This chapter introduced the background of the study, research purposes and questions, significance of the study, and definitions of terms.
Background of the Study
In the past 25 years, because of nursing shortage, much research has focused on nursing issues such as nursing turnover (Wagner, 2007), patient satisfaction (Wagner & Bear, 2009), and work stress (Hung, 2004). Due to the competitive medical market, medical organizations reduce their cost and expense to maintain their competitive advantages. Under this condition, the most common strategy for hospitals is to cut the number of nursing staff. This strategy results in insufficient nurses, overloading work, and unstable working hours, which at last cause lower job satisfaction and work efficiency (Chen, 2005). Wagner (2010) asserted that nursing turnover is a dangerous outcome because it could cause loss of individual and organizational performance, significant reduction in healthcare quality, and increase of workload for remaining nurses. However, in hospitals, nursing staff is always on the front line, providing professional care for patients, dealing with patients’ relatives, and executing doctors’ orders. In order to maintain the healthcare quality and nurses’ professional image, the insufficient nurses overloaded with work are expected to provide satisfying service—not only professional medical skills but also sincere care—for their “customers”.
In addition to professional knowledge and skills, nurses are also qualified to do the job with some important traits, for instance, they need to possess lots of patience, carefulness, and sympathy. These traits are especially needed for nurses in Intensive Care Unit (ICU) because of its job characteristics. ICU nurses generally have heavier and stronger job stress than other nurses in general care unit because they need to provide comprehensive and
(Wu, Perng, Perng, Huang, & Lee, 2009; Hsiao & Pan, 2011). In the aspect of work environment, ICU is a dynamic area of the hospital and the nurses need to be able to adjust to the rapid changes of the patients and new situation. Besides, compared with general care units, the supportive instruments are much more complex in terms of different types and complicated operation procedures (Hu, 2000). During the visit time, ICU nurses also need to deal with the patients’ relatives, providing them with support. However, the presence of a distraught relative can be a heavy burden and stress for nurses (Marco et al., 2006). Due to the concern for the patient, the relative may constantly ask about the patient’s condition or ask for something more than information. Actually, ICU nurses are not allowed to answer the details about the patient’s condition which should be explained by the physicians. However, with many visitors who observe the nurse’s every action, if they see the nurse spend more time with another patient, they may feel their loved ones are not getting adequate care and thus complain to the nurses (Hay & Oken, 1972). Sometimes, if they do not deal with the demands well, that is, if their attitude or response is not satisfied, people would report their poor attitude to the superiors or the hospital. Some nurses are even sued by patients or their relatives because of bad attitude or inappropriate response, so the expression and control of emotion is the ability or skill that is required for doing a nursing job (Su, 2005). Therefore, nursing job is indicated to be a service profession which is high level of emotional labor, and nurses are emotional labor workers, who need to keep a good attitude and emotion while working and even need to cover or hide their real emotion (McQueen, 2004). Under such work condition, different emotional incidents can happen every day. While many findings have demonstrated the strategies that emotional labor often used at work, few have shown the consequences after using strategies in particular circumstances. Moreover, many researchers examined the level of emotional labor or emotion management strategies by randomly choosing samples from all sections of the hospital. However, the work condition and work stress are different in every hospital section, and the work in ICU is considered as high level
of emotional labor. Therefore, the primary purpose of this study was to understand ICU nurses’ experience of using emotion management strategies in emotional incidents. This study also aimed to explore the incident outcome after using the strategy and discussed what influence the outcome brought to the involved ICU nurses.
According to Taipei Nurses Association’s investigation, in 2007, turnover rate of nurses who worked within 3-month is 32%, and 58% for nurses who worked within a year. New nurses’ challenges may come from every aspect of their work, such as professional skills and different emotional incidents. Hung (2004) found that the work pressure of ICU nurses was over the medium level, and the major pressure was from interpersonal relationship. For instance, every new patient presented new obstacles to overcome in ICU, which was not a predictable field of nursing. To help new ICU nurses adapt to the rapid changing work environment, a new ICU nurse is usually assigned to a senior nurse for a short period of time to learn and get familiar with the basic operation. They can also observe and learn how the seniors deal with different emotional incidents which are inevitable and often happen in ICU.
In Taiwan, the learning situation during orientation training had significant influence on new nurses’ intention to leave (Liu, 2010). It was suggested that “the retention strategies need to focus on ensuring a positive, supportive orientation to nursing practice for new graduates”
(Nelsey & Brownie, 2012, p.200). In other words, the creation of supportive learning environment can also help enhance their retention intention. Furthermore, because ICU nurses are usually randomly scheduled to work with different team members, new nurses may interact with different seniors every day and go through different learning process and experience. However, few researches have examined how nurses connected their social learning experience to the selection of emotion management strategies. Therefore, another purpose for this study was to understand ICU nurses’ learning process for emotion management.
Research Purposes
Based on the research background, this study developed three research purposes. First, this study aimed to identify ICU nurses’ experience of using emotion management strategies in emotional incidents at work. ICU nurses’ emotion management strategies were analyzed based on Gross’s (2002) five categories of strategies in emotion regulation process to see the consequences brought by the strategies used at different points during the process. Second, this study explored the incident outcome after using emotion management strategies, as well as the influence of incident outcome on the involved ICU nurses. Third, through social learning perspective, this study also aimed to understand ICU nurses’ learning process for emotion management strategies.
Research Questions
In order to reach the research purposes, this study aimed to respond to the following research questions after the investigation of ICU nurses’ emotion management experience from social learning perspective:
1. What emotion management strategies do ICU nurses use in emotional incidents?
2. How do emotion management strategies influence the incident outcome? And how does the incident outcome influence the involved ICU nurses?
3. Through social learning perspective, how do ICU nurses learn the emotion management strategies?
Significance of the Study
In health care industry, the role of patient has changed from healthcare recipient to healthcare consumer (Laschinger, Hall, Pedersen, & Almost, 2005). Like other service providers such as hotel industry and restaurants, consumers’ satisfaction with the perceived service quality is crucial for attracting healthcare consumers (Liu & Wang, 2007). While the
factors like physical surroundings and the relationship with medical personnel can also influence patients’ satisfaction with the hospital experience (Johansson, Oleni, & Fridlund, 2002), the nursing care services provided by nurses have a direct relationship with patients’
satisfaction (Abramowitz, Cote, & Berry, 1987).
Emotional labor is believed to have double-edged effects. From organizations’
perspective, it enhances organizational success, enables employees to successfully achieve organizational goals, and affects customers’ perception of service quality as well as their satisfaction. From individuals’ perspective, it’s harmful to employees’ well-being, job satisfaction, emotional exhaustion, organizational commitment, and intent to leave, and so on (Hwa, Thurasamy, & Wafa, 2010). Therefore, in a stressful work environment like ICU, how nurses manage their emotions and display expressions is important for both organizations’
image and individuals’ physical and psychological health.
Thayer, Newman, and McClain (1994) found that the most frequently used emotion management strategies were the most effective strategies for coping with difficult situations.
Thus, finding that a strategy is used most often in response to a certain circumstance may mean that the strategy is especially useful in that situation. To identify the alignment between emotional incidents and emotion management strategies may also help the development of interventions that aims at training employees how to manage their emotions at work (Diefendorff, Richard, & Yang, 2008). The findings of this study about effective emotion management strategies can help organizations develop the training program and help emotional labor workers find an appropriate strategy in an emotional incident.
Mistakes are inevitable in the workplace. However, in nursing care work, every procedure is potentially lifesaving, so any mistake may be life-endangering. This is also one of sources of ICU nurses’ work stress. The potential mistakes bring anxiety especially to the new nurses. Under this kind of stress, the nurses may become too anxious to perform efficient
nurses’ orientation training was found to have significant influence on their intention to leave (Liu, 2010), so a positive, supportive learning environment is important for helping them adapt to the work condition and enhance their retention intention. Observational learning, which is the core concept of social learning theory, allows individuals to learn behaviors without going through trial-and-error process. Similarly, emotional responses can be developed through the learning experience of observing others’ affective reactions and the consequences (Bandura, 1977). Therefore, through social learning perspective, this study explored ICU nurses’ learning process for emotion management, and the findings can provide as a reference for organizations to create appropriate learning environment for employees and develop mentoring, teamwork, and simulation program.
Diefendorff et al. (2008) have studied emotion regulation at strategy-level and conducted descriptive survey to investigate the circumstances that most frequently lead individuals to each strategy. They found that the circumstances for each emotion regulation strategy (ERS) were quite varied. Researches at the event-level have linked the work event, emotions, and ERS, but each of them only examined affective customer event (Grandey, Dickter, & Sin, 2004), emotion (Grandey & Brauburger, 2002) or ERS (Totterdell & Holman, 2003), or only examined two of them simultaneously. It was thus suggested that the effectiveness of each ERS should be examined to know if a particular ERS was effective for organizational outcomes or if a certain strategy was beneficial for some outcomes but harmful for others. Therefore, this study adopted a multi-dimensional approach to examine ICU nurses’ emotion management. That is, this study examined emotion management at four levels: (1) incidents that induced emotions, (2) emotion regulation strategies, (3) incident outcome after using the strategy, and (4) the influence of incident outcome on involved ICU nurses.
Definition of Terms Emotion Management
In Hochschild’s (1983) definition, emotion management refers to “the management of feeling to create a publicly observable facial and bodily display” (p.7). To understand ICU nurses’ emotion management strategies, this study adopted Lazarus’s (1994) definition for emotion management, which referred to cognitive and behavioral regulatory strategies that individuals adopted to maintain emotion harmony and reduced negative emotions when facing disturbing situations that elicited negative emotions.
Emotional Labor
Emotional labor is a kind of occupational emotional demand, which describes that an individual needs to regulate his or her emotions to comply with social norms or to meet organization expectations (Hochschild, 1983). In this study, nursing job was considered having high level of emotional labor and the nurses expressed appropriate emotions to meet expectations.
Emotion Regulation
Emotion regulation is considered one of emotion management strategies. This study adopted Gross’s (2002) emotion regulation strategies as framework. In his definition, emotion regulation refers to “the processes by which individuals influence which emotions they have, when they have them, and how they experience and express these emotions” (p.275).
Social Learning Theory
Social learning is the idea that people learn by observing others. According to Bandura (1977), Social Learning Theory (SLT) has four central elements: attention, retention, reproduction, and reinforcement and motivation. An individual can learn a certain behavior not only through observing the way others present their behavior, but also through simply seeing the consequence of others’ experience. The study adopted this definition and applied