COMMENTARY

When Nurses Need Nursing: The Toll of Emotional Labor

Laura A. Stokowski, RN, MS

Disclosures

May 13, 2014

In This Article

Viewpoint

I have always thought of the NICU as "the best-kept secret in nursing." The babies are adorable, the work is intellectually stimulating, and there is very little heavy lifting. Like other intensive care units, however, it can be fast-paced, unpredictable, and overstimulating. It is emotionally draining to take care of sick and dying babies while at the same time trying to console devastated and sometimes angry parents. Fortunately, this element of the job is balanced by the rewards of seeing tiny, premature babies or those with serious congenital conditions thrive and finally go home, against all odds.

Over the years, the construct that circumscribes the more negative or demanding emotional aspects of NICU nursing has evolved. What we now refer to as emotional labor has been called "burnout," "compassion fatigue," "job strain," or just plain old "stress." Purists might view these as different types of distress or consequences of emotional labor, but when we stray into the notoriously subjective psychosocial domain, we can expect to find ambiguous and overlapping definitions.

Still, there is something unique about considering the subjugation of emotions associated with working in the NICU (or indeed, any highly stressful area of nursing) as a type of labor, because that is often what it feels like. And emotional labor is more than just suppressing emotions; it's also the exertion of portraying emotions that one doesn't feel, to meet the patient's or society's expectations.[2] The sheer exhausting effort of having to "keep smiling," regardless of one's true emotions, justifies the relief that is often felt when the room is empty of visitors and nurses are free to express frustration, self-doubt, or cynicism and talk over their feelings. These opportunities, however, are rare.

When I first read Cricco-Lizza's study about emotional labor in the NICU, I wondered how universal the experience of emotional labor really was in nursing. Little research has explored this topic in nurses -- it has been studied more often in customer service employees and those who have to smile for a living, such as debt collectors, flight attendants, and even cheerleaders. Is it ubiquitous in nursing? Probably, although the evidence suggests that it's not the same for everyone.

The impact of emotional labor on health and well-being shows high interindividual variability[2] and may be linked to emotional intelligence.[3,4] People have different levels of cognitive control resources, so they also have different capacities for coping with emotional labor or for being adversely affected by it.[2] Workplace factors could also figure in, as some evidence suggests that a well-functioning interprofessional team has a moderating influence on emotional labor in nurses.[5]

Unfortunately, emotional labor is not something that nurses are prepared for.[6] They aren't taught in nursing school to put on a brave face so that they can exude confidence around patients and coworkers, even when they are falling apart inside. Nurses just intuitively know that they have to do this, and with experience, they perfect the art.

But that doesn't mean we should just accept emotional labor as an inevitable part of the job and get on with our work. Emotional labor might be integral to the practice of nursing, but it impairs psychological health, and depression, absenteeism, burnout, and turnover intention are among the consequences of unrelieved emotional labor.[2,7]

Cricco-Lizza's work shows that with few outlets for nurses to discuss their emotions outside of work, and minimal opportunities to do so in the workplace, organizations have a responsibility to address emotional labor. Right now, most organizations do not screen for emotional labor, prepare nurses to deal with it, or even admit that it exists.

For starters, employers should acknowledge that "calm on the outside" day after day doesn't happen without taking a toll on the nurse. By virtue of their near-constant contact with patients and families, it is more difficult for nurses than for other healthcare professionals to escape emotional labor, and recharge their batteries for the next encounter. More research is needed to seek solutions to the problem, as well as to better understand the impact of emotional labor on nurses and nursing care.

Emotional labor isn't easily quantified, so ethnographic studies such as this one that contexualize emotional labor within the demands of a real work setting are a valuable piece of the puzzle. The best people to inform what might help nurses deal with emotional labor are going to be the nurses themselves.

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