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The frontline nurses´challenges fighting against COVID-19: Nursing Emotional Labour Performance

Authors:
Paula Diogo at Escola Superior de Enfermagem de Lisboa
Paula Diogo
Odete Lemos at Escola Superior de Enfermagem de Lisboa
Odete Lemos
Joana Rodrigues at Administração Regional de Saúde de Lisboa e Vale do Tejo
Joana Rodrigues
  • Administração Regional de Saúde de Lisboa e Vale do Tejo
Márcia Leandra Ferreira Santos at Escola Superior de Enfermagem de Lisboa
Márcia Leandra Ferreira Santos
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Abstract

Objectives: Understand the nurses’ challenges in the frontline fighting against COVID-19; Identify emotional management strategies in the caring process; Analyse the nursing emotional labour performance. Method: Qualitative, descriptive, and exploratory research. The research encompassed 15 experienced nurses who provided nursing care to child, juvenile, adult and elderly people, from health institutions in the Lisbon region, Portugal, who expressed their willingness to participate in the defined time frame, using a convenience sample. The data was collected using self-report techniques, 15 written narratives and focus group. Conventional content analysis, building a categorical tree by inductive reasoning and reports comparison. Results: The qualitative data was organised into 4 categories: 1) nursing daily basis challenges experienced; 2) emotionality and reactivity inherent in the care provision; 3) emotional labour of nursing during the care process; 4) development opportunities arising from the emotional challenges. Discussion: The challenges faced by nurses at caring organizational level are highlighted, with virus exposure risk and work overload, in an environment demanding performance and adaptation in a short period of time, which are aligned with the anxiety sources among health professionals(1). Nurses faced a deep emotional experience providing care, which is associated with fear, anxiety, insecurity, stress, anguish, powerless, sadness, anger, frustration, and uncertainty. This can be an intense and lasting emotional experience and may have negative consequences on their mental health(2). Regarding the emotional reactivity, they have shown physiological changes as responses to trauma and interpersonal conflicts(3). In relation to infected patients, the participants describe extreme negative reactivity or passivity and denial reactions(4). Respecting to emotional labour in the caring process of COVID-19 infected patient, its shown that performance is fundamental for effectively handle challenges, managing disturbing emotions and creating knowledge out of the experience. These results are in line with the triple centrality of emotional management, which characterizes emotional labour of nursing: focus on the client, the nurse, and the nurse-client relationship(5). Participants referred that development opportunities would be stimulated with discussion groups, psychological support, sharing of feelings, and the existence of online platforms for frontline nurses, which is also confirmed by other studies. This research broadens the understanding of the emotional labour of nursing, identifies nurses’ emotional challenges and proposes a framework of emotional management strategies in a pandemic scenario. The results defy the nursing managers to consider nurses' needs in the teams’ leadership and organization of work. (1)https://jamanetwork.com/journals/jama/fullarticle/2764380 (2)http://search.ebscohost.com/login.aspx?direct=true&db=ccm&AN=142434437&lang=pt-pt&site=ehost-live (3)http://search.ebscohost.com/login.aspx?direct=true&db=mdc&AN=28962540&lang=pt-pt&site=ehost-live (4)http://search.ebscohost.com/login.aspx?direct=true&db=mdc&AN=32179380&lang=pt-pt&site=ehost-live (5)http://pensarenfermagem.esel.pt/files/2. páginas-21-40.pdf
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24th International Nursing Research Conference
12th november| 15.30-17.30h
Gender and Health CODE 20057
The frontline nurses´challenges
fighting against COVID-19: Nursing
Emotional Labour Performance
Research Line EMOTIONS IN HEALTH - ESEL/UI&DE
Team work
There is no conflict of interest
Objectives
•Understand the nurses’ challenges
in the frontline fighting against
COVID-19
•Identify emotional management
strategies in the caring process
•Analyse the nursing emotional
labour performance
Nursing has a strong technical component, but also cognitive, relational and emotional. Emotions play a
fundamental role in an individual's mental development. In this way, a need to understand emotions
experienced by oneself emerges.
Emotional Labour –Pam Smith
•Fundamental in nursing care
•Affective-emotional dimension
•Management of negative emotions and feelings, so
that they become a non-disturbing experience
(which minimizes suffering) or with positive
nursing results for the people being cared for
•Emotional and humanized care
•Satisfaction and gratification
Arlie Hochschild
(1983, 2003)
Sociology
Pam Smith
(1992, 2012)
Nursing
Patient and
professional
focus
Extra, Inter
and
Intrapersonal
Positive effect
perspective
(Diogo & Mendonça, 2019)
Method •Qualitative, descriptive, and exploratory research.
•The research encompassed 17 experienced nurses
who provided nursing care to children, adolescents,
adult and elderly people, from health institutions in
the Lisbon region, Portugal who expressed their
willingness to participate in the defined time frame,
using a convenience sample.
•The data was collected using self-report techniques,
17 written narratives and 1 focus groups.
•Conventional content analysis, building a categorical
tree by inductive reasoning and reports
comparison.
FINDINGS
The qualitative data was organized into 4 categories:
1) nursing challenges
experienced in combating
COVID-19
2) emotionality and reactivity
inherent in the care provision
3) emotional labour of nursing
during the care process
4) development opportunities
arising from the emotional
challenges
4 Categories
1. Nursing challenges experienced in combating COVID-19
•Possibility of contagion hovers in teams
•Use of personal protective equipment
•Complexity of the patients' situation
•Demanding adaptation to new care dynamics
•Transformation of services and teams
•Accumulated tiredness and physical exhaustion
•Separation from the family to prevent contagion
•High emotional load and mental exhaustion
Emotions experienced by nurses
•Anticipated fear, anxiety and insecurity
•Fear of getting infected
•Fear of spreading to family and loved ones
•Anxiety, restlessness and apprehension,
anguish, impotence, sadness, revolt, frustration,
uncertainty
•Feeling of danger, feeling of isolation,
depersonalization feeling
•Intense stress
Nurses' emotional responses
•Negative reactivity
•Physical and relational distance
•Change in emotional state and behavior within
the team´s relationship
•Physiological changes
Emotional responses of patients with
suspected or diagnosed COVID 19 and
family
•Negative and exacerbated reactivity
•Passive reactivity, understanding and
collaboration
•Manifestation of the lack of gaze, smile and
human presence
2) Emotionality and reactivity inherent in the care provision
Factors that hinder the
performance of emotional
nursing labour
•Perception of dehumanization of care
•Impediments to affective and
welcoming care (restriction of touch,
hug, invisible smile)
•Barrier of individual protective
equipment
•Glass barrier
•Difficulty in emotional management
Factors that facilitate the
performance of emotional nursing
labour
•Support and emotional support within
the team
•Team experience gives security
•Recognition of nurses and nursing care
Emotional labour performance: focus on
the patient and the nurse-patient
relationship
•Build a relationship of trust and closeness
•Mobilize emotional management strategies during
care (availability to help; empathy and sensitivity to
the experience of emotions; promoting tranquillity
through conversation and explanation; promoting
emotional comfort and human touch)
•Provide conditions for patients to ask questions and
vent feelings
•Interaction that emphasizes small gestures but that
are great strategies for managing emotions
•Optimize interaction using gestures, voice, look and
also through technology
•Use music, dance, good mood and play
Emotional labour
performance: focus on the
nurse
•Mobilize positive and adaptive
emotional management strategies
•Transform the experience positively
•Mobilize relief and relaxation
strategies
•Enlist the support of family and friends
•Try to occupy oneself in their free time
3) Emotional labour of nursing during the care process
Experience of growth and
transformation
•Awareness of a challenging but
transforming and growing reality
•Growth through sharing, learning and
inner revelation
•Individual and team resilience - learn,
overcome and grow with the situation
Adaptation over time and
experience
•Adaptation over time
•Need to adapt to a new reality of
care
•Increased organization effectiveness
and restructured care
•Adaptation facilitated by security
and support
Increased cohesion and sense of
belonging in a new normal
•Formation of cohesive and excellent
teams in the new normal
•Relaxed moments of sharing to ease
tensions
•Support and empathy among
colleagues
•Growing confidence within the
multidisciplinary team
Strategies to enhance development
and emotional well-being
•More consideration for nurses' suggestions
and feelings at institutional level
•Training activities
•Psychologist support outside the institution
•Group meetings to share experiences and
vent feelings
•Creation of a website (space for sharing
and discussing care situations; support
groups; writing about the experience;
anonymous space for sharing emotions)
4) Development opportunities arising from the emotional challenges
“Without knowing how to manage emotion,
none of the remaining competences are
supported ”.
(Cury, 2018, p.8)
References
1. Shanafelt T, Ripp J, Trockel M. Understanding and Addressing Sources of Anxiety among Health Care
Professionals during the COVID-19 Pandemic [Internet]. JAMA - Journal of the American Medical Association.
American Medical Association; 2020. Available from:
https://jamanetwork.com/journals/jama/fullarticle/2764380
2. Lai J, Ma S, Wang Y, Cai Z, Hu J, Wei N, et al. Factors Associated With Mental Health Outcomes Among
Health Care Workers Exposed to Coronavirus Disease 2019. JAMA Netw open [Internet]. 2020 Mar
2;3(3):e203976. Available from:
http://search.ebscohost.com/login.aspx?direct=true&db=ccm&AN=142434437&lang=pt-pt&site=ehost-live
3. Creighton G, Oliffe JL, Ferlatte O, Bottorff J, Broom A, Jenkins EK. Photovoice Ethics: Critical Reflections
From Men’s Mental Health Research. Qual Health Res [Internet]. 2018 Feb 1;28(3):446–55. Available from:
http://search.ebscohost.com/login.aspx?direct=true&db=mdc&AN=28962540&lang=pt-pt&site=ehost-live
4. Asmundson GJG, Taylor S. How health anxiety influences responses to viral outbreaks like COVID-19: What
all decision-makers, health authorities, and health care professionals need to know. J Anxiety Disord
[Internet]. 2020 Apr 1;71. Available from:
http://search.ebscohost.com/login.aspx?direct=true&db=mdc&AN=32179380&lang=pt-pt&site=ehost-live
5. Diogo P, Mendonça T. Emotional labour in healthcare: a scoping review of literature. Pensar Enferm
[Internet]. 2019;23. Available from: http://pensarenfermagem.esel.pt/files/2. páginas-21-40.pdf
... Nurses participate in raising public awareness, prevention, screening, monitoring, and direct care of Covid-19 patients (Nanthini & Jeganathan, 2021;Sharma et al., 2020). During the performance of their jobs, nurses are exposed to the potential risk of infection or transmission of the infection to their loved ones or patients (Deressa et al., 2021;Diogo & Lemos, 2020;Nanthini & Jeganathan, 2021;Sharma et al., 2020). The high risk of infection is confirmed by the statistics of the Czech Medical Chamber (CMC); as of 4 October 2020, the CMC recorded 1,021 Covid-19 infected doctors and 1,984 infected nurses; during one week in October, the number of infected nurses increased by 323 (IHIS CR, 2020; Kubek, 2020). ...
... Nurses must cope with a variety of stressors. The following are commonly mentioned stressors: high risk of exposure to infection, working for long periods of time in protective equipment, constant adaptation to changes in the work environment and in the work team, the health and social situation of patients, accumulated fatigue, lack of sleep, exhaustion, isolation from family, and emotionally demanding work (Diogo & Lemos, 2020). High public expectations and public pressure, new work tasks, high mortality, the nature of Covid-19 disease and its high infectivity, psychosocial stress, lack of personal protective equipment, high job demands, and lack of adequate psychological counselling (Alwani et. ...
... Although the aim of employing nursing students and volunteers was to reduce workloads, the nurses did not always appreciate the contributions of such students and volunteers, and the presence of students in the workspace was also perceived as a source of stress because teaching nursing skills is often time-consuming. All of the above-mentioned factors can contribute to the development of burnout syndrome, which can significantly interfere with the successful practice of the nursing profession (Diogo & Lemos, 2020;Maben & Bridges, 2020;Sharma et al., 2020). ...
Nurseʼs mental health during Covid-19 pandemic
Article
Full-text available
  • Mar 2023
Aim: The aim of the research was to ascertain the feelings of frontline nurses during the Covid-19 pandemic. Design: Qualitative research using a phenomenological approach. Methods: Qualitative research using a phenomenological approach was carried out with eight nurses working with Covid-19 patients in a hospital and in a seniors home in Kladno, in the Central Bohemia region of the Czech Republic. Two diagrams, which show ties between identified categories, were generated based on results. Results: External stresses during the first wave were: lack of information, lack of protective equipment, different attitudes towards the pandemic management. During the third wave, they were: lack of nurses and other medical personnel, overwhelming of the healthcare system, too much administrative work, and long working hours spent in protective gear. The stress-reducing factors revealed after the first wave were: solidarity and gratitude expressed by society. During the third wave, nurses noted greater self-confidence and pride, better interpersonal relationships. Conclusion: The effective management of stressors in the pandemic period can contribute to better healthcare. Therefore, we should pay more attention to describe of them in future.
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... Nurse are frequently exposed to infections as well as the potential to transmit the infection to loved ones or patients [6,8,5]. ...
Opinions of citizens of the Czech Republic on the role of nurses in primary care during the COVID-19 pandemic
Article
Full-text available
  • Mar 2023
Introduction and objective: In spite of the general current decrease in COVID-19 incidence, the epidemiological situation on the territory of the Czech Republic is still unfavourable. Nurses play an essential role in the fight against this disease. Material and methods: A non-standardized questionnaire was used to discover the expectations regarding nursing care provided during the COVID-19 pandemic. The sample of respondents was constructed using quota selection. The sample consisted of 1,815 respondents. Results: The study identified a significant correlation between the age of respondents and the method used to contact general practitioners (p < 0.001). The oldest respondents (65+) more likely contacted GPs by phone. Respondents with basic education used outpatient services more often before than during the pandemic (p < 0.05). The behaviour of nurses was considered as professional and accommodating. The oldest respondents (65+) reported nurses did not to make them feel rushed. Other age groups rated nurses more critically (p < 0.01). Respondents, especially women, described the psychological burden on nurses during the COVID-19 pandemic as demanding (p < 0.01). Women, more than men, reported that nurses lacked protective equipment during the pandemic (p < 0.05). The use of an online system was significantly influenced by respondent education (p 0.001). Respondents with lower education were less likely to welcome this option. Conclusions: Due to the persisting COVID-19 incidence on the territory of the Czech Republic, citizens` opinions of the position of nurse in primary care in the period of COVID- 19 pandemics need to be known.The behaviour of nurses was considered to be accommodating and satisfactory.
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Factors Associated With Mental Health Outcomes Among Health Care Workers Exposed to Coronavirus Disease 2019
Article
Full-text available
  • Mar 2020
Importance Health care workers exposed to coronavirus disease 2019 (COVID-19) could be psychologically stressed. Objective To assess the magnitude of mental health outcomes and associated factors among health care workers treating patients exposed to COVID-19 in China. Design, Settings, and Participants This cross-sectional, survey-based, region-stratified study collected demographic data and mental health measurements from 1257 health care workers in 34 hospitals from January 29, 2020, to February 3, 2020, in China. Health care workers in hospitals equipped with fever clinics or wards for patients with COVID-19 were eligible. Main Outcomes and Measures The degree of symptoms of depression, anxiety, insomnia, and distress was assessed by the Chinese versions of the 9-item Patient Health Questionnaire, the 7-item Generalized Anxiety Disorder scale, the 7-item Insomnia Severity Index, and the 22-item Impact of Event Scale–Revised, respectively. Multivariable logistic regression analysis was performed to identify factors associated with mental health outcomes. Results A total of 1257 of 1830 contacted individuals completed the survey, with a participation rate of 68.7%. A total of 813 (64.7%) were aged 26 to 40 years, and 964 (76.7%) were women. Of all participants, 764 (60.8%) were nurses, and 493 (39.2%) were physicians; 760 (60.5%) worked in hospitals in Wuhan, and 522 (41.5%) were frontline health care workers. A considerable proportion of participants reported symptoms of depression (634 [50.4%]), anxiety (560 [44.6%]), insomnia (427 [34.0%]), and distress (899 [71.5%]). Nurses, women, frontline health care workers, and those working in Wuhan, China, reported more severe degrees of all measurements of mental health symptoms than other health care workers (eg, median [IQR] Patient Health Questionnaire scores among physicians vs nurses: 4.0 [1.0-7.0] vs 5.0 [2.0-8.0]; P = .007; median [interquartile range {IQR}] Generalized Anxiety Disorder scale scores among men vs women: 2.0 [0-6.0] vs 4.0 [1.0-7.0]; P < .001; median [IQR] Insomnia Severity Index scores among frontline vs second-line workers: 6.0 [2.0-11.0] vs 4.0 [1.0-8.0]; P < .001; median [IQR] Impact of Event Scale–Revised scores among those in Wuhan vs those in Hubei outside Wuhan and those outside Hubei: 21.0 [8.5-34.5] vs 18.0 [6.0-28.0] in Hubei outside Wuhan and 15.0 [4.0-26.0] outside Hubei; P < .001). Multivariable logistic regression analysis showed participants from outside Hubei province were associated with lower risk of experiencing symptoms of distress compared with those in Wuhan (odds ratio [OR], 0.62; 95% CI, 0.43-0.88; P = .008). Frontline health care workers engaged in direct diagnosis, treatment, and care of patients with COVID-19 were associated with a higher risk of symptoms of depression (OR, 1.52; 95% CI, 1.11-2.09; P = .01), anxiety (OR, 1.57; 95% CI, 1.22-2.02; P < .001), insomnia (OR, 2.97; 95% CI, 1.92-4.60; P < .001), and distress (OR, 1.60; 95% CI, 1.25-2.04; P < .001). Conclusions and Relevance In this survey of heath care workers in hospitals equipped with fever clinics or wards for patients with COVID-19 in Wuhan and other regions in China, participants reported experiencing psychological burden, especially nurses, women, those in Wuhan, and frontline health care workers directly engaged in the diagnosis, treatment, and care for patients with COVID-19.
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Emotional labour in Healthcare: a scoping review of literature
Article
Full-text available
  • Sep 2018
The concept of emotional labour is investigated in healthcare by various disciplinary areas, but in different perspectives. The purpose of this scoping review is to identify and systematize the production available in research database about the emotional labour in healthcare, not only regarding the distribution of publications, but also the areas of health that have contributed to the development and operationalization of emotional labour, and its conceptualization. According to the methodology of Arksey & O'Malley, were initially identified the search terms, later undertook an extensive research, having obtained 136 publications for review, in which predominant scientific literature. Regarding the design of emotional labour were identified three areas of focus, Nursing was the health area with more publications. There are significant gaps in qualitative and quantitative research, including mix studies, in all groups of health professionals in the Community context, and as well as in conceptual models and clinical studies of emotional labour.
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Photovoice Ethics: Critical Reflections From Men’s Mental Health Research
Article
Full-text available
  • Sep 2017
  • QUAL HEALTH RES
As photovoice continues to grow as a method for researching health and illness, there is a need for rigorous discussions about ethical considerations. In this article, we discuss three key ethical issues arising from a recent photovoice study investigating men’s depression and suicide. The first issue, indelible images, details the complexity of consent and copyright when participant-produced photographs are shown at exhibitions and online where they can be copied and disseminated beyond the original scope of the research. The second issue, representation, explores the ethical implications that can arise when participants and others have discordant views about the deceased. The third, vicarious trauma, offers insights into the potenial for triggering mental health issues among researchers and viewers of the participant-produced photographs. Through a discussion of these ethical issues, we offer suggestions to guide the work of health researchers who use, or are considering the use of, photovoice.
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