Caring with a Forced Smile: Emotional Labour Among Private Hospital Nurses in Sri Lanka

Abstract

Emotional labour among nurses is researched extensively. However, whether nurses in market-oriented, for-profit and customer-focused healthcare contexts performed emotional labour similarly to other nurses is severely underexplored. The minimal research available on this phenomenon have focused on Western for-profit healthcare contexts. Therefore, this article explores how nurses from for-profit healthcare sector performed emotional labour in a non-Western context—Sri Lanka. Using 30 interviews with private hospital nurses, this qualitative study found that scripted and closely managed behaviour routines, being subordinate to patients and their relatives, constant exposure to service recipients’ aggression and minimal organisational support led to a significant sense of powerlessness, loss of face, emotional exhaustion and tit-for-tat exchange of emotions with patients among nurses.

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https://doi.org/10.1177/23220937211037221
South Asian Journal of Human Resources
Management
1 –21
© The Author(s) 2021
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DOI: 10.1177/23220937211037221
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Research Article
Caring with a Forced
Smile: Emotional Labour
Among Private Hospital
Nurses in Sri Lanka
S. D. K. Wanninayake,1 M. E. O’Donnell2 and
S. Williamson2
Abstract
Emotional labour among nurses is researched extensively. However, whether
nurses in market-oriented, for-profit and customer-focused healthcare contexts
performed emotional labour similarly to other nurses is severely underexplored.
The minimal research available on this phenomenon have focused on Western
for-profit healthcare contexts. Therefore, this article explores how nurses from
for-profit healthcare sector performed emotional labour in a non-Western
context—Sri Lanka. Using 30 interviews with private hospital nurses, this
qualitative study found that scripted and closely managed behaviour routines,
being subordinate to patients and their relatives, constant exposure to service
recipients’ aggression and minimal organisational support led to a significant sense
of powerlessness, loss of face, emotional exhaustion and tit-for-tat exchange of
emotions with patients among nurses.
Keywords
Emotional labour, private sector, nursing
Introduction
This study explores how nurses in the private healthcare sector in Sri Lanka
perform emotional labour. Service work combines physical, cognitive and
emotional challenges. During face-to-face and voice-to-voice customer
interactions, employees are often expected to exchange their emotions and
2 School of Business, University of New South Wales, Canberra, Australia.
1 Department of Human Resources Management, Faculty of Management and Finance, University of
Colombo, Colombo, Sri Lanka.
Corresponding author:
S. D. K. Wanninayake, Department of Human Resources Management, Faculty of Management and
Finance, University of Colombo, Cumaratunga Munidasa Mawatha, Colombo 7, Sri Lanka.
E-mail: dananja.wanninayake@hrm.cmb.ac.lk

2 South Asian Journal of Human Resources Management
feelings for a wage, which turns their emotions and feelings into organisational
commodities (Watson & Ward, 2013). This element of emotion work in service
encounters has been labelled ‘emotional labour’ (Hochschild, 1983).
Emotional labour is an integral part of nurses’ job role (Schmidt & Diestel,
2014). Healthcare employees, including nurses, often performed emotional labour
differently to those who were involved in for-profit customer service (Bolton,
2000). For-profit service employees often took an instrumental approach to
emotional labour, involving little emotional engagement with customers, beyond
commercial interaction, while healthcare professionals took a caring approach to
emotional labour by enacting a deep level of humanity towards service recipients
(Korczynski, 2009; Ward & McMurray, 2011). Additionally, healthcare
professionals were less supervised in their emotion work, and they, often, did not
confine their emotion performances to organisational display rules because their
skilled status allowed them to exercise a great deal of autonomy when delivering
patient care and in maintaining carer–patient relationships (Bolton, 2000, 2005;
De Raeve, 2002).
However, findings of a few subsequent studies (Bolton, 2001; Theodosius,
2008) suggest that nurses in Western customer-oriented healthcare environments
with a market mentality tend to perform emotional labour similarly to employees
engaged in for-profit, face-to-face service work. In such customer-oriented
healthcare environments, nurses’ emotion management was often complex
because patients were reinvented as ‘customers’, and nurses’ emotion performances
were guided by commercially influenced display rules. As a result, nurses were
vulnerable to patients’ complaints, and patients were often the superior party in
nurse–patient interactions (Bolton, 2001; Theodosius, 2008). In market-oriented
healthcare environments, nurses’ caring skills also may often be used as a
marketing strategy to manipulate the image of the organisation for financial gain
(Phillips, 1996).
Whether nurses in non-Western for-profit healthcare contexts responded to the
complex emotion demands at work similar to Western nurses is underexplored. A
contextual perspective to emotional labour suggests that regulating emotions and
expressing feelings are influenced by social, cultural and organisational norms
and values (Syed & Ali, 2013). However, more research in this area is required
because emotional labour in general and among healthcare staff, in particular, has
been frequently explored in Western contexts (Babatunde, et al., 2021; Nixon et
al., 2019). Therefore, to add to the minimal research on nurses’ emotional labour
performances in for-profit healthcare contexts and to understand the contextualised
and nuanced nature of non-Western nurses’ emotional labour performances in for-
profit healthcare environments, this study explored how private hospital nurses in
Sri Lanka performed emotional labour.
Emotional labour among healthcare staff in for-profit healthcare environments
is heavily under-researched in Asia and Sri Lanka. Though a number of studies
have explored nurses’ experiences of managing their emotions in Asian contexts
such as Korea (Kim & Jang, 2018; Yoon & Kim, 2013), India (Roopalekha et al.,
2012; Thomas & Abhyankar, 2014), Iran (Zamanzadeh et al., 2013), China (Zhou
et al., 2015), Taiwan (Yang & Chang, 2008) and Pakistan (Banning & Gumley,

Wanninayake et al. 3
2012), only few studies (Kaur & Malodia, 2017) have explored emotional labour
among healthcare staff, including nurses, in profit-oriented and customer-focused
private hospitals, and found that private hospital healthcare staff performed and
experienced more emotional labour than in the public sector. In Sri Lanka, a small
body of research has explored emotional labour among school teachers (Dias &
Bhadra, 2014), bank tellers (Kodikara & De Alwis, 2015; Perera & Arachchige,
2014), academics in state universities (Thisera & Bandara, 2018), cabin crew and
frontline airport staff (Perera & Kailasapathy, 2013), and frontline hotel workers
(Wanninayake & Williamson, 2018). A few studies have investigated emotional
labour and emotional exhaustion among public sector female nurses (Thisera &
Silva, 2017) and coping strategies of public and private sector nurses (Wanninayake,
2018), while emotional labour among private hospital nurses remains unexplored
in Sri Lanka.
Emotion Requirements and Emotion Regulation
The sociologist Arlie Hochschild initially coined the term ‘emotional labour’ in
1983 in her groundbreaking work on the use of emotions at work by flight
attendants and bill collectors. Emotional labour described the efforts employees
took to modify their emotions for a wage to meet the expectations of their job
roles (Hochschild, 1983). Hochschild’s (1983) social theory on emotions, also
known as the emotion management theory (Cottingham, 2015), gave birth to a
new wave of research on work in the service sector.
Emotional labour occurs when a combination of attributes can be observed
(Hochschild, 2012): first, when emotion management is no longer a private act
but a public act managed by managers and supervisors; second, when social
exchange of employees’ emotions is forced into narrow channels with less room
for individuals to manage their own emotions; And third, when feeling rules are
no longer rules that guide emotions in private spheres of life but are dependent on
social and organisational norms that guide external emotional expressions of
employees (Hochschild, 2012).
To incorporate the influence of context and culture-specific differences to
Hochschild’s concept of feeling rules, which were a ‘set of socially shared, albeit
often latent (not thought about unless probed at) rules’ (Hochschild, 1979, p. 563),
the term ‘display rules’ was introduced to the subsequent literature on emotional
labour. The term ‘display rules’ was inspired by Ekman’s (1973, 1993) work on
emotion and facial expressions and implies that organisations are only concerned
with controlling employees’ outward appearances and not employees’ internal
emotional states (Ashforth & Humphrey, 1993; Humphrey et al., 2015). Emotional
display rules guide the process of expressing emotions and provide standards for
the appropriate display of emotions at work (Diefendorff et al., 2010). These
standards state how emotions should be expressed, or should not be expressed, on
the job. These display rules are both explicit and implicit (Buckner & Mahoney,
2012). Explicit rules highlight the appropriate emotions required of employees,

4 South Asian Journal of Human Resources Management
while implicit rules are unwritten and are governed by organisational and societal
norms (Buckner & Mahoney, 2012).
To adhere to display rules, employees may either surface act or deep act.
Surface acting involves ‘trying to change how one outwardly appears’ by
modifying emotional displays without shaping inner feelings (Hochschild, 1983,
p. 35). When surface acting, workers try to simulate unfelt emotions and/or
suppress felt emotions through careful use of verbal and non-verbal cues such as
facial expressions, gestures and voice tone (Ashforth & Humphrey, 1993). In deep
acting, individuals display ‘a natural result of working on feeling; the actor does
not try to seem happy or sad but rather expresses spontaneously … a real feeling
that has been self-induced’ (Hochschild, 1983, p. 35).
Emotion Events, Performances and Responses
Researchers (Bhave & Glomb, 2016; Humphrey et al., 2015) have highlighted
that performing emotional labour can be rewarding for many employees. However,
none have denied the potential for emotional labour to cause job stress and burnout
for employees who have to regulate their emotions at work. Research findings on
the impact of emotional labour on employees have revealed that people who often
fake their emotions when delivering service could experience a physical and
mental toll, which impacts on their well-being and job satisfaction (Grandey et al.,
2015; Hülsheger & Schewe, 2011; Wang et al., 2011).
Emotion events employees experienced at work often evoked a discrepancy
between one’s emotions and emotion requirements (Grandey & Gabriel, 2015).
Service interactions with hostile and rude customers have been identified as a
significant emotion event that can give rise to surface acting, emotional dissonance,
which is the contrast between employees real felt emotions and their expressed
emotions, and job burnout (Jackson et al., 2013; Yagil, 2017). Yagil (2008)
categorised hostile treatment by customers in the form of verbal aggression,
physical aggression and sexual harassment. Verbal aggression includes sarcasm,
condescending remarks, swearing, yelling and threatening behaviours (Boyd,
2002; Grandey et al., 2007). Physical aggression includes ‘being pushed, punched,
kicked, slapped, scratched, struck with an object, spat at, pointed at or poked and
inappropriate contact’ (Boyd, 2002, p. 160). Sexual harassment includes sexist
statements, inappropriate sexual advances, coercive sexual activity or sexual
assault (Yagil, 2008).
On the one hand, hostile customer behaviour may be motivated by financial
gains (to obtain assets in either monetary or physical form), ego gains (misbehaving
to increase their self-worth) and revenge (misbehaving to take vengeance on the
organisation, or a person in the organisation, as a punishment or payback strategy)
(Daunt & Harris, 2012). On the other hand, excessive organisational tolerance
may enhance hostile customer behaviour. This includes excessive deference to
customer sovereignty, denying customer misbehaviour and structuring service
roles in a manner that gives customers too much power over employees (Yagil,
2008). In such environments, customers are often referred to as the ‘second

Wanninayake et al. 5
managers’ because feedback on service is sought from customers, and receipt of
gratuities from customers depends on their perceptions of customer service.
Therefore, employees are expected to be friendly, cheerful and courteous though
customers are not expected to reciprocate these gestures (Grandey et al., 2007).
Deference to customer sovereignty can also encourage organisations to focus
more on customer loyalty and customer satisfaction over the well-being of service
workers, which may provide customers the expectation of zero mistakes, short
wait times and impeccable interpersonal treatment (Yagil, 2017). It may also lead
employers to deny and/or ignore incidents of customer misbehaviour towards
employees (Yagil, 2008, 2017).
Emotional dissonance created by hostile customer treatment may increase the
emotional strain experienced by employees. Emotional strain includes diminished
mental resources, fatigue, a weakened sense of authenticity and an impeded
capability to create rewarding social relationships (Grandey, 2000; Hülsheger &
Schewe, 2011). Due to emotional strain, employees may suffer job burnout that
would lead to distress, low job performance, depression, poor self-esteem,
physical illnesses like heart attacks and cancer, and develop intentions to leave
organisations (Ashforth & Humphrey, 1993; Grandey, 2000; Grandey et al., 2015;
Pandey & Singh, 2016). These effects may spill over to other domains of
employees’ lives and create work–family conflicts (Perera & Kailasapathy, 2013).
Employees may use problem or emotion-focused strategies to replenish their
mental and physical resources caused by emotional strain of performing emotional
labour (Demerouti, 2015). Problem-focused strategies refer to strategies that
enable employees to directly tackle or combat the cause of the stress (D’Souza et
al., 2009; Jang et al., 2019). These strategies enable individuals to acquire and
maintain sufficient resource reservoirs to act early when signs of a problem arise
(Hobfoll, 2001). For example, when nurses are trained only on technical aspects
of their role, their ability to deal with job stress is reduced. However, when their
training includes building social support when dealing with stressful patient
encounters, it can help them to respond to job stress more effectively (Hobfoll,
2001).
When individuals do not possess sufficient resources for proactive coping,
they may use reactive emotion-focused strategies (Hobfoll, 2001). These strategies
may help individuals to take their minds temporarily off their work problems
(Lazarus & Folkman, 1984). Examples include physical exercise, meditating,
venting anger and seeking social support. Some emotion-focused strategies may
result in higher levels of depression, stress and emotional isolation because they
can involve self-blaming and responses that are harmful to workers’ health and
well-being (Demerouti, 2015; Rexhaj et al., 2016).
Method
This study explored how Sri Lanka’s private hospital nurses performed emotional
labour. The qualitative data were collected through 30 semi-structured, face-to-
face interviews with private hospital nurses (10 men and 20 women), with nursing

6 South Asian Journal of Human Resources Management
experience ranging from 1.5 years to 40 years. Interviews lasted between 30 min
and 90 min. Participants were purposively selected, and they shared details from
their current and previous work experiences in private hospitals. Out of the nurses
interviewed, five were retirees from the public sector, nine had worked only in one
private hospital and others possessed work experience in multiple private hospitals.
Data collection was through interviews, which were conducted in 2016 (17
interviews) and 2018 (13 interviews). The second round of interviews was
conducted to gather further in-depth information and insights related to the themes
that emerged from the data collected during the first round. The themes that
emerged were not participant-specific; therefore, during the second round, the
interviews were conducted with participants who could be contacted from the first
round (four nurses), together with new participants. During the second round, the
interviewer discussed the preliminary findings of the first round of interviews
with nurses who participated in both rounds to ensure that their experiences and
performances were captured accurately.
The Sri Lankan researcher (i.e., the first author) conducted all interviews in
Sinhala language. A few participants were relatively conversant in English, and
even the ones who were not conversant in English were able to communicate
medical terms and procedures in English. The researcher, who conducted the
interviews being a Sinhala-speaking Sri Lankan, a ‘cultural insider’ according to
Liamputtong (2008), was able to translate the interviews from Sinhala to English.
Further, the researchers verified the claims made in Sinhala with other nurses who
were conversant in English and Sinhala languages to reduce the scope for
misinterpretation. The study was conducted based on the ethics approval issued by
the Ethics Committee of the University of New South Wales, Canberra, Australia.
To analyse data thematically, the researchers followed Braun and Clarke’s
(2006) six-step approach. The digitally recorded interviews were transcribed
verbatim. Using NVivo as a data management tool, researchers generated the
initial codes. Thereafter, the researchers collated these open codes that emerged
from the transcripts into broader categories. These broader categories were then
collated into themes, which were later refined to ensure that they cohered together
meaningfully, and that there were clear and identifiable distinctions between the
themes. Finally, a detailed analysis was undertaken for every theme identified
earlier to develop the narrative revealed by each theme, and findings were
appropriately documented.
Findings
Emotion Requirements and Emotion Events
Serving with a (Forced) Smile
Sri Lanka’s private hospital nurses’ emotion management was more complex
because they managed care work, while maintaining a high level of customer
service. These nurses were expected to serve with a smile and be courteous to

Wanninayake et al. 7
patients at all times. Patients’ complaints affected nurses’ performance appraisals
and could even lead to loss of employment. Patients often documented their
perceptions of differences in the level of service provided by different nurses on
feedback forms. One nurse highlighted:
...Being a private sector nurse is more challenging than being a public sector nurse...
Some people think that they can buy us for money... recently, at a session organised
by the hospital, we were taught how to deal with patients and the importance of
smiling... We have to listen to the issues of the patient but we have to be pleasant.
The patient should feel that we are listening … and are concerned. (Male nurse, 14
years, dialysis unit)
There were times when nurses’ customer service role superseded their therapeutic
relationship with patients and their relatives. For example, under the hospital
display rules, nurses had to appear friendly, caring and empathetic towards
patients. Nurses were monitored by nursing supervisors and senior management
on how well they adhered to these display rules. Nurses were likely to receive
warnings and demands to change behaviour if they failed to adhere to them. One
participant stated:
…We constantly receive guidelines on how important it is to be pleasant to the
patient. For instance, sometimes when my child is sick, I can’t be happy at work
because it is there in my head. However just because I have a problem in my head,
I cannot treat the patient differently. I have to say 'good morning sir, how are you sir?
did you take your medicine?' despite my situation. (Female nurse, 8 years and 4
months, renal transplant unit)
At Patients’ Service
Nurses highlighted that service recipients believed that they could impose a level
of control over nurses because they paid for their treatment. For example, some
patients demanded certain types of medicines, which nurses were not allowed to
provide without instructions from doctors. On such occasions, patients shouted
at nurses, stating that their expectations were not being met. Patients also
expected nurses to be responsible for issues unrelated to nursing care, such as
housekeeping, patients’ dietary requirements and hospital facilities. Patients
believed that nurses should be responsive to their requests, regardless of whether
nurses had the authority to respond. Further, some patients provided negative
feedback just to take ‘revenge’ for not adhering to their requests. Such acts
represent misbehaviour over ‘ego gains and revenge’ in literature (Daunt &
Harris, 2012). One participant noted:
…Customer care includes cleanliness, food and all other requirements of patients.
Patients always talk to nurses about their issues... We have to attend to everything …
if there is an issue with the bill the patient will talk to us. Then we can’t say that it is
not our duty to handle the bill. We have to personally go to the billing department
and sort it out for the patient. If the food is not good the patient doesn’t tell the

8 South Asian Journal of Human Resources Management
kitchen staff but tells us. Then we have to look into it… Nursing and customer care
should go hand in hand... We have to make patients happy…. (Male nursing
supervisor, 23 years, surgical and medical unit)
The need to be at ‘patients’ service’ often subjected nurses to verbal aggression
and sexual harassment by service recipients. Concerns over hospital bills was the
primary reason for verbal aggression by service recipients. While patients knew
that they had to pay for their treatment in private hospitals, the majority were
unaware of different types of hospital charges. When the bill was presented to
patients, they often questioned why hospital prices were so high. Service recipients
also tried to find fault with the service provided by nurses, or with hospital
facilities, with the intention of obtaining a discount on their hospital bill, or a free
service. One nurse stated:
…No matter how good they are, when they get the bill most of them become
aggressive…. (Male nurse, 5 years, dialysis unit)
Additionally, private hospital nurses experienced verbal aggression from patients
when medical specialists did not attend to patients in a timely manner. Some 25
out of 30 nurses interviewed experienced patient aggression when specialist
doctors’ visits were delayed or rescheduled. The majority of specialist doctors
worked in public hospitals during the day, and they would visit their patients in
the private hospital in the morning or evening. Waiting for their specialist doctor
caused considerable frustration for many patients and their relatives. Nurses were
not authorised to discharge patients until these specialist doctors had visited the
patient and decided that they were well enough to be discharged. Where there
were delays in their visits, patients had to pay for the extra hours, or days, of their
hospital stay. Additionally, some specialist doctors did not arrive on time for
surgeries or other medical treatments. Since patients were expected to be fasting
until their surgery was completed, late visits by consultants made patients wait
longer without consuming any food and drink than anticipated, which further
increased their levels of frustration. One nurse highlighted that:
…The specialist doctors come from public hospitals. But the patients here don’t
understand that the doctors can come only early in the morning or evening. The
patients here are impatient. They want the doctors to come immediately to visit
them. The doctors come when there is an emergency … people get aggressive over
this (male nurse, 23 years, surgical and medical unit)
Female nurses were also subjected to sexual harassment by male patients. Male
patients complained of fake aches and pains or rang the calling bell unnecessarily
to get female nurses to visit their rooms and touched female nurses inappropriately
when they performed medical procedures. One participant noted:
There are patients [male] who call us to them often. They call us even for minor
things. Sometimes after we do a procedure, for example extract blood, they call us
to get a water bottle and sometimes call us to inform aches and pains which are fake.

Wanninayake et al. 9
When we send a male nurse, the patient doesn't complain of pain. (female participant,
15 years, medical and surgery ward)
When female nurses complained to the senior management regarding incidents of
sexual harassment, the managers rarely took action to prevent such incidents,
revealing the insensitive nature of the senior management to sexualised violence
by patients. A nurse stated:
...When we report to the management, they ask us not to send female nurses but to
send male nurses. The management doesn’t want to lose the patient. But we don’t
have enough male nurses…. (female nurse, 5 years, paediatric and maternity ward)
For nurses, being at ‘patients’ service’ while being subjected to acts of patient
misbehaviour often became a resource-depleting event that increased their levels
of emotional exhaustion. They believed that being exposed to constant verbal
aggression of service recipients negatively impacted their image of being nurses,
which increased their emotional strain. Nurses had to use significant cognitive
effort to hide their genuine anger towards patients and to display organisationally
sanctioned emotions like friendliness. One participant noted:
…I get fed up with nursing. Sometimes we have to work full day. When we come
here at 6am by the time we go home it’s 8pm... We do so much and have almost
given up children for work, but if a minor incident happens there will be complaints
and we get scolded. Then we feel fed up with nursing…. (female nurse, 18 years,
maternity and paediatric unit)
Patient is Always Right
Nurses were often expected to conform to the ‘patient is always right’ culture that
emphasised customer sovereignty. This approach to patient care helped hospital
managers to reach their revenue targets but meant that the hospital management
was highly sensitive to the complaints and negative feedback from patients or
their relatives. Nurses revealed that the senior management was only interested in
increasing the number of patients and repeat customers and rarely took into
consideration nurses’ experiences of staff shortages, a lack of medicines and
medical equipment, and ever-increasing patient numbers. During incidents of
patient misbehaviour, the senior management tended to side with patients and
would apologise to them to maximise potential patients’ revisits. One nurse stated:
At the start they [patients] say ‘Miss, insert the canula in one prick’. From there
onwards they start creating issues. Then they complain to the management. They
always try to take the power of money… The management always takes the side of
the patient… The management... is highly money minded and they don’t care about
the nurse. They only think that they should receive more customers. They always
want to get the patient back.... (female nurse, 18 years, maternity and paediatric unit)
Hospital managers also sent employees from their in-patient department to gather
feedback from patients by asking questions like ‘what do you think of the service

10 South Asian Journal of Human Resources Management
you receive from nurses?’ Further, nurses were regularly questioned on issues like
minor delays in providing patients with water bottles or changing linen. Service
recipients were treated as ‘second managers’ and exerted a high degree of authority
over nurses; their feedback played a role in nurses’ performance appraisals. The
high level of sovereignty placed in the hands of patients by the hospital
management often placed service recipients in a position to exert a degree of
power and authority over nurses. One nurse stated:
…The customer service unit took feedback from patients… Once, when I was about
to enter a room of a patient, I heard the patient being asked ‘did the nurse insert the
canula in one prick?’ and ‘do nurses come immediately when you ring the bell?’…
When patients are asked such questions, they also try to take the upper hand….
(male nurse, 10 years, surgical and medical ward)
In response to the interplay between emotion requirements and emotion events,
nurses engaged in emotion regulation to provide organisationally sanctioned
emotion performances.
Emotion Regulation, Performances and Responses
Pretending, Restraining and Being Real
Nurses exerted their agency in response to patient aggression by relying on
emotion regulation techniques such as ‘pretending’ and ‘restraining’. ‘Pretending’
refers to ‘faking unfelt emotions’ or ‘magnifying the intensity of their feelings’ to
display the required emotions to service recipients, while ‘restraining’ refers to
‘suppressing or suspending internal feelings that may prevent the achievement of
goals’ during service interactions (Yin, 2016, pp. 11–12). A total of 26 out of 30
participants revealed that they used ‘pretending’ in response to patients’ demands,
while 28 out of 30 nurses interviewed noted that they ‘restrained’ their emotions
and hid their anger and frustration when dealing with aggressive patients,
demanding relatives or when responding to patient complaints. One nurse noted:
…In most situations, we can’t show our feelings. What you see on a nurse’s face is
not what the nurse actually feels. Nurses hide sadness, stress, anger, workload and
the responsibility placed upon them. But others think nurses are relaxed…. (male
nurse, 14 years, dialysis unit)
A significant emotional challenge nurses experienced was to create the right
emotional mindset in service recipients. Following long-term exposure to patient
aggression, nurses could become emotionally hollow and display limited
empathy towards patients or their families (Doshi, 2014). In such situations,
nurses had to ‘pretend’ to suppress their lack of empathy and display emotions
that were socially acceptable and in line with the hospital’s emotional display
rules. On the other hand, they could not appear too sympathetic towards patients.
One participant stated:

Wanninayake et al. 11
…We have to be tactful in managing emotions in front of patients. We should not
fail in front of patients … if there is a cancer patient, we know that the patient could
die. We don’t show that to the patient or the family. We always motivate the patient
by saying that we are going to help you to live. But the thing is you cannot lie to the
family. We have to tell them the truth step by step. If we become emotional in front
of the patient, we become failures…. (male nursing supervisor, 23 years, surgical
and medical unit)
Private hospital nurses did express their real emotions on occasion. They were
prepared to ‘show frustration’, ‘be stern’ and ‘be assertive’ in response to excessive
patient demands. However, nurses faced the likelihood of patient complaints and
negative performance appraisals for responding assertively to patient demands.
They experienced constant monitoring and surveillance from hospital managers
and supervisors and were expected to adhere to the hospital display rules, which
emphasised adopting a deferential approach towards patients. One nurse noted:
…There have been instances where nurses have been assertive with patients. In the
private sector it’s less because if a patient makes a complaint, it would impact
nurses’ jobs…. (male nurse, 23 years, medical and surgical ward)
Nurses used numerous strategies to overcome the emotional strain and exhaustion
they experienced due to the interplay between emotion requirements, emotion
events, emotion regulation and emotion performances.
Proacting and Reacting
In private hospitals, two groups of nurses could be identified. They included nurses
who had directly joined the private sector and were trained in private nursing
schools, as well as nurses who joined the private sector, following their retirement
from the public sector. The second group revealed that their extensive training,
experience and exposure to large numbers of patients and diverse emotional
demands helped to be prepared to handle emotional challenges successfully.
However, nurses trained in private nursing schools and less experienced struggled
to be proactive in responding to emotional strain as they were hardly trained to
handle ‘end-of-life care’ or provide ‘loving care’, which were emotionally
demanding. Additionally, nurses were not provided access to professional
counselling services, recreational activities or special training on coping to help
nurses to prepare themselves for emotional challenges. One nurse noted:
...There is a section in nurses’ training called ‘end of life care’ and ‘loving care’
which caters to looking after patients who are near death … we find nurses who have
come from different nurses training schools. Senior nurses who have undergone
three years’ training know it, but the juniors have not received it…. (female nursing
supervisor, 15 years, medical and surgery ward)
Private sector nurses also used several emotion-focused reactive strategies. A total
of 20 out of 30 participants used avoidance strategy, where they tried to take a
break from the stressful work environment until they felt emotionally neutral. In

12 South Asian Journal of Human Resources Management
the long term, some nurses developed intentions to leave the nursing profession.
Additionally, nurses often used the distancing strategy, where they tried to distance
their personal lives from their professional lives. Male nurses were more successful
at distancing their professional selves from their personal selves. One nurse
mentioned:
…When something like that [patient aggression] happens, despite the workload I
take a break for 10 minutes…. (female nurse, 12 years, emergency treatment unit)
Seeking social support from colleagues, supervisors and/or family members was
a common emotion-focused strategy private sector nurses used. While sharing the
emotional burden with colleagues, participants used humour or discussions of
movies or weekend activities to avoid psychological distress. One nurse stated:
…I go to my senior staff nurse...because they teach me where I went wrong, what I
need to do in future as well as how I can overcome this situation. (female nurse, 8
years and 4 months, renal transplant unit/emergency treatment unit)
Some participants revealed that they vented their stress by talking with friends
outside of work. This is referred to as ‘third-party involvement in emotional
labour’, where a party not involved in the service interaction shared the experience
of the interaction (Niven et al., 2013). One nurse revealed:
…I have two close friends who are not nurses. They know that when I feel
emotionally burdened, I just keep talking. Even if they don’t understand what I am
saying, they just calmly listen…. (male nurse, 14 years, dialysis unit)
There have been instances where nurses vented their emotional strain on family
members, friends and/or colleagues by shouting at them or completely ignoring
them. One nurse stated:
...My parents don’t see this because they are far away. But my husband suffers. I
don’t go to shout or fight with him. But I am not my normal self. I just go to a
corner...Sometimes he gets angry with me.... (female nurse, 4 years, intensive care
unit)
As a reactive measure, some nurses engaged in religious and spiritual practices.
For example, visiting religious places; engaging in religious activities; and
connecting concepts in Buddhism such as Dukka (unescapable suffering), Karma
(one’s fate in this birth is a result of good and bad deeds done in previous lives) and
Nirvana (eradicating attachment and desire to attain salvation) to illnesses, death
and suffering of patients to overcome the emotional trauma. One nurse stated:
…According to our religion [Buddhism] we know that these things happen because
it is the nature of life … I think about the religion rather than getting mentally
affected by revisiting these incidents [traumatic events].... (female nurse, 1.5 years,
emergency treatment unit)

Wanninayake et al. 13
Discussion
Emotion requirements of Sri Lanka’s private hospital nurses were often driven by
the need to ‘serve with a smile’, be at ‘patients’ service’ and the notion ‘patient is
always right’. Adhering to these expectations became an emotional strain to
nurses because significant levels of aggression by patients or their families
towards nurses was commonplace. Research (Roche et al., 2010) has shown that
patients’ experiences of pain, anxiety, helplessness, loss of control, frustration and
a perceived sense of lack of care and communication led to aggression by patients
and their relatives towards nurses. On top of these reasons, in Sri Lanka’s private
sector, patients and their relatives were often verbally aggressive for financial
(discounts on medical bills or free medical attention) and ego gains where service
recipients believed that nurses were effectively their ‘servants’ because they paid
substantial amounts for their treatment.
Sexual harassment was rife, and it included inappropriate touching of female
nurses and complaints of fake aches and pains to get female nurses to visit patients’
rooms by male patients. This confirmed that gendered and sexualised violence by
service recipients towards nurses was also an issue in private hospitals as reported
in previous West-based research (Jackson et al., 2013; Kahsay et al., 2020). Prior
research reveals that victims of sexual harassment in general (Mills & Scudder,
2020), and healthcare environments, in particular (Jackson et al., 2013), often
remain silent or under-report such incidents due to shame and fear. In contrast,
where Sri Lanka’s private hospital nurses reported such incidents, the senior
management was often insensitive to such complaints as they deferred to customer
sovereignty because of their desire to maintain patient loyalty, patient satisfaction
and patient revisits over the well-being of employees, as documented in previous
literature (Yagil, 2017). Though Sri Lanka is one of the first Asian countries to
address sexual harassment at workplace through government legislation and
consider it a criminal offence under the Penal Code (Amendment) No. 22 of 1995
(Adikaram, 2018, p. 102), this study confirmed that some Sri Lankan managers to
date took an ‘avoidant approach’ to make decisions relating to sexual harassment
complaints by ‘pushing them under the carpet’ (Adikaram & Kailasapathy, 2021).
Research (Bolton, 2000) has revealed that nurses often exercised a great deal
of autonomy in their nurse–patient relationships and adhered only to implicit
occupational display rules, also known in the literature as nursing ethics (De
Raeve, 2002; Izumi et al., 2012), implicit feeling rules or professional value
systems (Bolton, 2000; Mann, 2005). In contrast, organisationally sanctioned and
commercially influenced emotional display rules played a significant role in the
jobs of Sri Lanka’s private hospital nurses. Nurses were expected to provide a
high level of customer service to patients and their relatives in addition to
therapeutic care. This led to the introduction of explicit display rules that
prescribed the behaviour, emotions and language expected of nurses during
interactions with service recipients, and deviations from these rules led to
warnings from hospital managers. Additionally, the senior management referred
to patients as ‘customers’, and patient revisits were known as ‘customer revisits’.
This change of terminology and introduction of strict display rules commodified

14 South Asian Journal of Human Resources Management
nurse–patient relationships, which failed to acknowledge the emotional
relationships expected of nurses, as documented in studies on Western paid
healthcare contexts (Bolton, 2001; Mann, 2005; Theodosius, 2008).
The scripted and closely managed behaviour routines expected of private
hospital nurses led them to experience a significant sense of powerlessness, loss
of face and emotional exhaustion. Being subordinate to customers, being subjected
to strict surveillance and having to face negative consequences for any deviances
from display rules made many private hospital nurses feel like emotionally
‘crippled actors’ (Hochschild, 1983). Further, this study found that Sri Lanka’s
private sector nurses represented an emotional proletariat. The concept of
emotional proletariat was developed by Macdonald and Sirianni (1996), and
being ‘emotionally crippled’ is one aspect of workers categorised under emotional
proletariat. In addition, emotional proletariat refers to frontline employees who
were ‘subjected to control, intervention and monitoring from supervisors,
behaviourally scripted and routinised, subordinate to customers and dealt with
fleeting, massive contacts with customers’ (Qian & Miao, 2017, p. 71). As
emotional proletariat, private hospital nurses were expected to display friendliness
and deference towards the hospital’s patients and were given little formal power
to alter the nature of their service encounters with patients (Macdonald & Sirianni,
1996; Wharton, 2009). This often led to emotional exhaustion because of the
attentiveness they were expected to maintain towards emotional display rules and
the constant monitoring and intervention by the senior management of their
customer interactions.
However, there were instances where nurses actively resisted the negative
patient behaviour they encountered and expressed their genuine negative emotions
to patients and their relatives. Such acts of emotion expression often led to
negative patient feedback, complaints or warnings by the senior management. For
private hospital nurses, whose behaviour was scripted and routinised, moving out
of hospital-endorsed ways of expressing emotions by displaying genuine anger or
frustration was the only means available to maintain their dignity and self-respect
when dealing with uncooperative service recipients’ (Leidner, 1999). Paules
(1996, p. 286) claim that this form of employee behaviour normally takes place
out of sight of service recipients though there may be instances where employees
‘break the character and reject the role of the servant’ and actively resist the
coercive forces they encountered instead of continuing to suffer psychological
distress. These were the times when employees refused to be ‘robots’ and showed
their true selves.
Pressure from visitors, harassment by patients, strict surveillance and minimal
management support caused considerable emotional strain for private hospital
nurses. Nurses responded to organisational display rules and the expectation that
they would be respectful towards aggressive patients by adopting surface-acting
strategies like ‘pretending’ and ‘restraining’. Such strategies led nurses to
experience emotional dissonance because of the increased mental effort required
to suppress their genuine emotions and to pretend to be polite and deferential
towards private hospital patients. Nurses’ expression of negative emotions in
response to patient misbehaviour highlighted the potential for a ‘tit-for-tat’

Wanninayake et al. 15
exchange of emotions between hospital patients and nurses and highlighted the
limits of hospital managers’ ability to enforce emotional display rules (Gabriel &
Diefendorff, 2015).
Coping with the emotional strain of regulating emotions was a ‘personal
process’ (Zander et al., 2010) for Sri Lanka’s private hospital nurses, where they
decided their own coping methods. The limited support received from private
hospitals and not possessing sufficient authority or resources to modify the
threatening or challenging service encounters led nurses to use more emotion-
focused reactive strategies (Lazarus & Folkman, 1984). This often led nurses to
select destructive coping methods like venting out anger or developing intentions
to leave the profession (distancing), which resulted in work–family conflicts and
employment issues (Yun et al., 2013). However, the constructive coping strategies
such as avoidance (taking a break), receiving social support backed by Sri Lanka’s
largely collectivist culture and the use of religious practices and spirituality,
referred to as meaning-based coping in the literature, often reduced their emotional
strain and feelings of isolation, as found in other studies (Byrne et al., 2011;
Cricco-Lizza, 2014; Pandey, 2017).
Contributions, Limitations and Future Research Areas
The findings of this study have several theoretical and practical implications. This
article adds to the existing understanding of emotional labour by providing
insights into the complex nature of nurses’ emotional labour in for-profit healthcare
contexts, where they maintained a caring cum customer service role with limited
autonomy, customer superiority and minimal organisational support. Further, this
study extended theory on emotional labour by adding the contextual and nuanced
nature of employees’ emotional labour performances and experiences in a non-
Western context and how cultural attributes and religious beliefs may influence
these. From a practical perspective, this study highlighted how nurses’ emotions
were exploited in for-profit contexts by service recipients and hospital management
and the importance of minimising such acts. Further, the findings revealed the
need for hospital management to maintain nurses’ welfare by protecting them
against verbal and sexual harassment by service recipients, which often
exacerbated nurses’ negative experiences of emotional labour. Additionally, this
study showed the need to provide nurses with resources to act proactively to
emotion demands at work to prevent nurses from using destructive coping
methods that would lead to negative personal and professional outcomes.
Despite the significant theoretical and practical contribution of this study,
limitations may be identified. The study was based on self-reported information
from nurses, and these were retrospective accounts of their experiences. This may
have resulted in participants revealing selected information of their experiences,
and this information may have been affected by subsequent events. Though these
are common limitations in qualitative research (Adikaram & Kailasapathy, 2021),
they may influence the explanations provided.

16 South Asian Journal of Human Resources Management
The findings suggest many avenues for future research. First, how nurses
performed and responded to emotional labour in other non-Western for-profit
healthcare settings could be explored. Second, this study could be replicated with
a different group of frontline healthcare professionals in for-profit healthcare
contexts to explore if their emotional labour performances and experiences varied
from those of nurses. Third, in-depth research into the emotion performances
expected by service recipients from nurses would reveal the variety and complexity
of emotional labour in for-profit and market-oriented healthcare contexts.
Conclusion
Sri Lanka’s private hospital nurses’ experiences highlighted the complex tensions
between their roles in delivering patient care and customer service in a non-
Western for-profit healthcare sector. Being subjected to strict surveillance and
constant patient demands made many private hospital nurses feel like ‘emotionally
crippled actors’ who represented an ‘emotional proletariat’. This feeling was
exacerbated by managers’ insensitive nature to incidents of harassment by service
recipients towards nurses and provision of minimal resources for nurses to respond
proactively to emotion demands. The findings help to understand the importance
of taking measures to minimise nurses’ emotional exploitation to enable them to
maintain an improved therapeutic relationship with service recipients.
Declaration of Conflicting Interests
The authors declare no potential conflict of interest with respect to the research, authorship
and publication of this article.
Funding
The authors disclosed receipt of the following financial support for the research, authorship
and/or publication of this article: This work was supported by University of New South
Wales, Canberra, Australia, through a scholarship offered to PhD candidates.
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