International Journal of Nursing Studies 70 (2017) 71–88

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International Journal of Nursing Studies

journal homepage: www.elsevier.com/ijns

Review

Nurses’ resilience and the emotional labour of nursing work: An

integrative review of empirical literature
Cynthia Delgadoa,b,c,* , Dominic Uptond , Kristen Ransed , Trentham Furnessa,e,
Kim Fostera,e
a
School of Nursing, Midwifery & Paramedicine, Australian Catholic University, Fitzroy VIC 3065, Australia
b
Sydney Nursing School, The University of Sydney, Camperdown NSW 2050, Australia
c
Consultation Liaison Mental Health, Royal Prince Alfred Hospital, Sydney Local Health District, Camperdown NSW 2050, Australia
d
Faculty of Health, University of Canberra, Bruce ACT 2617, Australia
e
The Royal Melbourne Hospital & Northwestern Mental Health, Melbourne Health, Parkville VIC 3050, Australia

A R T I C L E I N F O A B S T R A C T

Article history: Background: The emotional labour of nursing work involves managing the emotional demands of relating
Received 26 September 2016 with patients, families and colleagues. Building nurses’ resilience is an important strategy in mitigating
Received in revised form 5 February 2017 the stress and burnout that may be caused by ongoing exposure to these demands. Understandings of
Accepted 7 February 2017
resilience in the context of emotional labour in nursing, however, are limited.
Objectives: To investigate the state of knowledge on resilience in the context of emotional labour in
Keywords: nursing.
Resilience
Design: Integrative literature review.
Emotional labour
Emotional dissonance
Data sources: CINAHL, Medline, Scopus, and PsycINFO electronic databases were searched for abstracts
Nurses published between 2005 and 2015 and written in English. Reference lists were hand searched.
Nursing work Review methods: Whittemore and Knafl’s integrative review method was used to guide this review. The
constant comparative method was used to analyze and synthesize data from 27 peer-reviewed
quantitative and qualitative articles. Methodological quality of included studies was assessed using the
Mixed Methods Assessment Tool.
Results: Emotional labour is a facet of all aspects of nursing work and nurse-patient/family/collegial
interactions. Emotional dissonance arising from surface acting in emotional labour can lead to stress and
burnout. Resilience can be a protective process for the negative effects of emotional labour. Several
resilience interventions have been designed to strengthen nurses’ individual resources and reduce the
negative effects of workplace stress; however they do not specifically address emotional labour. Inclusion
of emotional labour-mitigating strategies is recommended for future resilience interventions.
Conclusion: Resilience is a significant intervention that can build nurses’ resources and address the effects
of emotional dissonance in nursing work. There is a need for further investigation of the relationship
between resilience and emotional labour in nursing, and robust evaluation of the impact of resilience
interventions that address emotional labour.
© 2017 Elsevier Ltd. All rights reserved.

What is already known about the topic?

Without adequate supports, emotional labour can lead to stress
and burnout in nurses. Consequentially, this can negatively
impact nurses’ well-being, their job performance, and the quality
of their care delivery.

Building nurses’ resilience through personal and professional
development and education can increase their capacity to deal
with workplace stress and burnout.

What this paper adds

* Corresponding author.
This review explores resilience in the context of the emotional
E-mail addresses: Cynthia.Delgado@sydney.edu.au,
Cynthia.Delgado@sswahs.nsw.gov.au (C. Delgado),
labour of nursing work.
Dominic.Upton@canberra.edu.au (D. Upton), Kristen.Ranse@canberra.edu.au
Emotional labour is a characteristic of nurse-patient/family and
(K. Ranse), Trentham.Furness@acu.edu.au, Trentham.Furness@mh.org.au collegial interpersonal interactions, and the emotional
(T. Furness), Kim.Foster@acu.edu.au, Kim.Foster@mh.org.au (K. Foster).

http://dx.doi.org/10.1016/j.ijnurstu.2017.02.008
0020-7489/© 2017 Elsevier Ltd. All rights reserved.
72 C. Delgado et al. / International Journal of Nursing Studies 70 (2017) 71–88
dissonance arising from the surface acting in emotional labour
can lead to nurses’ stress and burnout.

Resilience interventions have been designed to strengthen and
build nurses’ individual resources and reduce the negative
effects of workplace stress. Inclusion of emotional labour-
mitigating strategies is recommended for future interventions.
1. Introduction
Resilience in nursing has been identified as a personal capacity
that aids nurses to deal with workplace adversity and demands
(Hart et al., 2014; McDonald et al., 2013). These demands include
the emotional challenge of witnessing human suffering and
distress, and interpersonal difficulties and conflict with other
staff (Jackson et al., 2007). This can be particularly demanding for
nurses, involving the emotional labour of managing self and others’
negative emotions (Theodosius, 2008). Without adequate support
and resources, these workplace demands and related emotional
labour can have significant negative effects on nurses’ well-being
and job performance over time, potentially leading to high levels of
stress and burnout (Karimi et al., 2014; Melvin, 2015). Building
nurses’ resilience has potential to strengthen their capacity to
address the effects of emotional labour on their well-being and
work (McDonald et al., 2012, 2016; Sorensen and Iedema, 2009). To
date, however, there have been no reviews of resilience in the
context of emotional labour in nursing.
2. Background
2.1. Resilience and nursing
The broader literature defines resilience as a trait, process or
outcome depending on which context the concept is applied to
(Fletcher and Sarkar, 2013). Masten (2015) asserts that resilience
can be understood as the capacity to positively and successfully
adapt to challenging circumstances or adversity, and can occur in
individuals, families, or other dynamic systems. In nursing,
resilience has been explored primarily in relation to individuals,
and conceptualized variously as an ability or attribute, a set of
characteristics, or innate life force (Grafton et al., 2010; Hart et al.,
2014; Jackson et al., 2007), or a contextual and dynamic process
between individuals and their environment involving internal and
external protective factors (Aburn et al., 2016; Gillespie et al.,
2007). Internal resilience-promoting factors are characterized by
individual personal/intrapersonal attributes including optimism,
sense of purpose, faith/belief, sense of self, empathy, insight, self-
care (Buikstra et al., 2010; Edward, 2005), hope, self-efficacy,
coping, control, flexibility, adaptability and emotional intelligence
(Gillespie et al., 2007; Hart et al., 2014). External or environmental
resilience- promoting factors relate to protective mechanisms that
are external to the individual and include social networks and
supports, workplace supports and resources, and role-models
(Cusack et al., 2016; Garcia-Dia et al., 2013; McPhee, 2011). These
factors have been attributed to strengthening resilience in nurses,
and have formed the basis of resilience-building strategies focused
on building and enhancing nurses’ internal and external resources
to help them overcome and adapt to the challenges of nursing work
(Jackson et al., 2007; McAllister and Lowe, 2011).
High levels of resilience in nurses have been associated with
increased overall well-being (Ablett and Jones, 2007), psychologi-
cal health (Mealer et al., 2012a), improved work relationships
(McDonald et al., 2013), professional quality of life (Hegney et al.,
2015), and increased job-satisfaction (Matos et al., 2010).
Accordingly, resilience has been correlated to wellbeing, and
prevention of conditions such as stress and burnout, compassion
fatigue, vicarious trauma and psychological or physical ill-health
arising from workplace stress and demands (Craigie et al., 2016;
Mealer et al., 2014; Potter et al., 2013). This is significant in the
context of the emotional labour of nursing work, as these adverse
conditions can also occur from the potential negative effects of
emotional labour on nurses’ well-being and their interpersonal
work (Melvin, 2015; Sorensen and Iedema, 2009).
2.2. Emotional labour and nursing
The term ‘emotional labour’ was initially coined by sociologist
Arlie Hochschild in her seminal work in 1983. She defined it as “the
management of feeling to create a publicly observable facial and
bodily display” (Hochschild, 2003, p.7). That is, workers manage
their feelings and emotional expressions in exchange for a wage
guided by feeling rules (Hochschild, 2003). Feeling rules are the
norms in which people are socialized into how, when and what
emotions are expressed in various contexts, such as social or work
contexts (Grandey et al., 2013; Hochschild, 2003; Theodosius,
2008). Within these rules, people manage their emotions through
the strategies of ‘deep’ and ‘surface’ acting. ‘Deep’ acting refers to
self-inducing ‘real’ emotions, or attempting to experience and
express a required genuinely felt emotion. ‘Surface’ acting is the
suppression of genuine felt emotions, or simulating unfelt
emotions in order to demonstrate a professionally appropriate
response (Hochschild, 2003). Since Hochschild’s work, the concept
of emotional labour has continued to be explored and applied in
various fields, including sociology, psychology, organizational
behaviour, and nursing (Grandey et al., 2013). In the nursing
context, Hochschild’s concept of emotional labour was developed
further and applied by Theodosius (2008) who identified three
types of emotional labour in nursing; therapeutic, collegial and
instrumental. Therapeutic emotional labour refers to interpersonal
relationships and interactions between nurses and patients and/or
their families. Instrumental emotional labour refers to nurses’
interpersonal communication skills and confidence in performing
clinical tasks to minimize patients’ pain or discomfort, or patients/
families’ concerns relating to clinical processes and procedures.
Collegial emotional labour refers to interpersonal relationships
and interactions between nurses and their colleagues where the
exchange of information informs and promotes effective nursing
care.
All three types of emotional labour involve interactive
interpersonal processes within the nurse-patient/family/colleague
relationship (Theodosius, 2008). Within these relational processes,
nurses manage their emotions and emotional expressions, through
the strategies of deep and surface acting, to display behaviours that
are conducive to others feeling cared for (McQueen, 2004;
Theodosius, 2008). Both deep and surface acting can be
emotionally demanding (Debesay et al., 2014), and both strategies
can be incorporated into a single interaction (Mann and Cowburn,
2005). Deep and surface acting however have different effects.
Deep acting is associated with positive aspects of emotional labour,
such as job-satisfaction, increased sense of connection with
patients, and patient satisfaction (Chou et al., 2012; Golfenshtein
and Drach-Zahavy, 2015). Conversely, surface acting has been
associated with emotional dissonance, where there is a discrep-
ancy between authentic felt emotions and the required emotional
expression (Cheng et al., 2013; Karimi et al., 2014). Surface acting
can result in negative impacts including emotional exhaustion,
stress and burnout, and psychological and physical ill-health
(Schmidt and Diestel, 2014). Managing the emotional demands of
nursing work can include care-outcomes that result in a positive
emotional experience; however for nurses emotional labour is
more often related to managing the suffering, vulnerabilities and
negative health outcomes of patients (Humphrey et al., 2015;
 C. Delgado et al. / International Journal of Nursing Studies 70 (2017) 71–88
Huynh et al., 2008). These experiences can result in high levels of
emotional labour, which can affect nurses’ well-being and their
work and relationships with patients, families and colleagues
(Andela et al., 2015). Thus, emotional labour can be considered a
form of workplace adversity. Building and strengthening nurses’
resilience therefore may help them deal with the emotional
adversity and demands of managing others’ distress, and mitigate
potential adverse effects on nurses’ biopsychosocial well-being
and on their work and professional relationships (McDonald et al.,
2012, 2016).
2.3. Previous reviews
Over the past decade, there have been several reviews defining
(Aburn et al., 2016; Grafton et al., 2010; Zander et al., 2010), and
identifying, strategies to build resilience among nurses (Hart et al.,
2014; Jackson et al., 2007). In specialty nursing areas, resilience
was defined as an innate energy and motivating life force that
results from nurses developing their biopsychosocial-spiritual
well-being (Grafton et al., 2010). In the broader nursing context
however there appears to be no universal definition of resilience
(Aburn et al., 2016). Despite this, resilience was considered to be
improved with personal and professional development/education
Fig. 1. PRISMA flow chart of search strategy.
Adapted from Liberati et al. (2009).
73
(Grafton et al., 2010; Jackson et al., 2007). Authors suggested these
processes were essential to build and maintain nurses’ resilience
and could positively impact recruitment and retention (Hart et al.,
2014). The most effective methods to build and maintain resilience
however are yet to be identified. Although these reviews were
specific to resilience, there were some emergent linkages made
between resilience and emotion, including developing emotional
intelligence, toughness, detachment, insight and/or stamina as
focal areas for building nurses’ resilience (Grafton et al., 2010; Hart
et al., 2014; Jackson et al., 2007). In terms of emotional labour, in
their review, Riley and Weiss (2016) identified socio-cultural
expectations, gender aspects, management of emotions (intraper-
sonal), conflicts with colleagues (collegial), and the organization as
sources and barriers to engaging in emotional labour.
Although there have been some emergent linkages made
between resilience and emotional labour in earlier reviews, this is
under-explored. Understanding the current evidence on resilience
in the context of emotional labour will inform education and
practice in the field, and provide a basis for future resilience
interventions. The aim of this review was to investigate the state of
knowledge on resilience in the context of emotional labour in
nursing. Three questions guided the review: 1) What aspects of
nursing work are associated with emotional labour? 2) What is
74 C. Delgado et al. / International Journal of Nursing Studies 70 (2017) 71–88

Table 1
Summary of studies included in review.

Study Study aim(s) Design & methods Setting & participants Key findings Limitations Quality
Author/s score
(Year)
Country
Ablett and To describe hospice Design: Qualitative, Setting: One hospice in the High level commitment, Homogenous sample ****
Jones nurses’ experiences of phenomenology north west of England sense of meaning and (palliative care nurses)
(2007) their work, and Data collection: Semi- Participants: Palliative care purpose to their work, and from one setting 
UK To explore the processes structured interviews nurses interpersonal factors Findings may have limited
by which nurses continued (n = 10: 9 female; 1 male) contribute to nurses’ generalizability to the
to work in palliative care resilience and buffer work broader nursing
and maintain a sense of stress. population
well-being. Ten themes on nurses’
experiences of their work
in the context of resilience:
An active choice to work in
palliative care; past
personal experience
influences care-giving;
personal attitudes to care-
giving; personal attitudes
towards life (and death);
awareness of own
spirituality; personal
attitudes towards work;
aspects of job satisfaction;
aspects of job stress; ways
of coping; and personal/
professional issues and
boundaries.
Bailey et al. To explore how emergency Design: Qualitative, Setting: One large Nurses who invest their Homogenous sample ***
(2011) nurses manage the ethnography emergency department in therapeutic self into the (Emergency department
UK emotional impact of death Data collection: the UK nurse-patient relationship nurses) from one setting 
and dying in emergency unstructured observations Participants: are able to manage the Findings may have limited
work. of practice and semi- (For observations) All emotional labour of caring generalizability to the
structured in-depth emergency department for the dying and their broader nursing
interviews staff relatives through population
(In-depth interviews) development of emotional Researchers’ influence in
Emergency department intelligence. the process is not clearly
staff, patients and families: reported
 nurses (n = 10) (nurses’
gender was not reported)
 patients’ relatives (n = 7)
 patients who had
experienced an emergency
department admission
within 6 months (n = 6)
 doctors (n = 2)
 emergency department
assistants (n = 2)
 student nurse (n = 1)
Cameron and To identify the factors that Design: Qualitative, Setting: High care Determinants of resilience Homogenous sample ***
Brownie impact the resilience of phenomenology residential aged care include clinical expertise; (aged care nurses) from
(2010) registered aged care Data collection: semi- facilities in Queensland, a sense of purpose in a one type of setting
Australia nurses, that is their structured interviews Australia (number of holistic care environment; (residential aged care
capacity to adapt to the facilities not reported) a positive attitude and facilities)  Findings may
physical, mental and Participants: Aged care work-life balance. have limited
emotional demands of Registered Nurses (n = 9: 9 Resilience develops generalizability to the
working in aged care female) through clinical broader nursing
facilities. knowledge; and skills and population
experience. Researchers’ influence in
the process is not clearly
reported
Chou et al. To investigate the effects of Design: Quantitative, Setting: One teaching Frequency of interacting Potential information bias ***
(2012) job demands and cross-sectional survey hospital in Taiwan with difficult patients due to survey containing
Taiwan resources as well as (53% return rate) Participants: Registered related positively to all self-reported measures
emotional labour on job Data collection: nurses (n = 240: 85.3% surface acting and Participants only from one
satisfaction and emotional Questionnaires, female; 14.7% male) emotional exhaustion; and hospital in Taiwan 
exhaustion among nurses.  Frequency of (Nurses’ clinical specialty negatively to job results may not be
interactions with difficult was not reported). satisfaction. generalizable due to
patients scale, Perceived organizational potential cultural
 Survey of Perceived support related positively differences
Organizational Support– to deep acting and job
Shortened version, satisfaction; negatively to
 Emotional labour scale, surface acting and
 Maslach Burnout emotional exhaustion.
Inventory, Surface acting related
 Michigan Organizational negatively and deep acting
 C. Delgado et al. / International Journal of Nursing Studies 70 (2017) 71–88 75

Table 1 (Continued)
Study Study aim(s) Design & methods Setting & participants Key findings Limitations Quality
Author/s score
(Year)
Country
Assessment Questionnaire positively to job
Job Satisfaction Subscale) satisfaction.
Job demands, resources
and emotional labour can
predict nurses’ well-being.
Cottingham To explore the strategies Design: Qualitative Setting: Various clinical Engaging in deep acting, Data is not statistically ***
(2015) that men use to manage Data collection: audio settings (examples male nurses frame control representative of all male
US emotions as nurses. diaries and in-depth provided included over their own emotions as nurses therefore limiting
interviews pediatrics, emergency, a means for managing generalizability.
intensive care, community others’ emotions. Researchers’ influence in
health, primary care, Strategies for managing the process is not clearly
psychiatry) in various self-emotions included reported
regions of the United reframing the nurse role;
States. distancing; and
Participants: Male relinquishing control.
registered nurses (n = 40)
Cricco-Lizza To examine the nature of Design: Qualitative, Setting: One children’s Emotional labour was an Homogenous sample ****
(2014) the nurses’ emotional ethnography hospital in northeastern under-recognized (Highly specialized
US labor and explore their Data collection: participant United States component in the care of neonatal intensive care
coping strategies. observation and formal Participants: Level-4 vulnerable infants and unit nurses) from one
interviews with key (highly specialized families. setting (Children Hospital)
informants services) neonatal Coping strategies included  Findings may have
intensive care unit nurses talking with the sisterhood limited generalizability to
(n = 114) of nurses; being a super the broader nursing
 All 114 participated as nurse; using social talk and population
general informants (113 humour; taking breaks;
female; 1 male); offering flexible aid;
 18/114 participated as withdrawing from
key informants (17 female; emotional pain;
1 male) transferring out of the
neonatal intensive care
unit; attending memorial
services; and reframing
loss to find meaning in
work.
Debesay et al. To examine nurses' Design: Qualitative Setting: Home healthcare Emotional labour is a Homogenous sample ***
(2014) experiences through the Data collection: semi- within four city districts in demanding experience (Community nurses) from
Norway lens of emotional labour in structured in-depth Oslo, Norway, whether performed one type of setting (Home
working with ethnic interviews Participants: Community through deep or surface healthcare)  Findings
minority patients in the nurses (n = 19: 17 female; 2 acting. may have limited
context of pressures male). Time pressures and generalizability to the
arising from uncertainties affected broader nursing
organizational reforms. strategies that home care population
nurses adopted in Researchers’ influence in
performing their work in the process is not clearly
their interaction with reported
ethnic minority patients.
Foureur et al. To pilot the effectiveness Design: Mixed methods Setting: Two teaching
Quantitative findings: Potential for information ***
(2013) of an adapted pilot study. metropolitan hospitals in Statistically significant bias due to survey
Australia mindfulness-based stress Quantitative component NSW Australia results indicating better containing all self-
reduction intervention on included a pre and post Participants: Nurses general health, a more reported measures
the psychological well- intervention design. (n = 20) and midwives positive orientation to life,
being of nurses and Qualitative component: (n = 20) and lower stress levels as
midwives. was a non-specific (Nurses & Midwives’ per improvements on the
qualitative design. gender was not reported. GHQ General Health
Data collection: Nurses’ clinical specialty Questionnaire 12
 Questionnaires (70% was not reported). (p = 0.011); Sense of Co-
return rate) (General herence-orientation to life
Health Questionnaire-12 (p = 0.009); manageability
scale, Sense of Coherence- subscale (p = 0.075); and
Orientation to Life scale, stress subscale of the De-
Depression Anxiety Stress pression Anxiety Stress
Scale measured pre- Scale (p = 0.004).

Qualitative findings:
intervention and 4–8
weeks post-intervention)
 Interviews (focus groups  acceptability of inter-
and individual interviews vention
with participant sub-  range of enablers and
group (35%)) barriers to incorporating
 facilitator/interviewer mindfulness practice into
field notes, and the business of life identi-
 participant logs of fied.
mindfulness-based stress
76 C. Delgado et al. / International Journal of Nursing Studies 70 (2017) 71–88

Table 1 (Continued)
Study Study aim(s)
Author/s
(Year)
Country
Glass (2009) To investigate the
Australia significance of hope,
resilience, and optimism
to nurses’ and midwives’
practice and
responsibilities; and the
degree to which hope,
resilience, and optimism
were implemented in their
work environment.
Design & methods
reduction practices (50%
return rate)
Design: Qualitative,
ethnography
Data collection: participant
observation, semi-
structured conversational
interviews and art-based
and written reflections
Setting & participants
Setting: Three different
sites from Schools of
Nursing in public
universities
Participants: Nurses and
midwives (n = 20: 18
female; 2 male; 13/20
nurses and midwives also
had clinical involvement)
(Nurses’ clinical specialty
was not reported).
Key findings Limitations Quality
score

Resilience Participant sample were ****
Nurses and midwives academics from education
identified resilience as an settings  findings may
essential requirement for have limited
effective everyday work generalizability to the
practices, working well in broader nursing
universities and health- population
care, inner balance, sur-
vival and sanity.
Not limited to situations of
“stereotypical” adversity.

Hope and optimism

Perceived as necessary
components of developing
and sustaining levels of
Gray and To investigate the tacit and Design: Qualitative, Setting: One hospital in Features of nurses’ Results are context-bound ***
resilience.
Smith uncodified emotions of ethnography East London, UK emotional labour in: to East London  Findings
(2009) nurses in several different Data collection: In-depth Participants: Nurses therefore may have limited
UK clinical settings and semi-structured (n = 16: 12 female; 4 male)
Primary care setting: generalizability
interviews working in three clinical Emotional labour is Researchers’ influence in
specialties: demonstrated through the process is not clearly
 primary care the managing of self and reported
 mental health others’ emotions and
 children’s oncology used to create a com-
(number of nurses in each fortable environment
specialty was not for patients and relatives
reported) (involves concealing
own true emotions).

Mental health setting:
duty of care and social
control elements of care
in working with patients
with mental illness and
unpredictable behaviour
cause unresolved emo-
tional pressures and
stresses.

Children’s oncology and
bone marrow trans-
plant: Emotional labour
was used to support
relationships with
patients, relatives and
colleagues. Emotional
dissonance is experi-
enced in managing a
‘good death’.

Haycock- To examine emotions in Design: Qualitative Setting: Three health Nurse leaders undertook Participant sample were ***
Stuart et al. leadership, particularly Data collection: Semi- boards in Scotland surface acting to mask community nurse leaders
(2010) collegial emotional labour structured interviews Participants: Community their emotions, to  findings may have
UK within community nurse leaders (n = 12) maintain a dignified and limited generalizability to
nursing. (Nurses’ gender was not professional demeanour the broader nursing
reported). with colleagues. population
Researchers’ influence in
the process is not clearly
reported
Hodges et al. To explore the nature of Design: Qualitative, Setting: Acute care settings Personal growth in new Potential sampling bias ****
(2008) professional resilience in interpretive hermeneutic from a variety of clinical nurses is evident by the due to recruitment of
US new baccalaureate- phenomenology and specialties (labour & evolving clarity of nurses from the same
prepared nurses in acute Hybrid model for the delivery; mother-baby; professional identity, an baccalaureate nursing
care settings. concept development of emergency department; edifying sense of purpose, program.
professional resilience. neonatal intensive care; and energy resources to Nurses older than
Data collection: semi- medical adult care; move forward. inclusion criteria may have
structured interviews and telemetry) Professional resilience provided other salient
observation Participants: New yields the capacity for self- information about their
baccalaureate-prepared protection, risk taking, and particular transitional
nurses (BSN) (n = 11: 10 moving forward with experiences.
female; 1 male) with at reflective knowledge of
least one year of self.
experience in acute care
nursing
 C. Delgado et al. / International Journal of Nursing Studies 70 (2017) 71–88 77

Table 1 (Continued)
Study Study aim(s) Design & methods Setting & participants Key findings Limitations Quality
Author/s score
(Year)
Country
(number of nurses in each
specialty was not
reported)
Kornhaber To explore the concept of Design: Qualitative, Setting: One adult burns The concept of building Limited generalization of ***
and Wilson building resilience as a phenomenology unit in a large, acute care, resilience as a strategy for findings due to small
(2011) strategy for responding to Data collection: In-depth public hospital in Sydney, coping with adversity was sample size and single
Australia adversity experienced by semi-structured Australia identified and organized clinical setting
burns nurses. interviews Participants: Registered into six categories: Subject to sampling bias
nurses (n = 7: all female) toughening up; natural (participants were all
with a minimum 3 years selection; emotional Anglo-Saxon female)
full-time burns nursing toughness; coping with
experience the challenges; regrouping
and recharging; and
emotional detachment.
It is vital for burns nurses
to build resilience to
endure the emotional
trauma of nursing patients
with severe burn injury.
Li (2005) To examine how palliative Design: Qualitative, Setting: Three settings (2 ‘Niceness’ meant being Homogenous sample ****
UK care nurses do criticism of grounded theory with an hospices and 1 general professional, supportive, (palliative care nurses) 
other professionals in talk ethnomethodological- hospital) in the South of polite, discreet and Findings may have limited
within settings for care of ethnographical England sensitive to another generalizability to the
the dying. perspective Participants: Palliative care person’s reaction or broader nursing
Data collection: Participant nurses (n = 28) response to criticism; population
observation (Nurses’ gender was not being involved striving to
reported). maintain a neutral stance
in interactional
difficulties; and produced
from re-enacting others’
voices in their absence
(patients and/or
colleagues).
Emotional labour serves to
help nurses adjust their
emotional responses and
manage interactional
conflicts arising from the
nature of their work.
Communication skills are
an important feature of
emotional labour.
Mann and To aid understanding of Design: Quantitative, Setting: One psychiatric Emotional labour Subject to non-response ***
Cowburn the complex relationship descriptive unit in northwest England. positively correlated with bias due to response rate of
(2005) between components of Data collection: Self- Participants: 35 mental interaction stress; and 29%
UK emotional labour and reported questionnaires health nurses daily stress levels. Limited generalizability of
stress within the mental and scales (29% response (Nurses’ gender was not The deeper the intensity of findings due to small
health nursing sector. rate) (Emotional Labour reported). interactions and the more number of respondents,
Scale, Emotional Labour variety of emotions response rate, and
Inventory, Stress felt experienced, the more geographical spread (one
during nurse-patient emotional labour was psychiatric unit)
interactions 1-item reported. Potential for information
questionnaire and the Surface acting was a more bias due to self-reported
Daily Stress Inventory). important predictor of measures/questionnaires
emotional labour than
deep acting.
McCreight To investigate nurses’ Design: Qualitative Setting: Gynaecological Emotional involvement Homogenous sample ***
(2005) experiences and feelings in Data collection: in-depth units from 10 hospitals in with parents by nurses, (Gynae nurses)  Findings
UK dealing with parents who semi-structured northern Ireland although emotionally may have limited
had experienced a interviews Participants: Nurses draining, was more likely generalizability to the
pregnancy loss. (n = 14) to be a positive feature of broader nursing
(Nurses’ gender was not their work. population
explicitly reported). Essential elements of Researchers’ influence in
nurses’ work excluded/ the process is not clearly
devalued because of their reported
emotional entailments can
be recovered through
narrative (critical
reflections on practice)
and increased
understandings of
emotional encounters.
78 C. Delgado et al. / International Journal of Nursing Studies 70 (2017) 71–88

Table 1 (Continued)
Study Study aim(s) Design & methods Setting & participants Key findings Limitations Quality
Author/s score
(Year)
Country
McDonald To develop, strengthen and Design: Qualitative, Setting: A metropolitan Three major themes in Subject to selection/ ***
et al. maintain personal Instrumental collective women’s and children’s relation to the effects of sampling bias due to
(2013) resilience among nurses case study health service in Australia the intervention: personal participants being able to
Australia and midwives. Data collection: Pre-and- (specific settings within gains from resilience self-select
post face-to-face semi- the service not reported) workshops; professional Risk of inter-subjectivity
structured interviews Participants: Nurses and gains from resilience due to doctoral researcher
(pre-intervention, midwives (n = 14: all workshop; and personal being the group facilitator
immediately after female). resilience initiatives. of the workshops.
intervention, and 6 (Nurses’ clinical specialty Primary effects of the
months post- was not reported). intervention included
intervention), and enhanced self-confidence;
participant evaluations self-awareness;
collected at the end of each assertiveness; and self-
workshop. care.
McMillen To explore the experiences Design: Qualitative, Setting: One intensive care Two themes and related Homogenous small sample ***
(2008) of intensive care unit grounded theory unit in the north of subthemes summarized (intensive care unit
UK nurses caring for patients Data collection: Semi- England intensive care unit nurses’ nurses) from one setting 
who have had their structured interviews Participants: Intensive care experience: Findings may have limited
treatment withdrawn unit nurses (n = 8)  the nurse’s role generalizability to the
(Nurses’ gender was not (experience counts; not broader nursing
reported) really a nurse’s decision; population
planting the seed; Theoretical saturation did
supporting the family and not occur due to small
being the patient number of participants.
advocate)
 perceptions of the
withdrawal of the
treatment (getting the
timing right and emotional
labour)
Mealer et al. To identify mechanisms Design: Qualitative Setting: Various intensive Four major domains were Homogenous sample ****
(2012b) employed by highly Data collection: Semi- care units across the USA identified that illustrated (Intensive care unit
USA resilient intensive care structured telephone (other specifics not the difference between nurses)  Findings may
unit nurses to develop qualitative interviews reported) highly resilient nurses and have limited
preventative therapies to Participants: Two cohorts nurses with a diagnosis of generalizability to the
obviate the development of intensive care unit post-traumatic stress broader nursing
of post-traumatic stress nurses (total n = 27) disorder: worldview; population
disorder in intensive care working for at least 5 social network; cognitive Subject to sampling bias:
unit nurses. years: flexibility; and self-care/ participants self-selected;
 Highly resilient balance. gender and cultural
intensive care unit nurses Highly resilient nurses variables were not
based on the Connor- identified spirituality; a sampled
Davidson Resilience Scale supportive social network; Researchers’ influence in
(n = 13: 100% female) optimism; and having a the process is not clearly
 Intensive care unit resilient role model as reported.
nurses with q diagnosis of characteristics used to
post-traumatic stress cope with work related
disorder based on the stress.
posttraumatic diagnostic Nurses with a diagnosis of
scale (n = 14: 93% female) post-traumatic stress
disorder possessed
unhealthy characteristics
including poor social
network; lack of
identification with a role
model; disruptive
thoughts; regret; and lost
optimism.
Mealer et al. To determine if a Design: Quantitative, pilot Setting: Single center Multimodal resilience Small homogenous sample **
(2014) multimodal resilience randomized controlled intensive care units training program was (intensive care unit
US training program for intervention study Participants: Intensive care feasible to conduct and nurses) from same setting
intensive care unit nurses Data collection: unit nurses (n = 29) acceptable to intensive limits generalizability.
was feasible to perform  Demographic working 20 h per week at care unit nurses. Randomization and
and acceptable to the questionnaire the bedside: Four main themes blinding process not clear.
study participants.  Questionnaires  14 nurses (92% female) identified in written
administered pre and post randomized to the exposure sessions about
(within a week) intervention nurses’ experience of their
intervention (Connor-  15 nurses (86% female) work: patient centric;
Davidson Resilience Scale, randomized to the control cognitive processing; work
Posttraumatic Diagnostic arm structure; and workplace
Scale, the Hospital Anxiety relationships.
and Depression Scale, the Nurses in intervention
Maslach Burnout group had significant
Inventory) reduction in symptoms of
 C. Delgado et al. / International Journal of Nursing Studies 70 (2017) 71–88 79

Table 1 (Continued)
Study Study aim(s) Design & methods Setting & participants Key findings Limitations Quality
Author/s score
(Year)
Country
 Client/Patient depression (P = 0.03).
Satisfaction Significant decrease in
Questionnaire-8 post-traumatic stress
 (Nurses’) Satisfaction disorder symptoms after
surveys for each the intervention was
component of the demonstrated in both
intervention. nurses randomized to
treatment group (P = 0.01)
and nurses randomized to
control group (P = 0.02).
Improved resilience scores
was demonstrated in both
nurses randomized to
treatment group (P = 0.05)
and nurses randomized to
control group (P = 0.03).
Potter et al. To evaluate a resiliency Design: Quantitative, pre- Setting: One outpatient None of the covariates Self-selected participants ****
(2013) program designed to and-post-test descriptive infusion center. (age, years in nursing, and in small sample size limits
US educate oncology nurses pilot intervention study Participants: Oncology years in oncology) were generalizability of
about compassion fatigue. Data collection: nurses (n = 13). significantly associated findings.
 Questionnaires (Gender reported prior to with the outcome
administered pre- participant dropout: 2 measures.
intervention, immediately male and 12 female No statistically significant
post-intervention, 3 nurses) changes in Maslach
months and again at 6 Burnout Inventory–
months post-intervention Human Services Survey
(Professional Quality of subscales, burnout scores,
Life IV, Maslach Burnout or job satisfaction
Inventory–Human subscales.
Services Survey, Impact of Statistically significant
Event Scale–Revised, differences and
Nursing Job Satisfaction improvement compared
Scale), and with baseline observed in
 weekly and final secondary traumatization
program evaluation forms scores, and Impact of Event
(5-point likert scales). Scale–Revised scores.
Participants evaluated the
program positively with
respect to their ability to
apply and benefit from
resilience techniques.
Sorensen and To understand the impact Design: Qualitative, multi- Setting: One large Clinicians’ attitudes to Limited generalizability of ***
Iedema of emotional labour in method qualitative intensive care unit from death and dying and findings due to (single)
(2009) specific health care ethnographic study one acute public tertiary clinicians’ capacity to specific research site
Australia settings and its potential Data collection: patient hospital in Sydney, engage with the human Researchers’ influence in
effect on patient care. case studies, family Australia needs of patients the process is not clearly
conferences, interviews Participants: Intensive care influenced how emotional reported.
(with chaplain, nursing unit clinicians, patients labour was experienced.
and medical staff) and and family members Negative effects of
focus groups with nursing  Nurses (n = 32) emotional labour (stress
staff  Medical staff (n = 28) and anxiety) were not
 Patients (n = 16) formally acknowledged in
 Family participants clinical work places and
(n = 15) institutional mechanisms
 Chaplain (n = 1) to support clinicians did
(Participant gender was not exist.
not reported).
Stayt (2009) To explore the emotional Design: Qualitative, Setting: One adult Nurses invest several Small sample and single ****
UK labour nurses’ face when Heideggerian intensive care unit in a emotions when caring for site study limit
caring for relatives of the phenomenology large teaching hospital in families in the intensive generalizability of
critically ill in intensive Data collection: In-depth the UK care unit. findings.
care unit. open ended interviews Participants: Registered Nurses experience a lot of
nurses (n = 12: 10 female; 2 emotions that are
male). frequently suppressed
within the clinical
environment but
accumulate over time.
Six common themes were
identified: significance of
death; establishing trust;
information giving;
empathy; intimacy; and
self- preservation.
80 C. Delgado et al. / International Journal of Nursing Studies 70 (2017) 71–88

Table 1 (Continued)
Study Study aim(s) Design & methods Setting & participants Key findings Limitations Quality
Author/s score
(Year)
Country
Timmons To analyse the emotional Design: Qualitative, Setting: Operating theatres Operating theatre nurses Small sample and single ***
and Tanner labour operating theatre ethnography from five UK National assumed the ‘hostess role’ site study limit
(2005) nurses perform with Data collection: Participant Health Service Hospitals where they perceived that generalizability of findings
UK surgeons observation and follow up Participants: Operating it was their responsibility Researchers’ influence in
interviews theatre nurses (n = 17: 15 to ‘look after’ the surgeons the process is not clearly
female; 2 male) and (by ‘keeping them happy’) reported.
operating department and ‘not upsetting the
practitioners (technicians) surgeons’.
(n = 3: all male). Gender plays a part in the
expectation that
emotional labour will be
performed
Emotional labour was
performed by Operating
theatre nurses to maintain
sentimental order in the
operating theatre; and
maintain a light-hearted
and convivial mood with
minimal disturbances for
the surgeons.
Walsh (2009) To examine the emotional Design: Qualitative Data Setting: Three adult
Phase 1 Findings Small sample size and ***
UK labor of nurses working in collection:  Semi- prisons  Nurses working in pris- specific clinical specialty of
prisons in England and structured interviews Participants: Registered ons experience emotional participants limits
Wales. (Phase 1) and supervisory nurses (n = 9) labour as a consequence of generalizability of findings
relationship with  9/9 nurses interviewed four key relationships: Researchers’ influence in
researcher for monthly in Phase 1 with the prisoner patient; the process is not clearly
clinical supervision  2/9 nurses engaged in officer colleagues; the in- reported.
sessions (Phase 2). clinical supervision in stitution; and “intranurse”.
Phase 2  The effect of the rela-
(Nurses’ gender was not tionships on nurses, both
reported). internally and externally,
has an impact on the care
they give, the way in which
they practice, and how
they feel both internally
and in their public dis-
plays.
 Nurses’ own level of
emotional intelligence
dictate the way they
manage emotional labour.

Phase 2 findings

 Four dominant dis-

courses were uncovered in
clinical supervision within
the “intranurse”: posi-
tioning and conflict; nurs-
ing practice and
professional safety; confi-
dence, empowerment and
accountability; and clinical
supervision being impor-
tant in developing emo-
tional intelligence and
managing emotional la-
bour.

Zamanzadeh To describe the emotional Design: Qualitative Setting: Hematopoietic
et al. labour experienced by Data collection: Semi- stem cell transplantation
(2013) nurses who care for structured interviews adult, paediatric and
Iran hematopoietic stem cell haematology wards from
transplantation patients in one university hospital
Iran. (also main hematopoietic
stem cell transplantation
centre) in Iran.
Participants: Nurses
(n = 18: all female)
 adult hematopoietic
stem cell transplantation
(n = 10/18)
 paediatric
Three categories described Specific specialty focus ***
the emotional labour from one setting may limit
involved: emotional generalizability of findings
intimacy; feeling to the broader nursing
overwhelmed with the population
sadness and suffering; and Researchers’ influence in
changing self. Five sub- the process is not clearly
categories described this: reported.
witnessing suffering;
struggling mentally;
hurting emotionally;
feeling drained of energy;
and escaping grief.
Nurses had compassion
 C. Delgado et al. / International Journal of Nursing Studies 70 (2017) 71–88 81

Table 1 (Continued)
Study Study aim(s) Design & methods Setting & participants Key findings Limitations Quality
Author/s score
(Year)
Country
hematopoietic stem cell and empathy for their
transplantation (n = 2/18), patients, contributing to a
and close nurse-patient
 hematology-oncology relationship.
(n = 6/18) Dealing with death and
dying on an ongoing basis
promoted the nurses’
changing self.
Zander et al. To explore the concept of Design: Qualitative, case Setting: One eight-bed Seven ‘aspects of forming Small sample and single ***
(2013) resilience among study inpatient unit with an resilience’ described site study limit
Australia paediatric oncology nurses Data collection: Semi- adjoining outpatient nurses’ perception of generalizability of findings
who work at the bedside, structured interviews clinical paediatric resilience and how it Researchers’ influence in
and the process these haematology/oncology underpinned their work: the process is not clearly
nurses underwent in order unit in one tertiary the individual reported.
to develop resilience. metropolitan paediatric conceptualization of
hospital in Australia. resilience; the issues and
Participants: Registered challenges faced; actions
nurses (n = 5) and strategies; the need
for support; insight;
processing situations
through reflection; and
personal and professional
experience.
Good health and energy
were necessary to be
resilient in the paediatric
oncology setting.

understood about the role of resilience in the context of emotional
labour in nursing? 3) What interventions have been developed to
strengthen nurses’ resilience in the context of emotional labour?
3. Methods
of nursing work; and/or resilience-building interventions for
nurses. Literature reviews, commentaries, editorials and grey
literature were excluded. Studies that focused on nursing
students’, allied health professions’, patients’ or families’ resilience
or emotional labour were also excluded.

3.1. Design 3.3. Search outcome

An integrative review was conducted to synthesize findings
from both quantitative and qualitative studies, in order to provide a
more comprehensive understanding of knowledge on resilience in
the context of emotional labour in nursing. Whittemore and Knafl’s
(2005) methodology was employed to guide the review and the
rigour of the process.
3.2. Search strategy
The review questions and variables of interest (concepts, target
population, problem) were developed based on Whittemore and
Knafl’s (2005) guide for problem identification. The search strategy
included systematic searches in the Cumulative Index to Nursing
and Allied Health Literature (CINAHL), Medline, Scopus, and
PsycInfo electronic databases. Search terms were derived from
existing literature on the topic and in consultation with a librarian.
Terms employed in combined searches using Boolean operators
included resilien* (resilience, resilient, resiliency) OR emotional
labour (or emotional labor) AND nurs* (nurse, nurses and nursing)
AND nursing care. During secondary screening full text articles
were read and assessed, and reference lists were hand searched.
Peer-reviewed empirical articles, published between January
2005 and December 2015 in the English language, were included in
order to capture contemporary understandings of the concepts of
emotional labour and resilience. Registered Nurses (RNs) needed to
be the majority of the sample population. Any study design was
included as long as the focus was RNs’ emotional labour; RNs’
resilience with reference to emotional aspects or emotional labour
The initial search yielded a total of 758 studies. Studies that
explicitly examined the relationship between resilience and
emotional labour could not be found. Consequently, the search
included papers on both constructs and the link between resilience
and emotional labour was made in the analysis of the studies. The
combined search strategies resulted in 27 relevant articles that met
the inclusion criteria (Fig. 1).
3.4. Data evaluation
The studies included four quantitative, twenty-two qualitative,
and one mixed method study of varying designs. Quantitative
studies included pre-and-post intervention (n = 1), randomized
controlled trial (n = 1), cross-sectional survey (n = 1), and descrip-
tive survey (n = 1) designs. Qualitative studies included non-
specific qualitative (n = 7), ethnography (n = 5), phenomenology
(n = 5), case study (n = 2) and multi-methods (n = 1) designs. The
mixed-method study employed an initial pre-and-post interven-
tion design followed by a non-specific qualitative design. To
provide a summary of all included studies, data were extracted
relating to study aims, design, setting and participants, key
findings, and limitations. Methodological quality of included
studies was evaluated using the Mixed Methods Appraisal Tool
(MMAT) (Table 1). The Mixed Methods Appraisal Tool has
established validity and reliability for summarizing overall quality
across a range of study designs, including quantitative, qualitative,
or mixed methods studies (Pace et al., 2010, 2012; Pluye et al.,
2011; Pluye and Hong, 2014). This is consistent with integrative
82 C. Delgado et al. / International Journal of Nursing Studies 70 (2017) 71–88

review methodology which allows for the inclusion of a range of
study designs (Whittemore and Knafl, 2005). Given that this
integrative review included quantitative, qualitative and mixed
methods studies, the Mixed Methods Appraisal Tool was the most
appropriate tool to appraise the quality of included studies. The
studies were assessed against the relevant Mixed Methods
Appraisal Tool criteria based on the methodology used, and
quality scores were assigned to each study ranging from (*)
representing one criterion met to (****) representing all criteria
met (Pluye et al., 2011). Two authors independently appraised each
article followed by a discussion about the Mixed Methods
Appraisal Tool scores. A consensus was reached through discus-
sion. A third reviewer was nominated to adjudicate on discrep-
ancies however this was not necessary. All authors participated in
the review process. All studies met at least two criteria, and no
studies were excluded based on their quality scores as each study
contributed to this review’s overall findings. Mixed Methods
Appraisal Tool scores are included in Table 1.
3.5. Data analysis
Data evaluation was conducted using Whittemore and Knafl’s
(2005) methodology. Studies were initially divided into three sub-
groups according to their focus; emotional labour, resilience, and
resilience-building interventions. A data matrix template was
developed, and data from all studies were extracted and coded
under the three questions guiding the review. For question one,
Theodosius’ (2008) therapeutic, collegial and instrumental emo-
tional labour framework informed data extraction from articles
where there was a focus on nursing work and emotional labour. A
process of iterative constant comparison and contrast (Patton,
2015) was used within and across studies to integrate results and
guide data analysis.
4. Results
4.1. Description of studies
Of the twenty-seven included studies, sixteen focused on
emotional labour and eleven on resilience. Studies were predomi-
nantly from the United Kingdom (n = 11), Australia (n = 7), and the
United States of America (n = 6). Remaining studies were from Iran
(n = 1), Norway (n = 1) and Taiwan (n = 1). Two authors had written
more than one study. Seven studies included a mixed nurse
participant cohort representing more than one clinical specialty.
Intensive care was the most represented clinical specialty (n = 8).
Four articles did not explicitly report clinical specialties; three of
these included midwives among a mixed cohort of participants,
and one included nurse academics (Table 1).
4.2. Nursing work associated with emotional labour
Sixteen studies focused on emotional labour. Most related to
therapeutic (n = 12), followed by instrumental (n = 8) and collegial
(n = 6) emotional labour. Seven studies included both therapeutic
and instrumental emotional labour, two included therapeutic and
collegial emotional labour, and one reflected all three types of
emotional labour. In the context of emotional labour strategies,
four studies referred to both deep and surface acting and one
referred to surface acting only. Seven studies referred to the
suppression or concealment of emotions which meets the
definition of surface acting however this term was not explicitly
referred to. The notion of emotional dissonance associated with
surface acting was referred to in five studies (Table 2). All sixteen
studies cited the interpersonal and situational emotional demands
of nursing and caring as the main source for all three types of
emotional labour. Findings are presented under the three
emotional labour types, with identified sub-themes within each.
Although not specifically a component of the three types of
emotional labour, gendered aspects of emotional labour was an
identified theme in six studies contextual to therapeutic and
collegial emotional labour. A further category on the gendered
aspects of emotional labour was therefore also added.
4.2.1. Nursing work and therapeutic emotional labour
Twelve studies referred to therapeutic emotional labour in the
context of nursing work. Four sub-themes were developed to
illustrate this: dealing with negative emotions/distressed behav-
iour; caring for the dying; therapeutic presence; and caring in
diversity (Table 3). Dealing with negative emotions/distressed
behaviour involved nurses witnessing or being the target of
patients/families’ heightened emotions while needing to suppress
their own emotions to remain professional and maintain the
therapeutic relationship. Examples included nurses suppressing

Table 2
Types of emotional labour.

Author (Year) Emotional labour type Emotional labour strategy

Therapeutic emotional Instrumental emotional Collegial emotional Surface Deep Emotional Dissonance
labour labour labour Acting Acting
p p
Bailey et al. (2011)
p p p p
Chou et al. (2012)
p p p p
Cottingham (2015)
p p
Cricco-Lizza (2014) Suppressiona
p p p p p
Debesay et al. (2014)
p p p
Gray and Smith (2009)
p p
Haycock-Stuart et al. (2010)
p
Li (2005) Suppressiona
p p p p
Mann and Cowburn (2005)
p p a
McCreight (2005) Suppression
p p p
McMillen (2008)
p p
Sorensen and Iedema Suppressiona
(2009)
p
Stayt (2009) Suppressiona
p
Timmons and Tanner
(2005)
p p p
Walsh (2009) Suppressiona
p
Zamanzadeh et al. (2013) Concealeda
a
Suppression or concealment of emotions fit definition for surface acting. Studies using the terms suppression or concealment did not explicitly refer to surface acting.
 C. Delgado et al. / International Journal of Nursing Studies 70 (2017) 71–88 83

Table 3
Nursing work associated with emotional labour.

Author Nurse-patient/family/ Nursing work associated with therapeutic emotional Nursing work Nursing work associated Gendered
(Year) collegial interactions labour associated with with collegial emotional aspects of
instrumental labour emotional
emotional labour labour

Nurse- Nurse- Collegial dealing with Caring Therapeutic Caring Procedural care Navigating Maintaining –
patient family negative emotions/ for the presence in expectations order
distressed dying diversity
behaviour
p p p p p
Bailey et al.
(2011)
p p
Chou et al.
(2012)
p p p p p p p
Cottingham
(2015)
p p p p p p p p
Cricco-Lizza
(2014)
p p p p p
Debesay et al.
(2014)
p p p p p p p p
Gray and
Smith
(2009)
p p
Haycock-
Stuart et al.
(2010)
p p
Li (2005)
p p
Mann and
Cowburn
(2005)
p p p p p p p p
McCreight
(2005)
p p p p p p p
McMillen
(2008)
p p p p p p
Sorensen and
Iedema
(2009)
p p p p p p
Stayt (2009)
p p p
Timmons
and Tanner
(2005)
p p p p p
Walsh (2009)
p p p p p p
Zamanzadeh
et al.
(2013)

their grief reactions when confronted by patients/families crying
or grieving (McCreight, 2005; Stayt, 2009; Zamanzadeh et al.,
2013); or suppressing frustration when dealing with uncoopera-
tive, demanding or complaining patients/families (Chou et al.,
2012; Cottingham, 2015; Stayt, 2009).Suppressing feelings of
rejection or offense due to discrimination, such as being
disrespected because of the colour of their skin (Debesay et al.,
2014), nurses not being parents themselves (Cricco-Lizza, 2014);
and dealing with patients who were aggressive (Gray and Smith,
2009; Walsh, 2009) or threatened to self-harm (Cottingham, 2015),
were other examples.
Caring for the dying was associated with grief and bereavement
situations relating to a patient’s death; or critically unwell and
deteriorating patients and their families where it was unlikely the
patient would recover. End of life decisions and withdrawing
treatment from a dying patient were examples of nurses managing
their emotions in this context (McMillen, 2008). Another example
includes nurses portraying stoicism through the act of controlling
and keeping their grief private as a measure to support an infant’s
parents, when the infant died (Cricco-Lizza, 2014). From a different
perspective, Sorensen and Iedema (2009) identified that families
felt supported and that their grief was acknowledged when nurses
openly displayed emotions, such as sadness and crying in response
to a shared loss. While neither Cricco-Lizza (2014) or Sorensen and
Iedema (2009) explicitly referred to emotional labour strategies,
each example illustrated deep and surface acting. Other examples
of nursing work related to emotional labour in caring for the dying
included nurses’ breaking bad news, feeling unprepared for the
task of delivering bad news, and experiencing bereavement
following this task (Bailey et al., 2011; McCreight, 2005; Sorensen
and Iedema, 2009; Stayt, 2009). Providing comfort while watching
patients’ condition deteriorate, and the uncertainty of care
outcomes were further examples (Bailey et al., 2011; Cottingham,
2015; Cricco-Lizza, 2014; Zamanzadeh et al., 2013).
Therapeutic presence is defined as a clinician’s ability to make
others feel safe, valued and understood through genuinely
demonstrated empathy, compassion and respect (Chochinov
et al., 2013, p. 1710). Therapeutic presence was embodied within
nurses’ interpersonal communication skills, being physically and
emotionally present and available to patients/families, and
maintaining an emotionally supportive environment amid
competing demands and time constraints. Demonstrating
empathy and/or compassion in emotionally difficult situations
was the most common example (Debesay et al., 2014; McCreight,
2005; McMillen, 2008; Stayt, 2009; Zamanzadeh et al., 2013).
Containing and managing patients’/families’ emotions and
behaviour, including alleviating distress through providing
information, was another example (Cottingham, 2015; McMillen,
2008; Sorensen and Iedema, 2009; Stayt, 2009). Nurses were
able to maintain a calm environment by using therapeutic
84 C. Delgado et al. / International Journal of Nursing Studies 70 (2017) 71–88
presence. They managed their own emotions so as to not
personalize patients’/families’ emotional expressions, and they
used interpersonal skills to support patients/families within a
demanding and stressful environment (Cricco-Lizza, 2014; Gray
and Smith, 2009). Bailey et al. (2011) noted that without
effective emotion management, nurses are unable to create a
calm environment.
Caring in diversity refers to emotionally intense and prolonged
interpersonal work with patients/families that are culturally and
linguistically diverse and/or require more specialized care. This
sub-theme was commonly illustrated by nurses’ experience of
prolonged close interpersonal contact with patients/families, or
spending the duration of their shift at the same patient’s bedside
(Cricco-Lizza, 2014; Mann and Cowburn, 2005; McCreight, 2005;
Stayt, 2009; Zamanzadeh et al., 2014). The high interactional
frequency and emotional intensity associated with caring for
people who are mentally unwell was also a common source of
intense emotional work (Cottingham, 2015; Debesay et al., 2014;
Gray and Smith, 2009; Mann and Cowburn, 2005). Working with
critically unwell, vulnerable or dying infants or children and
their families (Cricco-Lizza, 2014; Gray and Smith, 2009;), or
with prisoner patients (Walsh, 2009) were two further examples
of patient/family populations in which emotional labour is
performed. Nurses’ performed emotional labour to provide
comfort, or to manage potential safety risks and emotional
exploitation if emotions were openly displayed. In the context of
working with culturally and linguistically diverse patients/
families, nurses’ emotional labour evolved from their uncertainty
about appropriate emotional and behavioural norms in the
context of patients’/families’ language and cultural differences
(Debesay et al., 2014).
4.2.2. Nursing work and instrumental emotional labour
Eight studies referred to instrumental emotional labour in the
context of nursing work (Table 3), and all informed the
development of one sub-theme: procedural care. Procedural care
refers to technical aspects of nursing work that may be intrusive
and/or invasive, occurring during a clinical intervention, assess-
ment and/or administering treatment. For example, Cricco-Lizza
(2014) describes neonatal intensive care nurses’ experience of
instrumental emotional labour when needing to perform invasive
procedures on critically unwell infants. Nurses managed their
emotions in the knowledge that the procedure caused the infant
discomfort and pain but was necessary for the infant’s recovery.
Administering to the bodies of stillborn or miscarried babies
provided a poignant example of nurses suppressing their emotions
when attending to the technical aspects of their job (McCreight,
2005).Turning off inotropic drugs and decreasing ventilator
support from the dying patient was another (McMillen, 2008).
Focusing on physical/technical aspects of nursing care was also
used by nurses as an emotion-distancing tactic to manage feelings
of fear, distress and worry or feelings of failure and loss of control in
relation to patient/family interactions and/or care outcomes
(Bailey et al., 2011; Cottingham, 2015; Debesay et al., 2014; Gray
and Smith, 2009; Stayt, 2009).
4.2.3. Nursing work and collegial emotional labour
Six studies referred to collegial emotional labour in the
context of nursing work (Table 3) and contributed to the
development of two sub-themes: navigating expectations and
maintaining order. Navigating expectations refers to situations
arising from direct and indirect interactions between nurses and
their colleagues related to staff’s interpersonal communication
that seemingly impacted quality of care delivery, and/or
seemingly breached standards of care. Four studies included
navigating expectations as an aspect of nursing work associated
with collegial emotional labour (Table 3). Examples of this
include nurses’ dealing with medical decisions to suddenly
withdraw treatment once a patient had been assessed as dying
without their input; or conversely, nurses needing to initiate
discussions with medical colleagues about withdrawing care
(Sorensen and Iedema, 2009; McMillen, 2008). Instances where
colleagues’ work was perceived to be below nursing standards
and expectations (Walsh, 2009), or when colleagues demon-
strated unprofessional behaviour (Haycock-Stuart et al., 2010)
were also highlighted as examples.
Maintaining order refers to nurses’ actions that are used to
prevent, contain and manage colleagues’ potentially negative
behaviour, avoid interpersonal confrontation, or promote more
positive interpersonal interactions to maintain a collegial and
convivial work environment. Two studies related to this aspect of
collegial emotional labour (Table 3). Both articles referred to
nurses engaging in emotional labour to maintain ‘sentimental
order’ (Glaser & Strauss, 1968 cited in Li, 2005, p.1957; Timmons &
Tanner 2005, p.89) to prevent colleagues’ potential volatile
behaviour, avoid interactional conflict, and thus be able to
effectively conduct their work. Through the suppression and
management of their emotions, nurses modified their practices to
suit colleagues’ preferences and ways of working, accommodate
their demands, and/or not openly challenge unprofessional
behaviour. In this way, nurses maintained collaborative and
comfortable relationships. Both studies also noted existing power
imbalances in collegial relationships as a consideration in collegial
emotional labour.
4.2.4. Gendered aspects of emotional labour
The final aspect of emotional labour identified during analysis
was in relation to gendered nursing work. Gender was referred to
in six studies (Table 3) in the context of therapeutic and collegial
emotional labour. The great majority of participants in these
studies were female (Table 1).
In therapeutic emotional labour, women’s stereotypical
societal role was compared to nurses’ work and role in some
nursing contexts. For example nurses who were mothers
working with infants, tended to identify with certain infant-
patients, suppressing their emotions through the act of staying
silent, which could also be carried through to their home life
(Cricco-Lizza, 2014). From an ethnocultural context, such as that
of nurses working in Iran (Zamanzadeh et al., 2014), the
woman’s role of caring and attending to other family members
was also reflected in their nursing work. This was exemplified
by nurses spending extra time with, or bringing meals to,
patients who may not have their own families. In psychiatric
settings, both female and male nurses demonstrated therapeu-
tic emotional labour in the context of experiencing conflict
between providing therapeutic care and the social control
elements of their work. In managing their emotions, emotional
expression, however, was more constrained in male nurses who
took on a patriarchal role and remained more emotionally
distant than female nurses (Gray and Smith, 2009). Cottingham
(2015) asserts that male nurses have an acute awareness of
their and others’ emotions, contradicting the notion that male
nurses tend to focus on technical expertise to minimize role
strain. Rather, focusing on technical expertise is used by both
male and female nurses as a strategy to manage negative
emotions borne from their experience of emotional labour.
In collegial emotional labour, the gendered division of labour
between different health disciplines was highlighted. This includ-
ed an expectation from some professionals, such as doctors
(McCreight, 2005) or operating theatre practitioners (OPDs)
(Timmons and Tanner, 2005), that engaging in emotional labour
was inherent to, particularly female, nurses’ work.
 C. Delgado et al. / International Journal of Nursing Studies 70 (2017) 71–88
4.3. The role of resilience in the context of the emotional labour in
nursing work
Eight of the eleven resilience studies referred to aspects of
therapeutic, instrumental or collegial emotional labour (Theodo-
sius, 2008). For example, nurses suppressing or modifying their
emotions and behaviour in caring for their patients (Ablett and
Jones, 2007; Cameron and Brownie, 2010; Foureur et al., 2013;
Kornhaber and Wilson, 2011; Mealer et al., 2012b) relate to aspects
of therapeutic emotional labour. The example of nurses suppress-
ing their emotions during interpersonal interactions with col-
leagues (Glass, 2009; Hodges et al., 2008; McDonald et al., 2013) is
related to collegial emotional labour. In Kornhaber and Wilson’s
(2011) study, an example related to instrumental emotional labour
was described; that is, nurses suppressing their emotions whilst
attending to dressings of patients’ burns and dealing with patients’
emotions resulting from their physical pain. Some linkage between
the concepts of resilience and emotional labour is implicit in the
studies. This includes nurses managing their emotions in the face
of emotional demands encountered in nursing work, and negative
impacts, such a stress, burnout and ill-health (associated with
emotional labour) being factors that could be more effectively
managed through the development of resilience. These linkages
however were not explicitly made by the authors. Another study
specifically referred to emotional management as a resilience-
building strategy (Zander et al., 2013), and two further studies
referred to emotional labour as an aspect of nursing work that
could be addressed through resilience but did not detail this in
depth (Hodges et al., 2008; McDonald et al., 2013).
Two studies on emotional labour referred to resilience but
neither identified explicit associations between emotional labour
and resilience. Walsh (2009) suggested that if nurses are not
supported in managing the emotional demands of their work, their
emotional labour could negatively impact their resilience.
Haycock-Stuart et al. (2010) framed resilience as a factor in
preventing burnout from the emotional labour experienced by
nurses. Neither report expanded on these concepts.
4.4. Resilience building interventions
Four studies described interventions specifically designed to
build resilience in nurses. Two examined educational interventions
(McDonald et al., 2013; Potter et al., 2013), one described a
multimodal intervention (Mealer et al., 2014), and one explored a
more practice-focused intervention (Foureur et al., 2013). Details
of interventions have been included in Table 4.
All four interventions focused on building or enhancing
individual nurses’ capacity to decrease the negative impacts of
workplace stress and enhance self-care. Each intervention intro-
duced practical educational components comprising of strategies
that attended to physical, psychological, social and/or emotional
(biopsychosocial) aspects of well-being. Emotions and the impact
of negative emotions as an aspect of nursing work was therefore
recognized in most of the interventions, but did not appear to
explicitly form part of the intervention’s theoretical framework.
Two papers included mindfulness-based stress reduction (MBSR)
techniques as a practical self-care strategy (Foureur et al., 2013;
Mealer et al., 2014). Other self-care strategies included exercise,
psychological therapy-based interventions such as cognitive
behavioural therapy and written exposure therapy (Mealer et al.,
2014). Relaxation techniques such as massage and aromatherapy
(McDonald et al., 2013), and a healing arts program (Potter et al.,
2013) are other examples. Potter et al.’s (2013) intervention also
included the self-development strategies of self-regulation, self-
validation, intentionality and (social) connection. These are
relevant to emotional labour but were not explicitly identified
85
as such. In their intervention, McDonald et al. (2013) included
education about the resilience-building elements of positive and
nurturing relationships and networks, mentoring, positive out-
look, hardiness, intellectual flexibility, emotional intelligence, life
balance, spirituality, reflection and critical thinking. All four
interventions also included didactic or discussion-based education
to increase nurses’ knowledge focusing on the topics of resilience,
stress and types of psychological distress experienced by nurses
(Table 4).
The conceptual framework and definition for resilience differed
among the studies. Resilience was conceptualized as an innate
energy contextual to psychological well-being (Foureur et al.,
2013); ability/characteristic contextual to personal resilience
(McDonald et al., 2013); and a trait contextual to psychological
resilience (Mealer et al., 2014). One study did not provide a
definition or context for resilience (Potter et al., 2013).
All studies employed pre and post-intervention measures to
assess the effects of their interventions, with all reporting overall
positive effects (Table 1). Post-intervention measures however
were taken only in the immediate or short term, with only two
studies (McDonald et al., 2013; Potter et al., 2013) taking measures
at a maximum of six months post-intervention. Further, only one
study was of high level evidence, being a randomized control study
(Mealer et al., 2014).
5. Discussion
Nursing work encompasses a combination of clinical knowl-
edge, and technical and communication skills enacted through
interpersonal interactions with patients, families and colleagues
(Brewer and Watson, 2015; Peplau, 1991). This synthesis and
review identified several key new findings. The relational and
situational emotional demands within nurse-patient, nurse-family
and collegial interpersonal interactions were identified in this
review as central factors in therapeutic, instrumental and collegial
emotional labour (Theodosius, 2008). Nurse-patient/family inter-
actions were more prominently represented than collegial
interactions. This is likely to reflect the key focus on patient/
family centred care in nursing. Conversely, the lack of studies
addressing collegial interactions contextual to emotional labour
may reflect the profession’s perceptions about what constitutes
nursing work. It may also be representative of what other authors
have reported to be a continuing lack of understanding, recogni-
tion and acknowledgment of the emotional labour of nursing work
and how collegial relationships and organizational demands
contribute to this (Riley and Weiss, 2016). Additionally, in relation
to the gendered aspects of emotional labour, findings from this
review suggest that there is substantial ongoing and unchallenged
acceptance of the demands nurses (primarily female) face in
dealing with and attending to emotions expressed by other health
discipline colleagues (McCreight, 2005; Timmons and Tanner,
2005). Further, there are differing expectations of male nurses’
emotion management to that of female nurses in the context of
their day-to-day work (Gray and Smith, 2009; Cottingham, 2015).
Congruent with Riley and Weiss (2016) and Cottingham et al.
(2015) it would seem that the hegemonic masculine culture in
healthcare is reflected in divisions of labour, thus, there will be
differences in the way emotional labour is performed and
experienced between genders. Gender issues in relation to nursing
and emotional labour however need further investigation.
Irrespective of gender and context, this review identified that
nurses suppress their emotions, or engage in the strategy of surface
acting, more regularly than deep acting. This is significant for two
reasons. Firstly, surface acting is linked to emotional dissonance
which causes stress and can lead to burnout, affecting nurses’ well-
being (Andela et al., 2015). Secondly, emotional self-regulation is
86 C. Delgado et al. / International Journal of Nursing Studies 70 (2017) 71–88

Table 4
Description of resilience-building interventions.

Study Description Knowledge and practical foci of intervention

Author/s
(Year)
Country
Knowledge development components (Topics Practical components (Skill development)
covered)
Foureur 8-week practice-focused intervention  Physical, psychological and emotional stress from a  Two to twenty minutes time graduated mindfulness
et al. consisting of: physiological and neurosciences perspective practice sessions incorporating taught MBSR
(2013)  1-day educational workshop with  Impacts of stress on being (thinking, feeling and components (present moment; focused attention;
Australiadiscussion topics and practical physical body states) rhythmic breathing; observation; noticing;
components  Introduction to mindfulness (definition of MBSR; acceptance; non-judgment & labeling)
 Self-applied daily 20 min guided components of MBSR)  ACT grounding and diffusing techniques (specific
(through pre-recorded compact disc)  Acceptance and Commitment therapy (ACT) description not provided)
mindfulness-based stress reduction strategies of grounding and diffusing techniques
(MBSR) practice sessions  Conditions and behaviours to creating effective
 Keeping a daily log of MBSR practice to habits
note practice habits
McDonald 6-month work-based educational  Resilience and resilient characteristics (Positive and - Practical activities (to practically explore topics and
et al. intervention consisting of: nurturing relationships and networks; mentoring; build individuals’ strengths) including drawing;
(2013)  six (monthly) 1-day resilience positive outlook; hardiness; intellectual flexibility; painting; collage; art and photography interpretation;
Australia workshops with didactic and practical emotional intelligence; life balance; spirituality; journaling; and creative movement.
components reflection; and critical thinking) from a nursing and  Self-care practices and relaxation techniques
 mentoring programme midwifery perspective including massage; aromatherapy; therapeutic use of
 Assertive communication music
 Increasing self-awareness for the need to maintain
health and well-being and related strategies
(conserving energy; better sleep; work regimes;
attending to/seeking medical help for untreated
chronic health issues)
Mealer 12-week multimodal intervention  Introduction to resilience training  12 (weekly) scheduled writing sessions and
et al. consisting of:  Types of psychological distress experienced in the receiving feedback from experts on written exposure
(2014) For intervention group ICU and resilience on various topics (challenges faced at
US  2-day educational workshop  Self-care topics work; feeling incapacitated; feeling conflicted; and
 weekly written exposure therapy  Introduction to CBT ruminating about sensitive topics)
 Event-triggered cognitive-behavioural  Introduction to written exposure  MBSR techniques including body scan and sitting
therapy (CBT) counseling sessions. meditation.
 15 min MBSR guided (through pre-  Aerobic exercise (suggestions included treadmill,
recorded compact disc) practice sessions at elliptical machine, stair climbing, stationary bicycle,
least 3 times a week. or rowing machine) for 30–45 min at least 3 days per
 protocolized aerobic exercise regimen week.
Control group  CBT counseling sessions when a participant
 entered amount of time spent exercising experienced a stressful/distressing work-related event
during the week such as a patient's death, participating in end-of-life
family discussions, performing cardiopulmonary
resuscitation, performing futile care with a terminal
patient, caring for a patient with massive bleeding, or
caring for a patient with traumatic injuries.
Potter 5-week compassion fatigue resiliency  compassion fatigue/contributing factors to - Study reported that practical activities were included
et al. program including: compassion fatigue in program to develop the skills of self-regulation,
(2013)  Four weekly 90 min education sessions;  effects of chronic stress intentionality, self-validation, connection and self-
US and  effects of chronic sympathetic stimulation on care however limited details provided
 One 4-h retreat conducted off site cognitive and behavioural function  Each participant completed a self-care plan to
 stress management in a healthcare role follow to practice self-care
 resiliency (self-regulation; intentionality; self-  Debriefing and self-care practices, including a
validation; connection; and self-care) healing arts program conducted during retreat
 relaxation exercises (details not provided) to
achieve self-regulation and manage chronic stress

both interpersonal and intrapersonal in nature (Walsh, 2009; Riley
and Weiss, 2016), and therefore nurses’ ongoing experience of
emotional dissonance can be linked to negative impacts on their
interactions at work and patient/family outcomes (Andela et al.,
2015). Accordingly, attending to emotional self-care through
specific resilience-building strategies could mediate the stress
caused by emotional dissonance, and thus address the risks of
emotional labour. The resilience-building interventions in nursing
that were reviewed focused on developing individuals’ internal
resources with an emphasis on self-management. Further, their
effectiveness appeared to be based on nurses’ individual efforts in
applying and sustaining knowledge and skills gained, and highly
dependent on organizational and external supports and resources.
In line with other authors (Cross, 2015; Hart et al., 2014), we
recommend that resilience-building interventions focus on
enhancing both internal and external resources through a multi-
faceted approach, inclusive of organizational support. Our findings
also indicate that there is a lack of empirical evidence in relation to
the long term sustainability and impact of resilience-building
interventions on nurses, particularly in the context of their
emotional labour.
Although there was reference in the literature to the emotional-
relational aspects of nursing work being a significant factor in
nurses’ stress, burnout, ill-health, and negative impacts on their
relationships with patient, families and/or colleagues (Huynh et al.,
2008; Kornhaber & Wilson; Potter et al., 2013), our findings
highlight that resilience has generally not been explicitly linked to
emotional labour. A related construct, emotional intelligence, has
 C. Delgado et al. / International Journal of Nursing Studies 70 (2017) 71–88
however been previously linked to preventing negative impacts
and promoting positive aspects of emotional labour (Bulmer Smith
et al., 2009; Foster et al., 2015). In this review, emotional
intelligence was identified as a characteristic of resilience
(McDonald et al., 2013). This is also reflected in other resilience
studies (Glass, 2009; Mealer et al., 2012b). Emotional intelligence
therefore is recognized as a key factor in resilience (Edward and
Warelow, 2005; Foster and Robinson, 2014). In the emotional-
relational context of nursing work, resilience can be considered the
overarching protective process that can enable and build nurses’
capacity to deal with and adapt to the risk of emotional dissonance
in nursing work. A recommendation arising from this review is for
future interventions to target emotional labour as a potential
(emotional) adversity of nursing work, and explicitly include
emotional labour as part of the conceptual framework underpin-
ning the development of resilience-building interventions. More
specifically, future interventions could be developed to include
components that focus on emotional regulation to address nurses’
emotional labour, and build nurses’ emotional intelligence and
resilience.
5.1. Strengths and limitations
This integrative review of empirical literature contributes to
current knowledge on the concepts of emotional labour and
resilience in nursing by identifying how emotional labour in
nursing work is linked to, and can be addressed through, building
nurses’ resilience. Findings can inform further research in this area
across various nursing contexts. The review is limited to literature
in the past ten years in the English language, and other studies
containing relevant findings may not have been included.
6. Conclusion
This review has synthesized the knowledge on resilience in the
context of emotional labour in nursing work. Emotional labour is
a facet of all aspects of nursing work, and the experience of
emotional labour in regard to interpersonal interactions is
evident across clinical fields, health contexts and genders. In
particular, the emotional dissonance experienced through surface
acting can be understood as a form of workplace adversity that
can lead to stress and burnout. Without both, internal and
external resources, or protective factors, this can have serious
negative impacts on nurses’ work, professional practice and
overall well-being. Resilience is an important process in reducing
the impact of workplace stress and preventing poorer psychoso-
cial outcomes. Building nurses’ emotional resilience is a signifi-
cant point of intervention that can strengthen nurses’ internal
resources and address the risks of emotional labour and effects of
emotional dissonance. Additionally, professional development in
interpersonal skill development, and in resilience, and a
supportive workplace environment, psychological support, and
biopsychosocial health programs need to be implemented and
promoted by workplace organizations as external resources that
support and enhance nurses’ emotional resilience and well-being
(Cusack et al., 2016; Hart et al., 2014; Scholes, 2013). There is a
need for closer investigation of the relationship between
resilience and emotional labour, and for interventions that
expressly address the potential emotional adversities in various
nursing contexts.
Conflict of interest
None declared.
87
Funding
No external funding was received for the preparation or writing
of this manuscript.
Acknowledgement
This research is supported by an Australian Government
Research Training Program Scholarship.
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