The relationship between emotional labor level and moral distress

Abstract

Background

The coronavirus disease (COVID-19) pandemic has implications for health professionals.

Aim

The aim of this study was to explain the relationship between emotional labor levels and moral distress in health professionals during the COVID-19 pandemic using the Structural Equation Modeling (SEM) technique.

Research design

A descriptive and cross-sectional study was adopted.

Participants and research context

Data were collected between 7 February and 7 March 2021. 302 health professionals who were not on leave (annual leave, sick leave, prenatal and postnatal leave, etc.) at the time of the research and who volunteered to participate in the research were included. Research data were collected using a “Personal Information Form,” the “Emotional Labor Scale” and the “Moral Distress Thermometer.”

Ethical considerations

The Ethics Committee approved the study (dated 07.01.2021 and numbered 2021/1-3). The participants were informed of the study aim and written consent was obtained before completing the survey.

Findings

Conclusion

In this study, the relationship between the level of emotional labor and moral distress in health professionals during the COVID-19 pandemic was evaluated with a structural equation model.

Keywords

Emotional labor health professionals moral distress

Introduction

The COVID-19 virus emerged a few years ago in Wuhan, China, and soon afterward, it spread around the world, eventually being declared a pandemic by the World Health Organization (World Health Organization).^1–3 With this pandemic, a host of new issues and problems have surfaced in a variety of areas. Especially during periods when the spread of the virus increased, the healthcare services suffered a lot and the provision of healthcare services was severely affected. Most important among service sectors, the healthcare services rely on interpersonal relations for improved quality of service.^4,5 Health professionals, who are in constant face-to-face proximity with people and show a range of emotions due to their job, intensively exhibit “emotional labor” behaviors.⁵ The term “emotional labor” refers to the ability to manage emotions with observable facial and body movements.^6,7 Emotional labor is also defined as “planning and controlling efforts needed to show emotions that an organization expects from employees during interpersonal interactions.”⁸ In available literature, it has been stated that the emotional labor tendencies of health professionals are high.^9,10 However, no study of yet has examined how the difficult working conditions and the mandatory restrictions on health professionals’ social needs during the COVID-19 pandemic have affected emotional labor states.

The primary purpose of the healthcare services during the COVID-19 pandemic is to provide sufficient health services to a large number of patients.¹¹ However, especially in periods with a high number of cases, the need to provide fair services with limited resources requires difficult, critical decisions. In this case, health professionals may face moral distress, with or without being aware of it.¹² The American Association of Critical-Care Nurses (AACN) stated that moral distress leads to dissatisfaction with professional life, and physical and emotional stress in health professionals and reduces the quality and quantity of health services. In studies carried out during the COVID-19 pandemic, it has been seen that the level of moral distress was low among health professionals in Norway, but high in managerial staff.¹³ In a study conducted by Donkers et al. (2021) with health professionals, it was observed that the level of moral distress among nurses was higher compared to others, but there was no increase in the level of moral distress after the onset of the COVID-19 pandemic.¹⁴ In Turkey, although there are papers on the pandemic course and moral distress, no research has been published.^15,16

The effort made by healthcare professionals during the day requires both emotional and physical energy. Especially in extraordinary situations such as epidemics, healthcare professionals make extra efforts and act with intense responsibility. It is thought that this situation will affect the level of emotional labor in health workers and may cause moral distress. The limited number of studies conducted on this subject, both in Turkey and abroad, and the common content of the concepts of moral distress and emotional labor show the necessity of conducting relevant studies. It is thought that examining the moral distress of health professionals laboring both physically and emotionally during the COVID-19 pandemic will also be an institutional guide.

Purpose

Research questions

1. What are the descriptive characteristics of health professionals?

2. What are the score means of the emotional labor and moral distress scales?

3. Is there a relationship between providing service to patients with COVID-19 and the emotional labor levels of health professionals?

4. Is there a relationship between having had COVID-19 and the emotional labor levels of health professionals?

5. Is there a relationship between the emotional labor levels and moral distress of health professionals?

Method

Research population and sample

The population of this descriptive and cross-sectional study consisted of 545 individuals providing health services in a state hospital in the Black Sea region of Turkey. In the study, no sample selection was made as it was intended to reach the entire population. Data were collected between 7 February and 7 March 2021. 302 health professionals who were not on leave (annual leave, sick leave, prenatal and postnatal leave, etc.) at the time of the research and who volunteered to participate in the research were included.

Data collection tools

Research data were collected using a “Personal Information Form,” the “Emotional Labor Scale,” and the “Moral Distress Thermometer.”

Personal Information Form

This form consists of 5 questions about age, gender, profession, willingness to choose the profession, and providing health service to a patient diagnosed with COVID-19. The questions were prepared by the researcher.

Emotional Labor Scale

The scale was developed by Pala and Surgevil (2016) to measure the level of emotional labor of employees. It consists of three subscales: surface acting, deep acting, and suppression.¹⁷ This 38-question tool is ranked on a five-point Likert-type scale with items personally evaluated as “strongly agree,” “agree,” “indecisive,” “disagree” and “strongly disagree.” The reliability of the scale dimensions was determined as 0.77 for surface behavior, 0.68 for emotion suppression, and 0.53 for deep behavior. In this study, it was determined that the scale was highly reliable (α = 0.835).The authors’ permission was acquired for the use of this scale.

Moral Distress Thermometer

Developed by Wocial and Weaver (2009), this tool consists of emotional descriptors that represent the level of moral distress experienced by an individual in a particular moment with a vertical line on a plane.¹⁸ It was translated into Turkish and its validity and reliability were established by Kızıltepe (2019).¹⁹ Moral distress is evaluated between not experiencing any distress at all (e.g. none = 0) or experiencing totally (e.g. worst possible = 10). Permission was acquired from the authors for the use of the scale.

Data collection

Research data were collected by online survey through a link. After the tools of the project were prepared on Google forms, a link was sent to the WhatsApp groups of health professionals through service head nurses. After clicking the link of the questionnaire, participants were directed to a section containing brief information about the research and confirming their voluntary participation. Next, the Turkish forms were completed. Confidentiality of the answers of health professionals participating in the research was ensured and the answers were provided on Google forms only via an email used by the researchers.

Ethical considerations

In order to conduct such research, permission was acquired from the relevant institution and the ethics committee of the university (dated 07.01.2021 and numbered 2021/1-3). Approval of the Ministry of Health was acquired by applying to the Scientific Research Platform of the General Directorate of Health Services, Ministry of Health. Before filling out the data collection tools, health professionals were informed about the study on the first page of the online link and were asked to mark the statement “I approve to participate in the study” if they agreed to participate. Health professionals who completed the form online were considered to have accepted participation in the research.

Data analysis

The analysis was made by transferring data to the IBM SPSS Statistics 26 program. In data evaluation, frequency distributions were given for categorical variables and descriptive statistics (mean ± SD) were given for numerical variables. A reliability analysis was performed for the Emotional Labor Scale, which was used as a measurement tool in the research, and its subscales, and the study was initiated after confirmation of reliability. The scale and subscale scores of the health professionals were obtained by averaging the relevant items. Accordingly, the Kolmogorov–Smirnov test of normality (n > 50) was implemented to all scores in order to determine the analyses to be performed. The results showed that all scores fit a normal distribution and therefore parametric tests were used in comparisons. An independent sample t-test was used to examine whether there was a difference between the two independent groups according to their mean scores. A one-way Analysis of Variance (ANOVA) was used to determine whether there was a difference between more than two independent groups according to mean scores. The Tukey test was used to determine between which groups there was a difference. Pearson’s correlation coefficient was used to establish the degree of non-causal relationship between two numerical variables. A research model was established and the relationships were determined with a Structural Equation Model (SEM) in order to more clearly reveal the relationship between Emotional Labor and Moral Distress scores.

Structural equation modeling (SEM) analysis is used to test a priori hypotheses between latent variable correlation and covariance matrixes, while estimating error variance parameters in order to determine and analyze relationships between theoretical concepts.²⁰ Structural relationship is the key concept of SEM. It questions the relationships between latent variables. SEM has high flexibility as it handles a system of regression equations, not just one or more linear regressions. The range of variables that affect each other can only be analyzed with SEM. Unlike ordinary regression analysis, SEM processes multiple regression equations simultaneously. While one variable is the predictor in one equation, it may be the criterion in the other. We call such a system of equations a model. But it is a little different to understand. Here, the model is the judgments based on the relationships between the variables. As the model shows the linear effect of one variable on the other, it can also insert another variable and question its mediating effect. Road diagrams come from direct, indirect and total effects path analysis method.^21,22 Path analysis is used to estimate the significance and magnitude of the assumed causal link between variables.

Results

Distributions of demographic characteristics

The demographic characteristics of the health professionals (n = 302) are presented in the table below with frequency and percentage values (Table 1).

Table 1.

Distributions of demographic characteristics.

Age (Mean ± SD)	34.47 ± 8401
Age (Mean ± SD)	N	%
Sex
Female	229	75.8
Male	73	24.2
Mission in the hospital
Anesthesia technician	3	1
Emergency medicine technician	7	2.3
Nutritionist/dietician	2	0.7
Midwifery	33	10.9
Physician	61	20.2
Nurse	172	56.9
Laboratory technician	4	1.3
Paramedic	12	3.9
Radiology technician	8	2.6
Did you provide health care to a patient diagnosed with COVID-19?
Yes	258	85.4
No	44	14.6
Have you had COVID-19?
Yes	112	37.1
No	190	62.9
Working time in the profession (months) (mean±SD)	110.01±107,754	—

Of the health professionals studied, 75.8% were female and 24.2% were male. 26.8% were aged between 19 and 26, 25.2% between 27 and 35, and 48.0% were over 36. The mean age was 34.47 ± 8.401.

The majority of the health professionals participating in the research were nurses, with a rate of 56.9%. While 85.4% of the health professionals had provided health services to patients diagnosed with COVID-19, 62.9% had not had COVID-19 and 36.4% had been employed for 121 months or more. The mean duration of employment in the profession was 110.01 ± 107.754.

Results regarding emotional labor scale

Comparison results

The differences between health professionals’ status of having had COVID-19, the status of providing service to patients diagnosed with COVID-19 and their professional experiences according to mean emotional labor, subscales, and moral distress scores are listed in the following tables.

According to Table 2, as a result of the independent sample t-test, there was no statistically significant difference between those who provided health services to patients with COVID-19 and those who did not provide according to their mean scores of emotional labor and suppression, deep acting subscales (p > .05), whereas there was statistically significant difference in terms of the mean scores of the surface acting subscale and moral distress (p < .05). Accordingly, the mean score of health professionals who provided health service to patients with COVID-19 of the surface acting subscale and moral distress was significantly higher than the mean score of those who did not provide health service to patients with COVID-19.

Table 2.

An investigation of the difference between the situations of serving a patient diagnosed with COVID-19 according to the mean scores of emotional labor and moral distress.

	Did you provide health care to a patient diagnosed with COVID-19?	n	Mean	SD	t	P
Emotional labor scale	Yes	258	3.20	0.708	1821	0.070
Emotional labor scale	No	44	2.99	0.632	1821	0.070
Subscales
Surface acting	Yes	258	2.83	0.934	1982	0.048^a
Surface acting	No	44	2.54	0.838	1982	0.048^a
Suppression	Yes	258	3.34	0.870	1717	0.087
Suppression	No	44	3.10	0.738	1717	0.087
Deep acting	Yes	258	3.84	0.872	−0.583	0.561
Deep acting	No	44	3.92	0.747	−0.583	0.561
Moral distress score	Yes	258	5.95	2543	4633	0.000 ^**
Moral distress score	No	44	3.82	2871	4633	0.000 ^**

^ap < .05 **p < .001. Abbreviation. t, independent t-test value; SD, standard deviation

According to Table 3, as a result of the independent sample t-test, no statistically significant difference was found between the professional experiences of health professionals in terms of mean emotional labor, deep acting, suppression and moral distress scores (p >.05), whereas there was a statistically significant difference in terms of mean deep acting score (p < .05). Accordingly, the mean deep acting score of health professionals who had professional experience of 19–120 months was significantly lower than the mean score of health professionals who had professional experience of 121 months and more.

Table 3.

An investigation of the difference between professional experiences according to mean scores of emotional labor and moral distress.

	Professional experience	n	Mean	SD	F	p
Emotional Labor Scale	18 months and under	96	3.20	0.719	0.748	0.474
	19–120 months	96	3.10	0.697
	121 months and above	110	3.20	0.689
Subscales
Surface acting	18 ay ve altı	96	2.89	0.978	0.912	0.403
	19–120 ay	96	2.76	0.858
	121 ay ve üstü	110	2.73	0.935
Suppression	18 ay ve altı	96	3.28	0.864	1107	0.332
	19–120 ay	96	3.22	0.840
	121 ay ve üstü	110	3.39	0.860
Deep acting	18 ay ve altı	96	3.82	0.912	3759	0.024^a
	19–120 ay	96	3.69	0.825
	121 ay ve üstü	110	4.01	0.806
Moral distress score	18 ay ve altı	96	5.90	2544	0.804	0.449
	19–120 ay	96	5.65	2780
	121 ay ve üstü	110	5.42	2754

^ap < .0; SD, Standard deviation. F = ANOVA

As shown in Table 4, there was a weak, positive, and significant linear correlation only between the moral distress score and the surface acting subscale score (p < .05).

Table 4.

Investigation of relationships between emotional labor and its sub-dimensions and moral distress scores.

	Moral distress
Emotional labor	r	0.071
Emotional labor	p	0.220
Surface acting	r	0.135
Surface acting	p	0.019 ^a
Suppression	r	0.029
Suppression	p	0.614
Deep acting	r	−0.104
Deep acting	p	0.071

^ap < .05. r = Pearson Korelasyon Katsayısı.

Structural Equation Modeling

In structural equation modeling, the concept of mediation is used to describe sequential causal relationships between variables. In practice, a mediator explains the one-way causal relationship (direct effect) between the independent variable and the dependent variable in more detail.

As shown in Figure 1, given that “providing service to a patient with a COVID-19” and “having had COVID-19” were predictors (independent variable), “moral distress” was a predicted variable (dependent variable), “emotional labor” was a mediating (mediator) variable, the direct effect of providing service to a patient with COVID-19 on moral distress and the direct effect of having had COVID-19 on moral distress should be statistically significant. The logic here is that if providing service to a patient with COVID-19 and having had COVID-19 were not correlated to moral distress, then there was no association that could mediate either. There are 3 types of mediation: indirect effect, partial mediation and complete mediation.²³

Figure 1.

Model established with an intermediary variable.

Before examining whether the emotional labor variable mediated in the theoretical model we established, the correlation of providing service to a patient with COVID-19 and having had COVID-19 to moral distress was examined. The direct effect of providing service to a patient with COVID-19 on moral distress was significant (p <0.05), whereas the direct effect of having had COVID-19 on moral distress was not significant (p >0.05). For this reason, only the results related to the variable of providing care to a patient with COVID-19 are presented below.

In Table 5, primarily the significance of the direct effect in the absence of a mediator variable in the model was examined. The results without the mediator variable are shown in the first column. The r-value indicates the direct effect and the p-value indicates the significance of the direct effect. Accordingly, it can be said that the effect of providing service to a patient with COVID-19 on moral distress was statistically significant (r = 0.280, p < .001).

Table 5.

Hypothesis results of the model established with the emotional labor variable.

	When there was no mediator variable		When the mediator variable		Type of mediation
Hypotheses regarding mediation	R	p	R	p	Type of mediation
Providing service to a patient with COVID-19 -> moral distress	0.280	0.000 ^a	0.276	0.000 ^a	No mediation
Providing service to a patient with COVID-19 -> emotional labor	—	—	0.105	0.068
Emotional labor -> moral distress	—	—	0.042	0.450

^ap < .001.

In the second stage, the situation including the mediator variable in the model was examined. Despite being lower, the effect of providing service to a patient with COVID-19 on moral distress was statistically significant (r = 0.276, p < .001). Considering the mediator variable, the effect of providing service to a patient with COVID-19 on emotional labor was not statistically significant (r = 0.105, p > .05) and the effect of emotional labor on moral distress was not statistically significant (p > .05) either. Accordingly, the direct effect of providing service to a patient with COVID-19 on moral distress, which was found to be significant in the mediation relationship of “providing service to a patient with COVID-19-> emotional labor-> moral distress” when there was no mediator variable, remained significant when the mediator variable was included in the model. However, the relationship was not transferred by emotional labor. In this case, it can be said that emotional labor had no mediator effect.

In Table 6, first the significance of the direct effect when there was no mediator variable in the model was examined. As mentioned in the previous model, the effect of providing service to a patient with COVID-19 on moral distress was statistically significant (r = 0.280, p < .001). In the second stage, the situation including the mediator variables in the model was examined. Accordingly also here, despite being lower, the effect of providing service to a patient with COVID-19 on moral distress was statistically significant (r = 0.259, p < .001).

Table 6.

Hypothesis results of the model established with emotional labor sub-dimensions.

	When there was no mediator variable		When the mediator variable		Type of mediation
Hypotheses regarding mediation	r	p	r	p	Type of mediation
Providing service to a patient with COVID-19 -> suppression -> moral distress	—	—	0.099	0.085	Partial mediation
Suppression -> moral distress	—	—	−0.013	0.818
Providing service to a patient with COVID-19 -> moral distress	0.280	0.000 ^***	0.259	0.000 ^***
Providing service to a patient with COVID-19 -> surface acting	—	—	0.114	0.047 ^a
Surface acting -> moral distress	—	—	0.143	0.009 ^**
Providing service to a patient with COVID-19 -> moral distress	0.280	0.000 ^***	0.259	0.000 ^***	No mediation
Providing service to a patient with COVID-19 -> deep acting	—	—	−0.034	0.559
Deep acting -> moral distress	—	—	−0.126	0.020 ^a

^ap < .05 **p < .01 ***p < .001.

Considering the suppression mediator variable, the effect of providing service to a patient with COVID-19 on suppression was not statistically significant (r = 0.099, p > .05) and the effect of suppression on moral distress was also not statistically significant (r = −0.013, p > .05). Accordingly, the direct effect of providing service to a patient with COVID-19 on moral distress, which was found to be significant in the mediation relationship of “providing service to a patient with COVID-19-> suppression-> moral distress” when there was no mediator variable, remained significant when the mediator variable was included in the model. However, the relationship was not transferred through suppression. In this case, the suppression subscale had no mediator effect.

Considering the surface acting mediator variable, the effect of providing service to a patient with COVID-19 on surface acting was statistically significant (r = 0.114, p < .05) and the effect of surface acting on moral distress was statistically significant (r = 0.143, p < .01). Accordingly, the direct effect of providing service to a patient with COVID-19 on moral distress, which was found to be significant in the mediation relationship of “providing service to a patient with COVID-19-> surface acting-> moral distress” when there was no mediator variable, remained significant when the mediator variable was included in the model. However, the relationship was also transferred through surface acting. In this case, the surface acting subscale partially mediated the relationship of “providing service to a patient with COVID-19 -> moral distress.”

Considering the deep acting mediator variable, providing service to a patient with COVID-19 on deep acting was not statistically significant (r = −0.034, p > .05), whereas the effect of deep acting on moral distress was statistically significant (r = −0.126, p < .05). Accordingly, the direct effect of providing service to a patient with COVID-19 on moral distress, which was found to be significant in the mediation relationship of “providing service to a patient with COVID-19 -> deep acting -> moral distress” when there was no mediator variable, remained significant when the mediator variable was included in the model. However, the relationship was not transferred through deep acting. In this case, the deep acting subscale had no mediator effect.

Discussion

During the COVID-19 pandemic, health professionals, who are in constant communication with both healthy and sick individuals, must manage their emotions and exhibit emotional labor behaviors while providing service. While handling emotions, they show reactions expected from them in their work-life and hide their real emotions when necessary. As they constantly try to manage feelings, they may experience both physical and emotional fatigue and exhaustion. This study was conducted to help understand the relationship between emotional labor levels and the moral distress of health professionals with structural equation modeling. The findings obtained in the study were discussed in line with the literature.

In accordance with this general purpose, all measurement models defined in this model were examined as to whether they were verified by the research data. As a result, it was confirmed that the measurement models were verified by the research data.

In the study, it was determined that health professionals experienced a quite high level of moral distress during the COVID-19 pandemic. The mean moral distress score of the workers who provided health service to a patient with COVID-19 was found to be significantly higher than the mean score of those who did not provide health service to a patient with COVID-19 (Table 3) (p < .05). It was determined that moral distress was also experienced in studies conducted by Kherbache et al. (2021)²⁴ with physicians and by Silverman et al., (2021)²⁵ with nurses providing care to COVID-19 patients. In the literature, it is emphasized that the level of moral distress is high among health professionals and that measures should be taken.²³ This finding of this study is consistent with the literature.

Emotional labor is defined as the regulation of emotions by employees and their reflection to other parties through facial and body movements which can be observed from the outside. Emotional labor is a factor that determines quality of service, increases efficiency in the patient-employee relationship and thus affects satisfaction. This study showed that health professionals generally endure a high level of emotional labor. This finding is important in order to account for the emotional labor expenses of health professionals working overtime with heavy workloads during the pandemic period and to improve their communication with patients.

The mean surface acting score of health professionals providing health services to patients with COVID-19 was found to be significantly high (p < .05). Surface acting is defined as behaving in a way not reflecting the feelings that employees actually hold in order to protect their institutions and managing stereotyped behaviors toward their environment.^6,26 In studies conducted by Dogan and Sigri (2017) with nurses,²⁷ it was found that the level^28,29 of emotional labor was high and nurses exhibited surface acting behaviors in the first years of their profession. In the literature, there are studies conducted with individuals working in the healthcare services where surface acting had the highest average.^26,30 In a study conducted by Demir et al. (2021)³¹ with health professionals, the surface role-playing subscale had the lowest score, whereas in a study conducted by Öz and Baykal (2018)⁶ and Kocak et al. (2014)³² with nurses, the score on the deep acting subscale was determined the highest. During the pandemic process, the emotions that health workers show around because of the fact that they have to work with masks are reflected by differentiating from what they feel. Perhaps deep emotional labor will be exhibited, while superficial emotional labor will remain. Because each equipment used makes it difficult for nurses to adjust gestures, facial expressions and tone of voice. The differing results in the literature may have arisen due to the fact that in this study was carried out in different institutions during the COVID-19 pandemic period.

An employee who exhibits deep acting internalizes the expectations of their institution, accepts that this behavior is right logically and believes that it will be appropriate to act this way. In other words, the individual harmonizes his/her behaviors with the expected behavior that should be exhibited. As a result, they gain the ability to behave without acting.^6,26 In this study, when the professional experience of health professionals on the level of emotional labor was examined, it was determined that deep acting behaviors of health professionals significantly increased as their professional experience increased (Table 4) (p < 0.05). In a study conducted by Öz and Baykal (2018) with nurses, it was determined that deep acting and sincere behaviors of nurses increased as the duration of employment increased.⁶ In a study conducted by Özen and Yüceler (2019) with health professionals, it was found that the level of emotional labor increased as the employment year increased.³³ The finding of this study is consistent with the literature. Individuals often benefit from their experiences when exhibiting deep acting behaviors. Health professionals, who have more experience with emotional events and situations, can more easily reflect the necessary emotions. Furthermore, since they are more successful in managing their emotions with experience, they can adapt more easily to behaving as expected and typically do not go beyond the appropriate emotions and behaviors while fulfilling their responsibilities.³⁴ This can explain why health professionals with more experience exhibit more deep acting behaviors.

According to the study findings, moral distress scores increased significantly as surface acting increased in health professionals (Table 5) (p < .05). It was reported that health professionals experience emotional inadaptability due to surface acting, which causes them to feel like they are pretending and hypocritical.^7,35 At the same time, it was stated that emotional inadaptability causes stress and that the stress experienced arises due to playing superficial roles for a long time and feeling fake.³⁶ Hochschild reported that emotional inadaptability affects personal well-being negatively.⁷ Therefore, moral distress increases with emotional inadaptability due to surface acting.³⁵ This finding of this study supports the literature.

In the present study, the mediator role of emotional labor in the effect of providing service to a patient with COVID-19 and having had COVID-19 on moral distress was examined in health professionals and it was found that there was a correlation between providing service to a patient with COVID-19 and moral distress regardless of whether or not emotional labor had a role in this relationship. There is a limited number of studies in the literature including the variables of “emotional labor” and “moral distress,” and no study has been carried out to determine the mediator role of emotional labor in the relationship between providing service to a patient with COVID-19, having had COVID-19 and moral distress. The absence of such a study in the literature increases the originality and importance of this study and in this way, it can be said that this study is a pioneer in the literature as the mediator role of surface acting in moral distress of health professionals who provide care to COVID-19 patients was determined.

Limitation

A limitation of the study is that due to the convenience nature of the sample individuals who chose to participate in this study may not be reflective of all nurses and hence the results cannot be generalized.

Conclusion and recommendations

In this study, the relationship between the level of emotional labor and moral distress in health professionals during the COVID-19 pandemic was evaluated with a structural equation model. It was determined that emotional labor did not have a mediator effect, that deep acting increased as professional experience increased and that surface acting and moral distress increased in health professionals who provided care to patients with COVID-19. Considering that surface acting increases moral distress while natural emotions reverse this effect and reduce moral distress, activities can be organized to raise awareness of health professionals about the importance of surface acting and natural emotions in their interactions with patients and to reduce moral distress. Training programs can be planned on emotion management to increase awareness about the concept of emotional labor and moral distress in health professionals, and adaptation training can be provided to health professionals with little professional experience. Additionally, interventional studies to reduce moral distress can be recommended. The study has a generalizability weakness as it presents data from a limited number of populations. In order to increase the diversity of data within the scope of this limitation, a data pool can be created with the information given by the participants of the study by observing them periodically or when the pandemic intensifies and/or stagnates.

Footnotes

Authors’ Contributions

MDI: Study conception, designed data analysis, wrote first draft of the manuscript, approved final version to be published.

NÇ: Study conception, designed data analysis, approved final version to be published.

HE: Data analysis, approved final version to be published.

EY: Data collecting, approved final version to be published

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest concerning the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship and/or publication of this article.

Ethical approval

Correction (November 2023):

Article updated online to correct the article category “Review” to “Original Manuscript”.

ORCID iDs

Mahinur Durmus Iskender

Nurcan Çalışkan

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