Abstract
As uses of plasma-derived medical products increase globally, so does the demand to collect plasma from donors. There is evidence that positive interactions with center staff motivate plasma donors to return. This paper reports on a focused ethnography investigating experiences of nurses and phlebotomists in one of Canadian Blood Services’ first source plasma collection center during the COVID-19 pandemic. Participants found the transition from whole blood collection to source plasma amid a global pandemic challenging, but they adapted by coming together as a team, and then worked to put the donor experience first. Their experience resonates with scholarship on emotional labor. As blood services worldwide attempt to increase source plasma collection, there is a need to understand care work that nurses and phlebotomists perform on the front-line. This study offers insight into how blood services can support staff in plasma operations by recognizing emotional labor.
Background and Purpose
Plasma-derived medical products (PDMPs) include albumin, coagulation factors and immunoglobulins, which treat chronic and acute life-threatening diseases. Several PDMPs are included in the World Health Organization (WHO) Essential Medicines List. A 2018 expert panel on immunoglobulin product supply in Canada indicated that immune globulins are the most widely used PDMP, and demand for immune globulins continues to increase steadily in Canada and globally (Canada, 2017). The panel, run by Health Canada, assessed Canada’s long-term ability to ensure the ongoing supply for immune globulins for Canadians and recommended that Canada collect more source plasma. As uses of PDMPs increase around the world, so does the demand to collect plasma from donors. Source plasma is plasma collected through plasmapheresis and manufactured into PDMPs through a process called fractionation.
In Canada, Canadian Blood Services (CBS) is the blood service in every province except Quebec (where Héma-Québec operates as the provincial blood service). CBS is a not-for-profit charitable organization regulated by Health Canada as a biologics manufacturer, and collects plasma through voluntary non-remuneration. CBS has long been concerned about the sufficiency of source plasma for the production of PDMPs domestically. In 2019, with the support of the Provincial and Territorial Blood Liaison committee, CBS initiated a plan to increase Canada’s domestic plasma sufficiency for the manufacture of PDMPs. It began with three proof of concept source plasma collection sites and is in the process of expanding to include eight more sites across the country. CBS continues to take measures to increase and protect the supply of plasma to make immunoglobulins for patients in Canada (Canadian Blood Services, 2022). The first three plasma centers opened in the summer of 2020 at the beginning of the COVID-19 pandemic. These new plasma sites collect plasma for PDMPs. The success of the plasma program relies on plasma donors to donate regularly, thus donor retention is of central importance.
A recent study of voluntary non-remunerated plasma donation in Canada indicated that a major incentive for donors to continue to donate plasma is their interactions with nurses and phlebotomists in the center, and the interactions that those members of the staff have with each other (Holloway, 2022). Unlike a whole blood donation that takes approximately 15 to 20 min and can be done every few months, plasmapheresis can take up to 40 to 50 min and can be done weekly, depending on the donor. The length of donation time and frequency of donation means plasma donors can develop a relationship with staff in the center. There is evidence that social networks contribute to a sense of community related to the plasma center, and to feeling safe and supported during donation (Holloway, 2022).
Given that nurses and phlebotomists can play a central role in the donor experience, the purpose of this study is to examine their experiences in one of the first source plasma collection sites in Canada, outside Quebec. The study sought to understand how nurses and phlebotomists managed the challenges involved in a transition from whole blood collection to source plasma collection in a small community, amidst a global pandemic, considering how the social and political context has an impact their experiences. It involved a week of focused ethnography including in-depth qualitative interviews with 16 plasma nurses and plasma associates in the center. Plasma associates have training in phlebotomy and the role involves preparation of supplies, donor screening, registration and consent, venepuncture, product preparation and recruitment/retention initiatives. Study findings are analyzed using reflexive thematic analysis and examined in relation to the theory of emotional labor, the labor that some workers undertake to manage their emotions and emotional expressions to perform the best care (Badolamenti et al., 2017).
The concept of emotional labor comes from sociologist Arlie Russell Hochschild, who investigated emotion work of flight attendants in the airline industry. Her work highlights the significance of emotion to everyday life for individuals, families and work (Hochschild, 1983). Hochschild wanted to understand the relationship between emotions that are really felt by a social actor, and ones that are acted out for the benefit of others (ibid). These are not two easily distinguished states of being, but rather constitute a social act of expressing emotion within a given social context. Hochschild’s work was inspired by sociologist Erving Goffman, whose scholarship attended to how people behave and how they present themselves to others (Theodosius, 2008). This paper takes up Badolamenti et al. (2017) definition of emotional labor as “a multidimensional and complex concept, which refers to the management of expressions and manifestation of emotions in interpersonal relationships according to workplace demands” (Badolamenti et al., 2017). This definition captures the way that the concept has been applied to work in nursing. Badolamenti and colleagues’ review of literature indicates that nurses experience strong emotions during their work and also consciously “use those emotions to hone, refine and improve their practice.”
This concept of emotional labor has been applied to nursing work because nurses are required to consider the feelings and emotions of their patients, and engender feelings of safety, comfort and caring (Theodosius, 2008). Research on nurses’ experiences of emotional labor demonstrates that it contributes to patient well-being and positive outcomes, and can have positive effects for nurses, and also negative effects (Badolamenti et al., 2017), such as burnout and dissatisfaction (Han et al., 2018; Pisaniello et al., 2012). For some scholars, emotional labor is connected with gender identity because professionals in women-dominated occupations are expected to use emotional skills to bring about organizational goals more than male-dominated professionals; thus many studies on emotional labor demonstrate how women provide more and are subject to expectations that they will do so (Badolamenti et al., 2017). Identifying how and when emotional labor takes place can uncover assumptions about gendered work and potentially offer solutions to mitigate harm from negative effects.
Literature Review
There is very little literature about the experiences of nurses, phlebotomists and other front-line staff in blood collection (Gemelli et al., 2018; A. Smith, 2015; A. S. Smith et al., 2011) and less about these experiences in plasma collection (Castillo et al., 2022; Thorpe et al., 2020). There is a dearth of literature exploring phlebotomists’ experiences in general, which is in keeping with a general lack of attention to the gendered work of ancillary health workers (Armstrong et al., 2008). A study conducted in Australia analyzed the barriers and motivators to anti-D plasma donation (Thorpe et al., 2022). Researchers interviewed anti-D co-ordinators, medical officers and donors and found that interactions between donors and staff build trust and community, which can lead to donor dedication to the program (Thorpe et al., 2022). A Canadian study explored the perspective of nurses and supervisors in two centers that collected plasma on the new eligibility criteria for gay, bisexual, and other men who have sex with men (Castillo et al., 2022) reporting that staff can find it stressful to catch up with the changing eligibility criteria. This translates to confusion for new and existing plasma donors. Center staff therefore advocate for clear communication across the program and a need for continuous training and support to be comfortable with the changing eligibility policies to be able to clearly explain the donation policies to plasma donors and enhance their donation experience (Castillo et al., 2022). The results of the scholarly work on staff in plasma collection suggests that staff can play a central role in ensuring a positive donor experience, and indicates that further research in this area is necessary to explore the role of emotional labor in plasma collection.
Methods
This study involved a week of focused ethnography in one of the first source plasma collection sites in Canada in September 2021, including 16 interviews with front-line staff, plasma associates (phlebotomists) and nurses who work at the plasma collection site. Focused ethnography is a contemporary adaptation of ethnography, based on the assumption that cultures and subcultures do not just exist in far-off places, but are everywhere (Wall, 2015). In this instance, the culture under investigation is the norms, expectations and practices of a source plasma center, as it exists in a small Canadian city. Focused ethnography is suitable for problems in a specific context in an applied social science research study (Wall, 2015). The project was approved by the Canadian Blood Services Research Ethics Board (REB2020.022).
I joined CBS in 2020 as a research associate and then scientist. In February 2020 I met the team that had been hired to work in the plasma center during a bus trip that was organized for them as a training and team-building activity. I sat with them in meetings about the mission and vision of the proof of concept; we learned about the uses of plasma and met with a recipient of plasma products. Prior to conducting this research in September 2021, I sent a notice that I would be coming to the center and would like to do interviews through the manager of the center. The manager circulated the notice with the informed consent document, indicating that all participation is voluntary, and that participants’ contributions will be de-identified in all reports. Front-line staff in the plasma center are organized into two teams with two team lead positions. Team leads are Registered Nurses, and there are two RNs on the floor at all times.
Data Collection
To visit the center, I complied with the same COVID-19 protocols as staff in the center, including COVID-19 vaccination, masking, physical distancing, screening and temperature checks. I spent approximately 40 hr in the center. A manager was out of the office for the week, so I set up in her office and conducted interviews there. Six participants were Registered Nurses and 10 were plasma associates. All participants identified as female. Participants had a wide range of working experience with CBS—some had been in the center focused on whole blood for 30 years, and others had just joined the plasma center the year of the study.
As an exploratory, qualitative project, the interviews were similar to a conversation, and were led by an interview guide outlining questions and topic areas to be explored. Interviews lasted between 18 and 48 min. Participants were asked about their professional background and expertise, the history of the proof of concept, their experiences in the plasma center, and the political context of plasma donation. All interviews were conducted in English and audio-recorded with the participant’s consent. Recordings were transcribed by a professional transcriptionist, de-identified and uploaded onto their own password-protected secure server space at CBS. Any quotations are attributed with reference to a participant ID, S1 to S16.
During the 5 days I spent in the center, I walked around taking notes and observing, saying things like “can I follow you?” “Can I take a picture of this machine?”; “I’m just going to hang out here.” I observed how front-line staff interacted with each other and with donors in the space. I took detailed field notes in a physical journal and took pictures of the equipment. A few days in when things were more comfortable, I ask some members of the staff to show me around the back where the freezers are located. In the back of the center, nurses and phlebotomists label, test, put the bottles of plasma in the freezer, and then another freezer, then they box the plasma and ship it. Nurses and phlebotomists walked me through the process, discussing their multiple roles in the center.
Data Analysis
Field notes and interview data were analyzed using reflexive thematic analysis (Braun & Clarke, 2023), to identify, analyze and report patterns within the data (Braun & Clarke, 2006). This study is informed by an interpretivist social constructionist approach, meaning it is guided by the belief that participants create their own meanings and the researcher engages in a process of understanding that meaning from the participants perspective (Schwandt, 1994). Interviews and observations were focused on how front-line staff experienced the opening of a new plasma center. In undertaking reflexive thematic analysis, first, I read through all transcripts and field notes and wrote memos in an effort to understand the meaning of the data. Second, interview transcripts were entered into a qualitative software analysis tool called Nvivo 12 (QSR International) and coded line by line. Participants were de-identified. Inductive open coding resulted in 26 codes which were analyzed through memoing. For instance codes “background,” “joining the team” and “start of the center” were grouped into the theme “the uncertainty of transition” because through discussing their history with the organization and the beginning of the plasma center, participants reflected on the transition from a center focused primarily on whole blood and the opening of a new plasma center, and the difficulties related to that transition. These codes were interrelated and spoke to the theme of transition. Codes were grouped into six themes: the uncertainty of transition; the pandemic challenge, teamwork through adversity, prioritizing relationships with donors, connection through knowledge, and engaging with research. Ethnographic notes were reviewed during the coding process and used to inform and deepen understanding of the themes. Through this process, I reflected on my own position as an embedded researcher in the organization by using reflexive journaling, making note of the potential power dynamics between an outsider in a research role and front-line staff. I worked to refine themes, considering each in relation to the literature on emotional labor. The following findings section begins with a narrative overview of the study themes and their relationship to each other, and then presents a descriptive analysis of each theme, and the relevance of the concept of emotional labor.
This study demonstrates credibility, the trustworthiness and plausibility of research findings, through thick description, a presentation of the data that indicates culturally situated meaning and concrete detail (Tracy, 2010). Further, the quality of the study is marked by sincerity, the researcher’s honesty and transparency through self-reflexivity (Tracy, 2010) as demonstrated through reflection on my positionality as a researcher, and through the analysis presented in the theme “engaging with research.”
Findings
Participants described two interrelated challenges involved in opening one of the first source plasma centers in Canada; the transition from a long-standing center focused on whole blood to a source plasma center, and the COVID-19 pandemic. This section will outline themes related to the uncertainty of transition amid a pandemic to detail how participants experienced these challenges. The transition to plasma represented a cultural shift that was felt more acutely by participants who had worked for many years in the longstanding whole blood center. The uncertainty related to adjusting to a new center was exacerbated by the measures undertaken to ensure safety during the pandemic. Staff engaged in emotional labor to work in these challenging conditions. The latter themes in this analysis address how emotional labor was undertaken to manage challenges in order to work as a team and create a positive experiences for donors. They were motivated to do so because they understood the importance of plasma collection and wanted to ensure the security of CBS in the region. They also engaged in emotional labor to become knowledgeable about plasma, because it was an integral part of reassuring donors and making them feel comfortable. Through the period of investigation, participants re-oriented their management of emotions to the researcher to express the impact of the challenges, and offer concrete solutions related to working conditions.
The Uncertainty of Transition
There have been several changes to blood collection in this region over the years, including decreased mobile collection sites. For the proof of concept involving Canada’s first three source plasma collection sites, centers that collected mainly whole blood closed, and new source plasma sites opened. Due to differences in skills required, most but not all the staff who had worked at the former centers found positions at the new source plasma sites. Thus the transition from a center focused on mostly whole blood to one focused on source plasma collection created tensions in the participants’ close-knit community. When the center opened, some participants were concerned about the future of the blood service in their city. A participant said, “when they came to announce that closure [of the whole blood center], I think a lot of people thought we had the monopoly, so we were going to be sustainable somehow, you know, till our retirement years” (S4). Despite reassurance that the new plasma center was there to stay, there was a general concern about the future of the blood service in the area and the implications for employment.
The transition represented a cultural shift from a longstanding center focused on whole blood, to a source plasma center. Participants who had worked in the whole blood center said that prior to the plasma center opening, they discussed the security of their employment, as well as concerns about how the transition to plasma would take place, and what their work would be like in this new context. The plasma center was organized with the notion of a multi-skilled worker who could engage donors and also participate in the processing and shipping of plasma units. For participants who came from whole blood this was a major shift, because their focus was the blood collection from the donor, and because there were a lot of new tasks to learn. Participants described the fact that the plasma center represented a new way of doing things: Um, it was exciting. It was a lot. Coming from whole blood, it was so structured, and everything was like so set in place, and it was so up in the air, for plasma; I’m a very structured person so I found that really hard (S5).
Participants who joined the center a few months after the opening did not express the same concerns. One new member of the team was nervous at the beginning about learning new things, but said other members of the staff were really helpful and the donors were kind and understanding. The way that the team pulled together through the difficulty of the start of the center made new members of the staff feel supported.
The Pandemic Challenge
When asked about the challenges that they have faced in the process of opening a new plasma center, participants also talked about both internal and external challenges stemming from the uncertainty of the global pandemic. The pandemic meant they had to train online, they had more responsibilities in the center (for instance, temperature checks and screening), they had to socially distance from each other and the donor, which was difficult given that their jobs require close interaction. And there were donors who expressed frustration when they did not pass the COVID screening. Some participants were unhappy with the fact that staff were required to receive the COVID 19 vaccination, where donors were not. Finally, they expressed concerns related to their mental health. While they were told that they should prioritize their health, participants were unsure of how to do this while also doing their jobs.
Other challenges were tangentially related to the pandemic. Participants said a primary challenge was the schedule. Most participants worked part-time, but still had to work a shift 6 days per week. Some did not feel that they had time to decompress outside of work, or found it difficult to find another part-time job. The scheduling challenge was exacerbated by the pandemic, where illnesses and school closures made it difficult to manage work/life balance.
Another challenge was having to do their training online. Whereas in whole blood the trainer would be on site, in plasma centers in the midst of a pandemic, the trainer worked remotely and trained staff online. One participant felt that training online did not prepare her to operate with confidence when the center opened. She wanted more of an acknowledgment about how difficult it was to convey the skills related to the job online, particularly for people who had never learned that way before. Other participants who were new to the plasma center were learning how to do phlebotomy in an online session.
[Learning about] the phlebotomy, I found, it was challenging, cause we had this document that we read through, that was pretty much it. Like the actual technique is, it’s hands-on, like there’s no other way to learn it, so I found that really hard at first and I was thinking like, I don’t know if I’m ever going to get this, like it was, it was hard. [. . ..] I’d practice on bananas at home (S16).
This inability to learn in person enhanced feelings of uncertainty when the center opened—some participants felt that they were not ready.
Finally, several participants expressed a concern that there were fewer donations over the summer of 2021. Lockdowns, masks, vaccines, fears about contracting COVID and concerns about safety, affected donations during this period. Participants said it is not unusual for numbers to drop over the summer, but still felt nervous about their ability to meet targets for plasma collection that were set before the pandemic. This was connected to the concerns expressed about the presence of the blood service in the city, and the broader economic context of the region: It is pretty scary seeing the numbers this low, and not just for the staff, you know, for, for our job security, but also just, it is in high demand right now, plasma, [. . .] it kind of breaks, it breaks a lot of our hearts to not see, even some of our regulars not come in (S15).
There was a dual anxiety when numbers were low; that they weren’t collecting enough plasma for patients in Canada that really need it, and that their employment could be compromised.
Finally, participants identified challenges related to being one of the first source plasma centers in Canada. Given that the initiative was new, and they were committed to its success, they wanted to be a leading example.
I want to see us be able to completely be self-sufficient and not have to rely on the United States, or anywhere else for plasma. Like I would, I would love to see it just be a Canadian effort for Canadians, and, yeah. I think it’s really important. And I think it can be done. (S13).
Participants expressed a desire for the proof of concept to succeed because they understood what that means for recipients of plasma products, and so that they could continue their work.
Teamwork Through Adversity
Emotional labor was used to cope with the challenges described above. Participants engaged in emotional labor to build an effective team. They identified their ability to work effectively as a team as a skill that they valued because it offered support in a challenging time, and because it allowed them to collaboratively work toward creating a positive experience for donors. Prior to the center opening, center managers organized a bus trip for staff to come together, learn about plasma, meet with a plasma recipient and participate in team-building exercises together.
Participants who were part of these initial training activities prior to the pandemic said it was a bonding experience that allowed them to talk about their concerns about the transition to plasma, and find a way to cope with the transition together. It possibly prompted participants to undertake the emotional labor of prioritizing teamwork. Their bond was disrupted when they then had to stay at home during a pandemic lockdown and do their training online. They were separated and isolated and did not have access to that network.
We kind of were able to build a team that was pretty tight knit, right from, right from the get-go, which was great. And then COVID hit and we were all at home, and, yeah. Then we all just missed each other. (S13).
Despite this setback, this participant felt that the ability to bond at the beginning of their training meant that staff did not experience the divisiveness that happens under pressure. Several participants compared to their colleagues as a family, and to their coworkers as sisters. They said one of the best aspects of their experience in the center was being part of this team.
I think it’s just we all have each other’s backs, you know, if we have a problem or, you know we don’t hesitate, somebody’s there to finish a job or, you know, you’ll take your bottle over, put it in the bin, somebody’s cleaning your bed or, it’s just, give and take (S7).
Through the transition to the plasma center, participants learned that the ability to work as a team was a source of strength in a challenging period. There were tensions between staff in the center, but they learned to manage emotions to prioritize working together effectively. Sometimes they did this by supporting each other: The team player ability that I have, and that my teammates, team, colleagues also have [. . .] that really ends up helping in special situations, where if other team, my colleagues are stressed out, I feel like sometimes I end up being the go-to person, cause I’m able to help, like, listen to them, and like, just kind of calm them down. (S11).
This participant described teamwork as an area of expertise. They also said that this teamwork was oriented toward creating a good experience for the donor: I love working in a big team, and everyone pitching in to get the main job done, which is obviously getting all the donations through, but most importantly, having the positive donor experience (S11).
Participants engaged in emotional labor by concealing stresses and challenges when they were with donors to ensure that the donor has a good experience, and to keep the focus on collecting a needed resource for patients. There were some tensions among staff; some teams worked together more effectively than others, and participants in a leadership role did not always feel that their authority was respected. Participants worked to ensure that tensions or difficulties in the workplace were not visible to donors, because they wanted the donor to have a positive experience. As a participant explained: because as different as we are with personalities, we all we all put on a face or if you wanted to say, we’re all on when the donors are here (S4).
When asked about their roles and responsibilities in the donor experience, one participant explained all of the ways that they make the donor feel valued, and then added: Um, the only thing I want to add to that is team dynamic, I feel like that’s super important, to have a really cohesive team [. . .] to make those donors feel like they, that they’re gonna have a positive experience every time they come here. Or as positive as, as we can manage (S15).
This participant acknowledged that they actively attempted to foster a positive dynamic between staff in order to give the donor a positive experience. Thus, despite the challenges, participants worked to display positive emotions to the donor.
Prioritizing Relationships With Donors
Participants engaged in emotional labor to manage the challenges identified above and prioritize the donor’s experience. They very consciously oriented toward the donor while they were on the floor. Front-line staff in the center have multiple roles in the center, including assembling supplies and equipment, conducting screening, and preparing product samples for shipment. When asked about their roles and responsibilities in the center, participants stressed making the donor feel welcome. They do this by talking to them, thanking them for coming in, telling them that they are appreciated, and explaining procedures. Two participants articulated the way they defined their roles in a way that was consistent with other participants: [Our role is] to make the donor feel welcome, and appreciated, and to show our gratitude. And to try and make their experience as pleasant as possible, so that they’ll come back, to book, to rebook, to get them to come back (S2). [We focus on] making sure that like, that they’re appreciated and that they know they’re doing a really good thing and, just yeah, make sure they’re comfortable and everything’s well, like you have a big needle in your arm (S5).
Participants also stressed that they create a good experience for the donor by making them feel safe. They try to make the environment cheerful and relaxing, and they check on the donor to make sure they are feeling comfortable during the donation.
I’ve always let them know once the needle is in, the machine starts up, we let them know that please let any of us know if you’re feeling some sort of way that you weren’t feeling before the donation started (S11).
Another participant discussed the fatigue related to working with the challenges identified above (the uncertainty of transition and the pandemic), and their effort to ensure that the donor does not see it: I think the donors might be, I hope they don’t, I hope they don’t sense it, cause we really try our best not to (S6).
This effort to ensure that the donor does not notice their fatigue requires emotional labor from staff. Another participant said the environment in the center is supposed to be interactive and friendly, but during the pandemic they had to alter their behavior to minimize the spread of illness and be sensitive to donors’ concerns about transmission of COVID-19.
We have to be kind of careful how we interact with people, how uncomfortable people are, which is difficult to do here, because it’s such a kind of, it’s such an interactive, friendly environment, or it’s supposed to be, anyway, for, for the donors. So, to have to kind of restrain yourself a little bit with social distancing and all that is, I think that would be considered kind of a challenge for, for all of us. (S15)
The pandemic presented challenges for staff, as outlined above, but participants strived to put the donor first, orienting their activities on the floor to ensure the donor felt appreciated, comfortable and safe.
This focus on the donor was challenging given that the center is organized to maximize efficiency, with a lean model requiring staff take on multiple roles. Some participants reflected on the fact that attending to the donor was not easy given their responsibilities related to screening, assembling supplies and preparing shipments. A participant said sometimes it feels like they do not have enough staff, but also wondered if it is because staff have too many responsibilities in addition to caring for the donor: We also do have a lot of responsibilities with the lean staff model. It’s not just managing the donors. If all we had to do is manage the front, I think it would be, we would be really, well, I don’t think we should complain about staffing. But managing the back end, and, you know, like, it’s a lot (S15).
Thus another dimension of the emotional labor involved the energy required to be present for the donor while managing multiple responsibilities.
This emotional labor oriented to donors was not always burdensome for participants; they derived a great deal of fulfilment from this work. Almost every participant said the best experiences they have with donors is the relationships they form, and the joy they experience through their interactions. They like sharing about themselves and connecting with donors as one participant put it, “it almost seems like you become family members. The, the more you talk, like I know the first couple interactions, you’re shy, it’s very professional, but as they keep coming back, you know, they talk about their grandchildren” (S3). My observations of the participants working in the donor center indicated that emotional labor involved orienting to the donor in a positive way by smiling, chatting and carefully explaining procedures (data from field notes). The emotional labor of orienting their work to ensure the best donor experience could foster a connection between staff and donor, as evidenced in their interviews and also through observation such as this one: “The machine makes a loud whirring noise and the staff makes a joke to the donor, ‘this one is a little loud when it starts up’ and then both the staff and donor laugh” (field notes).
Observations such as this indicated that staff were attentive to putting the donor at ease (in this case, in relation to the machinery involved in plasmapheresis) and through this interaction they could develop a rapport where both parties appeared relaxed and comfortable.
Connection Through Knowledge
Being knowledgeable about plasma represented an additional form of emotional labor. Participants who had experience in the whole blood center for many years took pride in the knowledge that they had developed in that setting. They liked being experts in their work and feeling they could offer sound advice. Participants found the entire process interesting, including the sound of the plasma “hitting the bottle” and the work that they did to prepare the plasma for shipping. An excerpt from my field notes illustrates this point: In the back they label, test, put the bottles of plasma in the freezer, and then another freezer, then they box, ship it off. I talk with two nurses and a plasma associate that walk me through the process. The nurses are familiar with what we are testing for, what’s in the blood. [. . .] A nurse who has taken bottles out of the freezer and lined them up says she just loves how this looks—all the plasma lined up to be shipped off. And then she starts talking with another member of the staff about how they love the sound when the plasma hits the bottle. Sometimes it’s quiet, but sometimes you really hear it like a fountain and its satisfying because then you really know it’s working (Field notes).
Some who had come from whole blood were uncertain about their knowledge in the plasma center, because everything was new, and as outlined above, the training had to be conducted online.
Participants demonstrated some knowledge of how plasma is manufactured and what illnesses it can treat, but also said things like “there was a whole list of cancers, maybe?” (S3) and “I know I’ve read, but it doesn’t stick in my head” (S9). They had to manage that feeling of uncertainty while interacting with donors. A participant said donors also ask her to explain how plasma has an impact on a patient, and she tries to explain in an effort to be transparent, but feels uncertain: Sometimes they ask, so I do, I do tell them. Because I think we should be transparent and honest. You know, and so, yeah I do tell them and they find it very interesting, and you know, try to explain with my limited knowledge (S1).
Observations of staff interactions with donors indicate that donors are curious about why this plasma center has opened and what it means for the blood service: I overhear a member of the staff telling a very curious donor that this this town only collects plasma now. She says we used to purchase plasma from the US—we still do—but in smaller quantities because we are trying to me more self-sustaining (field notes).
This observation suggests that staff are asked to be knowledgeable about not only the donation process, but the complex context of self-sufficiency for plasma collection in the country.
Participants also expressed how they were managing uncertainty by offering solutions that could help them. They wanted to know more about the uses of plasma through videos about what is and where it goes and had suggestions about how this information could be displayed so that they could be reminded of this information. One participant suggested a booklet for staff that would outline the various illnesses that plasma is used to treat and how it helps the recipient.
They also wanted posters in the center with a list of illnesses that plasma can treat, and a chart in the lounge that shows a truck taking it through all o the relevant steps from the donation to the patient.
While uncertainty was difficult for some, becoming an expert in plasma was also something they could be proud of. When participants were asked about what kind of expertise they bring to their position, those that had worked in whole blood for many years emphasized the knowledge and expertise that they had gained through experience, related to work instructions, phlebotomy, regulations and work environment. Knowledge gained through experience was very important to participants. Further, when participants talked about their best experiences in the plasma center, they also highlighted the ability to learn new things.
“I like the variety of stuff we get to do. It’s just so much more interesting than whole blood” (S2). “Well, the fact that I got to learn a new, a new skill, for sure. Because you know, at that point, I was feeling kind of stale, like I needed to get a challenge, I needed something” (S4). “It’s, it was really daunting at first, but I’m pretty proud of myself cause I, I can troubleshoot really well now” (S5).
Gaining this knowledge and expertise was often rewarding for participants. They were open to acquiring knowledge and offered concrete solutions that could mitigate uncertainty.
Engaging With Research
Participants in this study also engaged in emotional labor when they interacted with the researcher. They had to assess whether the research would be a meaningful use of their time, and then convey sometimes emotional stories to offer insight into the program. On my first day in the center, the manger gave me a tour of the facility, including the freezers and storage area. The staff lead introduced me to the staff on the floor, and I asked people if they would like to participate in an interview. I was there for a few hours and there did not appear to be a lot of interest in participating in an interview. On the second day, staff began to express interest in the study. Some members of the staff indicated me that they were not going to participate because they do not feel that anything useful comes from research. However, after a few participants volunteered to speak with me, they encouraged others.
Participants had to decide how to convey their experience to me in a way that could offer insight into the success and challenges of the plasma program, and potentially address their work-related concerns. They had to interpret my presence, decide how to relate to me, and then decide what to convey to me about their work experience through participation (or not). My location in a manager’s office could have influenced how I was perceived by participants, as associated with management, and this could impact how and what participants shared. Some of them engaged in emotion work collaboratively, as another instance of teamwork. I walked past one member of the staff consulting with another member immediately prior to her interview, where she brought the notes from their meeting to the interview and consulted them throughout (data collected from field notes). Others were outwardly emotional during the interview, as they recalled a difficult experience. One participant expressed that the experience was like visiting a therapist; suggesting that it was a space to explore emotions. Others demonstrated that they were managing emotions when they talked about the challenges. For example, a participant that talked about the struggle to learn the multiple tasks of a plasma associate said, “I don’t mean to sound like a whiney baby.” (S7). This exploration of their feelings during the interview differed from their behavior on the floor, where they were cheerful and caring with donors (data from field notes), lending support to the idea that they engaged in emotional labor to prioritize the donor experience. This quotation also suggests that the participant was conscious of sounding like she was complaining. There was emotional labor involved in conveying the challenges while also indicating that they were grateful to be employed, that the work was rewarding, and that they understood that plasma is collected to save lives.
Participants indicated that they actively demonstrate that they are caring for the donor during the process of donation by smiling, chatting, and explaining procedures. In the interview, emotional labor involved orienting toward me as a researcher, offering insight into their experiences in the plasma center, including those that were challenging, and conveying sadness and frustration in order to offer the necessary information to enact change in their workplace. For instance, when asked about challenges they consistently talked about scheduling issues and appeared united in seeing this as a problem that should be addressed. In this way, emotional labor was possibly undertaken to change workplace conditions. To go back to an aspect of Badolamenti et al. (2017), they experienced strong emotions during their work and also consciously used emotions to improve practice, and possibly working conditions.
Discussion
This study focused on one of the first source plasma centers dedicated to meeting sufficiency for Canada’s plasma protein products. In several locations in Canada, centers dedicated mainly to whole blood collection closed, and source plasma collection centers opened, asking staff to transition to plasma collection. Participants in this study identified the challenges of this transition in the context outlined above by discussing the difficulties around closing the long-standing whole blood center, and opening a new center that needed to demonstrate success. They worried about diminishing opportunities for employment, the future of the blood service in their city, and what it meant for their long-term employment. However, they were also devoted to plasma collection. While the transition was a challenge, particularly during the pandemic, and the economic context contributed to uncertainty, they wanted the initiative to succeed.
Participants engaged in emotional labor to work as a team in order to cope with the challenges of the transition to plasma amid a pandemic; to prioritize relationships with donors; to demonstrate that they are knowledgeable about plasma; and to engage with research to change their working conditions. This emotional labor is situated in a social context. Participants discussed prioritizing the comfort, safety and happiness of donors amid uncertainty about the center, their employment, and the economy. They undertook this work against a backdrop of meeting the needs of patients who require PDMPs.
When the concept of emotional labor has been applied to nursing, there is a recognition that the work is a collaborative and therapeutic relationship between the nurse and patient—an interactive and relational process (Theodosius, 2008). In this setting, the donor is not vulnerable in the same way as a patient. They are healthy, often they are there to do something good for someone else. However, nurses and phlebotomists in plasma collection engage in collaborative relationships with the donor to collect needed plasma products for patients. They wanted the enterprise to succeed. Further, as discussed previously, they wanted to ensure the success of the program because it represented the security of their employment in the region. Nurses in a clinical setting have to generate trust so that they can provide the appropriate care to the patient. In the context of VNR donation, this trust and connection matters, particularly in a pandemic (Haw et al., 2022), because establishing trust can help donors feel safe, and encourage them to return (Holloway, 2022). Regular donation is an essential part of the stability of the plasma supply, where donors can come every week.
The concept of emotional labor has not been applied to experiences of nurses and phlebotomists in blood donation, but Haw et al. (2020) studied frontline staff involved in donor recruitment and cord blood collection in hospitals for CBS’ cord blood bank. They found emotional labor was performed with donors and hospital staff, indicating that further attention should be paid to organizational conditions that induce the performance of emotional labor and add to frontline staff workload (Haw et al., 2020). This empirical study emphasizes how working conditions can prompt the performance of emotional labor; and a better understanding of how emotional labor operates in a workplace can offer insight into how best to support front-line staff (Haw et al., 2020).
The effort to address the relationship between working conditions and the impetus and consequences of emotional labor is present in a growing body of literature on the emotional labor that frontline healthcare workers have had to perform during the COVID-19 pandemic (Allen & Macaulay, 2023; Diogo et al., 2021; Hayes et al., 2020; Lapum et al., 2021; Nelson et al., 2021). This literature demonstrates the need to recognize and address emotional labor as a significant health issue for frontline staff, particularly during a pandemic. Nelson et al.’s phenomenological study with nurses’ experiences of the COVID-19 pandemic in Canada (Nelson et al., 2021) revealed emotional challenges, uncertainty and protective factors. They also found that the pandemic brought some units closer as a team, and this team cohesiveness operated as a protective factor that enabled nurses to feel valued and safe (Nelson et al., 2021).
The relationships that particularly nurses have with each other and within a multidisciplinary team has been referred to as collegial emotional labor, the labor undertake to promote effective communication between nurses and their colleagues to facilitate the best care (Theodosius, 2008). The way that this concept plays out is specific to a particular workplace (Theodosius, 2008). In the context of the new plasma center, the challenge of the pandemic, and the broader concern over the economy this region, participants suggested that prioritizing teamwork constituted a form of emotional labor, and this allowed them to perform the emotional labor that was necessary to put donors first.
Another protective factor that Nelson and colleagues identify is education, in that nurses who received accurate information felt more confident in maintaining their safety. This finding was specifically related to nursing during the pandemic, but it resonates with the experiences of nurses and phlebotomists in this study, in that knowledge was connected to greater confidence. They felt the need to appear knowledgeable to provide good care to donors; emotional labor was apparent when they felt they lacked knowledge of the uses of plasma but needed to convey this information confidently to donors. In a context where there is a rising need for plasma for PDMPs, and increase efforts to collect plasma from VNR donors, part of their work is about communicating the importance of why plasma matters. Participants wanted more information to convey this message to donors.
Armstrong et al. (2008) discuss the way that ancillary health workers require multiple forms of knowledge to do their work and establish credibility in their work. They indicate that many ancillary jobs in healthcare require formal and on-the-job experience, and they must navigate new technologies, new work organization, new kinds of health issues, and this new knowledge is gained without formal credentials or recognition (Armstrong et al., 2008). The participants’ interest in gaining technical knowledge of plasma collection (from phlebotomy, to hearing the plasma hit the bottle, to lining up bottles for shipping) represents a codification of expertise that participants found rewarding. This acquisition of expertise possibly cuts against the marginalization of ancillary health work. The relationship between the rising need for plasma, the work of plasma collection, and knowledge and awareness of PMDPs requires further investigation, as it could have meaningful implications for effective training methods.
One limitation of this exploratory study is that it is focused on one plasma center in a particular moment in time. Thus, the findings cannot be generalized to every plasma center, or to staff experiences in general. However, the findings can be useful in assessing how staff in this context manage uncertainty and transition, features that are present in many jurisdictions attempting to manage sufficiency in plasma supply. The study sought to value the experiences and insights of staff in one setting. More scholarly work must attend to the experiences of staff in plasma centers in different contexts.
Another limitation of this study is that in order to properly de-identify participants I was not able to define the differences between nurses and phlebotomists. The unique differences between nurses and phlebotomists in plasma collection, and the way that different forms of emotional labor are experienced differently among these professions deserves further study.
Conclusion
As blood services worldwide attempt to increase plasma collection there is a need to understand the experiences of front-line staff, who are centrally involved in the ongoing interactions with donors. This kind of work has not received a great deal of attention in the literature on blood and plasma donation. The professions of nursing and phlebotomy are dominated by women, and as with many caring professions, the gendered nature of this work means that the care can be rendered invisible (Armstrong et al., 2008). This is especially the case for phlebotomists who have yet to receive much attention as a skilled profession. This paper attempts to situate the emotional labor involved in this work as knowledgeable and skilled work worthy of attention. Further, there is evidence to suggest that this care work is central to the success of plasma programs (Holloway, 2022). A Canadian study of plasma donors indicates that plasma donors return for subsequent donations when they develop positive relationships with staff in the center (Holloway, 2022). Thus efforts to increase retention and build a plasma program could be usefully focused on ensuring staff are supported in the center.
This study suggests that nurses and phlebotomists in one of Canada’s first source plasma centers engage in a management of expressions and emotions in interpersonal relationships in accordance with workplace demands, constituting emotional labor as defined by Badolamenti et al. (2017). Participants used their emotions to refine and improve practice, to meet the needs of Canadian patients for plasma products, and to ensure the longevity of the plasma center in their city. Further recognition of how emotional labor manifests in the center can enhance the workplace experience and minimize potential harm such as burnout.
Blood services must carefully consider how to support staff in the center so that that they can thrive; so they feel confident about their knowledge; so that they can interact with donors; so that they can communicate the value of plasma donation. This can mean addressing internal center structures; scheduling issues, training and time to care for mental health. It can also mean addressing fears about the future of the blood service and economic insecurity in the community, or the emotional and mental impact of the pandemic. This study suggests that there is a need to integrate care work into the operations of plasma collection, to recognize the emotional labor that staff perform, value the effect this has on donors, and identify potential burnout or dissatisfaction that can result when emotional labor is not recognized.
Footnotes
Declaration of Conflicting Interests
The author declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
This research received funding support from Canadian Blood Services, and open access publishing was funded by the federal government (Health Canada) and the provincial and territorial ministries of health. The views herein do not necessarily reflect the views of the federal, provincial, or territorial governments of Canada.
