Introduction

The concept of community nursing was first put forward in 1970, and described as the combination of public health and nursing work [1]. The district or community nurse is central to the healthcare of community residents [2]. Currently, community nursing work in China covers basic therapeutic care (70%) and public health services (30%) [3], such as inpatient and outpatient care, preventive healthcare, maternal and child healthcare, chronic disease management, health education, and family nursing [4]. The complexity of the community nursing working environment and the diversity of services creates higher requirements in terms of the knowledge and abilities of community nurses [5]. To meet the requirements of their job, community nurses need to provide high-quality mental and physical healthcare services, and also need to maintain the necessary emotional communication with service recipients to achieve performance satisfaction [6]. To understand patients’ experiences and support relationships with patients, relatives, and colleagues, community nurses use emotional labor and control their emotional expressions [7]. Emotional labor is the third kind of labor after physical and mental labor, and refers to the process of psychological adjustment necessary to express the emotions expected by an organization [8]. Nurses should know and control the process required for managing their emotions and expressions [9]. Excessive emotional labor can cause mental health problems [10], musculoskeletal symptoms [11], cardiovascular disease [12], and other physical health problems [13]. Although emotional labor is an important part of nursing practice, it is usually invisible, neglected and under estimated [14]. And even literature shows that emotional labor exists across a broad spectrum of nursing work [15], only few researches on conditions and related factors of community nurses’ emotional labor is available [16–18], and this topic remains to be investigated.

With the expansion of the scope of community nursing and improvement in quality requirements, the psychological pressure on community nurses has increased [19], along with issues associated with professional satisfaction [20] and career success [21]. Career success refers to the gradual accumulation or acquisition of work-related achievements and positive feelings by individuals throughout their work experience, including remuneration, promotion, recognition, and acceptance [22]. A previous study among nurses indicated that the process of applying emotional labor aimed to achieve organizational goals and improve nurses’ salary, promotion opportunities, and recognition [23]. Previous studies have shown that emotional labor strategies have significant predictive effects on job stress, job satisfaction, and subjective job performance [24]. Researchers also found that nurses’ career success was mainly affected by emotional labor [25]. How about the relationship between career success and emotional labor in community nurses is need to be explored.

Emotional labor is the multi-level and dynamic essence of emotional regulation [26], and includes surface acting (e.g., concealing negative emotion with a fake smile), deep acting (e.g., taking a positive and optimistic approach to eliminate negative emotions and conform to the requirements of the organization), and natural expression dimensions (e.g., the true expression of one’s emotions in accordance with work requirements) [27]. The effect of emotional labor is the result of the mixed effect of these dimensions [28]. Previous research on emotional labor in nursing mainly centered on the degree of total and each dimension of emotional labor or their relationship with other occupational factors, and the results did not clarify the specific situation and characteristics of emotional labor for an individual [24,29,30]. Therefore, even if the scores for emotional labor measurement were consistent, internal heterogeneity could not be determined [31]. To solve this problem, it is necessary to use an individual-centered research method to analyze the heterogeneity of emotional labor among community nurses. Latent class analysis (LCA) focuses on the heterogeneity of individuals, and the latent class classification of individuals can be determined according to the response pattern of an individual in the detection questions; this means the number and proportion in each category can be clarified [32]. Therefore, the level and internal characteristics of emotional labor of community nurses are a research issue that needs further discussion. Analysis of the potential categories of emotional labor among community nurses (from surface variable analysis to internal characteristic analysis) and the relationship between the level of emotional labor and the sense of career success were taken based on LCA. The results may be valuable for improving the emotional labor among community nurses, which may provide scientific data for improving the quality of community nursing services and promoting career success and team stability.

Method

Materials and methods

Results

Participants’ characteristics

A total of 382 questionnaires were completed anonymously and 352 valid questionnaires were recovered (effective recovery rate: 96.8%). Table 1 shows participating community nurses’ sociodemographic and occupational characteristics. Participants’ mean age was 36.93±9.29 years and most were female (98.9%). Most participants (49.1%) had an associate degree, 45.2% has a bachelor’s degree or above, and 5.7%graduate from secondary vocational schools. The average daily work duration was 8.11±0.68 hours, 20.5% (n = 72) of participants participated in continuing education, and 4.3% (n = 15) were engaged in scientific research. Community nursing work involved various roles such as nursing operations, family visits, chronic disease management, health education, prevention, and healthcare services.

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Table 1. Sociodemographic and occupational characteristics of community nurses (N = 352).

https://doi.org/10.1371/journal.pone.0268188.t001

Description of classifications

The fit indices for the series of latent class models are presented in Table 2. All fit indices were considered, but the BIC value was emphasized according to the recommendation of a previous study [38]. The BIC value (12623.04) was lowest in the 3-class model and the LMR (0.0124) and BLRT (0.000) reached significant levels (P<0.05). In the 4-class model, the LMR (0.8961) was no longer significant and the BIC value showed no further increase. Therefore, the 3-class model was selected as the final model with high reliability.

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Table 2. Latent class analysis results for emotional labor among community nursing staff in Beijing.

https://doi.org/10.1371/journal.pone.0268188.t002

Based on the LCA results, the 3-class model for community nurses’ emotional labor is shown in Fig 1. Community nurses in class 1 had the highest scores for emotional labor, and 25.6% (n = 90) of participants belonged to this group. These nurses tended to score higher on most ELS items. Item 10 (“I work hard to feel the emotions that I need to show to customers”) had the highest score. This indicated that these community nursing staff used a positive pattern to regulate emotional labor and keep their own emotions consistent with the requirements of the organization. Therefore, it was named the positive class.

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Fig 1. Scores of the three latent classes for community nurses’ Emotional Labor Scale items (N = 352).

Note: p<0.01.

https://doi.org/10.1371/journal.pone.0268188.g001

Community nurses in class 2 exhibited different emotional labor patterns, and comprised 18.5% (n = 65) of participants. These nurses had the lowest ELS scores. The third item, “I put on a ‘show’ or ‘performance’ when interacting with customers,” had the highest score of all classes. This indicated that these community nurses were good at using false emotions in their work. This lack of active use of emotional regulation meant that emotional labor was in a negative state. Therefore, this class was named the apathetic class.

The score curve for class 3 was basically the same as that for class 1. Community nurses in class 3 displayed medium ELS scores, and comprised 55.9% (n = 197) of participants. Community nurses belonging to class 3 were classified as the moderate class.

Demographic and occupation characteristics by latent class

Table 3 presents participants’ demographic and occupation characteristics by the three latent emotional labor classes. Professional title showed significant differences among the three class (p = 0.047). There were significant differences among the three emotional labor classes in different work places (p = 0.039) and for different work contents (Table 3). Good nurse-patient relationships and colleague relationships were significantly higher in the active class than in the other two classes (p<0.001). Community nurses in the active class had the highest job satisfaction (p = 0.005) and job relationships (p<0.001). Nurses in the active class had significantly higher levels of career interest (p<0.001) and positive attitudes about career prospects (p = 0.016) that the other classes.

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Table 3. Demographic and occupation characteristics by latent class (N = 352).

https://doi.org/10.1371/journal.pone.0268188.t003

The Pearson’s correlation matrix between the total ELS score and total CSS score as well as for each dimension are shown in Table 4. In addition to the career development and freedom and happiness dimensions, the emotional labor of community nurses was positively correlated with occupational success (p<0.01).

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Table 4. Correlation analysis between emotional labor and career success among community nurses (N = 352).

https://doi.org/10.1371/journal.pone.0268188.t004

The variance results are shown in Table 5. The latent subtypes were regarded as the independent variable and the CSS score was regarded as the dependent variable. The ANOVA results showed significant differences in the four career success dimensions between the active and apathetic classes (p<0.05). In addition, there was a significant difference (p<0.001) in the gain recognition dimension between the moderate and apathetic classes (C1>C3>C2).

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Table 5. Comparison of career success scale score by different emotional labor classes (N = 352).

https://doi.org/10.1371/journal.pone.0268188.t005

Discussion

This study used LCA to explore patterns of emotional labor among community nurses in China. The LCA method minimizes the differences within a category and maximizes the differences between categories and classifies group characteristics from the perspective of individuals; this approach clearly reveals difference between different heterogeneous individuals within the group [40,41]. Notably, we found there were distinct classifications of emotional labor in community nurses. The LCA results identified a 3-class model: class 1 = active group (n = 90, 25.6%), class 2 = apathetic group (n = 65, 18.5%), and class 3 = moderate group (n = 197, 55.9%).

The total mean emotional labor score was 3.51±0.49, which was higher than the medium critical value of 3.00 using the Likert scale 5-point scoring method [42]. This suggested that the emotional labor among community nurses was at a high level. It has also been reported that nurses’ emotional labor is maintained at a medium to high level, such as in emergency treatment [43], the intensive care unit [44], and the neonatal ward [45]. Bolton [46] suggested that nursing is one of the occupations most commonly associated with extensive emotional work. Smith [47] highlighted that the nursing process (a framework for planning and implementing nursing care) involves person-centered rather than task-oriented care. With the increasing demand for high-quality healthcare service, medical organizations have emphasized provision of healthcare that centers on patients’ needs. Furthermore, whether in the hospital or in the community, nurses need to comfort critically ill patients and their families, help them deal with illness correctly, and remove psychological barriers. All of which require the ability to exercise emotional labor. Thus, nurses’ emotional labor is recognized as an integral part of patient care [17,48].

Community nurses in the active class displayed the highest total emotional labor score for all items except item 3 (“I put on a ‘show’ or ‘performance’ when interacting with customers”). In particular, item 10 (“I work at developing the feeling inside of me that I need to show to customers”) showed the highest score. Most nurses agreed they overcame negative emotions at work, got along with others in a friendly way, and used deep acting emotional labor strategies, which means to keep inner feelings consistent with their displayed expression, instead of fake acting at work [49]. They may excel at actively regulating internal emotions and actively change to promote self-action, resulting in behavior consistent with organizational expectations [50]. Conversely, community nurses in the apathetic class displayed the lowest score for all items and the highest score of item 3. The highest score of item 3 in this class, may indicated that the apathetic class tended to use more fake emotions in work situations. They tried to hide their real emotional and facial expressions and show the emotion they expected to consisted with organization demand. Low emotional labor score may indicated that individuals in the apathetic class presented negative emotional manifestations and behaviors. Researchers found that emotional labor is usually stressful and has an adverse effect on nurses’ psychological well-being and health, when emotions that are not genuinely felt have to be conveyed [51]. An overview of the effects of this disguise on the health revealed effects ranging from burnout and fatigue to dysmenorrhea, disruptions in sleep patterns and suicidal tendencies [52]. We also found the lowest scores were for item 8 (“I try to actually experience the emotions that I must show to customers”) and Item 11 (“I work at developing the feeling inside of me that I need to show to customers”). Both of these items showed that nurses in the apathetic class did not want to “try to” or “develop” organizationally desired emotion expression during interpersonal transactions. A study found that if employees can actively internalize and integrate emotional performance norms and regard themselves as an important part of their work, their level of emotional labor motivation will be higher [53]. And previous researchers suggested to intervene by improving higher job autonomy, giving higher organizational identity and more support from superiors and colleagues to lower probability of mood disorders [8]. Class 3 was labeled the moderate group, the scores for emotional labor were in the middle range and the curves were basically the same as those for the active class. Previous studies proposed that financial rewards, genuine emotional expression and the maintenance of positive emotions, can make up for the mental resources consumed by emotional labor [54,55]. Grandey’s study proved that employees in the supportive work environment of superiors and colleagues are more likely to have the tendency to conform to the expected emotion, and have the real emotional feelings of negative individuals to negative events [50]. Therefore, adjusting personal emotions and improving organizational management would be helpful to improve the enthusiasm of emotional labor of Class 2 and Class 3.

Our results showed significant differences in occupation characteristics between the three classes (Table 3). Community nurses’ emotional labor was positively correlated with their job title, job contents, workplace, sense of job satisfaction, working relationships, career interest, and development [56]. Previous studies found that experienced workers have more mature emotional management skills [57]. Compared with a community health service center, health service stations have a smaller jurisdiction and population size, less contact between nurses and patients, lower workloads, and fewer interpersonal relationships to deal with. Therefore, they are relatively prone to a negative emotional labor state [58]. Mróz et al. investigated working emotion among 55 employees and showed that positive emotional labor improved employees’ job satisfaction [59]. A study reported that servers who expressed real smiles (didn’t feel "false") at work, had more job satisfaction than those who reported faking emotions [60]. A study by Li Yongxin et al. [61] also showed positive relationship between active emotional labor and career interest. Previous studies also found that the degree of professional identity and job autonomy of nurses will affect their emotional labor ability [8,62,63]. Our study indicated that the active class of community nurses had the highest sense of career success, followed by the moderate class and then the apathetic group, and the gaining recognition dimension showed significant differences in the three classes. A study on preschool teachers also mentioned a link between emotional labor and a sense of career success [64]. Recognition refers to recognizing or paying special attention to employees’ actions, efforts, behaviors, and performance, which is an important form of incentive for employees [65]. Herzberg’s two-factor theory suggests that incentives can produce a sense of achievement, identity, and responsibility [66]. Yu’s study also showed that professional identity, emotional labor, and job performance were positively correlated [67]. Above all, out study suggested to pay attention to employees’ emotional labor skills training, negative emotions management and policy support and technical guidance provision to help boost positive emotions at work, which in turn increases job satisfaction and career success.

Limitations

A limitation of this study was that it was a cross-sectional study rather than a longitudinal study. In addition, the sample size of this study was not large and widely enough, participants were nurses from 11 health service centers in four urban areas of Beijing, therefore, the representativeness and conclusions of its study were limited, and the results cannot represent all Chinese nurses. Further research may need to focus on nurses from national communities.

Conclusion

The emotional labor of community nurses in China can be divided into three classes: positive, apathetic, and moderate. Managers could implement a variety of measures to strengthen interventions for employees’ emotional labor that are targeted to incentive mechanisms, which will improve nurses’ sense of career success.

Supporting information

Acknowledgments

I would like to thank Ms. Jing Sun of the Peking University School of Nursing for her help in the research design and revision of the paper. I would like to thank my tutor Lanting lv an associate professor from Renmin University of China for her guidance on the design of research. Thank Dongmei Zhang, Aihua Li & Li Qian for their help in data collection and analysis.