Emotion management in children's palliative care nursing
This article explores the emotional labor involved for nurses providing palliative care for children/young people living with life-limiting illnesses/conditions, and their families. It highlights the challenges nurses face in managing their emotion when caring for children/young people and their families, and explores strategies to enable nurses to cope with this aspect of their role without compromising their personal wellbeing. It suggests that emotional labor within nursing goes largely unrecorded, and remains undervalued by managers and health care services.
Keywords: Children/young people, coping, emotional labor, palliative care
Emotional labor is defined as the work involved in managing feelings and emotion, as part of a public service role.  It involves displaying ways of working, including activities, behavior, and attitudes that make others feel cared for.  Hochschild  suggests that when people feel stressed by their work, and undervalued, the psychological demands on individuals, in managing their emotion at work, can be costly to their wellbeing. This may be especially so in areas of work that exposes its employees to high levels of extraordinary and emotive situations, as part of their normal routine of work.
There can be little doubt that caring for children and young people living with life-limiting illnesses/conditions, raises strong emotions in us.  The nurses' role in supporting and caring for children and young people, and their families, living with terminal illness, requires specialist expertise.  Arandon  maintains that self-knowledge and critical examination of one's own practice, both on an individual and a team perspective, are key mechanisms for surviving and thriving as a palliative care nurse, claiming that we need to see the whole commitment involved in holistic care to appreciate the significance of the contributions of the nurse to the patient's wellbeing. What remains underestimated, perhaps, is the emotional labor involved in achieving this. James,  in her study of the relationship between gender and the emotion work of adult hospice nurses, suggests that emotional labor is skilled work that goes largely unrecorded and may not be appreciated by managers.
Smith and Gray's  study on emotional labor, identified that nurses described it as making patients feel safe, being available for them, and making them comfortable. They identified that some nurses perceived it to be the social part of their role, including making patients feel valued and secure within the clinical environment. Edvardsson et al.  suggested that emotional labor is at the heart of interpersonal communication in the nurse-patient relationship, and maintained it to be an integral part of building up a trusting relationship with patients that can facilitate their care. Thoit's  concept of interpersonal emotion management identified that emotional labor requires time, effort, and skill. Similarly, James  states:
The emotional component of care, like the physical component, is labour in the sense of hard work.
Nursing is arguably one of the most intimate professions, with nurses often performing care at a level of intimacy not usually experienced outside close family relationships. Being intimately involved in the care of a patient has been described as "the privileged place of nursing,"  with Benner  claiming that the nurse-patient relationship is one of intimacy in some of the most dramatic, poignant, and mundane moments of life. One reason for this degree of intimacy in nursing is simply that nurses usually have the most contact with patients.
This article explores the challenges for nurses in providing emotional labor as central to their role in caring for children and young people living with life-limiting illnesses/conditions, and their families, without compromising their own personal wellbeing.
Caring for life-limited children/young people and their families is one of the most emotionally challenging areas of nursing.  It can be a stressful area of work, with the nurse accompanying the child and family on a rollercoaster of different and intense emotions. Underestimated, perhaps, is the fact that often the nurse may be involved with the child and family for many years, as pediatric palliative care is not only concerned with end of life care. In this context: "Aspects of palliative care may be applicable at other stages of illness; indeed there is not always a definitive point where a patient's terminal phase begins". 
Aspects of palliative care may be applicable at other stages of illness; indeed there is not always a definitive point where a patient's terminal phase begins. 
Because of improvements in treatment, many children who would previously have died in early childhood, for example, children with severe cerebral palsy or microcephalic syndrome, are now surviving, with an uncertain prognosis, into late adolescence and early adulthood.  For these children and families, their palliative needs are lifelong. Some nurses may, therefore, have had a relationship with a child and family over a considerable period of time. It would be difficult not to form an attachment to the child and family at some level. The expertise required in maintaining professional boundaries while providing a family-centered approach to care, that responds to children's changing needs as they grow and mature, is considerable. 
Lazarus and Folkman's  seminal work on the transactional model of stress, explores why some nurses become stressed by certain experiences and care situations, while others do not. They claim it is concerned with the nurse's ability to appraise the cause of the stress, and to work out strategies to minimize it, either on an emotional or practical level. Similarly, Benner and Wrubel  adopted a phenomenological approach when exploring health and illness in their work on caring and nursing, and put forward an interpretative theory of nursing practice which maintained that 'caring' defines what is stressful in practice, but is also what enables nurses to develop coping strategies in their role. In this respect: When stress and coping are viewed as an integral part of what matters to us, as the expression of our deepest concerns and connections, then we can see that out of loss and suffering, can come the possibility for new expressions of concern and connection. 
Why some nurses choose to specialize in an area of practice where they are continuously working within other people's grief, remains under-researched. Yet, there must be factors that make this an area of work in which nurses opt to specialize. It could be due to a relationship between the quality of care delivered, and the occupational and professional satisfaction of the nurse. Nurses who are satisfied with their work experiences are more likely to stay and specialize in that area of clinical practice. 
Vachon's  seminal work on occupational stress in palliative care advocates that nurses must feel that the individual needs of the dying are being met within the context of the environment of care, and that there are adequate resources available to provide best practice. Vachon  claims both are crucial factors in helping nurses cope with the emotion management of their role. In this respect, there is a sense of satisfaction that comes from:
the sense of competency and achievement that comes from knowing that you have been able to offer what you had to offer, when it was needed. 
Similarly, Benner and Wrubel's  study on the primacy of caring, claims that stress occurs when issues perceived to be important to an individual are not addressed, or met. What matters to children's palliative care nurses may be varied and many, for example having time to spend talking with the children and families, or having the resources, equipment and knowledge to alleviate symptoms effectively, or having opportunities to build a trusting relationship with the child and family. When those issues are threatened, the nurse's ability to cope with the stress of the job is reduced. 
Life experiences shape us as individuals. This may be an obvious statement perhaps, but its relevance may be underestimated. As an individual goes through different experiences, the meaning attached to those experiences is constantly being tested and re-evaluated.  When people work together as a group, and have a shared history of experiences, reciprocal meanings about courses of actions and behavior, can develop,  which is often underpinned by the occupational culture of the workplace.  This, in turn, reflects the distinctive system of beliefs, attitudes, expectations, and interactions of the occupation group. By creating an occupational culture, based on common cultural meanings, a group creates its own community, and that shared sense of community can become a means of support for those working within it. 
Professionals working within an occupational culture in areas of high emotion work often have a need to protect themselves from the exceptional demands of the work. The various strategies that nurses use in managing this aspect of care warrant further exploration. Hunter and Deery  claim, from their studies exploring the management of emotion within midwifery, that there are two principal ways used by professionals to manage their emotions at work. They state:
There appeared to be two main norms of managing emotion; one related to maintaining 'affective neutrality', the other to working in a manner that was 'affectively aware.'. 
They refer to Parson's  stance that affective neutrality is a process whereby the worker attempts to distance himself from the emotional demands within work.
Hochschild  described affective neutrality as behavior performed by workers which is aimed at enabling them to distinguish between their personal and work responsibilities. She referred to this as a process of 'de-personalization,' stating it is concerned with separating the demands of emotional labor within the workplace from that of personal self. In support of this, Hunter  in her study exploring the emotion work within midwifery, stated:
Distancing and task orientation are coping strategies for keeping work sustainable, for dealing with uncertainty, and for attaining the affective neutrality expected of health care workers, which is reinforced by professional feeling rules. 
Similarly, Froggart's  study of hospice nurses found they described themselves as "switching on and off" as a means of maintaining their personal boundaries, and avoiding emotional burnout by their work. In this context, nurses may put up an emotional barrier to prevent them becoming emotionally attached to the patient/family situation.  Although written at a time when a task allocation approach to nursing was the norm, Menzies  theory that nurses put up an emotional barrier by focusing on the task being performed rather than on the person receiving care is still relevant today. With this approach, the nurse arguably reduces care to the procedure being undertaken, frequently labeling patients according to their condition, for example, the appendicectomy in bed three, or the tonsillectomy in bed four. Such an approach to care is aimed at deliberately avoiding focusing on the person receiving that care, thus enabling the nurse to feel minimal involvement or identification with that patient as a person, thus protecting the nurse from the anxiety that can be created by close patient contact. 
Benner and Wrubel  suggested that emotion management within work is linked to the level of experience and expertise of the nurse. They identified that maintaining a distance can potentially be a barrier that causes yet more stress. In this respect, rather than becoming involved with the patient/family, some nurses work hard not to do so, and this, in itself, requires an extraordinary degree of emotional effort.  Conversely, Benner and Wrubel  maintain that expert nurses are more likely to be engaged with patients and put in a high level of emotion work in connection to their care. Indeed, for them, to not be connected causes more stress. It is this that Hunter  described as 'affectively aware' clinical practice. In this context:
"It is a peculiarly modern mistake to think that caring is the cause of burnout, and that the cure is to protect oneself from caring to prevent the 'disease' called burnout. Rather the loss of caring is the sickness, and the return to caring is the recovery". 
It is a peculiarly modern mistake to think that caring is the cause of burnout, and that the cure is to protect oneself from caring to prevent the 'disease' called burnout. Rather the loss of caring is the sickness, and the return to caring is the recovery. 
Benner  further suggested that by not becoming involved in the situation, and working to remain distanced from the patients, nurses are not able to:
Take advantage of the resources and possibilities that come from engagement and participation in the patients and families' meanings and ways of coping. 
Pediatric nurses, for example, adapt their care by learning about the children's/ young people's range of coping behaviors, their meanings, and responses to care within their family. By working with the way that the family and child are dealing with a situation, the nurses can apply the child and family's coping behavior as part of the child/young person's plan of care. Such an approach is based on the child's understanding and feelings about his/her condition and treatment options. Rather than remain distanced, as part of the assessment process, the nurses actively seek to get to know the child, and to understand what is important to that child within his/her family context. When this occurs, the nurses become better able to meet the child's individualized care needs in a way that makes sense to that child and family.  Nurses can respond positively and draw satisfaction from this, because they understand the meaning of the situation from the child and family's perspective. With experience, these meanings develop, and are shared by the nursing team, and become part of a recognized nursing approach toward palliative care.  This undoubtedly can have an effect on those receiving care. 
In her study examining nurses' caring behavior, Hegedus,  found that patients placed great value on a nursing approach that recognized their individual views/needs as well as those of the family. Arguably, the more nurses are aware of how their behavior affect others, and strive to meet individual needs, the more sensitive they are to their emotion labor.
The influence of good team work cannot be underestimated.  Smith  suggests that teams work best when each member is enabled to work to their strengths, while recognizing that members may have different skills which can compliment and add to the function of the team as a whole. When the team works together and has faith in each other's abilities, this can release pressure on individuals within it, as they know they are supported, and that other team members are 'pulling their weight' in doing the job.  Part of this involves recognizing when others within the team are struggling emotionally, and need help. This often involves the team leader being sensitive and supportive to her/his team members, encouraging the strengths of the nurses within the team, identifying areas of care that need improving, and providing help as needed. In this respect:
When the nurses felt appreciated and supported emotionally by the ward sisters, they not only had a role mode for emotionally explicit patient care, but they also felt able to care for patients in this way. 
Smith  is referring here to student nurses who naturally require more guidance and mentorship than do experienced nurses. However, the principle of feeling valued, in encouraging supportive working, arguably, applies to nurses of all levels of experience, i.e. the emotional support at each level influences the next level down in terms of experience.
Nurses may often develop protective, individual and team-work strategies to enable them to better manage their emotions within clinical practice, such as a shared and explicit underlying philosophy of care, or the development of a 'dark humor' that they would not share publicly. In this context:
Expert nurses use humour as an avenue of communication….humour can help reframe a situation; however, effective use of humour requires a deep background understanding of the situation, and at least, a modicum of trust and respect. 
It might be suggested that by so doing, the nurses are showing the degree of trust that is implicit between the team members, and their interdependence on each other within the team as a system of support.  This involves recognition of each team member's skills and how those skills can support the management of emotion in the workplace.  Some team members, for example, may be able to use humor to lighten mood, others may have exceptional organizational skills to help work run smoothly, while yet others may be good at calming people down and diffusing feelings of anger or frustration. 
To conclude, it would be difficult to dispute that it is emotionally demanding to care for a dying child and his/her family. Their vulnerability and dependence on the nurses is often considerable  and the expert nurse is required to induce and/or suppress his/her own personal feelings to inspire confidence and maintain an outward feeling of calm.  At a time when families are at their most vulnerable, they are looking for someone that makes them feel they are in safe hands. They want someone in whom they have confidence, someone that shows understanding and empathy to their situation, that remains calm, focused and alert toward managing their child's symptoms and wellbeing, someone who values their child, and makes their child feel safe and special.  In this respect, the nurse has to be responsive to subtle verbal and nonverbal signs in the behavior of the child and family within the environment of care. Nurses who work with life-limited children and young people are exposed daily to an atmosphere of grief. It is not the nurses' grief, but they can be affected by the grief of others. In this respect:
Our emotionalities do not simply switch off 
Arguably, however, if a nurse feels that she has provided appropriate care of a high quality, it can help her deal with the emotion work involved in caring for a dying child/young person. In this respect:
A holistic approach does exist in the practical context of a committed nurse-patient relationship 
When work conditions to support emotional labor are good, and the nursing team are encouraged to work to their strengths and areas of expertise, the nurses feel better supported, have improved team morale and are more able to meet the challenges inherent in their role. .