加護病房護理師之情緒管理與學習歷程

全文

(1)Emotion Management Strategies and Social Learning Process of Intensive Care Unit Nurses in Taiwan. by Wan-Ling Yao. A Thesis Submitted to the Graduate Faculty in Partial Fulfillment of the Requirements for the Degree of MASTER OF BUSINESS ADMINISTRATION Major: International Human Resource Development. Advisor: Wei-Wen Chang, Ph. D.. National Taiwan Normal University Taipei, Taiwan June, 2014.

(2)

(3) ACKNOWLEDGEMENT The process of writing thesis was very tough, but it made the accomplishment incredible. Qualitative research is hard, time-consuming, but interesting. At first, I need to give my deepest appreciation to twenty ICU nurses who are willing to be my participants. This study would not be completed without these angels. My inspiration came from my dear sister, Ivy, who used to be an ICU nurse. Thank you for discussing with me, providing ideas for me, and accompanying me to interviews. The journey is fun because of you. I want to thank my thesis advisor, Dr. Vera Chang, who is so warm and always guides me patiently. Thank you for always listening to my ideas and giving me suggestions with kindness. I also want to thank Dr. Steven Lai and Dr. Pai Po Lee for being my committee members. Thank you for reading my thesis carefully and attending my defense although you are busy. I would feel tougher in this journey if it were not IHRD friends who accompany me and give me support. You are all so passionate, interesting, and warm. I want to especially thank Carol, Sunny, Lulu, and Pei, who always share laughter with me and care for each other. You make me feel not so stressed and difficult. Last but not least, I want to thank my family and my boyfriend. Thank my family for supporting me these two years. Thank my boyfriend for always being patient with me when I felt stressed and had hard time searching for interviewees and fighting with my thesis. All of you make me become a better man during these two years..

(4)

(5) ABSTRACT Nursing job is considered as high level of emotional labor. Many research studies have examined the emotion management strategies by randomly choosing participants from all sections of the hospital. However, the work condition and work stress are different in every hospital section. Intensive Care Units involve highly intensive social interaction that is the primary source of ICU nurses’ work stress. Thus, this study focused on ICU nurses to understand their experience of using emotion management strategies in emotional incidents. This study also aimed to explore the incident outcome after using the strategy and discuss what influence the outcome brings to the involved ICU nurses. The highly intensive social interaction in ICU also made nurses go through different learning process at work. Therefore, another purpose of this study was to understand ICU nurses’ social learning process for emotion management. This study adopted the qualitative approach and collected data through interview and document review. The research participants were ICU nurses who came from different hospitals and had at least one year ICU work experience. Snowball sampling was utilized to enlist qualified ICU nurses through nurses’ networks. The techniques of triangulation and member check were applied to enhance the credibility of the study. The main findings indicated that situation modification, cognitive change, and response modulation were most widely applied emotion management strategies. Among all strategies identified in this study, “reassure patients or relatives” was found to result in more significantly satisfactory incident outcome, while “to hide emotions” often made nurses to finish their work with bad mood. The study also found that most nurses learned to use response modulation through observing the interaction between coworkers and patients and relatives. They were also found to learn cognitive change and situation modification from personal experience and observing others performing tasks. Moreover, this study connected social learning’s literature review with ICU nurses and discussed their social learning situation. The findings of the most used strategies were also compared with previous research studies and discussed. Finally, the study concluded with implications for ICU nurses and health care institutions and suggestions for future researches.. Keywords: emotion management strategies, social learning, Intensive Care Unit nurses. I.

(6) II.

(7) TABLE OF CONTENTS. ABSTRACT ................................................................................................ I TABLE OF CONTENTS ......................................................................... III LIST OF TABLES .....................................................................................V LIST OF FIGURES ................................................................................ VII CHAPTER I INTRODUCTION.............................................................. 1 Background of the Study ........................................................................................ 1 Research Purposes .................................................................................................. 4 Research Questions ................................................................................................. 4 Significance of the Study ........................................................................................ 4 Definition of Terms ................................................................................................ 7. CHAPTER II LITERATURE REVIEW ................................................. 9 Emotion Management Strategies ............................................................................ 9 Social Learning Theory ........................................................................................ 18 Emotional Factors within Nursing Work .............................................................. 23. CHAPTER III RESEARCH METHODS .............................................. 27 Research Approach ............................................................................................... 27 Research Framework ............................................................................................ 28 Research Participants and Sampling Criteria........................................................ 32 Data Collection ..................................................................................................... 33 Data Analysis ........................................................................................................ 35 Research Quality ................................................................................................... 39. CHAPTER IV FINDINGS AND DISCUSSIONS................................ 41 Emotion Management Strategies .......................................................................... 41 Outcome of Using Strategies and Influence on Individual ................................... 48 Social Learning of Emotion Management Strategies ........................................... 57 Discussions ........................................................................................................... 63. CHAPTER V CONCLUSION & IMPLICATIONS ............................. 65 Conclusion ............................................................................................................ 65 Implications .......................................................................................................... 66 Limitations & Suggestions for Future Research ................................................... 67. REFERENCES......................................................................................... 69 APPENDIX A: INTERVIEW QUESTIONS .......................................... 75 APPENDIX B: THE DIMENSIONS OF RESEARCH FINDINGS....... 81. III.

(8) IV.

(9) LIST OF TABLES Table 2.1. Definition of Emotion Management ........................................................... 10 Table 3.1. The Description of Interview Participants .................................................. 33 Table 3.2. The Example of Coding Process ................................................................. 37 Table 3.3. The Example of the Categorizing Process .................................................. 38 Table 4.1. Result of Emotion Management Strategies ................................................ 42 Table 4.2. Result of Incident Outcome and Influence after Using EM Strategies....... 50 Table 4.3. Result of ICU Nurses’ Social Learning ...................................................... 58. V.

(10) VI.

(11) LIST OF FIGURES Figure 2.1. Conceptual framework of emotion regulation ........................................... 12 Figure 2.2. A consensual process model of emotion regulation highlighting two major classes of emotion regulation. .................................................................................................. 14 Figure 2.3. A process model of emotion regulation..................................................... 15 Figure 3.1. Research framework .................................................................................. 28 Figure 3.2. Research procedure ................................................................................... 31 Figure 3.3. Data analysis procedure ............................................................................. 36 Figure 4.1. Framework of incident outcome after using EM strategies....................... 49. VII.

(12) VIII.

(13) CHAPTER I. INTRODUCTION. 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 intensive care for patients who are considered critically ill or facing life threatening problems 1.

(14) (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 2.

(15) 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.. 3.

(16) 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 4.

(17) 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 work and decision-making capacity (Hay & Oken, 1972). The learning situation during new 5.

(18) 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.. 6.

(19) 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 Singh, Dong, and Gero’s (2012) three social learning modes to distinguish learning process. 7.

(20) 8.

(21) CHAPTER II. LITERATURE REVIEW. The purposes of this study were firstly to identify ICU nurses’ experience of using emotion management strategies in emotional incidents at work, and to explore the incident outcome and the influence of the outcome on the involved ICU nurses. Through social learning perspective, this study also aimed to understand ICU nurses’ learning process for emotion management. This chapter reviewed some findings of previous research studies and connected this study’s main theories to nursing work.. Emotion Management Strategies In this part, emotion management was defined at first and then related emotion management strategies and models were explained and reviewed in the following sections.. Definition As time goes, the term “emotion management” has been defined by many scholars and researchers as shown in Table 2.1.. 9.

(22) Table 2.1. Definition of Emotion Management Source Hochschild (1983). Definition “The management of feeling to create a publicly observable facial and bodily display” (p.7).. Lazarus (1994). Emotion management refers to cognitive and behavioral regulatory strategies that individuals adopt to maintain emotion harmony and reduce negative emotions when facing disturbing situations that elicit negative emotions.. Lee (2002). Individuals can express emotions appropriately through perceiving others’ and their own emotions, and regulating their emotions effectively while understanding and empathizing others’ emotions to reach physiological and psychological coordination.. 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). Emotional labor involves people who enhance, suppress, or fake their emotions to modify the emotional expressions (Grandey, 2000). In the organization, people may need to modify or regulate their emotions because of the display rules regarding the expectations of organization (Ekman & Friesen, 1975; Goffrnan, 1959). In Ashforth and Humphrey’s perspective (1993), they defined emotional labor as the act that one displays appropriate emotions for managing the impression for the organization, so they considered emotional labor as an observable behavior more than a management of feelings. Hochschild (1983) proposed two main ways of managing emotions: surface acting and. 10.

(23) deep acting. Surface acting means the regulation of emotional expressions; deep acting means the modification of feelings in order to express the desired or expected emotions. These two ways demand different resources, because surface acting is about going through the motions, while deep acting requires putting one’s self in another’s shoes (Diefendorff, Croyle, & Gosserand, 2005). Surface acting means the expressions of emotional labor are not their real feelings inside; instead, they express it by faking. The modification of expressions usually with the goal of meeting organization’s expectations or display rules, so surface acting usually leads to emotion dissonance within emotional labor (Yu, 2012). When emotional labor workers try to modify their own real emotions in order to show a consistency with organization’s display rules, they are using deep acting strategy. The emotional labor workers who use deep acting strategy can have more sincere and natural expressions and are less likely to lead to emotion dissonance (Yu, 2012). Grandey (2000) developed a theoretical model of emotional labor, which is presented in Figure 2.1. The model was developed through utilizing and reviewing the general emotion regulation theories to provide a new way to conceptualize emotional labor. In the model, the situational variables, which are antecedents of emotion regulation, include the interactions between employees and customers. In previous emotional labor studies, the situational variables, which involve customer contact and the display rules of organization, are the factors that contribute to the emotional labor process (Morris & Feldman, 1996; Hochschild, 1983).. 11.

(24) Situational Cues. Emotion Regulation Process. Interaction Expectations. Individual Well-Being. Emotional Labor.  Frequency  Duration.  Burnout. Deep Acting: Modify Feelings.  Variety. Long-Term Consequences.  Job satisfaction.  Attentional deployment.  Display rules. Organizational Well-Being.  Cognitive change.  Performance. Emotional Events Surface Acting: Modify Expressions.  Positive events. .  Negative events.  Withdrawal behavior. Response modulation. Individual Factors. Organizational Factors.  Gender.  Job autonomy.  Emotional expressivity.  Supervisor support.  Emotional intelligence.  Coworker support.  Affectivity (NA/PA). Figure 2.1. Conceptual framework of emotion regulation. Adapted from “Emotion regulation in the workplace: A new way to conceptualize emotional labor,” by A. A. Grandey, 2000, Journal of Occupational Health Psychology, 5(1), p.101. Copyright 2000 by the Educational Publishing Foundation.. Emotion Regulation Strategies The first precursor of emotion regulation research has focused on reducing negative emotion experience through mental or behavioral control. However, the focus has expanded to concern with both conscious and unconscious processes that affect an individual’s positive or negative emotion experience (Mayer & Salovey, 1995; Parrott, 1993). The second significant precursor of emotion regulation research at first focused on responses to physical challenges and later expanded to responses to psychological challenges. Psychological stress and coping research, which is one of the roots of emotion regulation research, has concerned 12.

(25) with adaptive, conscious coping processes and has focused on situational variables instead of person variables (Parker & Endler, 1996). Stress and coping research has been distinguished between problem-focused coping and emotion-focused coping. The purpose of the former is to solve the problem, while the latter is to decrease negative emotion experience (Gross, 1998a). Emotion is elicited in different ways, including individuals’ subjective experience, physiological influence, and response tendencies. Emotion regulation is a process in which individuals try to have cognitive or behavioral change through situation reappraisal in order to influence the emotional incidents and modify the type, intensity, duration, or expression of emotion (Gross & Muñoz, 1995; Gross, 2009; Koole, 2009). Because emotions are unfolded over time during multi-componential processes, emotion regulation involves changes in “emotion dynamics” (Thompson, 1990). Emotion dynamics refer to responses’ impact in behavioral, experiential, or physiological domains as emotions proceed in different stages, which are latency, rise time, magnitude, duration, and offset. According to the consensual model as shown in Figure 2.2, emotion usually begins with evaluating external or internal emotion cues. Then, a set of behavioral, experiential, and physiological emotional response tendencies are triggered by the evaluations to express adaptive responding to the stimulus. However, the modulation of response tendencies forms the final shape to display emotional responses (Gross, 1998a).. 13.

(26) Emotional Responses Tendencies Emotional Cues. Emotional Responses. ‧Behavioral ‧Experiential ‧Physiological. Modulation. Evaluation. Figure 2.2. A consensual process model of emotion regulation highlighting two major classes of emotion regulation. Adapted from “Antecedent-and response-focused emotion regulation,” by J. J. Gross, 1998a, Journal of Personality and Social Psychology, 74, p.226. Copyright 1998 by the American Psychological Association.. During the process of emotion generation, ERS are potentially limitless, so it is difficult to find a way to organize countless strategies. As shown in Figure 2.3, Gross (2002) developed a process model of emotion regulation that shows how specific strategies can be differentiated along the timeline of the unfolding emotional responses. 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). In Figure 2.3, emotions can be regulated at two distinguishing phases: antecedent-focused emotion regulation and response-focused emotion regulation. The former occurs before the emotion is generated and modifies the stimulus, while the latter occurs after the emotion is generated and modifies an individual’s response to the stimulus (Gross, 1998a; Gross & Muñoz, 1995).. 14.

(27) Figure 2.3. A process model of emotion regulation. Adapted from “Emotion regulation: Affective, cognitive, and social consequences,” by J. J. Gross, 2002, Psychophysiology, 39, p.282. Copyright 2002 Society for Psychophysiological Research.. Antecedent-focused strategies refer to the things we do before emotional response tendencies are triggered and behavior and physiological responding is changed (Gross, 2002). The strategies used in antecedent-focused emotion regulation stage are similar to deep acting proposed by Hochschild (1983). Individuals regulate emotions through changing external situations and stimulus or internal psychological state (Gross, 1998b). For example, you can see a job interview as a chance to know more about a company instead of a decisive test. Strategies involving in antecedent-focused regulation process are further divided into four categories: (1) situation selection, (2) situation modification, (3) attentional deployment, and (4) cognitive change (Diefendorff et al., 2008), which were explained respectively later. Response-focused strategies refer to the things we do to modify our ongoing emotional response tendencies after emotion has already generated (Gross, 2002). The strategies used during this process are similar to surface acting proposed by Hochschild (1983). Individuals regulate emotions through reducing or reinforcing behavioral responding (Gross, 1998b). For 15.

(28) instance, one may hide his embarrassment after he makes a slip of the tongue in public speech. The strategy used during this emotion regulation process is response modulation, which was also discussed in the followings. Situation selection. The first of these strategies is situation selection, which regulates emotion by approaching or avoiding a certain situation involving particular people, places, or things (Gross, 2002). For example, you can choose a seat away from a friend who always disturbs and chats with you in class. However, short-term and long-term emotional benefits of situation selection often involves complex trade-offs. In Leary’s (1986) example, a shy person who avoids social occasions to decrease anxiety and get short-term relief may in the long run become social isolation. Situation modification. Second strategy is situation modification, which refers to a situation that may be tailored to modify its impact on one’s emotion (Gross, 2002). For example, if a patient is afraid of having an injection and judges that you look poor at it, you can reassure him by saying you are the expert (Chen, 2007). Attentional deployment. Third, situations have different aspects (e.g., a1, a2, a3…), and attentional deployment is that you can select which aspect of the situation you want to focus on. Three specific strategies here are distraction, concentration, and rumination (Gross, 2002). For example, you can distract yourself from an upsetting conversation by appreciating the restaurant’s decoration or by concentrating particularly on a topic or task. Cognitive change. The forth strategy is cognitive change, meaning to select one of the many possible meanings (e.g., m1, m2, m3) you attached to that aspect you chose. For example, you can see the exam as a self-evaluation of learning result instead of see it as a measure of your value. 16.

(29) Cognitive change is often used to decrease or magnify one’s emotional response, and even to alter the emotion itself, such as transforming anger at a piece of news into sympathy. The meaning that a person attaches to the situation is important because it would have powerful influences on physiological, experiential, and behavioral response tendencies that would be elicited in that situation. Response modulation. The last strategy is response modulation, which means trying to influence emotion response tendencies once they have been generated. In the model, the symbol “-“ means the response tendencies are regulated by decreasing expressive behavior, while “+” means reinforcing the expressive behavior. Emotional response tendencies involve three kinds of responses: behavioral, experiential, and physiological responses. For example, you might hide your fear and nervousness by standing behind a desk when giving a presentation. Physiological responses such as depression and anxiety can be controlled by drugs. Reappraisal and suppression. As mentioned above, it is difficult to organize all strategies because there are lots of different ways that an individual can use to regulate emotions. Two commonly used regulation strategies highlighted here are cognitive reappraisal, which happens in antecedent-focused emotion regulation process and expression suppression, which happens in response-focused. emotion. regulation. process.. Cognitive. reappraisal. is. one. of. antecedent-focused strategies and a type of cognitive change. Reappraisal is defined as “construing a potentially emotion-eliciting situation in nonemotional terms” (Gross, 2002, p. 283). Expressive suppression is one of response-focused strategies and a type of response modulation. Suppression is defined as “inhibiting ongoing emotion-expressive behavior” (Gross, 2002, p. 283). To investigate the consequences produced by these two emotion regulation strategies, Gross (2002) conducted an experimental study to compare each regulation strategy to a “no regulation” condition. Participants who were in “no regulation” 17.

(30) condition were not asked to use any regulation strategies and thus were free to regulate if they want. The premise of this study is that antecedent-focused strategies concern whether emotion response tendencies are triggered, and that response-focused strategies concern how emotion response tendencies would be modulated if they have been elicited. The affective consequences presented in the findings shows that based on the process model of emotion regulation, reappraisal leads to lesser physiological, experiential, and behavioral responses. Compared to reappraisal, suppression decreases expressive behavior but not decrease emotion experience. Further, the effort to inhibit ongoing emotion-expressive behavior might even increase physiological responses. In cognitive consequences, suppression requires self-monitoring and self-corrective actions in an emotional incident and impairs memory; while reappraisal does not need self-regulatory effort in an emotional incident and leaves memory intact (Richards & Gross, 2000).. Summary During emotion generative process, different strategies that act at different points may have different consequences; therefore, the adoption of Gross’s (2002) model as a foundation helped this research identify ERS that could be used in different phases and explored more potential strategies and the potential consequences among those strategies.. Social Learning Theory In this part, the development of learning theory in exploring human behavior was explained at first, and then the core concepts of social learning theory (SLT) and related research studies within nursing field were reviewed in the following sections.. Learning and Human Behavior Many theories have been developed over years to explore why people behaved as they do (Bandura, 1977). Early theories depicted behavior as driven by inner forces, which may be needs, and impulses that often happened below the level of consciousness. However, an 18.

(31) internal motivator cannot explain all the variation of human behavior for different social roles under different situations. The later development of learning theory changed the focus from inner determinants to external influences on human responsiveness. Researchers analyzed human behavior by investigating the antecedent stimulus that induced the behavior and the reinforcing consequences that altered the responsiveness. The findings showed that human behavior or response could be induced, eliminated, and regained simply by external environmental influences. In the social learning perspective, human is driven not simply by inner forces or environmental influence, but by a reciprocal interaction between behavior, environment, and cognitive factors. One can always learn something from an experience (Mumford, 1995). In traditional theories of learning, human behavior was viewed as the product of directly experienced response consequences. Actually, in addition to direct experience, an individual can also learn on a vicarious basis by observing others’ behavior and its consequences for them. Learning by observation enables an individual to acquire modeled behavior without having to build up the behavior patterns by trial and error.. Observational Learning and Modeling The core concepts of social learning theory are observational learning and modeling. Bandura (1977) thought that learning involved two different processes, one was learning from the consequences of direct experiences; the other was learning through observation processes. In social learning theory, it is emphasized that an individual’s behavior can be influenced by others in a social context. To elaborate this concept, Bandura provided observational learning and modeling as explanation. Observational learning refers to learning by observing others’ behavior. For instance, a little girl who has seen her mother putting on lipsticks may imitate her mother’s behavior and put on lipsticks by herself. During observational learning process, an individual constructs symbolic representations from 19.

(32) modeling activities, which directs observers to produce appropriate behaviors. Observational learning involves four processes (Bandura, 1977; Olson & Hergenhahn, 2009): Attentional processes. During the first phase of observational processes, individuals must firstly pay attention to the essential features of the role model’s behavior otherwise it is impossible to learn through observation. In this phase, the individuals need to select a role model that they would pay close attention to, and they choose the most relevant characteristics from the role model’s behavior. Observational experiences are influenced by lots of factors including the characteristics of the role model’s behavior, the role model’s characteristics and similarity, observers’ features, associational preferences and interaction relationship between role models and observers (Bandura, 1977; Black & Mendenhall, 1989). Retention processes. An observer cannot be much influenced by a role model’s behavior if he does not keep it in his memory, so the second phase of observational learning is retention processes. During retention process, observers transform the role model’s behavior into symbolic representations and keep in their memories so that they can remember the role model’s behavior with the absence of the role model. Bandura considers the observational learning mainly relies on two representational systems—an imaginal and a verbal system (Black & Mendenhall, 1989). The imaginal representation, for instance, when we hear the name of a friend, we always experience the imagery of his or her physical characteristics. The verbal coding of observed event, for example, when we try to memorize the itinerary, we may transform the visual information into a sequence of right and left turns instead of relying on the visual imagery (Bandura, 1977). Reproduction processes. The third component of processes involves transforming the observational learning into overt actions and the observers represent the modeled behavior. Actual reproduction of the modeled behavior can have physical limitations due to the physical differences between the role model and the observer. For example, a young child can 20.

(33) learn how to drive an automobile by observing his father’s action but if he is too short he is not able to drive successfully. Four phases of enactment are required for reproducing the modeled behavior (Bethards, 2013): (1) cognitive organization, (2) initiation, (3) monitoring, and (4) refinement based on feedback. Reinforcement and motivational processes. In the fourth stage, learners’ motivation of adopting modeled behaviors is influenced by the consequences of their behavior representation. They may be motivated by intrinsic motivation, which comes from inside an individual, by extrinsic motivation, which refers to any external source, or by vicarious association (Bethards, 2013; Black & Mendenhall, 1989). When an individual is motivated by positive incentives, the previous observational learning behavior is promptly translated into overt expressions (Bandura, 1965). The reinforcement function of observational learning consequences can help enhance the possibility that the learner represents the modeled behavior (Bandura, 1977). In observational learning, the role model can be anyone whom the individual has the opportunity to observe, such as family members, employers, co-workers, and teachers, who would either encourage or discourage the individual through the social learning steps (Betz & Hackett, 1981; Krumboltz, Mitchell, & Jones, 1976). During the social learning process, the presence of a role model and the relationship between individuals and role model can lead the individual to different result. For example, in Scherer, Adams, Carley, and Wiebe’s (1989) research of role model and entrepreneurial career preference, the career preference of individuals with a parent entrepreneurial role model is significantly different from individuals with an entrepreneurial role model, and from individual without a role model. SLT was also applied in simulation experience, and it was found that the participation in observer role has the same learning opportunities as the participation in process-based role (Bethards, 2013; Kaplan, Abraham, & Gary, 2012). In some research, SLT was also utilized as a theoretical framework that helped systematically examine expatriate workers’ cross-cultural learning and 21.

(34) outlined a new framework for the cross-cultural training (Black & Mendenhall, 1898, 1990). To shed some light on ICU nurses’ learning of emotion management, this study adopted SLT as a theoretical basis for understanding ICU nurses’ learning experience for emotion management.. Social Learning and Nursing Work Nurses who are trained to be able to work independently and professionally are also required to learn how to work in a team. Nurses who engage in effective teamwork can not only improve patients’ safety but also benefit less experienced nurses (Brunetto et al., 2013). To understand the role of social learning in terms of teamwork, which is important in nursing units, it is found that social learning opportunities in teams can vary from different situations. Among all situations, three modes are identified as consistent patterns of actions, interactions, and observations in social learning (Singh et al., 2012): (1) Learning from personal interaction (PI): Individuals can learn from personal experience with the task or from the direct interactions with others, which are the most direct form of learning. (2) Learning from interaction observations (IO): Individuals can learn from observing the interactions among others. (3) Learning from task observations (TO): individuals can learn from observing others performing a task. This study adopted these three modes of social learning to understand how ICU nurses learned to use emotion management strategies. Through these three modes, the relationship between observer and role model were also identified. To create a supportive learning environment, senior proficient nurses play an important role in students’ or new nurses’ learning during clinical practicum (Brammer, 2006; Dickson, Walker, & Bourgeois, 2006). To new nurses who need to learn how to work in practice, their learning is fostered by 22.

(35) working with senior proficient nurses who may become their role model and lead them to different learning experience for them (Henderson et al., 2010). However, the learning consequence can result in positive or negative reinforcement. For example, Pearcey and Elliott’s (2004) research shows that the interactions between students of nursing who were placed to clinical environments and the nursing staff could foster or hinder the development of the new nursing learners.. Summary Social learning is a continuous process in which individuals can learn something from the observation of or the interaction with others, and in hospitals, nursing work environment involves highly social learning interaction among nurses, doctors, patients, and patients’ relatives. Depending on different incidents and role models, the process of social learning could negatively or positively reinforce or influence learners’ behavior outcome. In this study, in order to explore nurses’ experience of using emotion management strategies in emotional incidents, SLT was adopted as a framework to explore nurses’ learning process for emotion management through social learning perspective.. Emotional Factors within Nursing Work In the past, nurses were trained to conceal their emotions at work and to maintain a professional front, while now it is considered more acceptable for nurses to express their emotions to show their humanity (Staden, 1998). In Hochschild’s study (1983), she referred to emotional labor as workers who were paid to engage in emotion management with their customers, and performing became part of their work. In order to make patients feel cared, nurses are always polite, considerate and respectful. They engage in various activities that correspond with caring behavior, such as helping patients when necessary, providing helpful information and advice, and these behaviors can be associated with positive or negative 23.

(36) emotions such as compassion, sadness, and joy (McQueen, 1997). ICU is a stressful work environment (Burgess, Irvine, & Wallymahmed, 2010). There are many stressful incidents that would increase nurses’ emotional labor, and many factors associated with work stress have been studied in previous research studies The first factor is excessive workload (Hay & Oken, 1972). In daily routine, in addition to regular observations and treatments, ICU nurses need to interpret about patients’ condition and maintain detailed records. Sometimes, the emergency situations require their full attention, which even stop the nurse from continuing her regular tasks on other patients. The daily visiting hours at specific time is another factor causing a big burden for ICU nurses. During visiting hours, they need to face patients’ relatives and their constant inquiries about patients’ condition. Sometimes, the relatives may ask for more than information. The nurses should provide reassurance and support for the relatives and take care of her patients at the same time. The emotional involvement with the relatives during the visiting was found to produce emotional stress and strain for ICU nurses (Hickey & Lewandowski, 1988; Kirchhoff, Pugh, Calame, & Reynolds, 1993; Krapohl, 1995). The third factor that increases job stress is work condition and environment, in which they need to contact with many very ill patients every day, so they are also afraid of potential physical health dangers. Psychologically, the repetitive exposure to death and dying brings ICU nurses tremendous psychological stresses. Besides, ICU nurses have no weekends and holidays, and during which their workload may be even greater. Among the job conditions in ICUs, interpersonal or psychosocial features of work situation are receiving greater attention in studies of work stress. Take recent news for example, in November this year, an ICU nurse in Linkou Chang Gung Memorial Hospital was slapped in the face by a relative whose father was an inpatient in ICU. The relative made a call to the hospital, asking the nurse to explain the patient’s condition to her. However, due to the concern for the patient’s privacy and regulation, the nurse could not reveal any information to the relative on the phone, so she asked the relative to come to the hospital in person. This 24.

(37) response irritated the relative, who came to the hospital and slapped the nurse in the face (Cheng & Chung, 2013). In research of emotional labor, it is often referred to interacting with customers and making efforts to manage their own emotions (Pugliesi, 1999). However, emotional labor exists not only in the interactions with customers but also in all social relations in organizational contexts (Gibson, 1997). In ICU, not only the interactions with patients and relatives, sometimes the emotional incidents that result from interactions with doctors, colleagues, and administrators also a source of nurses’ work stress (Hay & Oken, 1972). In Adomat and Killingworth’s (1994) research that focused on ICU, conflict between colleagues and organizational factors such as management style are identified to be the significant cause of work stress. Dealing with emotional incidents and work stress in ICU, nurses who have more years of nursing experience are found to have lower level of perceived stress, especially nurses with the experience in ICU context (Burgess et al., 2010) .. Summary The sources of nurses’ work stress are from excessive workload, interpersonal situations, and unpleasant work condition and environment. Among the factors of work stress, the intensive social interaction was identified as the primary source that raised the level of ICU nurses’ emotional labor. Therefore, the study focused on ICU nurses’ emotional experience with patients, patients’ relatives, coworkers, and doctors to understand their negative emotional experiences and emotion management strategies they used.. 25.

(38) 26.

(39) CHAPTER III. RESEARCH METHODS. This chapter presented how this research was conducted. This chapter described research approach and showed research framework based on the research purposes. The research procedure for this study was presented and followed by the research design, which included sampling strategy, the methods adopted for data collection, data analysis procedure. Finally, the techniques for ensuring research quality were explained.. Research Approach This study adopted qualitative research approach which aimed to understand people’s interpretations and perceptions, trying to explore ICU nurses’ experience of using emotion management strategies. Qualitative research seeks to produce in-depth, comprehensive information and obtain a wide understanding of the entire situation (Key, 1997), so this study conducted in-depth interview in which the ICU nurses share their experience of emotional incidents at work and their social learning process for emotion management strategies. On the basis of research questions, a series of interview questions were designed to guide interviewees to recall and share their experience. Compared to quantitative research, the goal of conducting qualitative research is to explore the depth of information rather than collect information from large numbers. While quantitative study is often adopted to verify a relationship or hypothesis that researchers already have in mind (Neuman, 2006), qualitative method is often inductive, which means hypotheses or theories are generated after the information is gathered (Houssemand & Meyers, 2013). Thus, this study adopted qualitative research approach to seek the answers not only for ‘what’ but also ‘how’.. 27.

(40) Research Framework The development of this study’s research framework was based on research purposes and research questions presented in Chapter I. This study aimed to identify emotion management strategies used by ICU nurses in emotional incidents and to explore the incident outcome and the influence on individual. As illustrated in the framework, how ICU nurses dealt with emotional incidents would affect their social learning process, and what they learned from previous social learning process would also influence how they dealt with later emotional incidents. Therefore, another purpose of this study was to understand ICU nurses’ learning process for emotion management through social learning perspective.. Emotion Management Strategies. Emotional Incidents. . Situation selection.    . Situation modification Attentional deployment Cognitive change Response modulation. Incident Outcome. Social Learning   . Learn from personal interaction (PI) Learn from interaction observations (IO) Learn from task observations (TO). Figure 3.1. Research framework. 28. Influence on Individual.

(41) To identify ICU nurses’ emotion management strategies in emotional incidents, this study adopted the conceptual framework of emotion regulation proposed by Gross (2002). The three modes of social learning, which were proposed by Singh et al. (2012), were also adopted to understand how ICU nurses learned to use emotion management strategies. Through these three modes, the relationship between observer and observed role model was also identified. Both of these two theories were already elaborated in Chapter II. This research framework was a basic structure for analyzing data after data collection.. Research Procedure As shown in Figure 3.2, the research procedure presented the steps of developing and conducting this study. 1. Identify Research Topic The research topic was identified after consulting with advisor and discussing with an ICU nurse to make sure that it was feasible to conduct this study. 2. Review Literature After deciding the topic, literatures about emotion management and social learning and nursing-related information were explored to understand the research background and identify research gaps and significance. 3. Determine Research Method Because of the gap that pointed out few research studied have studied emotion management in multi-dimensional way, this study adopted qualitative research to gain richer and deeper data. 4. Clarify Research Purpose and Questions Based on the research background, this study developed two research purposes. After consulting with the advisor, research questions were set according to research purposes. 5. Develop Research Framework. 29.

(42) Research framework was developed based on three modes of social learning and five emotion regulation strategies which were presented in literature review. The emotional incident, incident outcome, and influence on individual, which made the data of this study rich, were also put in the research framework. 6. Design Interview Questions In order to respond to research questions, interview questions were developed from research questions. 7. Conduct Expert Review and Pilot Test The interview questions were checked by two experts to ensure the reliability of questions. Two pilot tests were also conducted to make sure the questions were easy to be understood. The researcher modified the interview questions according to the suggestions of experts and the result of pilot tests. 8. Conduct Interviews Because this study adopted snowball sampling, the researcher interviewed ICU nurses through the network of their relationships. The interview questions were sent to interviewees in advance so that they can recall the memory and prepare for the interview. 9. Analyze Data After collecting all the interview data and relevant document, the researcher transcribed the interview verbatim and systematically categorized them based on research questions to discover the findings. 10. Present Research Findings After analyzing the data, research findings were presented to connect with literature review to respond to research questions. The implications and suggestions were provided for individuals and organizations involving emotion work.. 30.

(43) Identify Research Topic. Review Literature. Determine Research Method. Clarify Reserach Purpose and Questions. Develop Research Framework. Desgin Interview Questions. Conduct Expert Review and Pilot Test. Conduct Interviews. Analyze Data. Present Research Findings. Figure 3.2. Research procedure. 31.

(44) Research Participants and Sampling Criteria This study focused on ICU nurses. Because this study involved the interpersonal interactions among nurses, patients, patients’ relatives, colleagues, and doctors, if the participants chosen to be representative sample only came from the same hospital, the reliability of research result would be lower. Besides, different hospitals had different work atmosphere and environment, so the participants came from ICU in different hospitals could help this study discover more various cases. This study adopted snowball sampling, which “begins with one or a few people or cases and spreads out based on links to the initial cases” (Neuman, 2010, p.269), so the researcher interviewed ICU nurses through the network of their relationships. The total number of participants was 20 ICU nurses in this study, and because ICU was considered a complicated work environment, the participants in this study should have at least one year work experience in ICU, meaning they had at least one-year learning experience to share with the researcher. For senior ICU nurses, even if they had worked for many years, there were often unexpected incidents that they may not encounter before, so learning was an ongoing process for them. In this study, the participants’ age range was 21~45 years old, and they had one to more than five years of work experience. To ensure the confidentiality of hospitals and the privacy of participants, the participants’ names were coded using pseudonym (Table 3.1.).. 32.

(45) Table 3.1. The Description of Interview Participants Interviewee. Age Range. Location of Hospital. Year of Experience. Anita Betty Cathy Debby Emily. 26-30 26-30 21-25 31-35 21-25. Middle of Taiwan Northern Taiwan Middle of Taiwan Northern Taiwan Northern Taiwan. Above 5 3-4 1-2 Above 5 1-2. Fiona Gina Helen Ivy Jill. 21-25 31-35 26-30 21-25 21-25. Middle of Taiwan Northern Taiwan Northern Taiwan Northern Taiwan Northern Taiwan. 1-2 Above 5 Above 5 1-2 1-2. Kelly Lucy Maggie Nancy. 31-35 21-25 26-30 41-45. Middle of Taiwan Northern Taiwan Northern Taiwan Middle of Taiwan. Above 5 1-2 1-2 3-4. Olivia Penny Queen Rita Stacy Tracy. 26-30 26-30 26-30 26-30 26-30 21-25. Northern Taiwan Northern Taiwan Middle of Taiwan Middle of Taiwan Middle of Taiwan Northern Taiwan. 3-4 3-4 Above 5 Above 5 Above 5 1-2. Data Collection This study adopted qualitative research approach based on in-depth interview and document review. Due to the purposes of study, which aimed to identify ICU nurses’ emotion management strategies, the interview focused on participants’ sharing of emotion management experience. This study also tried to understand ICU nurses’ learning process for emotion management, so the relevant document that the participants provided was reviewed to enrich the research results.. 33.

(46) In-depth Interview This study adopted in-depth interview to focus on the ICU nurses’ experience of using emotion management strategies and the learning process for the strategies. In-depth interview was conducted to explore the participants’ perspectives on a particular “idea, program, or situation” (Boyce & Neale, 2006, p.3). Qualitative interviews can be generally categorized into three types: unstructured, semi-structured, and structured interviews (DiCicco-Bloom & Crabtree, 2006). This study adopted semi-structured in-depth interviews, which were considered the most appropriate technique when the researcher asked open-ended questions that explored depth of information from the participants. The flexibility permitted responses to be fully probed and allowed the researcher to be responsive (Guion, Diehl, & McDonald, 2011). This approach fitted this study because the content of the interview was about experience-sharing, in which the researcher asked an initial question and expected the participant to talk freely when answering the question. The follow-up questions also emerged from the dialogue for the researcher to probe more information. The length of each interview was about 60 minutes. The interviews were recorded with digital voice recorder and the researcher also took notes during the interviews. The interview questions were designed based on research questions. Because the participants’ native language was Mandarin, the interview questions were designed in Chinese. The questions were also translated into English later and checked by two peers majoring in human resource development and possessing good English ability. To ensure the participants could understand interview questions responding to research questions, interview questions were reviewed by two experts to ensure the reliability and validity. The questions were sent to two experts, one was physician assistant, who used to be an ICU nurse, and the other was a senior nurse who used to work in ICU. The experts suggested that the interview time should control within an hour because ICU nurses were busy and did not have many vacation, they may not want the 34.

(47) interview to occupy too much of their break time. The experts also gave some suggestions on the wording of interview questions to ensure the participants could understand what the researcher wanted to ask. The researcher revised some wording according to the experts’ suggestions. For example, the word “actions” were revised into “emotional responses.” After the revision of interview questions, the researcher conducted two pilot interviews to ensure the interviewees could catch the intended meaning of the questions.. Document Review Document review provided a valuable source of data for historical and discourses analysis. The document can include personal documentation such as diaries, letters, and films (Krahn & Putnam, 2008). Due to the convenience of internet, some people tended to keep a diary and shared their status on community websites such as facebook. Through social interaction activities, interpersonal influence could also be delivered. One of the research purposes of this study was to understand ICU nurses’ learning process of emotion management through social learning perspective. Thus, this study explored ICU nurses’ social learning with the assistance of diaries provided by the participants.. Data Analysis The researcher adopted a qualitative approach in this study to conduct in-depth interview and document review. The data analysis of this study was based on Taylor-Powell and Renner’s (2003) analysis process. After data collection, six steps of data analysis process were implemented (Figure 3.3.).. 35.

(48) Transcribe each interview verbatim. Get familiar with the data. Review the purposes and research questions of this study. Conduct open coding. Conduct axial coding. Present and explain findings. Figure 3.3. Data analysis procedure. Adapted from “Analyzing qualitative data,” by E. Taylor-Powell & M. Renner, 2003, Madison, WI: University of Wisconsin Extension.. Data analysis was an on-going process in qualitative research, including data collection and transcribing interview content. During interview process, the general ideas emerged from the conversation and the researcher transcribed each interview verbatim after the interviews. After the transcription, the researcher read the data and listened to the recordings several times in order to understand the data. To get familiar with the data helped the researcher identify answers and essential information for the research purposes and research questions. Then, the open coding and axial coding were implemented. Open coding means locating the themes and assigning initial codes to condense the data into categories (Neuman, 2006). Axial coding is the second stage of coding and the primary task is to organize the initial coded themes, link them, and identify the key analytic categories (Neuman, 2006). At last, the themes were finalized into findings in response to research questions. 36.

(49) In Table 3.2., the example of the coding process was presented. After the interview was transcribed verbatim, the researcher examined the transcripts carefully to identify useful data and gave each discrete idea “a name or label that stands for or represents a phenomenon” (Mertens, 2005, p. 424). In the example of Table 3.2., the first code stood for the interviewee, and the second code represented the series number of emotional incident with nurses. The researcher examined useful information from the original content for responding to the first research question, so the researcher gave the third code which denoted the strategy that the interviewee used in the emotional situation.. Table 3.2. The Example of Coding Process Interviewee Anita. Original Data. Coding. One time when I transferred the patient to. A_NI7_S2.1.1. general unit, I was spited by their head. I will ask my senior nurse to. nurse…I felt helpless at that moment. I said. help me with this injection.. ‘sorry, I will ask my senior nurse to help me with this injection.’. After all relevant ideas were coded, the researcher started to group the codes into categories, which was an important step because “this is how you bring the complexity of the context back into the picture” (p. 424). Then the relationship between categories was connected to identify the themes, and finally the themes were placed into different dimensions based on research quesitons. In order to response to three research questions of this study, four dimensions were identfied, which were emotion management strategies, incident outcome, influence on individual, and social learning for EM. Table 3.3. presented the example of the process that the researcher categorized the codes, and identified the themes and dimensions. 37.

(50) Table 3.3. The Example of the Categorizing Process Code. Category. Theme. Dimension. Cognitive Change. Emotion Management Strategies. S4.1.1 I told myself that at least he died without lots of pain. S4.1.2 Sometimes I would think maybe they really care about that.. Think from another perspective. S4.1.3 We were all doing good things for the patient, not for ourselves. S4.2.1 I would think what they needed and what I could do for them. Put oneself in other’s shoes S4.2.2 I thought from relative’s perspective to understand her decision 38.

(51) Research Quality The measures for achieving trustworthiness of research procedures and findings should be evaluated in every research. For evaluating qualitative findings and enhancing research’s trustworthiness, Guba and Lincoln (1985) proposed four criteria that can be incorporated into a research design.. Credibility The evaluation criterion of credibility was to assess research findings from participants’ or members’ perspective. In order to enhance to credibility of the study, the researcher included member checks into the research findings. Guba and Lincoln (1985) described member checks as “the most crucial technique for establishing credibility” (p.314). Mertens (2005) indicated that member checks can be conducted with formal and informal way. Because the nurses may be too busy to check the transcription after the researcher transcribed the interview verbatim, the researcher summarized the interview content and checked the notes again with the interviewees at the end of interview to ask if anything was misunderstood or omitted. Triangulation was also adopted to enhance the credibility of research results. In this study, in-depth interview and document review were both conducted to collect research data to ensure the consistency of the data.. Transferability Transferability refers to the degree that research findings can be transferred to other context. In order to enhance transferability, the researcher provided details of the research methods and context that underlied the study. This study focused on ICU nurses who did emotion work with high work stress, which had already detailed in the research background and literature review. Thus, the study could provide the research results for other emotional labor workers in other industries.. 39.

(52) Dependability Dependability is similar to the stability and reliability, which means the consistency of the findings under similar condition. However, because the findings of qualitative research is less able to be duplicated, it is important for the researcher to explain the changing contexts that are fundamental to qualitative research. To enhance the consistency of the research result, in data collection, the interview questions were sent to the interviewees in advance for them to prepare. During the in-depth interview, the interview process was recorded with digital voice recorder to ensure the quality of interview.. Confirmability Confirmability refers to objectivity, which means the extent to which the researcher notices individual subjectivity. In order to reduce bias, there was a nurse who used to work in ICU attending most interviews and observing the interview process. The consultation with the advisor also helped enhance the comfirmability of the study.. 40.

(53) CHAPTER IV. FINDINGS AND DISCUSSIONS. The purposes of the study aimed to address three research questions: (1) What emotion management strategies do ICU nurses use in emotional incidents? (2) How do emotion management strategies affect the outcome of the incident? And how does the incident outcome influence the involved ICU nurses? (3) Through social learning perspective, how do ICU nurses learn to use the emotion management strategies? In this chapter, the main findings responding to each research question were proposed and explained in the following sections.. Emotion Management Strategies To respond to the first research question, this section illustrated three emotion management strategies which were found to be most used strategies among ICU nurses’ negative emotional incidents. As shown in Table 4.1., more detailed strategies were identified for each emotion management strategies. The number of the participants using the strategies and the frequency that the strategies appeared among emotional incidents were also presented.. 41.