120, with higher scores indicating higher levels of emotional labor. An internal consistency reliability estimate of Cronbach's alpha coefficient for the scale was .91 [22]. The Cronbach's alpha coefficient for this sample was .90 for the total ELS score.

Demographic data
The demographic variables comprised the factors identified from previous studies as those that could influence emotional labor. These were age, educational level, marital status, work unit, work shift, number of children, level of nursing stage, years of nursing experience, religion, and monthly income.

Procedure
Permission to conduct the research was obtained from the hospitals where the study was to be conducted. Once ethical approval and study authorization by the participating hospitals, nurses were recruited into the study. Potential participants were identified by the researchers and approached to further assess eligibility and provide study explanation. Participants were explained that data was collected by the research team. Participants were requested to complete the demographic information sheet and ELS. The participants were spend 15 minutes to complete the questionnaires.

Ethical considerations
Ethical approvals to conduct this study were obtained from the Hospital Human Research Ethics Committee in Southern Taiwan. The main ethical considerations are confidentiality. It is important to ensure that each questionnaire would be identified by a number only. Nurses were assured that all information provided would be kept in strict confidence in a locked filing cabinet during the study period and would be held for five years, after which the data would be destroyed. Data were secured on a password-protected computer file with access available only to the researcher. Full assurances were provided to all participants that all information collected were confidential and would be not disclosed to anyone other than the researcher. Nurses were also advised that no information about the project would be published in any form that would allow any individual or hospital to be recognized.
The researchers approached all eligible participants and explained the purpose of the study, data collection methods, and confidentiality issues. All participants were informed that they had the right to withdraw from undertaking the study at any time without comment or penalty. The participants were informed that no personal data would be requested that would identify them; they were assured that participation in the study would not impact on their future care.

Data analysis
Several types of statistical analyses were performed to determine the relationship between the variables. The Statistical Package for the Social Science (SPSS) version 18 was used to analyze the data. An alpha level of .05 was used to test for the significance of statistical difference. For this study, means and standard deviations was used to ISSN: 2581-3846 summarize the scores for each scale and subscales. Alpha coefficients for all scales was calculated to determine the reliability of the scales. Pearson's product moment correlation coefficients and oneway ANOVA quantified the relationship between the demographic variables and ELS scores.

Sample characteristics
Of these 919 registered nurses, 100% were female and 34% were no religion belief. In regard to education, approximately 81% had, as their highest level of preparation, graduation from the baccalaureate level. Forty percent of the sample was married and nineteen percent had two children living at home at the time of the survey. The mean age of respondents was 33 years old with an average having about 9 years experience (SD=7.4) as a registered nurse. Among clinical areas of employment, 35% of the sample was employed in medicalsurgical units, 18% in intensive care units, 14% in outpatient service, 9% in emergency units, 8% in operating or recovery units, 7% worked in maternity with the remaining 9% in psychiatric or other units. The mean hours to delay to get off work were 5 hours per week. 15% of sample attended continuous education in university at night time at the time of the survey.

Emotional Labor Scale
For the overall ELS scale, the registered nurses who responded to this survey had a mean total score of 88 (SD = 10.5) with scores ranging from 35 to 120 from a possible range from 24 to 120, which is just higher than the mean of 72 average. The data showed that nurses were exposed to a moderately high degree of emotional labor.

Correlation between Demographic variables and Emotional Labor Scale (BSES)
Analyses of correlation coefficients were conducted to investigate the potential relationships between the demographic variables as independent variables and Emotional Labor Scale as dependent variables.
Pearson product moment correlations were used to analyze the relationship between the continuous independent variables, such as age, number of children, and year of nursing experience, with the continuous dependent variables of Emotional Labor Scale (ELS). The ELS was found to have a low, positive but significant correlation with age (r=.09, p<.01), number of children (r=.08, p<.05) and year of nursing experience (r=.10, p<.01). The results indicated that nurses with longer nursing experience and older had higher emotional labor.
One-way ANOVA were used to analyze the relationship between the categorical independent variables, such as educational level, marital status, work unit, work shift, level of nursing stage, religion, and monthly income. The ELS was found to have positive and significant correlation with educational level (F=2.59, p=.05), work unit (F=6.48, p<.01), and work shift (F=3.48, p<.01). The results indicated that nurses with higher educated, outpatient service, and night shift had higher emotional labor. The ELS was found no correlation with marital status (F=1.96, p=.12), level of nursing position (F=1.08, p=.3), religion (F=1.08, p=.38), and monthly income (F=1.62, p=1.52).

Discussion and Conclusion
The results of this study indicated that the overall emotional burden of the study sample is in a high degree. The results of this study are consistent with studies that found nurses with high level of emotional labor [23][24][25][26]. Nurses are the frontline staff to contact with patients Nurses are asked to provide the good quality of service by sacrificing for their dedication and having a gentle, careful and love the spirit as the white angel. Nurses are also required to maintain a friendly attitude and positive emotion to provide a good quality of care during the time of not only the physically and busily nursing care work but also the psychological pressure such as patients' sickness and death and families' grief and troublesome. Therefore, nurses often need to cover up or suppress negative emotions to provide their professional services. The result of suppressing the negative emotion during facing patients and their family and unrelieved these negative emotions and feelings could increase the nurses' emotional labor. Moreover, advanced medical technology and information, rapidly changes of medical system, complex relationship among nurses, patients and their families, heavy nursing works, complex nursing role, and required individual and professional promotion could also increase the nurses' emotional labor.
This study showed that nurses with longer nursing experience, higher educated, worked in outpatient service, and age older had higher emotional labor which consisted with previous studies [10,[25][26][27][28]. The older the age, the higher the emotional labor may be due to the currently heavy workload and pressures of professional promotion. Nurses need to cope with not only the heavy clinical patient care and relationship with patients' family but also the stress of professional promotion. Apart from the pressure of heavy workload, nurses with age older, longer nursing experience, and higher education level also have to bear the requirements from the organization such as leadership of the caring team, the role of educators, and advanced professional promotion. These stresses could increase the emotional labor which consisted with the previous studies [23][24][25].
The nurses worked in the outpatient unit had higher emotional labor which may be due to the high amount of outpatient visits. High amount outpatient visits every day indicates nurses need to take a long time to face-to-face to deal with patients' and their families' not only physical disease but also emotional distress. The negative feelings of the sickness such as depression, anxiety, or grief increase nurses' emotional labor.
This study only studied the clinical staff of a teaching medical center in Taiwan as a research sample, so that the results of the study cannot generated to whole nursing staffs through Taiwan. Therefore, it is suggested that future research can expand the scope of research and investigation through whole country, and can also compare the nurses in different classification of hospitals, making its research results more representative.
In the conclusion, nursing staffs need to face the divers and complex working environments such as various diseases, death of grief, or professional promotion. Also, in order to caring for the patients and their families, nursing staffs need to maintain a good attitude and emotions, which leads to the need to cover up and suppress the real feelings, becoming a psychological burden. Therefore, nursing manager should adjust the manpower allocation appropriately, reduce the non-care professional work, simplify the content of the work, and increase the time of professional care. Also, to provide the courses of stress management can also relieve negative feelings.