Emotional labor in public health care organizations in Russia: How to improve the current situation

* citing an interviewee so that show the meaning of the category as well as the kind of data that was coded into this category.

The goal of the research is to find out the peculiarities of emotional labor of medical personnel in 2 public children hospitals in Moscow.

This has been divided into several tasks which are as follows:

To determine the extent to which the medical personnel perform emotional labor (if they do).

To determine the factors that cause the appearance of emotional labor in the employees (such as, for example, severely ill patients, personal qualities etc).

To find out if there is any kind of management of emotional labor by the medical personnel themselves.

To find out if there is any kind of management of emotional labor by the hospital authorities.

To determine the main peculiarities of such a management (if there are any).

To suggest some improvements of the management of emotional labor based on the results of the research.

3. Data

Two major public children hospitals in Moscow were chosen as the object of the research. The hospitals have both plan and emergency rooms so the interviewees deal with both emergency patients and the usual ones. Nevertheless, in one of them mostly traumatic patients are treated, with a great number of successful recoveries and discharges from the hospital. In the other severely ill children are treated with high level of lethal outcomes that were claimed by the interviewees.

The interviewees were administrative and medical employees of the hospitals of different positions. They were 9 representatives of each hospital, 3 of who were heads of departments; 3- doctors and 3 - nurses, including 2 ordinary nurses and 1 superior nurse.

They were also of different age, starting from around 30 years old and finishing with over 70.

The respondents were both male and female, with 2 men and 16 women as interviewees.

The working experience in the hospital also differed: 4 interviewees were less than 5 years employed; the rest had over 10 years of working experience in their current place of employment.

There are two main reasons explain the choice of the interviewees. First, they represent the range of the hospital employees who most face emotional challenges in their work (heads of department as both administrative medical staff and doctors and nurses who are medical personnel). Secondly, they represent the variety of positions of medical personnel in the hospital. That is why the results of the research are expected to be relevant.

After the hospitals for the research were chosen, the chiefs of the hospitals were contacted. We presented ourselves on the phone, briefly explained the goal and the methods of the research, the interviewee that we expected to ask and the questions of the interviewer's guide. We made appointments to meet in person in the hospitals, which we did. During the meeting we discussed our research more in detail, and, finally, we got the permission to conduct the research. We were told that the interviewee would be asked by the chiefs to answer the questions of the research but that we had to respect their opinion and their anonymity, which we did. Also, not every interviewee, less than a half, gave their permission to be recorded during the conversation. There were no recording when it was not permitted by the respondents.

4. Findings

After having conducted the analysis of the gathered conversational data using the methods mentioned above, several findings relevant to the research were obtained.

The first finding concerns the causes of emotional labor.

In one of the hospitals where the interviews were conducted, unexpectedly, dealing with patients is not the main source of emotional labor of medical employees that they face at work. `There are very singular cases of me feeling unpleasant while working with a child,' - this answer of an interviewee is very representative. On the contrary, it is dealing with patients' parents that causes the major part of emotional labor of the medical staff. `A challenging thing is that about 90% of my time is spent on the contact with parents,'- states an interviewee. Work with parents was said to be challenging for some reasons.

First and foremost, the reason for this is that parents tend to not understand and/or acknowledge that the treatment prescribed by the doctor is necessary and even less parents agree that it is indispensible. `Unfortunately, it is very challenging to make parents change their minds, it is challenging to convince them that a … treatment is needed,' - claims an interviewee. Many parents `cannot adequately assess the medical condition of their children', and that is why they get emotional and disagree. Some of them, however, do accept the treatment but do not contribute to the process of the medical rehabilitation when patients get discharged from the hospital. `… parents are not willing to understand how important it is to keep doing physiotherapy at home. It is all in the hands of parents,'- confesses a respondent. This, consequently, leads to the fact that the time and attention of medical staff to a great extent has to be spent on persuading parents to give permission to performance of a medical procedure. As a result, the whole process of treatment loses its efficiency and sometimes even worsens the initial medical condition of the patient. The issue is even more important in case of working with patients in critical conditions when the swiftness of decision making may save a life.

Secondly, it is treating medical personnel badly. This appears in the lack of respect towards medical employees considering them just service providers rather than high-level specialists in their field who are trying to do their best for their patients. `When I started [working as a doctor], doctors were treated with respect … now this treatment has changed completely and very rarely can one see a respectful attitude towards one' - claims an interviewee. Health care personnel does, indeed, provide medical services and can be seen as an actor in this system. As the receiver in of medical services in a public service delivery system patients and, in this case, their parents have certain expectations about how, when, by whom etc these services should be provided. Whatever the reason is - the personal qualities, appearance or reputation of a medical employee - if their expectations are not met, parents begin to feel negative emotions and to perform emotional labor of not showing them that is hard for them. In any case parents should always remember that the medical personnel attempts to always provide services of best quality. They should keep in mind that the quality of the medical care of their children to some extent depends on how they treat those who are working on the case. It might be that parents understand that they are in the situation of dependence and that is what bothers them. Or it probably is the asymmetry of the information in the situation: doctors that have all the information on how, when and why perform a certain procedure whereas parents only posses the information that there is something wrong with their child. Disrespect of the medical personnel leads to distrust towards them. As mentioned above, doctors and nurses have to sacrifice a great part of their time and energy resources so that to persuade parents to agree to a procedure.

Moreover, it is parents' unwillingness to do more than average person would do for their children. `Some parents are attentive and careful, they try to find out as much as possible about the illness and the ways of treatment their child could get. Others just do what the doctors say without even knowing why it is so. This last group of parents upsets me,' - confesses an interviewee. Unwillingness and not inability is in question because in the world we live in nowadays all sort of information is accessible. The better a parent is familiar with their child's medical case, the most efficient and less problematic their interaction with medical staff is. Moreover, there are options of asking for alternative sort of treatment, probably, consulting another doctor or nurse for their professional opinion. It is not distrust towards medical personnel that is discussed here but the pluralism of opinions and approaches to diagnosing and treatment. This also enables parents to be in conditions of less information asymmetry and to feel less.

Furthermore, the fact that parents provoke and not prevent traumatism of their children worries the medical personnel. `I know there are many cases where a parent could have avoided that from happening,' - claims a respondent. Therefore, it is parents' negligence towards their children that is one of the reasons of emotional labor of the interviewees. This problem appears rather controversial in the realities of modern Russia. On the one hand, more severe sentences are pronounced to punish the careless parents. On the other hand, there are not enough improvements in the system that prevents children traumatism in order to make the system function efficiently and, consequently, to reduce the number of such cases. It is worth citing another interviewee as well: `our patients are the children of our patients'. This means that there is a relation of negligence between generations. It is now known whether it is genetically transmitted but, according to the respondents, it can be seen on practice that in effect the next generations repeat if not worsens the negligence of the previous one. This points out the extreme relevance of preventing measures of such actions of parents and other adults.

On the other hand, the majority of the interviewees of the other hospital named working with patients more stressful than dealing with their parents. A possible explanation of such results concerns the specialization of the hospitals and the peculiarities of their patients. The majority of the injuries that are treated in the first hospital are not life threatening, with a great extent of successful work done and children being discharged from the clinic in an improved medical condition. Whereas the second institution in question specializes on treating the patients, whose illnesses, according to the interviewees, often leads to lethal outcomes. That is why, probably, the medical personnel of the latter mentioned clinic has less energy and time for dealing with parents. Another explanation is that the psychological and other profile of those parents varies in the hospitals.

Two types of situations are the reasons for emotional labor that arises because of work with patients. First, it is the need to perform painful procedures that was named a source of negative emotions: feeling sorry for the patients, sympathizing them. Unfortunately, it is impossible to avoid such procedures. However, it is possible to find an approach to the patient before starting the procedure and being nice and understanding when performing them. This way, patients feel better and so do the doctors and nurses. It is worth saying that the majority of the respondents claimed to always make sure the patient is both medically and emotionally ready for the procedure. Some add that once the patient is ready and copes with a painful procedure with the help of medical staff, they rely on the personnel and treat them better in the future.

The mentioned situations are very common in the medical practice of both children and adult medical staff. It then when the medical personnel perform sympathy and not empathy, as was explained above. Whereas the only way to efficiently work on one's emotions would be learning to empathize and not sympathize.

Second, it is dealing with `…difficult patients who doctors and parents will have to work a lot on', patients whom the medical personnel cannot help which is followed by the death of the patients. Generalizing these arguments it could be seen that the main reason for medical personnel finding it difficult to deal with patients is dealing with severely ill or damaged children. Even after having worked on many similar cases, for medical personnel it is still challenging to realize that a patient will need long and difficult treatment. This might be because they sympathize with the patients but might be as well because of the great amount of work that they seen to be done in the future and the possible complications of the medical conditions of the children.

Despite all the mentioned above, the vast majority of challenges is faced when medical staff interact with patients' parents. `Well, usually you just find an approach to your patients and that is it. That is way easier,' - these words of one of the interviewees represent the opinion of the rest.

The second finding refers to the negative image of medical workers that appears in mass media which is one more source of emotional labor of these employees. `… our [Russian] mass media - newspapers, TV, radio etc - have put some significant effort to worsen our image more than you can imagine', - states an interviewee. It was claimed that such image was a result of the journalists only focusing on the unsuccessful outcomes of medical work and not even trying to find a real reason of what is happening. `It is … clear that there are some exclusive cases and there is always a severe punishment behind. This is what the journalists catch and exaggerate creating such a picture of our actions. And this way a negative picture of medical personnel is created,' - reckons a respondent. In effect, it is common that on the major channels of Russian television appear many scandalous medical cases that rarely are what they appear in mass media. Since there is certain proportion of trust towards TV programs, especially of elder people and mothers who spend much time at home. These categories of citizens believe what they see. As these exactly groups of people are who most often tend to use the services of public medical institutions, not only do they show their distrust when in a hospital but also they share their opinions with their social surrounding. At the mean time, among the positive cases only appear the ceremonies of handing in prizes or inauguration of a new health care institution is or its reopening after reconstruction. This, in its turn, affects the reputation of the health care system and medical personnel, in particular. When the actors of public medical organizations are shown in a negative way, it causes an increase in their emotional labor.

The third finding considers the existing set of norms, requirements, standards imposed by the existing public health care system. There is a number of issues concerning this problem. First of all, it was stated that the number of them is so great that it impedes the necessary performance of medical personnel. `It is very difficult to fit every requirement', - says an interviewee. This is because `there are far too many controlling state agencies,'- opines a respondent. Every such agency, according to the respondents, requires that the norms imposed by this very institution are followed.

Secondly, according to the interviewees, some of the requirements are set by the public authorities that are not competent enough, and that is why some claim that `Often new orders of the superior authority deny everything that was required before'. These two issues results in the medical personnel losing clearness of the actions that they are expected to perform, a confusion in their work and, eventually, in the feeling of incompetence which causes an increase in their emotional labor.

Moreover, it was claimed that `there are a lot of unnecessary diagnostical requirements, many of what are mistaken. Many times we do not understand if we should do the right thing or we should stick to all the instructions and rules, not performance of what is punished'. In both of the situations described above the cause of the problem are ambiguous orders and instructions that are not clear to those who are to execute them. Meanwhile, strict punishment for not performing in a requested manner were stated to exist. In the situation when instructions are not clear to those who are to implement them, there is no one way of assessing the performance of the workers, there is much ambiguity in such situations. Therefore, no severe punishment, if any, should take place. Otherwise, it would be unjust.

Furthermore, the amount of paper work that is provided by the health care system is so great that '90 per cent of our time has to be devoted to fill in medical documents,' - admits an interviewee. This also happens because apart from the enormous responsibility that lies on a medical worker, there is also a great burden of punishment that he or she can get if not all of the requirements are met. `We are obligated to pay the majority of our attention to correctly fill in the documents and not to help our patients directly,' - claims a respondent. As a result of these bureaucratic procedures children who come to the hospital to be treated suffer. There are only two possible outcome of such situation in the field public health care. It is either that patients do not get necessary treatment and medical attention and, as a result, medical staff gets punished. Or it is that the burden on the medical workers increases so much that it is no longer possible of carrying and eventually patients get hurt and medical personnel gets punished. In any of these two scenarios it is both children and doctors who loses in such situations. `The bureaucracy does that very emotional part of a doctor suffers,'- says one of the respondents. It is why some serious changes are essential in order to stop this from happening and avoid it in the future.

Moreover, the existing norms of treatment of patients give a doctor no freedom when it comes to choosing a way to treat. `… not it all has been standardized,' - points out an interviewee. Although the personnel recognizes the aims of the standards such as economy of time and other resources, this way, the medical procedures implemented by a medical employee makes their work more routine and less creative. According to the medical staff, routine causes much emotional stress for them. Moreover, repeating performance of the standardized procedures may lead to the situation when a worker is not ready to face a unique working situation exactly because they are no more implementing different methods in their everyday work.

One more cause of emotional labor in the medical staff was said to be the times when the external inspections are performed in the hospital. The reason for this is that it is very stressful to undergo such inspections because it is then when all the medical documents are checked and, as mentioned above, medical personnel is extremely concerned with the issue of filling all of them in adequately which seems impossible. The feeling of impotency as well as that of expectation of a punishment is felt at those moments.

Another drawback of the existing health care system that noted the interviewees are some technical imperfections or needs that also affect the emotional part of the job performance. Lack of all the necessary medical equipment was mentioned as one of them. On the one hand, this seems a problem of a particular department of a particular hospital. On the other hand, the issue of the public procurement of medical equipment and materials may be considered a general problem of public medical institutions that affects the results of the work of their employees. The interviewees mentioned the effectiveness of their work in terms of its results one of the source of positive emotions at work. For this reason the extent to which the medical personnel is satisfied with the equipment and materials that are used for work purposes reflects the extent to which emotional labor caused by this is reduced.

So, the main source of emotional labor can be defined as “external actors” meaning those that do not descend from the direct professional medical care. They are said to be patients' parents; the national and local mass media; the whole public health care system in Russia. The fact that these actors affect the work of medical personnel from outside means that the costs of their work increased by the amount of time and energy that is spent on dealing with these `institutions'. On the one hand, theoretically speaking, doctors and nurses could have done their work successfully without interacting with the mentioned forces. On the other hand, in practice it cannot be done so because of the existing Russian public health care system. This means that if these medical staff's resources are cut because of these reasons, a great efficiency of their medical work should be reached.

The fourth finding states the extent to which emotional labor arises in interviewees' work. An extremely common answer was: `I face [emotional challenges] all the time, many times a day'. This reveals the fact that medical employees are to deal with their emotions on a daily basis which causes a great amount of emotional labor. Another issue here is that the interviewees tend not to leave their working problems at work: `Almost always I wake up on a Sunday morning and my brain is still at work. And I ask myself if I have been dreaming about work…'. Some claimed that they can be called at any time at home, that they are always expecting decision making. These situations prove the fact that emotional labor is a constant component of lives of medical personnel, and this is not limited by the working hours. In other words, these professionals feel a great lack of rest and relaxation, both mental and emotional. In such conditions, and more when the employees do not recognize the problem, leads to them feeling tired, more easily irritated, which not only reduces their working efficiency but also sometimes causes social conflicts. This fact reflects the necessity of measures that would reduce the emotional labor of medical personnel.

The fifth finding concerns such measures. One of them that is already taken is that an external charity organization provides the hospital with psychologists that work with patients' parents. This way, the hospital does not incur expenses and at the same time the emotional labor of the medical personnel is reduced because of the indirect effect of such psychological work. Such measures are taken towards patients' parents exactly because parents are said to be the major source of emotional labor of medical personnel. The importance of this measure is indicated by the head of one of the departments who claims: `There are … some measures that although they do not help us directly they do in an indirect way. This is, of course, the work of our psychologists. They work with patients and their parents but a part of their work also affects us. We consult with them how to behave in some situations. We learn from them'. She acknowledged the necessity of such measures in the department: `[You as the head of a department, do you see the need for your department in such measures?] Absolutely. '

The respondents of the other hospital stated that there used to be a contracted psychological worker to deal with patients and their parents. Mostly, they used to help patients accept the fact that they have an incurable illness or worse. The interviewees pointed out the immense importance of such work.

Nevertheless, not only psychological measures are taken to manage to reduce the emotional labor of medical personnel. The employees of the second hospital mentioned that their internal events such as children concerts, celebrating of birthdays and other events organized by the hospital help them to relax, distract them from their work problems, turn them positive. Moreover, they make the personnel to meet and get to know each other better which improves their informal communication and by that strengthen the feeling of social support of the rest of the hospital staff. Finally, they favor the patients feeling more active and positive which make the medical personnel smile. To some extent that could also affect the process of recovery.

The sixth finding concerns how working experience affects the challenging issues of work. Many respondents believe that the longer one works in their profession, the easier it becomes overcome the difficulties. `Of course, it all comes with experience,' - states one of the respondents. There are a few reasons for this.

First of all, it is the development of psychological knowledge and skills when working with parents. This refers to finding out the approaches to speak to and to convince parents with different types of personalities. `… due to all my years of working experience I have come to a compromise, i.e. “feeling” a person I know what pedals I push for them to agree with my opinion,' - says an interviewee.

The same is claimed to be true concerning dealing with patients. It was found out that working with patients got easier with years of experience. Many explain that as getting to know better the psychological peculiarities of young patients. `I have already worked in kindergarten, I am familiar with children's peculiarities so this is not difficult for me now,' - claims one of the interviewees.

This fact favors decrease in emotional labor. It means that not only does the experience of medical work reduce the emotional labor of the medical staff, but also non-medical `life' experience does. It can be seen that less emotional labor appears despite the fact that the worker did not aim to reduce it by acting away from the hospital. Therefore, in such situations actions to reduce emotional labor can be viewed in term of effortless and/or unconscious work. In this sense every personal interaction of medical staff, both with children and adults, both inside and outside of the hospital, contributes to their better emotional state in terms of emotional labor.

Secondly, it is better management of one's feelings. `Another thing is that with practice I have learnt to take it with more calm,' - says one interviewee. When emotional labor is performed on a daily basis an employee learns to deal with it. This might be the only advantage of constant emotional labor o medical workers - the permanent process of improvement of reducing emotional labor skills. This refers exactly to gaining empathy skills on practice. Feeling less emotionally involved in the situation makes it easier to stay calm.

Thirdly, it is more free-of-work time that the interviewees have nowadays (because the situation at home changes and also because of the better time management skills). `I do have time now to go to the theatre, that I could not do when I was young because my children were small, I had my PhD and doctor thesis etc … I have learnt not to work nights like I was working earlier,' - confesses one respondent. This, however, means even more effective work in the working hours so might be seen as a shift in the burden from performing work after the working day is ended to doing so when at work.

Fourth, more professional experience favors taking it easier when dealing with emotional labor. `I now have more confidence in my diagnosis and therapy and by this I gain less emotional stress, - claims an interviewee,- When I was younger if I was not too sure about the diagnosis and besides parents were really mean to me I was sometimes desperate'. This refers to reducing emotional labor by gaining professional confidence and reducing the number of emotional stress causes.

Furthermore, professional experience enables medical staff to `to predict and prevent' possible worsening of medical conditions of their patients with more certainty. With such information, the employees undertake all the necessary measures in order to improve the situation as soon as possible. As a result, fewer patients' medical state worsens and more patients receive the more adequate treatment. This makes the results of the work of medical staff better and so serves as a source of positive emotions.

On the other hand, some believe that working experience, on the contrary, makes it more difficult to manage one's emotions. For example, an interviewee says that for her it has got harder to do her job. The following reason is given: `Because people have got more complicated.' As it was shown above, a problem of `degradation' of parents as persons exists. Another reason for this might be that `it all keeps accumulating'. It is worth mentioning that the latter cite was from the same person that argued that there were no instruments needed to reduce their emotional labor. This means that the need of reducing emotional labor does exists, it is only that not every employee wishes to discuss it.

The seventh finding reveals coping strategies that the respondents use in order to overcome their emotional challenges at work. Generally, it was found out that solely emotion-oriented kind of coping strategies is used. Some exact coping strategies were explained by the interviewees.

One of them is being optimistic. `I never fall into depressions… in the end there are weekends, - laughs an interviewee, - Everything is not bad no matter what'. `… if there is a very negative towards the medical personnel mother I just start with a positive motion. I may come in the room saying “What a beautiful face!”,' - claims a respondent. Another interviewee agrees, saying that `One has to try to do it all with love and care, and when it is like that you will always achieve your goals'.

Another one is distracting oneself from work issues. An interviewee states: `I just find my way out of the room to take a few deep breaths'.

One more simply putting up with the situation. `I know that it is impossible to change your patients' parents, I do not stress because of this, I take them as they are,' - says one interviewee.

Moreover, it is ignoring the stressful issues. `I know that it is impossible to change your patients' parents … sometimes I do not pay attention to this,' -

One more tool is self-control. `I just try to keep my temper,' - shares one of the interviewees.

Another coping strategy is distancing oneself from a stressful situation. An interviewee said: `… we just try not to pay much attention to it, just to try to not keep it to the heart'. Both self control and distancing refer to the empathy skill.

One more coping strategy named by the respondents is putting themselves in their patients' place. `I say to myself that those are sick children who are in pain and I understand why they sometimes are capricious or cry,' - shares one interviewee. This, in its turn, should be practiced very carefully because this is how the medical personnel get back to sympathizing.

A coping strategy that was said to be used by some interviewees is finding explanations to the existing problems. As the main issue in their work was named dealing with parents, this coping strategy consists in explaining why the parents behave in such a way. `Me personally, I am trying to find explanations to this and to think that not this very person is to blame but the time in which we find ourselves nowadays. [I am trying] to remove this guilt from a single person and to find a reason,' - shares her coping strategy an interviewee.

`Parents come with their mind made negatively about the medical staff. They probably are looking for someone to blame in the situation, but they do not think about themselves,' - comments a respondent. Another interviewee supposes that the reason for such behavior of parents is the realities of the modern world, the situation of the epoch we live in: `… this is all because of the time [we live in], the environment...'. `Maybe the reason is in their character or problems at home..,' - says another one.

Another coping strategy that was pointed out is concentrating on the work and nothing but the work. `You just have to only focus on the patient, not to pay attention to anything else,' - says an interviewee. Since the medical employees deal with great number of distractions of different kinds during their working day, the concentration skill is one of the most important for the result of their work. Not only is it performed concerning medical operations, but also speaking of dealing with patients' parents. For this reason, the coping strategy is probably the easiest to both learn and perform for them and might be one of the most utilized by the respondents.

The eighth finding refers to social support as a particular coping strategy. Many interviewees noted the immense importance of support of their colleagues. It was said that approval, help and being surrounded by the people who treated them with care was one of the main factors of reducing their emotional labor.

Social support consists in a few feelings that are perceived by interviewees.

To begin with, it is a feeling of trust towards their colleagues and subordinates. `Our nurses. I believe them, I rely on them, I rely on their professionalism,' - point out one respondent, - I go home and know that nothing serious should happen till morning'. `…they [the nurses] have already worked for 15-20 years and they are familiar with every detail about the burns trauma, the ager-considering treatment, as there are many children who stay without parents,' - claims another one.

Second, it is a feeling of ability to share one's emotions. `We share emotions. Everyone has their own ways of dealing with their emotions but we do share them with each other,' - says one of the respondents. This means that there is an environment of certain extent of trust among the employees if they are willing to express their emotions. This is the first and the simplest step of reducing emotional labor - just letting the steam out. Nevertheless, at the moment this is the limit of discussing their emotions process for the majority of the medical staff.

Third, a feeling of unity and/or friendship makes medical personnel cope with emotional labor. `I am friends with half of this hospital … We discuss our cases all the time,' - shares another. `We help each other, emotionally and materially, if there is such a need,' - adds another one. Moreover, here is the feeling of unity because of being in the same working conditions (considering stress levels and causes). `A colleague who is here would never get offended [on each other because of letting their emotions out]. Everyone understands that tomorrow it can be you in the same situation,' - confesses an interviewee. The informal contact is of significant importance to the process of reducing of emotional labor. This creates the feeling of being able to count on others, of being understood, of being helped if needed.

Fourth, a feeling of self-openness is important to the employees. `We are all friends here and we are open to each other,' - notes an interviewee. This `transparency' of each other makes others understand each other better, see that their problem is shared by everyone and to calm down.

Fifth, it is staying positive. To achieve that colleagues and subordinates share the success and all the positive results that are gained in their work. Irina Mikhailovna

Although the majority of the interviewees stated that they found social support among their colleagues, many of them claimed the need to

The ninth finding concerns the interviewees' perception of the concept of professionalism. Hiding emotions is one of the components of a professional in the field. `I am the administrator, I am the lightning rod, I do not have a right to be rude or harsh, to raise my voice, to splash out my emotions on something that I do not like. I just do not have the right,' - notes a respondent. `[sharing one's emotions] is inadequate and unprofessional,' - adds she. Felt emotions and working duty are seen as separated by the medical staff of the hospital. If one gets in the way of the other it is considered acting unprofessionally. `Here is the work you have to do and there are your emotions. We do not let them interfere. When we separate these categories we are able to work 3 days in a row,' - claims a respondent.

The perception of professionalism by the medical staff can be seen in termn of the classic Weberian bureaucracy. Weber M. et al. Bureaucracy //From Max Weber: essays in sociology. - 1946. - С. 196-244. The scientist describes a very impersonal, hierarchical, and professional organization where most individual phenomenon (such as emotions) have little relevance or role to play in the operation of the organization. In the case of the medical employees of the first hospital, used aspects of the bureaucracy (such as hierarchy and professional standards) to cope with emotional labor.

The tenth finding refers to the concept of emotional burnout. To the contrary of what was expected, it was claimed that emotional burnout is not possible in interviewees' work. The reason for this is that `“emotionally burnt” people are only those who have come here by accident,' - says an interviewee. This refers to the people who have not become medical employees by calling but for other reasons. Some of the interviewees reckon that such people face insuperable challenges on the earlier stages of their carrier, such as post-graduate course or residency. Those who have come all the way to the hospital and have worked there for some time are already resistant to emotional stress and, therefore, it is impossible for them to face emotional burnout at this phase.

It was also supposed that emotional labor was not only caused by the specificity of the work `but also is affected by some external factors' that is thought to be partly true, but not more than that.

The eleventh finding was that although the majority of the interviewees denied the fact that psychological assistance was needed in order for them to reduce their emotional labor, there were those admitted that it was necessary. Some of the interviewees pointed out that they would not mind receiving some kind of psychological help depending on its form and frequency. The following forms of psychological help were suggested by the respondents: personal (individual or group) psychological sessions; lections and workshops on coping strategies; others.

Both gender and job position aspects were shown in this finding. Generally, men insisted on the excessive role of such measures. A possible reason for this is the fact that men are generally more closed and tend to discuss with more difficulty their emotions. Women, to the contrast, tended to opine that at least one form of psychological work was necessary.

As for the job position differences in the opinions, the majority administrative workers did not admit the necessity of psychological work in their department. This might probably be explained by the fact that employee of such high organizational status are not supposed or expected to accept that there is lack of a resource in their department, including emotional resource. A second reason might be that, as mentioned above, professionalism of the health care employees includes suppressing their really-felt emotions at work and performing the organizationally needed ones. This is why such highly positioned worker as head of department feels obligated not to show the real necessity of psychological help so that not to be taken for an unprofessional. The argument is also relevant to explain the general trend of denying the need of psychological help by the majority of the interviewees.

Nevertheless, the opinions of the personnel of lower professional status differs as well. For instance, not every nurse stated that she would like to participate in psychological measures of reducing emotional stress. A nurse gives her reasons: `We may just not have a habit of asking for help. We are used to deal with our problems ourselves,'. Therefore, on the whole, the findings in this field are rather ambiguous.

In conclusion, many relevant findings were obtained after having analyzed the collected interview data. They are as follows.

The main cause of emotional labor was stated to be dealing with patients' parents.

Bad image that the medical personnel had in mass media was said to provoke much emotional work.

Ambiguity of norms and instructions, much paper work - imperfections of the Russian public health care system were said to also cause emotional labor.

The main causes of emotional labor were external actors - parents; mass media; health care system.

Medical personnel face emotional labor on a daily basis.

No measures are taken in order to reduce medical workers' emotional labor that come from the hospital, although there are some provided by external actors. There is a need for such measures to be taken. Some feel a need of psychological help in their work.

Many different coping strategies were defined. Social support was one of the most important of them. Measures to increase the feeling of social support are needed to be taken.

Medical workers consider suppressing their emotions as one of the major components of their professionalism. By this is meant not involving themselves emotionally in the situation, i.e. not sympathizing.

5. Discussion

In this chapter possible ways of dealing with the most common and important challenging issues that were found out are given. The suggestions are given based on the results of the interviews so are initially applied to the public health care institutions for children in this country. Next, it is shown how the majority of them can as well be used in any field of public administration in Russia. The suggestions follow the order in which the ideas appear in the findings of the research.

To begin with, the issue of patients' parents causing some important amount of emotional labor should be discussed. In order to improve the situation, the degree to which this group of actors influences the medical personnel of the health care institutions should be reduced. One of the possible ways to do this is to apply the practice of one of the studied hospitals that has already shown its effectiveness. It consists in cooperation with a charitable organization that provides the hospital with professional psychologists that conduct psychological work with patients' parents on a daily basis working on their emotions that they perform towards the medical stuff of the hospital. The goal of such work is to, first, help parents let their emotions out; secondly, to make them understand the importance of the work that the medical staff is performing on their children; thirdly, to tackle the very problems they state when dealing with doctors, nurse and the administrative employees as well as those who are asked to be solved by the medical personnel. Moreover, the psychological team works on establishing the appropriate communication of parents with the medical employees that enables both subjects to reduce their emotional stress and enhance effectiveness of the communication. Not only do psychologists work on parents, they also interact with the medical personnel on whichever emotional issues that they find challenging. As a result, a two-way effective and smooth communication is established between the medical staff and parents that enables both of them to express their emotions and ideas appropriately as well as to be heard. This, in its turn, is supposed to reduce much of the emotional labor that arises in the medical employees. Moreover, as the resource of charitable organizations are used, the state does not have to bear additional expenses.

Patients in difficult medical condition were said to cause other great amount of emotional labor in medical personnel of the hospitals. When this issue is discussed, a possible mechanism that serves to reduce emotional labor is also psychological work of an external charitable organization but different from the explained above. In case of dealing with emotions that arise when working with severely ill children it is essential for the medical personnel to only feel empathy and not sympathy. Many doctors who directly and indirectly work with very sick children destroy themselves as they feel sympathetic towards them, i.e. they let themselves get emotionally involved in the situation where there is very little or nothing to be done. To the contrary, the goal of the psychological work with doctors here is to teach them to separate empathy and sympathy for the medical staff to manage to only use empathy in their work. Such work might be initially conducted by organizing group theoretical lectures providing the doctors and nurses with the needed theoretical base of the concepts of empathy and sympathy. This work should be followed by practical personal training including the work with every member of medical personnel of the institution in order to make sure they understood the theory and to teach them to apply it to their everyday work taking into consideration the peculiarities of their temperament, their perception of their themselves, their work and their patients. As a result of learning to involve less emotions in their work, the medical staff is supposed to feel less emotional stress when working with patients in severe medical condition. Moreover, it is expected to contribute to their feeling of professionalism (because this is some sort of “self-control” or “keeping one's temper” that was mentioned by the interviewees as the essential components or a professional in their field).

Another issue that it is necessary to improve is the bad image of medical personnel in mass media of the country. In order to achieve this, collaboration of the state medical institutions for children with the national and local mass media is needed. The national and local mass media, from their part, should present to the society the exact ideas and opinions that medical staff, from their part, provide them with. An emphasis on the positive sides and outcomes of the work of the medical personnel should be done, importantly, not making the topics less real than they are. On the one hand, professional journalists and television and radio presenters state as well as independent should take part in the process. On the other hand, they are expected to cooperate and to provide the guidance of the work of the HSE Media communications faculty students that should be involved in the process (for example, in for of bachelor and master practices). This is believed not only to improve the image of medical personnel and their work in the realities of Russia but also raise people's trust towards mass media in general because of the participation of different groups of the society. Moreover, this is supposed to affect the mentioned students' feeling of justice, enhance professionalism and raise their desire to participate in the public sector actions and to cooperate with state and non-state organizations. Such kind of collaboration in order to create a realistic image of am institutions of public administration is necessary in any sector in order to increase the citizens' trust towards the actions of public actors.

As for the issues that concern the existing public health care legislation, several measures should be done in order to make the performance of medical personnel more efficient by reducing their emotional labor. It is necessary that the ambiguity of instructions is eliminated. This should be done by encouraging the state agencies to conduct a thorough expertise of the existent legislation in order to exclude the contradictions in the part of the norms and instructions that the employees are supposed to follow. It is possible that there is also a need for the legislators' competence on the subject examination. As a result, those who ratify the regulatory legal acts in the field of public health care should gain the clear and achievable norms and instructions. When necessary, this mechanism can be used in any field of public administration since the clear understanding of employees' duties is an obligatory condition of its appropriate performance according to the goals of the organization.

Considering stressful times when external inspections are conducted, there are no mechanisms of reducing the emotional labor of the medical workers. For this reason, the only way to gain this is creating some sort of compensations (extra charge for every successfully passed inspection or tickets to the theatre, for example). There should be a list of money as well as other types of compensation that the workers should be able to choose. Another idea is to involve some additional medical personnel in order to cover for those who are under inspection. Nevertheless, it is not known, if the costs of inviting additional specialists are appropriate for every hospital. This might also be discussed in terms of other fields of public administration. The idea is to involve additional help to those who during the inspection cannot be on duty. There are some limitations of this suggestion. If in the field of health care there is no doubt about the necessity of additional help, it might be not as important to cover for a public servant of another field of public administration. For this reason, the importance and necessity of such measure should be assessed first.

When is discussed the problem of technical needs rather poorly or inappropriately provided by the hospital such as medical materials and equipment, raising the extent of involving the medical personnel in the process of procurement of medical equipment and materials (probably, not only on the level of head of department but also taking into consideration more the opinions of the rest of medical personnel who uses the procured materials and equipment in their work). This can also be applied to any field of public administration when it comes to procurement the materials that a civil servant or another worker needs to perform effectively. Letting employees some extent of choice and freedom is said to be positively correlated with job satisfaction of the workers.