Emotional labor of nurses in the front line against the COVID-19

e20200660 http://dx.doi.org/10.1590/0034-7167-2020-0660 9 of ABSTRACT Objective: To analyze nurses’ experiences in the front line of the fight against the COVID-19 pandemic regarding the performance of emotional labor (EL), aiming at its characterization and identification of support strategies and development opportunities of nurses and practices. Methods: Qualitative, descriptive, and exploratory study, with content analysis of eleven written narratives and reports from a focus group composed of nurses with experience in caring for patients with COVID-19 from different Hospital Centers in Lisbon, Portugal. Results: Five themes were extracted: 1) Challenges experienced by nurses in the frontline; 2) Emotions experienced by nurses in service care; 3) Emotional responses of nurses and patients: impact on care; 4) EL of nurses in the patient care process; 5) Opportunities for development in the face of the emotional challenge required of nurses in combating COVID-19. Final considerations: The nurses demonstrated the ability to transform this profoundly emotional experience positively. Descriptors: Emotions; Nurses; Nursing Care; Pandemics; COVID-19.


INTRODUCTION
The current pandemic caused by the SARS-CoV-2 virus, which translates into COVID-19 disease, has become a major health crisis on a global scale in the course of 2020. Thus, nurses fighting the COVID-19 pandemic are exposed to an extreme and prolonged situation, subject to a high risk of contagion because their work is in direct and frequent contact with infected people. These nurses are in the "front line, " an expression originating from the combat in a war situation to designate the element or set of elements with greater exposure, more visibility, or more significant advancement in an activity.
In addition to caring for patients in severe and potentially fatal situations, nurses who are on the front line are at risk of contagion and death, as well as potential contamination of their relatives. Some health professionals are even avoiding physical contact with the family or community due to stigma or fear, making this moment, already challenging, much more difficult (1) .
In this scenario, nurses also face substantial changes in their workplace, mainly due to long hours, constant change in teams, and reallocation of services due to the new organization of patient care circuits "COVID and not COVID. " Such changes accentuate the stress, uncertainty, and even impotence experienced by these professionals, exposed to a complex, dynamic, and unexpected context; all of this brings to this experience profoundly emotional meanings.
Studies on extreme and borderline situations identify the sources of anxiety and fear among nurses on the front line of the fight against COVID-19 and are a reference for understanding the problem, but research in nursing is scarce. It does not clarify the emotional experience and emotional management skills of nurses (2)(3)(4) .
The pandemic exposes the nurse to a complex, very dynamic, and unexpected scenario that may hinder their adaptation and emotional well-being and, consequently, the provision of care. This experience involves a negative and disturbing emotionality, which requires intense emotional labor (5) that needs to be investigated, given the specificity of the COVID-19 pandemic. Thus, this research seeks to answer the question: How do front line nurses perform the EL in fighting against the COVID-19 pandemic?
In the performance of the EL in nursing, the process of management of emotions and feelings is considered the central aspect (6) . This emotional management has a triple centrality, since it has as focus the patient, the nurse, and the relation nurse-patient (7)(8) , aiming at both the humanized emotional care and emotional well-being of the people cared for, as well as the well-being, satisfaction, and emotional balance of the nurses.
The conception of EL in nursing fits, still, in the constructivist perspective of Nursing as a science of caring, which cannot remain indifferent to understanding the human experience of emotions, to its sharing and adaptive management in the patientnurse relationship (7,(9)(10) . Nursing care requires the management of emotions by establishing the relationship between nurse and patient and the flow of emotions omnipresent. In this sense, it is urgent to identify the limits and optimize the nurse's unique resources in different scenarios to understand the daily practice that they (re)construct and potentiate constantly.

OBJECTIVE
To analyze the experiences of nurses on the front line of the COVID-19 pandemic regarding the performance of EL in order to characterize them and identify support strategies and development opportunities for nurses and nursing practices.

Ethical Aspects
This research obtained a favorable opinion from the Ethics Committee of the Higher School of Nursing of Lisbon, guaranteeing respect, in all its phases, to the principles of research with human beings. The participants were provided with complete information about the study and requested to sign the Informed Consent Statement.

Design of study
A qualitative, descriptive, and exploratory study of content analysis, which allows interpreting data of a qualitative nature in a naturalistic paradigm (11) and, therefore, meets the subjectivity of the human experience, disclosing inductively the themes that represent the explanation of the EL phenomenon of nurses in the fight against the COVID-19 pandemic. Furthermore, it makes it possible to understand the process of developing emotional management strategies and, therefore, based on a constructivist perspective (12) .

Selection of participants
The option was for a convenience sample, based on the proximity and possibility of locating nurses available to participate in the survey during the month of May 2020, with a total of eleven participants selected.
The inclusion criteria were: nurses with experience in providing nursing care to people (regardless of age) with COVID-19. Managerial nurses or nurses who manifested self-reported emotional fragility were excluded.

Study setting: Collection of data
The participants are active in the following assistant sectors: pediatric emergency (5), general emergency (1), pediatric intensive care unit (1), hospitalization of adults/elderly (2), pediatric infectiology (1), and infectiology of adults/elderly (1), which belong to five Hospital Centers in the Greater Lisbon area of the Portuguese National Health System (public sector). These are places for priority care of positive COVID-19 patients, restructured with the definition of proper circuits for the circulation of patients and professionals, and assistance "COVID and not COVID. " In these, the nurses' schedules were extended (more weekly hours, overtime; in some sectors, the shifts went from 8 to 12 hours).

Collection and organization of data
The nurses were asked to write down narratives and participate in a focus group; two techniques of self-reporting personal experiences. The guide to the narratives provided to the participants of Emotional labor of nurses in the front line against the COVID-19 pandemic Diogo PMJ, Lemos e Sousa MOC, Rodrigues JRGV, Almeida e Silva TAAM, Santos MLF.
included: the description of a care experience with an emphasis on its emotional aspects, interactions, shared emotions; verbal and nonverbal communication, singularities; the facilities and difficulties in the relationship with patients, colleagues, and other health professionals; and the strategies used for the management of emotions.
The written narrative allows us to reach the richness of meanings, build reality, and understand the meaning people give to what they experience (13) . In turn, the focus groups gather from 4 to 12 people and are semi-structured discussions that aim to raise points of view on health issues, programs, interventions, and research, encouraging respondents to explore and clarify individual and shared perspectives (14) .
Each participant wrote a narrative of their experiences, resulting in eleven narratives presenting two to six pages in a Microsoft Word® file, and sent them by e-mail. The study adopted codes from NN1 to NN11 to codify the narratives, which were then assigned by order of arrival.
The focus group was gathered after the delivery of the narratives. The leading researcher coordinated the session, following the pre-established questions' script and articulating it with the findings that emerged from the analysis of the narratives. Seven nurses and two researchers participated in this two-hour focus group, one with the role of facilitator and the other to support and record contextual facts. The session was held at distance, due to the current pandemic situation and physical distancing measures, through the Zoom ® electronic platform, and recorded by the computer audio system. The transcription of the content was executed by two researchers, who agreed to follow the guidelines by assigning the GF code (15) and not discriminating participants. The transcription resulted in 24 pages in the Microsoft Word ® file. The data obtained was used in the construction of the thematic tree by employing inductive reasoning and constant comparisons in the reports, according to the conventional content analysis technique (11) .

RESULTS
From the nurses' experiences shared in the written narrative and the focus group, five themes were extracted, namely: 1) Challenges experienced by nurses in the front line of fighting COVID-19; 2) Emotions experienced by nurses in providing care to patients with COVID-19; 3) Emotional responses of nurses and patients with COVID-19: impact on care; 4) Nurses' EL in the care process of patients with COVID-19; 5) Development opportunities in the face of the emotional challenge required by nurses in fighting COVID-19. Chart 1 summarizes the themes and sub-themes that emerged from the content analysis.

-The challenges faced by nurses in the front line of the fight against COVID-19
The nurses mentioned that COVID-19 affects the "physical, social, behavioral and emotional dimension" of the patient, adding an "experience of different and unusual feelings, " which characterize special complexity situations. The perception of lack of preparation for such an atypical and demanding pandemic occurs due to the "unknown situation, different from everything else, frequent alteration of information and norms, " besides the initial news coming from Italy, which helped to "anticipate chaos" and the will to "do something, but without knowing well what. " Personal Protective Equipment (PPE) adds to the difficulty in providing care, besides the "high emotional burden and a demanding physical effort" experienced mainly in the early days of the pandemic and nowadays due to its cumulative effect.
At an early stage, I remember it was night in the COVID- 19  All this adds to the "physical distancing from the nuclear family to prevent infection. " Moreover, there is the "possibility of being infected by a lethal virus. " Many emotional and physical challenges get enhanced by this. Nurses also characterize the challenges they face using metaphors about care dynamics, such as "living in chaos, fighting during wartime, the world turned upside down, being together in a mission, fighting in the trenches, using protective filter; metaphors about the virus (bogeyman called COVID-19, getting away from people like the devil runs from the cross); and also metaphors about themselves (work to the bone, feeling of being a contagious germ with legs and arms, emotions cook up inside the PPE, running a marathon).

-The emotions experienced by nurses in providing care to patients with COVID-19
In the care process, nurses describe anticipated emotions as fear and anxiety when they receive the information "that they are going to care for an infected person"; and emotional instability because they are "upset and irritated much more easily. They often mentioned fear and is associated with: "getting infected, the lethality of the disease, not having PPE to protect themselves, infecting the family and loved ones and not knowing how to intervene." Besides fear, they experience other emotions and feelings: "anxiety, insecurity, pity, isolation, depersonalization, danger, irritation, apprehension, intense stress, anguish, impotence, sadness, revolt, frustration, uncertainty, nostalgia, strangeness. " [...]  This intense and disturbing emotional experience is conscious for the nurses and it is a concern about their mental health.
[…] The most recent signs show that we are not [nurses] immune to stress, anxiety, and isolation, or even depression. This pandemic is affecting the mental health of some colleagues […]. (NN2)

-The emotional responses of nurses and patients with COVID-19: impact on care
The nurses describe a reactivity that translates into behavior changes in the team's relationship manifested by "emotional ability, isolation, logorrhea, denial, " and the revelation of entirely different personality traits. Besides, they present physical alterations such as "difficulty in sleeping, back pain, headaches. " Moreover, it is added to this, especially in the pandemic's initial phase, the intentional reduction of contact between the nurse and the infected patient.
[…] a fellow nurse who was known to be very "sociable", altruistic, always in a good mood, with a contagious humor [ People with suspected or already diagnosed with COVID-19 have an exacerbated negative reactivity of "fear, aggressiveness, anxiety, irritation, crying". Other patients react very passively and in denial, and some hide the fact that they are infected. Other patients who resort to health services, but are not infected, manifest "much fear of being infected. " The parents' aggressiveness and reactivity in entering and staying in the [pediatric] emergency of COVID is visible and exacerbates as the hours go by, and even the fact that we provide meals, water and other amenities does not help, because in their minds the fear is such that they only think "I'm locked in a space with COVID and I can't leave. (NN4)

-The nurses' Emotional labor in the process of care for patients with COVID-19
The nurses identify factors that hinder the performance of the EL, such as "the barrier caused by the use of PPE, the impediment to a more affective and warm care, the loss of identity, emotional emptiness during the interaction, the perception of dehumanization and an unaccompanied death, the cold and low confidence relationship, the difficulty in emotional management and the superficial knowledge of the history of the person. " We don't know how to manage these emotions, we don't know how to deal with them, we don't know how to respond to the event at the moment; call a relative and say: "Good morning, Mr The performance of the EL presents a focus on the patient and the care relationship, which is characterized by: "being present, empathy, availability, sensitivity to the emotional state of the person, facilitating emotional expression, reassuring through information, touch and affection, optimizing the message through gestures, voice, look, humor, play and use of technology. " In one of the pressure rooms [or isolation rooms], we can talk a lot over the phone, and we have a camera. We can make contact in this way so that we are not using the PPEs and everyone can see... the face. Because one of the things [patients] say is that "I don't see your expression, I can't see", but when they see, is like that, and it has been very important to be able to talk, to be able to see us. (GF)

Along with comfort measures, play is in my daily practice a recurring strategy and even using all PPEs, continues to generate an effect. (NN4)
Along with this approach, the nurses describe a self-focused EL, characterized by strategies of positive and adaptive emotional management regarding their internal world, such as: "evidencing the effectiveness of an intervention, remembering the low percentage of new cases, sharing experiences and emotions with the team, having hope and reinforced motivation to care. Also, they seek to positively transform the emotional experience through strategies such as "being aware that taking care of transforms the situation, shifting the focus of attention to positive things: watch less news about COVID-19, reflecting on reality with other eyes and in a haven, seeking to deepen knowledge, inducing relaxation, asking for help when they are feeling on edge, using humor among colleagues. The support of family and friends is described as fundamental and occupy free time with leisure activities. However, "crying to reassure yourself" is sometimes necessary. [

-Development opportunities in the face of the emotional challenge demanded of nurses in the fight against COVID-19
The EL, as described, is necessary to deal effectively with this emotionally disturbing and stressful pandemic crisis, which is paradoxically potentiating "an experience of growth and transformation". It is noted: "the positive adaptation of nurses over time and experience, increased organizational effectiveness and restructuring of care, team cohesion and sense of belonging, recognition of the nurses' intervention, awareness of the importance of things they took for granted. " The emotional experience has been a great challenge, full of a negative burden, but transforming how to look at the reality, who I am and how, as a nurse, I grow personally and professionally, working with a focus on the emotional well-being of the patient and family, and minimizing the stress they refer to. (NN5) In general, COVID has become our new normal; and colleagues, a second family. Going to work is also an opportunity to break social isolation and be able to share emotions, tears, and smiles. These pandemic highlights situations that we take for granted and shows us the true importance of the little things of everyday life, such as a hug or that farewell that may be the last. (NN3) Still, from the participating nurses' perspective, development opportunities would be increased with the support of the health institutions. If the "teams had more collaborators, " if the senior management considered more the "suggestions and feelings of the nurses. If there were formally "groups analysis of situations and sharing feelings in the services, " if there was "psychological support outside the institution. " Furthermore, a website should be provided for scientific debate on the meaning of emotions, short training, information, and other interactive group activities for sharing and discussing feelings, but dynamized externally, especially for the front-line nurses on the fight against COVID-19.
It would be fundamental for all institutions to have more teams, so that we could rest physically and psychically, without having to be more than 20 days in a row without time off and every day we have to be in the COVID zone. (NN6) Of course, we always have the psychologists in teleworking, who are available. But maybe something more [a website] would also be useful for us to share, and even these groups I think are funny to be able to understand what our colleagues are also going through, and maybe they are going through things remarkably similar to ours. (GF) Our fears are shared, our expectations are shared, and this becomes also... I think that in emotional terms it also helps us to grow and therefore we would be able to adapt emotionally, with this [website], with the fact that these shared experiences, are also tools. (GF) The findings reveal that the nurses' EL's performance in the COVID-19 pandemic scenario is critical to confront challenges effectively, deal with disturbing emotions, minimize negative emotional responses, and transform the experience into learning and development. The findings also report on nurses' ability to positively transform this deeply emotional and stressful experience based on resilient emotional management and consequent progressive adaptation, as outlined in Figure 1.

DISCUSSION
The challenges experienced by the participating nurses facing the COVID-19 patient are related to the structure and organization of care, with the risk of exposure to the virus and the workload. All these changes, having occurred in a short period and associated with an unknown pandemic, atypical and, with no predictable outcome, generate stress, anxiety, impotence, fear, anguish, and other negative emotions.
Some of these challenges appear aligned with the sources of the anxiety of health professionals already identified (2) : 1) access to inappropriate PPE; 2) high probability of exposure to COVID-19 and, consequently, family exposure; 3) lack of support to personal and family needs due to increased hours worked (food, hydration, housing, transportation); 4) lack of access to up-to-date information and communications; 5) inability to provide competent care in an area which they were unfamiliar or never provided care. However, th e professionals also identified the following sources of anxiety (2) : 6) lack of access to CO-VID-19 rapid tests and, consequently, fear of spreading the infection at work; 7) uncertainty regarding the organization's support and care to the personal needs of professionals and their families, should they develop the infection; 8) lack of access to childcare during working hours before school closings. The characteristics of the disease, such as contact transmission, high morbidity, and lethality, linked to the need for frequent and close contact with patients and the increase in the number of working hours, may have contributed to intensifying the perception of danger felt by professionals (16) . Moreover, the predictable shortage of supplies and the increasing flow of suspected and Ability to transform the experience positively confirmed cases of COVID-19 may have contributed to increasing the concerns and pressures experienced by health professionals.
The challenges and emotions experienced by the participants fluctuated over time and with the updating of information. However, in the early phase of the pandemic, the probability of nurses being adequately informed about exposure or receiving adequate protections was lower, as was the case during the COVID-19 epidemic (17) .
The challenges and the intense and lasting emotional experiences, which are part of the new reality of health professionals, may have negative consequences on their mental health (18) , which corroborates this research's findings. An example of this is the association between stress and changes in sleep quality (19)(20) . A survey conducted in China with 1.257 health professionals assisting patients with COVID-19 in 34 health units identified a considerable proportion of nurses who reported depression, anxiety, insomnia, and distress (16) . This survey also identified such emotional responses.
The findings reveal that the nurses, in addition to intense emotionality and physical changes (such as difficulty in sleeping, back pain, or headaches), describe a reactivity that translates into behavior changes in the relationship with the team, marked by emotional lability, isolation, logorrhea, and denial, as well as the revelation of personality traits previously unidentified. It is known that the main symptoms that accompany responses to trauma and interpersonal conflicts are loss of appetite, fatigue, physical decline, sleep disorders, irritability, absence of mind, numbness, fear, and despair (21) .
As for the patients, the participating nurses described that some, suspected or already diagnosed with COVID-19, had an exacerbated negative reactivity, while others reacted very passively and in denial. On the other hand, people who resort to health services but are not infected revealed to be afraid of being infected. These findings are in line with research according to which, during an outbreak of infectious disease, especially in the presence of inaccurate or exaggerated information, anxiety can become excessive, impelling the individual to manifest unadaptable behaviors (22)(23) .
At this juncture, is highlighted the need for adequate training of health professionals to promote mental health (24) . Nursing as a science of care (9) cannot remain indifferent to human emotions before COVID-19 because the relationship between nurse-patient implies understanding the experience of emotions, their sharing, and adaptive emotional management. Thus, the nurse must act sensitively and affectionately, aiming to regulate the emotionally disturbing events and transposing the negative emotions (25) in the EL's performance in nursing (5) . This process of management of emotions and feelings emerges as central in the EL in nursing (6) .
The participating nurses identified not only the factors that hindered the performance of the EL before the patient with COVID-19 (barrier created by PPEs, perception of dehumanization and an unaccompanied death, cold and low confidence relationship, superficial knowledge of the patient's history) but also the facilitating factors (support and emotional support within the team, previous experience of pandemic, recognition by patients and relatives, recognition by external institutions). The nurses' EL's performance is directed to the patient and the care relationship as self-focused, thus contemplating positive and adaptive emotional management strategies. Therefore, it reveals itself as a process of gradual construction, by the selfdevelopment required in the current care scenario, in which the nurses (re)build their inner world, the particularities of their self, their being, their knowledge, their action-interaction, and their emotional competence.
Such conceptions are in line with the triple centrality of emotional management that characterizes the nurses' EL: focusing on the patient, the nurse, and the relationship between nurses and patients, aiming at the emotional well-being of the people cared for, emotional and humanized care, as well as well-being, satisfaction and emotional health of nurses (8) . Both EL and emotional intelligence may significantly affect the nurses' well-being and their perception of work stress (26) .
A study developed by researchers at the Center for Research in Health Technologies and Services, which follows the evolution of nurses' mental health during the COVID-19 pandemic in Portugal, corroborates the emotional management strategies described by the participating nurses (27) . They verified that resting between shifts, maintaining social contacts, verbalizing feelings, and eating healthy are strategies associated with lower levels of stress, anxiety, and depressive symptoms.
Therefore, the findings reveal that the EL performance of the nurses participating in the COVID-19 pandemic scenario is critical to overcoming challenges, managing troublesome emotions, minimizing negative emotional responses, and transforming the experience into learning and development. However, from these nurses' perspective, development opportunities would be enhanced with the support of health institutions, including more health teams, groups analyzing situations and sharing feelings, with psychological support outside the institution and the existence of online platforms for front-line nurses.
The importance of service planning in response to health professionals' needs is already recognized (28) . To have acceptance of the professionals it was intended to, a previously established program had to be redesigned, integrating their needs. This program contemplated a rest area, training care for patients with COVID-19, information on protection measures, leisure activities, and periodic visits to the rest area by an expert (28) . This adaptation of the program provided greater satisfaction among health professionals, emphasizing the need for feedback and adjustment of interventions to the professionals for whom they were intended.

Study limitations
In this study, we can consider the following limitations: a) the participants are all from the region of Lisbon and Tagus Valley, Portugal. It would be important to extend the research to other regions of the country, with greater incidence, because these places were closer to the point of saturation of services; b) on March 2, 2020, the first cases with SARS-CoV-2 were diagnosed in Portugal, and data collection occurred between the state of emergency and the beginning of the flexibilization of home isolation. Time seems to be an important variable in the experience of this phenomenon, so research should continue throughout and after the pandemic; c) the realization of the focal group at a distance of Emotional labor of nurses in the front line against the COVID-19 pandemic Diogo PMJ, Lemos e Sousa MOC, Rodrigues JRGV, Almeida e Silva TAAM, Santos MLF.
(via Zoom ® platform) may have influenced the spontaneity and stimuli that usually result from face-to-face interaction between participants, but the need for safety and respect for physical distance prevailed; d) the scarcity of specific scientific literature on the COVID-19 and EL pandemic limits the knowledge for data discussion, since the WHO only decreed the pandemic on March 11, 2020, and few nursing researchers approach EL.

Contributions to the field of Nursing
The study emphasizes the human experience of emotions associated with nursing care to patients with a recently known infectious and lethal disease, expanding EL's understanding in nursing in an atypical scenario like the COVID-19 pandemic. The nurses' challenges in the front line of combating the disease have been unveiled, allowing nurses to take them into account in the organization of work and team leadership, incorporating the following elements: motivation, conflict management, training, development, support, safety, and innovation. Furthermore, it was possible to verify that even nurses who have never worked in a pandemic crisis condition or a catastrophic environment demonstrated to have the resources to deal with adversities, managing emotions effectively and adaptively.

FINAL CONSIDERATIONS
Nurses' experiences on the front line against the COVID-19 pandemic with EL performance are characterized by the intense challenges and emotions experienced in providing care, the emotional responses of nurses and patients with COVID-19, and their impact on the care process, as well as the development opportunities in the face of the emotional challenge required. These identified dimensions revealed a progressive adaptation process, in which the nurses' EL performance translates resilient emotional management. The experiences reported by the participants demonstrated the capacity of the nurses to transform intense and emotionally stressful situations positively.
The nurses' EL is necessary to deal effectively with this pandemic, which paradoxically is potentiating "a growth and transformation experience" among the participants. Researchers should continue to investigate this issue since the impact of COVID-19 on the nurses" emotional and even mental health is well known.