Sundus Siddique MBBS,MPH ,Doctoral Research Assistant, Center for the Promotion of Health in the New England Workplace (CPH-NEW); Department of Public Health, Zuckerberg College of Health Sciences, University of Massachusetts Lowell; Rebecca Gore PhD, Center for the Promotion of Health in the New England Workplace (CPH-NEW); Department of Biomedical Engineering, Francis College of Engineering, University of Massachusetts Lowell, Lowell, MA 01854; Yuan Zhang, PhD, Solomont School of Nursing, Zuckerberg College of Health Sciences, University of Massachusetts Lowell, Lowell, MA 01854; Laura Punnett, ScD ,Center for the Promotion of Health in the New England Workplace (CPH-NEW); Department of Biomedical Engineering, Francis College of Engineering, University of Massachusetts Lowell, Lowell, MA 01854
This study investigated the association of depressive symptoms with preventable work environment factors, particularly understudied factors like surface-acting emotional labor (SaEL), work role functioning, and organizational perception of support for safety. An important goal was examination of these factors in a mixed population of clinical and non-clinical personnel where unlicensed assistive personnel predominated over licensed staff. We also examined the role of emotional exhaustion, a dimension of burnout, in mediating and/or moderating the association between emotional labor and depression, using a novel decomposition technique proposed by Valerie and VanderWeele (2013).
Healthcare jobs require workers to have a high level of work functioning while managing numerous mental, physical and interpersonal demands. Surface-acting emotional labor (SaEL) is an essential job demand in healthcare, requiring a worker to suppress their true emotions in order to maintain a professional appearance and acceptable job performance. This reactive modification of one’s emotions, or masking, results in a cognitive dissonance that imposes psychological stress, which might result in adverse health outcomes like burnout and depression. These associations are understudied in ancillary or unlicensed assistive personnel, such as medical assistants and allied healthcare workers, and non-clinical personnel who are also essential to provision of healthcare services.
A self-administered cross-sectional survey was distributed to all employees of five U.S. public sector healthcare facilities. Survey questions covered demographic, health, and work environment characteristics. Depressive symptoms were measured using the CES-D scale (continuous). Independent variables included SaEL, job strain, work-family conflict, work role functioning (Abma et al. 2018), and organizational support for safety (NOSACQ). Emotional exhaustion (continuous) was measured using an adapted version of the Oldenburg Burnout Inventory. Multivariable linear regression and mediation analyses was done using SAS. Causal mediation was examined using the VanderWeele method (2014) to decompose the mediation effect into four components (Figure 2).This data collection and analyses for this study have been completed.
A total of 1,060 surveys were collected from a predominantly female population. Depression scores were uniform across study sites, gender, and direct care/non-direct care jobs but higher in younger workers (18-40 yrs) (p=0.04). In multivariable regression models, SaEL, emotional exhaustion, job strain, and work family interference were positively associated with depression while perceived organizational support for safety and work role functioning were negatively associated. About 40% of the association between emotional labor and depression was mediated through emotional exhaustion (p=0.0004) (Figures 1 and 2).
In this population of predominantly unlicensed healthcare workers, SaEL, work-family conflict, decreased work role functioning, and lack of organizational support for safety were all associated with depressive symptoms. These findings are noteworthy because the latter three associations have not previously been documented, and emotional exhaustion has primarily been studied among licensed professionals. Also novel was the strong mediation of emotional labor by emotional exhaustion. Emotional exhaustion is an outcome in its own right, with risk for leaving the job, and in this study it is also identified as on the causal pathway to depression.
Our findings suggest that interventions regarding SaEL are needed for HCWs in order to reduce emotional exhaustion and consequently decrease the risk of depression. Further longitudinal studies are needed to verify these associations.