Emotional Labor of Nurses and Phlebotomists in a New Source Plasma Collection Site During the COVID-19 Pandemic

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.”

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.