Introduction

Nowadays, the medical system has undergone rapid changes such as competition among hospitals. As the customer satisfaction is perceived as an important factor, the efforts to control the staff’s emotional expression in the patient service are increasing (Kim et al., 2018). As the demands of high level of medical service are increased, emo-tional labor of hospital staffs is also increasing (Yun et al., 2019). Nurses take charge of patient satisfaction with providing medical services directly for patients (Han et al., 2011). In the study of nurses’ emotional labor, 97.9% of the nurses, 82.9% of patients, and 77.9% of caregivers are experienced emotional labor (Yeom et al., 2016). The factors increasing the emotional labor of nurses are diverse, and emphasis on the customer satisfaction (Kim et al., 2018).

In order to improve the patient’s satisfaction, the hospitals think that the kind attitude of the outpatient nurses is most important (Yun et al., 2019). According to customer satisfaction survey, outpatient nurses have to perform nursing and suppress emotions at the same time, which increases the intensity of work (Diefendorff et al., 2011). Waiting time management also makes emotional labor of outpatient nurses increasing (Song et al., 2011).

The recent precedent researches related to emotional labor (Baik et al., 2012; Han, 2016) were conducted mostly on ward nurses, and most of the studies have a partial understanding of the relationship with some variables. The impact of emotional labor of outpatient nurses on mental health, emotional labor, emotional intelligence, job stress of outpatient nurses was reported, but theses also show the relationship with some variables in a fragmentary way (Song et al., 2011). Multifaceted approach is need for emotional labor for using multiple variables such as job autonomy (Morris et al., 1996; Grandey, 2000), social support (Baik et al., 2012; Kim et al., 2013), self-esteem (Lee et al., 2016), emotional intelligence (Baik et al., 2012), affective well-being (Kim, 2017), perceived emotion requirement (Tak et al., 2012) which were analyzed as factors related to emotional labor in previous research.

The purpose of this study is to analyze emotional labor and factors related to emotional labor of outpatient nurses. The specific objectives of this study were as follows. At first, identify the correlations between emotional labor and factors related to emotional labor of outpatient nurses. Secondly, identify the degree of explanation of factors for emotional labor of outpatient nurses.

Materials and Methods

1. Study design

This study is a descriptive research to identify the relationship between the degree of emotional labor and the related factors of outpatient nurses.

2. Participants

The participants of this study were nurses who worked in outpatient clinics of Korea university hospital in Seoul and Geonggi city and had at least a year work experience in outpatient clinics. The researchers got the ethical approval from the institutional review board at K University before collecting data (IRB No. 1040548-KU-IRB-17-42- A-1). The number of participants in this study is based on the multiple regression analysis result of Chung (2013), assuming that the analysis of nine variables with effect size .078, significance level(α) .05, and power (1β) .8. As a result of calculating the G*power, the sample size was 210. The questionnaire was carried out after convenient sampling of 240 participants in consideration of drop-out rate. The participants were informed about confidentiality, anonymity, and ability to withdrawal from research at any time depending on the participant’s intentions without any disadvantages.

3. Measurement

1) Emotional labor

The emotional labor scale used in this study is the same as Brotheridge et al. (2003)’s Emotional Labor Scale (ELS) translated by Jung (2009). This scale is a total of 11 questions, consisting of 6 surface acting that pretend express emotion and 5 deep acting that try to feel the emotion in reality required by the organization. Likert scale consists of 5 points. The lowest score is 1, and the highest is 5, and it means the higher the score, the more emotional labor to implement. In Jeong (2009)’s study, Cronbach’s alpha was surface acting .86 and deep acting .89. In this study, Cronbach’s alpha was surface acting .84 and deep acting .69.

2) Emotional labor related factors

(1) Job autonomy

The job autonomy scale used in this study is the job autonomy scale which is the sub-domain of the index of work satisfaction (IWS) developed by Stamps (1997) and translated by Son et al. (2014). The total number of questions was 8. The questions 1, 3, 4, 6, 7 were reversed to the negative item. The range of the score is 1 to 5, and the higher the score, the higher the job autonomy. Cronbach’s alpha was .73 in Son et al. (2014)’s study, and .66 in this study.

(2) Social support

The social support scale used in this study was the social support measure scale developed by House (1981) and translated by Ko (1999). This scale is composed of 4 items superior support and 4 items peer support. The total number of questions was 8. The questions 4, 7, 8 were reversed to the negative item. The range of the score is 1 to 5, and the higher the score, the higher the social support. Cronbach’s alpha was superior support .74 and peer support .84 in Ko (1999)’s study. In this study, Cronbach’s alpha was superior support .84, and peer support .73.

(3) Self-esteem

The self-esteem scale used in this study was the self-esteem scale developed by Rosenberg (1965) and translated by Jeon (1974). The total number of questions was 10. The questions 3, 5, 8, 9, 10 were reversed to the negative item. The range of the score is 1 to 5, and the higher the score, the higher the self-esteem. Cronbach’s alpha was .85 in Jeon (1965)’s study, and .87 in this study.

(4) Emotional intelligence

The emotional intelligence used in this study was the Wong and Law Emotional Intelligence Scale(WLEIS) developed by Wong et al. (2002) and translated by Lim (2004). These questions are composed of 4 items of understanding self-emotion, 4 items of understanding of others, 4 items of emotional regulation, and 4 items of emotional use. The range of the score is 1 to 7, and the higher the score, the higher the emotional intelligence. Cronbach’s alpha was .95 in Lim (2004)’s study, and .94 in this study.

(5) Affective well-being

The affective well-being scale used in this study was the Positive and Negative Affectivity Scale (PANAS) of Watson (1988). These questions are composed of 10 items positive emotion and 10 items negative emotion. The total number of questions was 20. The range of the score is 1 to 5, and the higher the score, the higher positive and negative emotion. Cronbach’s alpha was positive emotion .91, negative emotion .83 in Watson D (1988)’s study and, positive emotion .89, negative emotion .90 in this study.

(6) Perceived emotion requirement

The perceived emotion requirement scale used in this study was the Emotional Work Requirement Scale (EWRS) developed by Best et al. (1997). This scale is a total of 7 questions with four positive expressions and three negative expressions. The range of the score is 1 to 5, and the higher the score, the more clearly the organizational expectations of appropriate emotional expression are perceived and internalized. Cronbach’s alpha was .78 in Best et al. (1997)’s study, and .92 in this study.

(7) General characteristics questionnaire

The general characteristics in this study consisted of 8 questions including gender, age, marital status, education level, position, total clinical career, career in current hospital, and career in outpatient clinic.

4. Data collection

The questionnaire was distributed and collected to 240 nurses working in outpatient clinics of K university hospitals in S and K city, from May 11 to May 30, 2017, who were informed about the purpose and process of this study. 236 data were used for the final analysis except for two unrecovered questionnaires and two questionnaires with the missing documents, and the recovery rate was 99%.

5. Data analysis

Analysis of the data was used SPSS/WIN 24.0 program. The specific method is as follows.

1)The descriptive statistics about general characteristics, emotional labor, factors related to emotional labor of outpatient nurses were implemented.

2)Correlation analysis was performed through Pearson correlation coefficient to confirm correlation between emotional labor and factors related to emotional labor.

3)Stepwise Multiple Regression was conducted to find out the degree of factors related to emotion labor.

Results

1. General characteristics of participants

The general characteristics of outpatient nurses are gender, age, marital status, education level, position, total clinical career, career in current hospital, and career in outpatient clinic. The result is Table 1. Marital status was unmarried 64 (27.12%) and married 172 (72.88%). The number of outpatient nurses who worked for 5 years or less was 109 (46.19%), for 5∼9 years was 72 (30.51%), for 10∼14 years was 41 (17.37%), for 15∼19 years was 12 (5.08%), and 2 (0.85%) were working for more than 20 years.

2. The descriptive statistics of the emotional labor and related factors

The descriptive statistics of the emotional labor and factors related to emotional labor in this study are shown in Table 2. Emotional labor showed 2.09∼4.91 points and an average of 3.41±.49, showing a higher level of emotional labor than that of the middle. Job autonomy was at least 1.88∼4.88 points, average 3.22±.45 points, slightly higher than the middle level. Social support was at least 1.75 to 4.88 and average 3.48±.60, and social support was higher than that of middle. Self-esteem was at least 2.20∼5.00 and average was 3.75±.58 points, showing a higher level of self-esteem than that of the middle. Emotional intelligence was at least 2.81∼6.56 points and the average was 5.09±.72 points, indicating that emotional intelligence of the outpatient nurses was higher than the middle level. Affective well-being was at least 1.05∼4.00 and average 2.43±.54. Affective well-being level of outpatient nurses was lower than middle. The perceived emotional requirement was at least 2.57∼5.00 points and average 3.97±.61, showing higher than the middle level.

3. Correlation between emotional labor and factors related to emotional labor

The correlation between emotional labor and factors related to emotional labor was analyzed. The results are shown in Table 3.

Table 3 indicates that emotional labor showed a significant positive correlation with perceived emotional requirement (r=.533, p<.0001), and a significant negative correlation with job autonomy (r=−.196, p=.003), self-esteem (r=−.146, p=.025). Job autonomy has a significant positive correlation with social support (r=.463, p<.0001), self-esteem (r=.324, p<.0001) and emotional intelligence (r=.201, p=.002), and showed a significant negative correlation with emotional labor (r=−.196, p=.003) and perceived emotion requirement (r=−.214, p=.001). Social support has a significant positive correlation with job autonomy, self-esteem, and emotional intelligence (r=.240, p=.000). Self-esteem showed a significant positive correlation with job autonomy, social support, and emotional intelligence (r=.482, p<.0001) and showed a significant negative correlation with emotional labor. Emotional intelligence showed a significant positive correlation with job autonomy, social support, and self-esteem. Perceived emotion requirement showed a significant positive correla-tion with emotional labor and negative correlation with job autonomy. Based on the above results, it can be seen that the emotional labor increases as the perceived emotion requirement increases and decreases as the level of job autonomy and self-esteem increases. Social support, self-esteem, and emotional intelligence have a positive effect on each other, and the higher the level of job autonomy, the more the emotional labor and perceived emotion requirement decreases.

4. Multiple regression analysis of emotional labor

The results of the multiple regression analysis of variables for emotional labor total value are shown in Table 4. We analyzed the explanatory powers of job autonomy, self-esteem, emotional intelligence, positive affectivity and negative affectivity of affective well-being, positive display rules and negative display rules of perceived emotion requirement about emotional labor.

The significance test of Table 4 showed that the F-value (p-value) was 34.64 (<.0001) which was significantly below the 5% significance level. As a result of the multiple regression analysis, self- esteem, positive display rules, negative display rules showed significant results. The standardized regression coefficient (β) of self-esteem was −0.15, and the t-value (p-value) was −2.66 (.008). When self-esteem increased by one unit, it affects emotional labor by about −0.15.

As a result of the above multiple regression analysis, when the degree of positive display rules and negative display rules increases, it affects the increase of emotional labor level. But increasing of self-esteem can affects the decrease of emotional labor. Also, positive display rules have the greatest effect on emotional labor.

Discussion

In this study, emotional labor was correlated with factors related to emotional labor. Perceived emotion requirement increased emotional labor, and job autonomy, and self-esteem decreased emotional labor. In addition, social support, self- esteem, and emotional intelligence have positive effects on each other, and they increase when the level of job autonomy increases, and they decrease when emotional labor and perceived emotion requirement increase. It is line with a research that peer support can resolve emotional labor of nurses in Byun et al. (2009) and another research that it has helped to resolve the problem through emotional support between peer nurses in Song et al. (2001). This implies that emotional labor decreases as the level of perceived emotion requirement of the nurses are lowered. Emotional labor decreases as the level of job autonomy, self-esteem, and emotional intelligence increases, and social support is solid. It is consistent with Tak et al. (2012)’s study on nurses that perceived emotion requirement are in a positive correlation with emotional labor. In addition, in the study of Han (2016), the job autonomy has negative effect on emotional labor. In the study of Song et al. (2011), it is consistent with result that social support has negative effect on emotional labor. Kim et al. (2013) found that emotional intelligence affects emotional labor negatively. It is also consistent with a negative correlation of hospital nurses by Kim et al. (2014), that the higher that superior support, the lower emotional labor, and another study of Morris et al. (1996), that job autonomy has negative correlation with emotional labor.

Therefore, it is very important to reduce the level of perceived emotion requirement in order to reduce emotional labor level of outpatient nurses, and systematic plan should be prepared to increase the level of job autonomy by changing the job design of outpatient nurse. In addition, it is also positive to reduce the level of emotional labor by establishing a social support system for outpatient nurses, providing education programs to enhance self-esteem, and effectively utilizing the high level of emotional intelligence possessed by outpatient nurses, and taking charge of your role.

In the multiple regression analysis of emotional labor, self-esteem, perceived emotion requirement (positive display rules and negative display rules) was significant, and the explanatory power was 30.9%.

Multiple regression analysis was conducted to confirm the explanatory power of the variables related to emotional labor of outpatient nurses.

When sum up the results of the multiple regression analysis, the related factor that have the greatest influence on the increase of emotional labor is perceived emotion requirement, among which ‘perceived emotion requirement: positive display rules’ is the greatest influence. In addition, it was found that job autonomy, self-esteem, emotional intelligence, social support had positive effects on emotional labor, and positive affectivity of affective well-being decreased emotional labor, and negative affectivity of affective well-being increase emotional labor.

Based on the results of this study, the suggestions for systematical manage of the emotional labor of outpatient nurses are followed. At first, it is suggested that research should be undertaken to develop an intervention program based on job autonomy, self-esteem, emotional intelligence, social support and affective well-being. Secondly, it is suggested that replication study about perceived emotion requirement, social support, affective well-being which were confirmed the most in-fluential variable among factors related to emotional labor of outpatient nurses.

Limitations

The study used convenience sampling with inclusion criteria. Thus the findings have the limitation of generalizability to a more diverse population.

Notes

Conflicts of interest

We confirm that this manuscript has not been published elsewhere and is not under consideration by another journal. All authors have approved the manuscript and agree with its submission to Nursing Research. Also, this manuscript hasn’t received additional payments or support in kind for any aspect of the submitted work. The authors have no conflicts of interest to report.

Funding

This manuscript haven’t received additional payments or support in kind for any aspect of the submitted work.

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