Knowledge of the emotional demands facing today’s nurses is critical for explaining how work stressors translate into burnout and turnover. Following a brief discussion of how the experience of burnout relates to the nursing shortage, we examine the scope of nurses’ emotional experiences and demonstrate that these experiences may be particularly consequential for understanding the higher levels of burnout reported by younger nurses. Using survey data collected from 843 direct care hospital nurses, we show that, compared to their older counterparts, nurses under 30 years of age were more likely to experience feelings of agitation and less likely to engage in techniques to manage these feelings. Younger nurses also reported significantly higher rates of burnout and this was particularly true among those experiencing higher levels of agitation at work. We conclude by suggesting the need for increased awareness of the emotional demands facing today’s nursing workforce as well as the need for more experienced nurses to serve as emotional mentors to those just entering the profession.

DOI: 10.3912/OJIN.Vol13No01PPT01
https://doi.org/10.3912/OJIN.Vol13No01PPT01

Key words: anger, age, burnout, care work, emotions, emotional labor, emotion management, nursing shortage, nurse well-being, nursing work environment

“You can recruit till the cows come home, and that’s what we see nurse recruiters in hospitals doing. Pull out all the stops, do the sign-on bonuses, basically bribe them in some way to get them in the door. But until you can stop the bleeding, they’re coming in the front door and leaving out the back door” (Bozell, 2004).

In 2002, the Bureau of Labor Statistics (BLS) projected that the United States would be 800,000 registered nurses (RNs) short of the national need by the year 2020. Recently, this number has increased to over one million RNs short of the need by 2012 (BLS, 2004). Although there has been some indication that the entry of older nurses into the profession, along with efforts to recruit foreign-born nurses, have helped to ease the shortage, scholars project that the predicted trends are likely to continue (Auerbach, Buerhaus, & Steiger, 2007; Buerhaus, Donelan, Ulrich, Norman, & Dittus, 2006; Larkin, 2007). As such, the need for understanding the factors contributing to the nationwide shortage has never been greater.

The current shortage is a problem of both supply and demand (American Hospital Association, 2006). As the population ages, there is increasing demand for nursing care both in hospitals and nursing homes (Hecker, 2001). At the same time, fewer individuals are choosing nursing as a career, the most experienced nurses are quickly approaching retirement age, and others have been leaving the profession before they reach retirement age citing poor working conditions as their reason for doing so (Buerhaus et al. 2006; Gordon, 2005; Hecker, 2001; Pinkham, 2003; van Betten, 2005). These trends have led many to speculate about the causes and solutions to the current shortage of registered nurses. In what follows, we show how attending to the emotional dimensions of nurses’ work environments provides new insight into the experience of burnout and why younger nurses may be particularly at risk for experiencing high levels of burnout and, potentially, lower rates of retention.

Burnout and the Nursing Shortage

Burnout is a unique type of stress syndrome that is fundamentally characterized by “emotional exhaustion” (Cordes & Dougherty, 1993; Maslach, Schaufeli, & Leiter, 2001). Because of the nature of their work, health care professionals are at especially high risk for experiencing the emotional exhaustion component of burnout. This is problematic because, as Lafer (2005, p. 36) observed, “the stress, danger, exhaustion, and frustration that have become built into the normal daily routine of hospital nurses constitute [the] single biggest factor driving nurses out of the industry.” Others have echoed this link between current work conditions and high rates of turnover (Peterson 2001; Vahey et al., 2004), noting the close connection between feelings of burnout and intentions to leave one’s job. In an international study on hospital care, Aiken and her colleagues have demonstrated, for example, that nurses experience burnout at significantly higher rates than expected for medical workers based on national norms (Aiken et al., 2001). In another study, 43% of surgical nurses who reported high levels of burnout said that they intended to leave their jobs within the next 12 months. In comparison, only 11% of nurses who were not burned out stated that they intended to leave their jobs (Aiken et al., 2002).

Exhausted, discouraged, saddened, powerless, frightened – these are the emotions experienced by nurses on a daily basis. Nurses’ negative feelings about their jobs, including their feelings of burnout, tend to be influenced more by the organizational practices governing the workplace than by the challenges inherent in caring for others (Aiken et al., 2001, 2002; Aiken & Sloane, 1997). Supporting this view, a report based on the National Sample Survey of Registered Nurses indicated that it was the “structure of the job, rather than the composition of the work” that influenced nurses’ job satisfaction (Spratley, et al. 2000, p. 31). Despite the prominent role that feeling and emotion play in nurses’ self-reflections about their work (Payne, 2001; Savett, 2000; Ufema, 2000), few researchers have systematically examined the emotional components of nurses’ work experiences and their relationship to the experience of burnout.

Such neglect is particularly surprising given the results reported by the ANA (2002) concerning “how nurses felt as they left their jobs each day.” The ANA reported that the four most frequent responses were: Exhausted and discouraged (50%); discouraged and saddened by what I couldn’t provide for my patients (44%); powerless to affect change necessary for safe, quality patient care (40%); and frightened for patients (26%). Exhausted, discouraged, saddened, powerless, frightened – these are the emotions experienced by nurses on a daily basis. Recognizing that burnout is rooted in such intense emotional experiences is integral to specifying the facets of the work environment that are directly affecting nurses’ well-being and to effectively managing the hospital work environment in ways that can improve nursing outcomes. As others have shown, having a healthy and satisfied workforce is consistently associated with higher rates of patient satisfaction (Leiter et al., 1998; Vahey et al., 2004). This is especially true in the case of nursing, a profession whose “ethic of care” is central to its claim for professional distinctiveness and in which the ability to effectively manage one’s own and others’ emotions is critical to the provision of excellent patient care (Sumner & Townsend-Rocchiccioli, 2003).

Despite the central place that emotion holds in the conceptualization of burnout (Aiken et al., 2001), and studies indicating that the experience and management of emotion are critical to nursing practice (Henderson, 2001; Bolton, 2000; Smith, 1992), scholars know relatively little about how emotional experiences may differ among nurses or whether such experiences correlate directly with job burnout. ...scholars know relatively little about how emotional experiences may differ among nurses or whether such experiences correlate directly with job burnout. As an initial step toward increased understanding, this paper explores the types of emotional experiences reported by direct care hospital nurses and how these are related to burnout. In what follows, we examine the prevalence with which direct care hospital nurses experienced and managed their emotions at work, and the extent to which these occupational experiences were associated with reports of job burnout. Because turnover has been shown to be particularly high among registered nurses who are under the age of 30 (Barron & West, 2005; Bowles & Candela, 2005; Kiyak et al., 1997), we further explore how these emotional experiences and their effects on burnout may vary by age. In the final section of the paper, we discuss the importance of emotional mentorship for novice nurses and the need to increase awareness of the emotional context of nursing care.

Study Method

Registered nurses employed within two acute care hospitals in an urban midwestern city were provided with a questionnaire at their place of employment. Eighty-one percent of the eligible registered nurses returned completed surveys. Although data were collected from both direct-care nurses and nurse managers, in this paper we limit the sample to the 829 registered nurses who provided direct care to hospital patients and for whom complete data were available.

Sample. Of these 829 registered nurses, 96% were female and 95% were Caucasian. In regard to education, approximately 30% had, as their highest level of preparation, graduation from a diploma program, 13% were prepared at the Associate Degree level, 53% were prepared at the Baccalaureate level, and 4% had earned graduate degrees in nursing. Seventy-five percent of the sample was married and sixty-five percent had children living at home at the time of the survey. The mean age of respondents was 41.5 years old with an average having about 16 years experience as a registered nurse. Our sample included 110 RNs under age 30 (13%) and 719 RNs over age 30 (87%). In regard to work characteristics, 63% of the sample worked at least 30 hours a week and 59% worked the day shift. Among clinical areas of employment, 22% of the sample was employed in medical-surgical units, 36% in critical care, 15% in operating or recovery units, 19% worked in maternity with the remaining 8% in psychiatric or other units.

Measures. In this study we examined the emotional exhaustion dimension of burnout, emotional experiences, and emotional labor both generally and by age. For the purposes of this study, nurses’ age was measured in years and then dichotomized to create a variable identifying those under the age of thirty (Over 30 = 0; Under 30 = 1). The emotional exhaustion dimension of the Maslach Burnout Inventory (MBI) was used to assess job burnout (Maslach, Jackson, & Leiter, 1996). Emotional experiences were assessed using a question that asked nurses how strongly or intensely they felt twelve different emotions while they were at work during the past week. Consistent with Erickson and Ritter (2001), factor analyses indicated that positive emotions and agitated emotions were the most commonly reported and, as a result, they serve as the focus for this paper. The “positive emotions” scale was created by summing the responses for happy, proud, excited, calm, and relaxed (Cronbach’s alpha reliability = .78). The “agitated emotions” scale summed responses for the feelings of frustration, anger, and irritation (Cronbach’s alpha reliability = .89).

Hochschild (1983) reported that surface acting and deep acting represent two distinct techniques to manage emotion. When emotion management is part of what it takes to perform a job effectively, as it is in nursing, the task is referred to as “emotional labor” (de Castro, 2004; Mann & Cowburn, 2005; Sumner & Townsend-Rocchiccioli, 2003). Surface acting involves managing the outward expression of feelings in the hope that authentic emotion will follow. In contrast, deep acting involves the attempt to actually feel the emotions one is expected to display. We examine both emotional labor techniques here. Consistent with the methodological approach introduced used by Brotheridge and Lee (2003), we asked nurses to what extent they managed their emotions in interactions with others by covering up (surface acting), pretending to have unfelt emotions (surface acting), and making an effort to actually feel emotions that were expected at work (deep acting). However, where Brotheridge and Lee asked only about interactions with customers, we asked the nurses about their interactions with patients, patient families, doctors or residents, their unit manager or director, nursing co-workers, and non-RN staff. As with other measures, the results were summed to create an overall index for each form of emotional labor.

For burnout, emotional experience, and emotional labor, t-tests were used with each of the scales to assess the extent to which the results reported for each age group (e.g., under and over age 30) were significantly different from one another. In presenting descriptive information regarding these outcomes, dichotomous categories were created. Those reporting “high burnout” scored greater than 24 on the standard MBI scale that ranges from 0-42. This operationalization of “being burned out” is the same as that used by Aiken et al. (2001). For reports of emotional experience and emotion management, nurses identified as experiencing “high” levels of these phenomena are those whose scale scores were higher than the mean, or average, score reported for the entire sample.

Protection of Subjects . This study was approved by both the university’s and the participating hospitals’ Institutional Review Boards. Letters inviting participation informed the potential participants of the study’s objectives. Written consent was not obtained from participants in order to allow participants’ responses to remain confidential. Instead, voluntarily returning a completed survey was viewed as an indication of a respondent’s consent. Surveys were returned to the researchers via the United States mail system in a previously addressed, stamped envelope. We further protected the confidentiality of the participants by using numerical codes to identify the completed questionnaires.

Results

Before we could assess the extent to which the role of emotion might provide new insights into nurses’ experience of job burnout, we needed to determine the levels of burnout experienced by the nurses in our sample. Using the standard measure of the emotional exhaustion component of burnout, we followed Aiken et al. (2001) in assessing the rate of “high” or “problematic” burnout. This level of burnout reflects scores that are significantly higher than those normally expected among medical workers (24 or higher on a scale ranging from 0-42; Aiken et al. 2001; Maslach et al. 1996) and that are most commonly associated with other negative outcomes such as lower job satisfaction, turnover intentions, depression, and decreased physical health (Janssen et al., 1999; Kalliath & Morris, 2002; Shamian et al., 2002).

Although fewer nurses in our sample experienced this problematic form of burnout than those studied by nurses in the Aiken et al. (2001) study – 38.4% compared with 43.2% - the rate is still high enough to be of concern. Our concern was reinforced once we compared the results for nurses under and over age 30. Our analyses indicated that more nurses under the age of 30 experienced this problematic form of burnout (43.6%) than did nurses who were over age 30 (37.5%). A t-test comparing the mean rates of burnout between the two groups confirmed that younger nurses were experiencing significantly higher levels of burnout than their older counterparts (t = -2.06, df = 827, p < .05).

This difference in the rate of burnout by age might be explained by the fact that ...younger nurses experience more stress than their older, more experienced counterparts. As noted above, although it has long been recognized that burnout is fundamentally characterized by the experience of emotional exhaustion, few researchers have examined how the emotional context of the nursing work environment might be related to this outcome. For example, one of the central occupational stressors associated with burnout that might explain the age difference is the need to cover up or evoke emotions that are appropriate for the particular interactional context. In her case study of three nurses, Staden (1998, p. 153) quotes one nurse as saying she not only has to be able to block out her own feelings but must be able to “drag up new ones from somewhere” to take their place. Nurses, as well as other health professionals, perform emotional labor in order to provide effective patient care. Successfully suppressing and evoking emotions can be experienced as stressful. Could it be that nurses under 30 experience higher levels of burnout because they are more likely to perform surface and deep acting than their older counterparts? To explore this possibility, we examined the extent to which these two forms of emotional labor were associated with burnout and then how the performance of surface and deep acting varied across age groups.

As indicated in Figure 1, 69% of those who experienced high levels of burnout also reported performing higher than average amounts of surface acting. This difference was confirmed through a t-test which indicated that the burnout rate was significantly higher among those reporting frequent masking of emotion than for those who tended not to engage in this form of emotional labor (t = -9.75, df = 827, p < .001). Similar results were found for pretending to have feelings that were expected but not actually felt. Sixty-four percent of those pretending at higher than average rates also reported they were burned out (t = -11.65, df = 827, p < .001). No significant difference in burnout was found for the deep acting technique of making an effort to actually feel the expected emotion.

Our analyses confirmed that emotions are a pervasive feature of nurses’ daily occupational experiences. The results presented in Figure 1 supported our expectation that performing surface acting would be related to the experience of burnout. However, contrary to our expectations, we did not find that nurses under age 30 performed this form of emotional labor more frequently. Instead, as shown in Figure 2, we found that younger nurses were significantly less likely than those over 30 to cover up their true feelings (t = 2.38, df = 827, p < .05) and to pretend that they had feelings that were expected but that they did not really experience (t = 2.38, df = 827, p < .05). No such age differences were found in regard to deep acting.

Finding that younger nurses report higher levels of burnout but lower levels of surface acting is surprising given that emotional labor has been identified as a central occupational stressor influencing burnout, retention, and other dimensions of well-being (Erickson & Wharton, 1997; Hochschild, 1983; Mann & Cowburn, 2005; Smith, 1992; Sumner & Townsend-Ricchiccioli, 2003).

In sum, the findings presented thus far indicate that nurses under the age of 30 and those who perform two surface acting types of emotional labor (i.e., covering up emotions and pretending to feel emotions) are more burned out. However, contrary to what these results might suggest, younger nurses are not performing more emotional labor than nurses over 30. In fact, we find the opposite: among those who are burned out, 57% of nurses over 30 report high levels of covering up compared to only 38% of nurses under age 30 (see Figure 3). Similarly, 40% of older nurses who are burned out frequently pretend to have emotions that are expected but that they do not feel. In comparison, only 23% of burned out younger nurses are frequently performing this type of surface acting. These results thus suggest that emotional labor does a better job accounting for the burnout experienced by nurses over age 30 than it does for their younger counterparts.

Registered nurses under age 30 reported experiencing significantly higher rates of the most intense levels of frustration, anger, and irritation (i.e., agitation) than those over 30. These anomalous results led us to the possibility that perhaps it is not the management of emotional experience that is problematic for younger nurses but the emotional experiences themselves. Because little is known about the distribution of emotional experiences or their management among nurses, our next goal was to examine the prevalence of these experiences.

Our analyses confirmed that emotions are a pervasive feature of nurses’ daily occupational experiences. Among our sample, 99.9% of nurses reported experiencing positive emotions (e.g., happiness, pride) during the past week at work, with 95.5% also reporting that they experienced feelings of agitation (e.g., frustration, anger). When we examined the frequency of emotions experienced at work by age, however, differences did emerge (see Figure 4).

Registered nurses under age 30 reported experiencing significantly higher rates of the most intense levels of frustration, anger, and irritation (i.e., agitation) than those over 30. These results were confirmed using the scale scores and testing for mean differences. Nurses under age 30 reported a mean level of agitation of 11.22 compared to a mean of 8.80 for nurses over 30 (t = -4.16, df = 827, p < .001). No significant differences were found between the age groups for positive emotional experiences (Mean = 17.62 for RNs under 30 and 18.00 for RNs over 30; t = -.56, df = 827, p = .576).

In examining whether low levels of positive emotion and high levels of agitation were more related to burnout for younger versus older nurses, we found different trends based on the emotion being experienced. As indicated in Figure 5, ...low levels of positive emotion were more commonly associated with burnout among older nurses while the experience of agitation was more frequently related to burnout among nurses under 30. low levels of positive emotion were more commonly associated with burnout among older nurses while the experience of agitation was more frequently related to burnout among nurses under 30. The t-tests indicated that the mean levels of burnout did not differ significantly by age when emotional experience was taken into consideration. However, these trends do suggest that well-being among older nurses may be somewhat more sensitive to their experience of positive emotions on-the-job while younger nurses’ feelings of agitation may be the most problematic. Further descriptive analyses lend support to the idea that feelings of frustration, anger, and irritation may be disproportionately problematic for the well-being of nurses under 30 in that thirty-three percent of younger nurses reported experiencing high levels of agitation and high burnout compared to only 26% of older nurses who reported this combination of experiences. In contrast, the results for positive emotions and burnout do not differ much by age in that 28% of younger nurses and 27% of older nurses reported experiencing low levels of positive emotion and high levels of burnout.

Conclusions

In this paper we have suggested that the emotional demands and effects of caring work should be considered when examining the sources of burnout among registered nurses. As our results suggest, understanding the emotional experiences of younger nurses may be particularly important for understanding why their burnout levels are disproportionately higher than those of their older counterparts.

As expected, the data show that nurses under the age of 30 are more highly burned out than their older counterparts, a result that supports what other researchers have previously shown (Aiken et al., 2001). In an attempt to explain this result, we explored how different forms of emotional labor might be contributing to job burnout. Through surface and deep acting techniques, nurses strive to appear as though they feel the emotions that are expected of them within their jobs and profession. Our data demonstrate that surface acting is indeed associated with higher levels of job burnout among nurses. Nurses who pretended to have unfelt feelings were more burned out than nurses who did not pretend to have unfelt emotions. And, ...nurses who covered up their true feelings were more burned out than nurses who did not cover up such emotional experiences. nurses who covered up their true feelings were more burned out than nurses who did not cover up such emotional experiences.

Given that the data showed an association between job burnout and age of the RN, we then wondered what role age played in the relationship between emotional labor and burnout. Our analyses indicated that age of the RN was associated with the extent to which one engages in surface acting techniques to manage emotions at work. However, it was not the younger nurses who covered up their feelings or pretended to have unfelt emotions, it was the nurses over age 30 who were more likely to employ these emotion management techniques. Therefore, contrary to our expectation, engaging in emotional labor did not explain the higher burnout we saw in younger nurses.

...creating roles for older, more experienced nurses to provide emotional mentorship...may be one way to help novice RNs cope with the emotional demands of the profession. Recalling research by Fredrickson (2000) who reported that positive emotions felt at work may insulate workers from job burnout, we decided to examine the types of emotion nurses report feeling at work. While there were no age differences in the experiences of positive emotions at work, nurses under age 30 reported significantly more experiences of agitated emotions (frustration, irritation, and anger) than nurses over age 30. Thus, the younger nurses sampled experienced more agitation and tended to be more burned out. Although our results are inconclusive as to the strength and direction of this relationship, these preliminary results suggest that the relationship between agitation and job burnout among younger nurses should be considered in future research as well as among nurse administrators seeking to lower levels of burnout and turnover among younger nurses. This suggested trend is also important because it shows that what is felt at work relates to burnout in ways that may be just as important than what nurses do with what they feel (i.e., perform emotional labor).

Given that older nurses were less likely to experience agitation or to be burned out, creating roles for older, more experienced nurses to provide emotional mentorship to younger nurses may be one way to help novice RNs cope with the emotional demands of the profession. Such roles would also be consistent with one of Buerhaus et al.’s (2006, p. 11) primary recommendations for reducing the nursing shortage. As these authors note, employers must look beyond recruiting initiatives and be “unrelenting” in their attempts to improve the work environment so that nurses entering the profession remain and those who are expected to retire choose to postpone that decision. Given that an estimated 40% of the RN workforce will be over age 50 by the year 2010, employers must work to develop roles that take advantage of older nurses’ years of clinical experience and knowledge of the nursing profession. Although nursing mentors are not new, our findings indicate that such mentorship must include an explicitly emotional component. Having more experienced nurses recognize and attend to the emotional experiences facing those new to the profession may go a long way toward improving the retention rates among both groups of nurses.

Increasing recognition of the emotional experiences and demands that constitute an essential facet of the nursing work environment is the first step to providing younger nurses with the support they need...[to] reduce their rates of turnover. In sum, our research indicates that there is a link between being younger than 30, feelings of agitation at work, and job burnout among nurses. Recognizing both the emotional experiences that are an integral but often invisible part of the nursing work environment, and the impact that such experiences and their management have on job burnout, are central to efforts aimed at increasing nurse retention. We encourage nurse managers and administrators to work toward the development of systems of care delivery that support nurses’ ability to experience and manage emotion in ways that improve the quality of patient care at the same time that they reduce the incidence of burnout. As one nurse suggested, “it may be particularly crucial, in these days of increasing patient acuity, nursing shortages, declining enrollments, and an aging nurse population, to recognize the impact of emotional work on nurses” (Henderson, 2001). Although more research is needed to confirm these relationships across a wider sample of registered nurses, our preliminary evidence suggests a role for older RNs to provide explicitly emotional mentorship to younger nurses. Increasing recognition of the emotional experiences and demands that constitute an essential facet of the nursing work environment is the first step to providing younger nurses with the support they need to reduce their feelings of agitation and job burnout, and ultimately, reduce their rates of turnover.

Authors

Rebecca J. Erickson, PhD
E-mail: rericks@uakron.edu

Dr. Rebecca J. Erickson, PhD, serves as a Professor of Sociology at The University of Akron. Dr. Erickson’s research on the experience and management of emotion now spans 17 years. During this period, she has examined the ways in which these processes affect the mental and physical health of individuals both at home and at work. Dr. Erickson’s most recent project focuses exclusively on the occupational experiences and outcomes of nurses and the emotional context of providing quality nursing care.

Wendy J. C. Grove, PhD
Northeastern Ohio Universities College of Medicine
E-mail: wendy.grove@odh.ohio.gov

Dr. Wendy J. C. Grove serves as a supervisor in the Bureau of Early Intervention Services at the Ohio Department of Health. As project manager for Dr. Erickson’s study on Nurses and Job Burnout, Dr. Grove helped plan, collect, and analyze data for this paper. Dr. Grove’s interests include care work, health care professions, medical sociology, and the sociology of death, dying, grief, and bereavement.

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