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

Moreover, some important improvements should be done in the field of personnel unity. As was mentioned above, medical personnel pointed out that social support helped their overcome their emotional challenges to a great extent. Many employees claimed that they were happy to work in a team of helpful and understanding colleagues whereas some said that they are not at that stage yet although some of their colleagues attempt to unite the team. In such cases, more work on the relationship in the team is necessary to be done. In order to achieve more united colleagues it is proposed to use some existing mechanisms of the business organizations. For example, Moscow Business School provides a “Couching in team management” Official web portal of Moscow Business School [Web resource]URL: https://mbschool.ru/(consulted: 20.05.2016) workshop; Buro Akzent - “Teambuilding” Official web portal of Buro Akzent company [Web resource]URL: http://buro-akzent.ru/ (consulted: 17.05.2016), “Team unity”; Intelekt Servis - “Teambuilding”. Official web portal of Intellect Service company [Web resource]URL: http://intservis.ru/(consulted: 13.04.2016) There is a wide range of different teambuilding activities proposed by big consulting and other companies. Those can be inside and outside, little and big group works in different professional fields.

Another component of the collective unity process is organizing collective events inside the medical institutions that involve medical employees of different departments and professional positions. Such events may be, for example, concerts organized by or for the children in the hospital, games, competitions, excursions, lectures etc. Not only do medical workers communicate on non-working topics during such events, they also perform positive emotions together which is perceived as success that was gained together. That feeling encourages them to communicate more when out of work, which, eventually, enhances their relationship at work as well. There is more trust and more emotions can be shared. This way, social support is created, and, therefore, emotional labor is reduced. These measures, like some mentioned above, are also not only used in health care organizations but in all sorts of institutions - educational, business, environmental, etc. Therefore, it can be applied to any field of public administration.

To sum up, based on the results of the conducted research, some suggestions in order to reduce emotional labor of medical employees (some of them applied to other fields of public administration) were given. They are as follows:

Psychological work with patients' parents in order to establish an effective communication between them and the medical workers of the children medical institutions provided by charitable organizations.

Collaboration of the public institutions with mass media in order to create a more realistic and trustworthy perception of the work of public administration organizations and to enhance their image in the recipients of public services.

Expertise on the public health care institutions legislation is order to achieve clear understanding of the medical staff of their actions.

Increase in the extent to which employees are involved in the procurement decisions that concerns their working materials.

Compensations to choose (additional payment or other) and/or supplying with additional personnel when inspections are conducted in order to cover for those who are inspected.

Teambuilding workshops in order to create more feeling of social support in the collective.

Organization of entertaining and other types of activities by involving employees of different specializations and positions in the organization also to enhance social support in the institution.

Conclusions

The concept of emotional labor in public sector as the effort that a civil servant makes so that to perform organizationally appropriate emotions when interacting with a citizen was studied in the paper. The result of such interaction affects the perception of the provided public service by citizens and defines their satisfaction with a service. According to the Decree No. 601 of the President of the Russian Federation dated May 7, 2012 On the Main Directions of Improving Governance, satisfaction of the citizens of the Russian Federation with the provided public services must account for 90% by the year 2018 Ukaz Prezidenta Rossiiskoy Fedetatsii ot 7 maya 2012 goda “Ob osnovnykh napravleniyakh sovershenstvovaniya sistemy gosudarstvennogo upravlenia” [Decree No. 601 of the President of the Russian Federation] . Therefore, the execution of the national policy is in to great extent affected by the emotional labor that is performed by the Russian civil servants.

In the field of health care, it is medical workers who provide public services (both for adults and children), for this reason the emotional labor of the medical personnel of public health care organizations for children was chosen the subject of the research.

The paper aimed at defining the main peculiarities of emotional labor of the administrators, doctors and nurses in public health care organizations for children in Russia.

In order to achieve that, first of all, the theoretical research was conducted. It consisted in analyzing and systemizing the existent scientific literature on the topic of the research. It was found out that very little research was conducted that considered emotional labor in public health care organizations and even less in the specific case of this country. That is why the study is of great relevance.

Secondly, the empirical research was conducted. 18 personal qualitative interviews with 3 heads of departments, 3 doctors and 3 nurses in 2 public children hospitals in Moscow were conducted. Every interviewee answered 10 to 20 questions on different aspects of emotional labor such as rewarding/ challenging parts of the work of the interviewees; situations in which emotional labor arose; coping strategies; social support; measures to deal with emotional labor; reduction of emotional labor and its consequences; burnout.

After the research data was gathered, it was transcribed and translated into English; then it was compared to the questions, coded, assessed and analyzed. Finally, the findings of the research were formulated.

The most relevant results of the research are as follows.

The emotional labor of the medical staff of the Russian public health care organizations for children was mostly caused by external actors - patients' parents; mass media; the Russian public health care system.

Emotional labor arises in the medical personnel on a daily basis.

Hospitals do not provide their medical workers with any kind of measures in order to reduce their emotional labor. In one of the hospitals an external organization supplies it with psychological workers that are said to help a lot. There is a need for some measures to reduce emotional labor be taken.

The medical personnel use many different coping strategies. One of the most important of them was claimed to be social support. Measures to increase the feeling of social support are needed to be taken.

To great extent the professionalism of the medical employees in question consists in suppressing their emotions at work which refers to gaining empathy skills.

Based on the discovered challenges when dealing with emotions of medical personnel of public children health care institutions in Russia, some suggestions were made of how to improve the current situation. Most of them were also applied to the public administration in general.

Firstly, psychological work with both patients' parents and the medical staff of the hospitals is recommended to be conducted. On the one hand, it is necessary that parents are taught to establish an effective communication with the doctors and nurses, and vice versa. On the other hand, there is a need for the medical personnel to learn to separate the emotions from their work, i.e. to perform empathy and not sympathy, as the majority does. Performing empathy at work is supposed to enhance their professionalism.

Secondly, in order to improve the image of the medical staff that has the Russian society nowadays, their collaboration with national and local sources of mass media is suggested. It was also proposed to involve the HSE students of the appropriate faculty in that work. Moreover, it is recommended to achieve such collaborations with the institutions of all the fields of public administration. That is expected to show to the citizens the realistic picture in the field as well as to increase their trust towards mass media.

Thirdly, some mechanisms of improvement of the public health care system were proposed such as to conduct an expertise of the legislation in order to eliminate the ambiguity; and to reexaminate the civil servants responsible for the legislation in the field.

Moreover, it was suggested to provide additional pay or some other ways of additional motivation to the medical personnel who successfully pass inspections. If needed, additional staff to cover for those inspected might also be provided. That as well might be efficient in other institutions of the public sector.

Furthermore, increase in the extent to which public employees participate in the process of choosing the objects of public procurement. That is supposed to make their work more efficient as well as to make it satisfy them more. That is why it is recommended to give the civil servants of all fields of public administration some proportion of right to participate in the decision-making process when implementing public procurement procedures in their jurisdiction.

Last but not least, teambuilding and other activities that unite the colleagues, chiefs and subordinates were proposed to be conducted. Like when organizing and participation of cultural, educational and entertaining activities, the administrators, doctors and nurses overcome their personal and professional challenges, establish informal communication that leads to increased social support and, as a result, reduced emotional labor of the employees. It is rather likely that the same is true for all the fields of the public sector. Civil servants of all positions are proposed to be made a team.

To conclude, the research was conducted in the sector of health care. Based on that, more general suggestions that could be applied to any field of public administration system in Russia were provided.

Even so, there is much place for future research. In the field of health care, the number of hospitals could be increased; the adult health care institutions could be included in the research; regional health care organizations could also form part of the research.

More generally, other fields of public administration could be studied.

Furthermore, a more thorough study might be conducted so that to find out the effect of the aspects of gender and age.

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Appendix №1. Interviewer's guide

Every day you deal with sick children. Can you tell me some of the most rewarding/ challenging things about this?

In your work do you face the need to perform emotions that interfere with the emotions you really feel? Towards whom do you feel these emotions?

Sometimes we have to just "perform" a needed emotion without actually feeling that way. In what situations do you face such a need? What do you feel when you do?

Sometimes we try to do some inner work, changing our perception of the situation and then we show our ЁchangedЁ emotions. When do you act like that?

The majority of doctors confess that they face some very strong emotions (nervousness, being afraid, being upset … ) in their work. I think this is even more common when working with children. How do you act in such situations? How do you overcome this situations?

Many of those who go through feeling emotional stress try to help others that are in the same situation, give advice. Do your colleagues and you exchange such advice?

Do the authorities of the clinic take any measures to reduce your emotional stress? If so, what are this measures? Are they efficient, to your mind?

What would you do to reduce your emotional stress?

If you faced less emotional stress would that somehow affect your job satisfaction? Effectiveness of your working performance?

How would strength of psychological support / salary increase/ having more helpers affect your work?

Unfortunately, some doctors cannot overcome emotional stress and are obligated to quit. In your opinion, is it possible to get emotional burnout in your work? Why?

Appendix №2. A sample interview

Every day you deal with sick children. Can you tell me some of the most rewarding and the most challenging things about this?

Of course, it is rewarding when a sick child gets better and all the effort we put into it was put in the right direction.

A challenging thing is that about 90% of my time is spent on the contact with parents and often in vain because unfortunately the other side does not want to hear you and they are like that from the very beginning. In other words, nowadays young parents, both mothers and fathers think that the easiest things are to teach and to treat and this is available to everyone. They suppose that if here [in the hospital] patients only get wound bandaging it can be done at home. Or [this can be done by] a neighbor, a doctor or a nurse of a totally different specialization than surgical and this can be easily done by them. Unfortunately, it is very challenging to make parents change their minds, it is challenging to convince them that a surgical treatment is needed. In other words, there are some issues. Nevertheless, 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. I guess this is it.

As far as I have heard you, with all your experience it has now become easier to deal with parents, has not it?

Of course, it all comes with experience. To contact with people, to argue my actions in the aspect of treatment, this is, indeed, gets easier with experience. Nevertheless, it has got more challenging to find that “key” to every parent and to convince them. Moreover, medical personnel is now treated differently. When I started in the far away year [19]73, 43 years ago, a doctor was a respected person in both direct and figurative sense not depending on whether they had just graduated from a university, doctors were treated with respect. I started working in adult surgery and it was all respect and honor. And now this treatment has changed completely and very rarely can one see a respectful attitude towards one. 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. And to somehow put up with it and this way calming down and putting off this inner fire and resistance inside a parent. Otherwise that would be extremely difficult, just horrible. It is like feeling being systematically burnt on a spit. This is one thing. Another thing is that with practice I have learnt to take it with more calm. It is not that my feelings towards a patient have been numbed, not at all. I am trying to find some arguments that eventually help me to get out of such situations. Once more, this is all because of the time [we live in], the environment, we have no more. I can only say that if I had to decide my profession now I would reflect on that over and over again. Nevertheless, I could have been useful in any profession. Anyway, in any profession positive sides can be founded.

All right, so this is your approach to handling a difficult emotional situations.

Yes, it is. I never fall into depressions, I do not feel this so-called emotional burnout because well in the end there are weekends. In the end a person grows up, and his at home situation changes. Their children grow up, their grandchildren appear, this is, indeed, a safety-valve, a distraction. Let's put it this way, when I was young my safety-valve was something, now it is something else. Like G.A. [another interviewee] said, you read less but 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 And now I feel freer, yes, I do have my students but I have learnt not to work nights like I was working earlier. So, the priorities change and you have more opportunities. Life goes on like a spiral. Well, it is not bad. Everything is not bad no matter what.

Could you please tell me if you take your emotional working problems home?

I have learnt to be patient. When I was young I was calling the hospital trying to know how my patients were doing. Now I do this more and more rarely. Do you know why? Our nurses. I believe them, I rely on them, I rely on their professionalism because our nurse have been working here for a long long time. They sometimes would act more adequate than a young doctor on duty. I totally rely on them. Secondly, if earlier it was me who was calling to the hospital, now it is me who is called. This is completely different. Thirdly, now I work longer hours, I leave later and all the challenging situations I work on them here. And then, with a light heart, I go home and know that nothing serious should happen till morning.

Good. In your work do you face the need to perform emotions that interfere with the emotions you really feel?

Such situations happen. Since I am the administrator [of the hospital] I think I should be a lightning rod between the medical personnel and parents. Secondly, if you can change your husband, your children, now I know that it is impossible to change your patients' parents, I do not stress because of this, I take them as they are and sometimes I do not pay attention to this. If someone offends me I do not get offended. In such a situation you can only say (to yourself) that this person has been badly brought up and cannot become nothing that would worth it so why would I teach his to behave himself, I do not do that. Sometimes I do just the contrary: 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!”. I say a phrase that a parent does not at all expect. If earlier I was just coming in the room and saying “You have to clean and order the room” than now I have a completely different attitude towards this. I leave that till later, not begin with that. Once more, this have come with experience, not just in a minute. First I was reacting emotionally and thinking that in surgery it is very important to have everything in its place, now I think this can be put off.

Do you work on our emotional inner self when dealing with parents?

Absolutely. Like my colleagues say, to enter a hospital room is like entering a tiger cage. I prepare myself to this and as a rule it does go well. Why do I say this? 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. Before it was harder because we were not prepared to all this negative but now we are. And once again it is all explained by the external factors.

Many of those who go through feeling emotional stress try to help others that are in the same situation, give advice. Do your colleagues and you exchange your emotions and advice?

Me myself I do not share my emotions with my colleagues but I suppose that acting like that, not splashing out my emotions but finding a brake for myself, my colleagues see that and those who want can take note. We do talk but I guess if a person is not dull he or she will take note of it. We are all adults here and I will not teach anybody.

Speaking of the need to get your emotions out, not about teaching anybody, do you believe there is a need to share emotions with your colleagues or do you consider this unprofessional?

This is inadequate and unprofessional. In the end, they also feel the same emotional stress as me and more, they have to be on the foreground [since she does not deal directly with ordinary patients ] they take the first kick getting to know a child and his parents and I only interfere when there is a real conflict.

Do the authorities of the clinic take any measures to reduce your emotional stress?

Well, there are no such special measures. There are, though, 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 [that are not provided by the hospital, but by an external charity organization]. 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. Nevertheless, this is not that often.

You as the head of a department, do you see the need for your department in such measures?

Absolutely. There was once a psychologist working in the department whose idea was to put a poster saying “Do not forget that doctors are also people!'. And I was once sent a picture saying “Do not forget you are patients and not clients and we are doctors not service staff”. In other words, obviously, our mass media - newspapers, TV, radio etc - have put some enough effort to worsen our image lower than you can imagine. The thing is, everyone is different. Not everyone goes to the medical university due to their calling, some do this because it has always been seen prestigious, some just to please their parents. Of course there are cases of absolutely indifferent people coming into medicine. It is clear that from this people we cannot expect anything good. It is also 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. It is seen when watching such TV programs that the journalists do not analyze anything or you read it between the lines in newspapers. And this way a negative picture of medical personnel is created. In the end, they are also people, they all have emotions - both positive and negative, they all have problems at home, financial problems and one cannot just ignore all that. There is too much permissiveness from the part of the patients' parents. Once more, this is the result of home and school education, and there is nothing we can change here. There is no respect for our work.

What would you do to reduce your emotional stress?

The problem nowadays is that there are far too many controlling state agencies. It is very difficult to fit every requirement. This controlling agencies do not work united to help a patient. We face many cases when we need to fit requirements or stick to instructions that were written by people who are far away from medicine. Often new orders of the superior authority deny everything that was required before. This just does not make any sense. Moreover, there is way too much paper work to be done. If before it was just a formal requirement, now this is severely punished. This is very challenging emotionally. 90% of our time has to be devoted to fill in medical documents. In the reality, this is such a formality. We are all humans, we do make errors sometimes. I do understand no mistakes in medicine should be made. Nevertheless, we are obligated to pay the majority of our attention to correctly fill in the documents and not to help our patients directly. And this is getting more and more challenging. Nowadays an illness is being treated, not a patient. 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.

So the health care system is absurd as far as I understand.

Yes. It is a system very difficult to understand. There were a lot of useful practices in the soviet times which with the time has all fallen apart as a card house. And in this sense our work is getting more and more challenging. Whereas the requirements are more and more strict.

And the last question. In your high position with a very high responsibility and many responsibilities do you think it is possible to reach a peak of one being able to emotionally deal with it all?

I suppose that “emotionally burnt” people are only those who have come here by accident.

So there is a selection on the earlier stages?

Yes. I think this is a forced term. Maybe forced by psychologists, I cannot say. I suppose that emotional burnout is not only connected to the work that is done by a person but also is affected by some external factors. It should all be taken together. If one is here due to their calling their work will not affect a person that much.

So it all comes from the inside?

Absolutely. One should always try to be positive no matter what.

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