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INTRODUCTION
Competition has been growing among hospitals as increased disclosure of quality assessments of their services is creating a customer-centered medical environment. As ambulatory care represents the first point of contact between the patient and the hospital, thus determining the image of the hospital, a customer service-orientation strongly emphasized for ambulatory care nurses. Previous studies have showed that kindness is the factor with the greatest influence on hospital satisfaction for outpatients [1,2], and the kindness of ambulatory care nurses is one of the factors considered when customers select hospitals [1]. Many hospitals provide training on expressing kindness and regularly conduct customer satisfaction surveys to improve customer-centered medical services [2], and actively intervene to follow a code of behavior and control the emotional expressions of medical personnel [2,3].
The regulations or strategies of hospitals that standardize and enforce rules regarding the emotional expression of individuals may require their emotional labor [4]. Emotional labor is defined as the regulation of individuals’ experienced emotions and emotional expression in order to achieve the goals of an organization. It refers to an individual’s efforts to control personal emotions in order to adapt to an organization or perform one’s duties effectively in situations where there is a gap between the emotional expression required by the organization and the actual emotions felt by the individual [4,5]. Emotional labor can take the form of either surface, deep acting or emotional dissonance. Surface acting refers to the outward expression of emotions in accordance with organizational regulations, contrary to the actual emotions of an individual. Deep acting, on the other hand, involves attempts to conscious change the actual emotions of an individual towards the desired action. The emotional labor performed by nurses directly affects the development of rapport with patients, and hence, the mental and physical well-being and recovery of patients as well. There is a positive aspect to emotional labor, in that it can be a symbolic emotional expression that provides reassurance to patients [6]. However, ongoing emotional labor can negatively influence service providers in the form of emotional exhaustion, depression or anxiety, additional stress, and negative effects on health, ultimately having a negative effect on the organization in the form of reduced job engagement, reduced motivation to provide quality service, and increased turnover rate [2,7].
Due to the nature of ambulatory care, nurses meet a variety of patients and tend to be focused more on indirect rather than direct care. Additionally, the severity of patients’ conditions has increased due to the decrease in the lengths of hospital stay by patients, and an increase in the number of patients with more complex conditions. Thus, there is an increasing demand for quality services from patients, and nurses are forced to perform emotional labor to overcome the conflict between their professional identity as nurses and the need to fulfill demands regarding quality of service [8]. Job satisfaction increases when the performance of deep acting emotional labor by an individual coincides with the regulation regulation of expression by the organization [4,9].
The purpose of this study is to analyze the impact of surface and deep acting emotional labor on emotional dissonance among ambulatory care nurses in a general hospital. The specific objectives of the study are as follows: 1) to identify the levels of surface acting, deep acting, and emotional dissonance of the study participants; 2) to identify variations in surface acting, deep acting, and emotional dissonance according to the general characteristics of the participants; 3) to define the correlations among surface acting, deep acting, and emotional dissonance of the participants; and 4) to define the factors that influence emotional dissonance of the participants.
METHODS
1. Study design
This study used a descriptive correlational design to examine the impact of surface and deep acting emotional labor on emotional dissonance among ambulatory care nurses in a general hospital.
2. Participants
The participants of this study were ambulatory care nurses from a tertiary hospital in Seoul who performed general ambulatory care tasks and faced patients directly. All subjects gave written, informed consent before participation. Exclusion criteria were a new nurse within 1 month and nurse managers. Hospital of this study is a large hospital which has about 2,000-bed and 31 medical units in ambulatory care department with 223 nurses.
The sample size was calculated using the G*Power 3.1 program (Heinrich-Heine University, Düsseldorf, Germany). With eight predicted variables, effect size of 0.15, significance level of 0.05, and power of 90%, it was calculated that a total of 166 participants were required for the study. As the dropout rate was estimated to be 20%, 189 surveys were handed out, of which 171 were returned. Among the returned questionnaires, eight were eliminated due to inadequate responses, resulting in a final total of 163 participants (73.1%).
3. Measurement tools
1) Surface acting and deep acting
The responses to each question are arranged on a five-point Likert scale, with a higher value indicating a higher degree of emotional labor. The Cronbach’s α values for the reliability of the tool when applied in the study by Lee [2] were 0.80 for surface acting and 0.78 for deep acting, whereas they were found to be 0.84 for surface acting and 0.78 for deep acting in the current study.
2) Emotional dissonance
The tool, developed by Morris and Feldman [10], was used to measure emotional dissonance. It calculates the emotions aroused from customer interactions with three questions. The responses to each question are arranged on a 5-point Likert scale, ranging from 1 point for “highly disagree,” 2 points for “disagree,” 3 points for “neither disagree nor agree,” 4 points for “agree,” and 5 points for “highly agree.” Higher values indicate a higher degree of emotional dissonance. At the time of development of the tool, its Cronbach’s α for reliability was 0.86, whereas it was 0.88 in the current study.
4. Data collection
Data were collected with the cooperation of the nursing department of the target hospital after obtaining approval from the Clinical Research Review Committee of the medical institution at which this study was conducted. The period of data collection was two weeks during March 2017. The author directly distributed the self-reporting surveys for data collection by visiting the ambulatory care unit of the concerned hospital. The participants were only asked to respond to the survey if they agreed to participate in the study, and the completed surveys were collected directly by the author.
For the ethical protection of the participants, prior to data collection, this study received approval from the Institutional Review Board (No. 2017-0285) of the institution to which the author is affiliated. Participants were given explanations on the purpose, method and process of the study, and were notified that they could withdraw from the study at any time if they did not wish to respond, and that the results would be anonymous. Only those participants who agreed to participate responded to the survey after providing written consent.
5. Data analysis
The statistical application SPSS version 22.0 (IBM Corp., Armonk, NY, USA) was used to calculate the error and percentage, mean and standard deviation of each variable from the collected data. The variations in surface acting, deep acting, and emotional dissonance according to the general characteristics were analyzed using t-test and one-way analysis of variance, and the posttest for the comparison between the groups was analyzed using Scheffé’s test. The correlations among surface acting, deep acting, and emotional dissonance were analyzed using Pearson’s correlation coefficients, and the factors that influence emotional dissonance were analyzed using multiple linear regression.
RESULTS
1. General characteristics of the participants
The general characteristics of the participants are shown in Table 1. The mean age was 34.7, and the most common age group was from 31 to 40, comprising 65.6% of the entire participants. In terms of employment status, 84.0% (n=137) were in regular and 16.0% (n=26) were in irregular employment, and the mean ambulatory care career length of participants was 4.2 years. Of the total participants, 31.3% (n=51) had 2 to 3 years’ experience in ambulatory care, 30.7% (n=50) had 6 to 10 years, 18.4% (n=30) had 4 to 5 years, 16.0% (n=26) had less than 1 year, and 3.7% (n=6) had over 11 years of experience.
2. Surface acting, deep acting, and emotional dissonance of the participants
The mean surface acting score of the participants was 3.47±0.80, whereas the mean deep acting score was 3.76±0.57, and the mean emotional dissonance was 3.36±0.90 (Table 2).
3. Surface acting, deep acting, and emotional dissonance according to the general characteristics of the participants
There was no meaningful variation in surface acting, deep acting, and emotional dissonance of the participants according to gender, age, marital status, religion, and education (Table 3). However, there was a meaningful difference in emotional dissonance according to the total career (F=3.12, P=0.027).
4. Correlations among surface acting, deep acting, and emotional dissonance of the participants
It was found that surface acting and emotional dissonance (r=0.817, P<0.001), deep acting and emotional dissonance (r=0.417, P<0.001), and surface acting and deep acting (r=0.383, P<0.001) had statistically meaningful positive correlations with each other (Table 4).
5. Factors that influence the emotional dissonance of the participants
A multiple linear regression analysis, including total clinic career, surface acting, and deep acting that showed meaningful differences in general characteristics, was conducted to identify the factors that influence the emotional dissonance of the participants. The model was found to be statistically meaningful (F=125.32, P<0.001), with an explanatory power of 67.4%. It was found that the factors that influence emotional dissonance are surface acting (β=0.77, P<0.001) and deep acting (β=0.12, P=0.011) (Table 5).
DISCUSSION
This study confirms that the ambulatory care nurses’ emotional labor relatively higher than ward nurses. This study confirms that the surface acting and deep acting of emotional labor effect emotional dissonance in ambulatory care nurses.
The emotional labor scores of the participants in the current study ranged from 3.36 to 3.76 out of 5. This was lower than the emotional labor scores of ambulatory care nurses from metropolitan areas (3.78) [11], but significantly higher than the average score of 3.25 of ward nurses [12]. Since patients have been demanding a higher quality of service from advanced general hospitals, the emotional labor of ambulatory care nurses, who are the first point of contact with patients, is still high. However, it was found that the values for emotional dissonance, which results in the tension, conflict, and stress that are some of the sub-factors of emotional labor, were low. This is seen as the effect of various education programs for nurses. The customer satisfaction education and counseling programs conducted by the medical institution at which this study was undertaken help nurses to control their emotions during the communication process. Further, customer experience management activities may have been effective in helping them understand the points of view of the patients/customers and solve problems.
The surface acting and deep acting scores of the participants were higher than the corresponding scores in a study of nursing hospitals in Seoul [13] and in studies of hospital nurses [3,8]. Therefore, it was identified that the ambulatory care nurses at the medical institution involved in this study function at high levels of deep acting. Although low levels of deep acting result in an increase in emotional exhaustion with increases in surface acting, this does not result with high levels of deep acting [14]. This implies that although the levels of surface acting increase due to the demand of higher quality service from patients, this will not automatically lead to an increase in emotional exhaustion, since there is a high effort to treat the patients with sincerity. Although it may be difficult to decrease the rigor of emotional labor due to the severity of patient conditions and the expectations and demands for higher quality service, there needs to be effort from nurses to attend to patients with sincerity. In addition, organizational support, emphasis on leadership and psychological counseling programs are other measures attempted to overcome the toll of emotional labor and resulted in positive changes.
The results of this study did not show meaningful variations in the emotional labor of ambulatory care nurses according to the general characteristics of the participants. These findings are contrary to studies that showed meaningful variations according to age, job position, clinical career, working unit, and employment status [1,12]. Surface acting and deep acting emotional labor strategies vary according to education level and types of hospital. No variable in the current study showed meaningful results, aside from total clinical career because the participants of this study were either staff nurses or charge nurses who have similar tasks in the ambulatory care unit, and it is recommended that the total clinical career be considered when selecting ambulatory care nurses who have the capacity to manage emotional labor.
It was found that ambulatory care nurses have high levels of emotional dissonance and deep acting while performing the tasks of patient education, counseling, and advocacy. This may relate to nurses’ awareness of the importance of these tasks. When they try to align their emotional states and expressions while they are on the job, they experience emotional dissonance when they are repeatedly exposed to situations where there are too many patients to handle and they always run out of time. Ambulatory care nurses try to change their own emotions, gradually accept the broad responsibilities of a nursing professional, understand the situations of the patients by coming out of the state of conflicting emotions, and experience a unification of their emotions and the expression required by the organization [15,16]. Job satisfaction levels of nurses increase when the nurses are identical to the expression regulations of the organization. Therefore, there needs to be an expansion of roles for ambulatory care nurses related to patient education, counseling, and advocacy for a positive influence on deep acting, support programs such as training in improving communication and counseling programs, and also a support system to regulate regulate factors such as total work hours, work intensity, and job rotation.
The emotional dissonance levels were found to be high or low, and that the level of deep acting was found to be higher than that of surface acting. Further, there were no meaningful variations in emotional dissonance, surface acting, and deep acting according to the general characteristics, and it was found that the factors that influence emotional dissonance are surface acting and deep acting. The results of the study show that ambulatory care nurses are currently trying to align their experienced emotions and expressions, and they feel emotional dissonance while working in the ambulatory care department. Therefore, certain measures, such as job relocation for ambulatory care nurses to expand the positive influence of deep acting in terms of managing emotional labor, training on improving communication to control emotional dissonance, supporting programs such as counseling programs, and regulation of employment factors such as the total work hours, job rotation, and support systems are necessary.
Following from these results, certain recommendations for future studies emerge, as follows: first, future studies should identify the various factors that influence the emotional dissonance of ambulatory care nurses and compare the factors according to the job characteristics of the department. Second, future studies should identify whether it is possible to reduce the negative factors of emotional labor by coordinating the tasks of ambulatory care nurses. Third, future studies should explore the development and application of education and clinical nursing programs for ambulatory care nurses aimed at effectively managing emotional labor.
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