Recurrent pregnancy loss (RPL) is marked by multiple pregnancy losses, placing intense emotional and clinical demands on gynecological nurses who often serve as both medical and emotional support for affected patients. While prior research on emotional labor in healthcare underscores the toll of caring for bereaved individuals, few studies have examined the unique, cyclical nature of grief inherent in RPL care.
A qualitative, phenomenological design was employed to explore the experiences of 12 gynecological nurses working in early pregnancy units. Semi-structured interviews investigated nurses’ perceptions of emotional labor, the coping strategies they utilized, and the influence of organizational factors on their well-being. Thematic analysis guided by Braun and Clarke’s framework illuminated emerging patterns, with member checking and peer debriefing ensuring analytical rigor.
Four key themes emerged. First, The Emotional Burden of Recurrent Loss highlighted nurses’ cumulative grief and sense of “compounding sorrow” as they supported patients through multiple losses. Second, Balancing Empathy and Professional Boundaries underscored the tension between offering genuine compassion and guarding personal emotional reserves. Third, Coping Strategies and Resilience-Building revealed a multilayered approach comprising reflective practices, peer debriefing, and self-care. Finally, Organizational Support and Gaps emphasized how institutional resources, staffing levels, and specialized training significantly shaped nurses’ capacity to sustain empathetic care.
Nurses caring for RPL patients experience heightened emotional labor due to repetitive, distressing encounters with loss. While individual and peer-based coping mechanisms foster resilience, organizational support—such as formal debriefing sessions and RPL-focused training—amplifies nurses’ well-being and ensures sustainable, high-quality care. These findings underscore the need for targeted interventions that address both the individual and systemic dimensions of emotional labor in RPL settings.
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Introduction
Background and context
Recurrent pregnancy loss (RPL), defined as two or more consecutive pregnancy losses before 24 weeks of gestation, affects approximately 1–2% of women trying to conceive [1]. The prevalence increases with maternal age, reaching up to 5% in women over 35 years [2]. While these statistics highlight the medical significance of RPL, they fail to capture the profound psychological and emotional impact on affected individuals and couples.
By its very nature, RPL creates a complex cycle of hope and despair, as couples navigate subsequent pregnancies while carrying the emotional burden of previous losses [3]. Patients experiencing recurrent losses often report severe emotional distress, including clinical depression (40–80%), anxiety disorders (30–50%), and post-traumatic stress symptoms [3]. Building on these findings, it becomes evident that this recurring trauma requires specialized emotional support from healthcare providers, particularly gynecological nurses who serve as primary caregivers [4]. Gynecological nurses in early pregnancy units occupy a unique position in RPL care delivery. Beyond their clinical responsibilities of monitoring early pregnancies, managing follow-up appointments, and providing educational resources, these nurses function as emotional anchors for patients experiencing repeated losses [5]. Their duties encompass a wide spectrum of emotional support, from delivering difficult news and counseling bereaved couples to offering hope and guidance for future pregnancies [6]. In this context, nurses often form close bonds with patients, heightening the emotional stakes whenever a new loss occurs.
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Numerous studies suggest that health professionals who repeatedly witness patient trauma may develop secondary traumatic stress and compassion fatigue [7]. In RPL settings, these risks are heightened when nurses must deliver similarly distressing news to the same patient multiple times, which can lead to emotional distancing as a form of self-protection [8, 9]. Unlike other acute care scenarios where interactions are relatively short, RPL care involves repeated encounters with the same patients, often through multiple losses [10]. This ongoing exposure to grief, coupled with the responsibility to maintain a supportive yet hopeful demeanor, can deplete nurses’ emotional resources and increase vulnerability to burnout if not properly addressed [11]. For instance, a nurse may initially approach each loss with deep empathy, offering unwavering emotional support. Over time, however, she may find herself hesitating at the patient’s door, anticipating another devastating outcome. This hesitation reflects a gradual shift from genuine empathy to a more guarded emotional stance, signifying the early stages of compassion fatigue.
Emotional labor: conceptual foundations
The concept of emotional labor, first introduced by Hochschild [12], describes the process of managing emotions and emotional displays in professional settings to meet organizational expectations. In nursing, emotional labor manifests as the intentional regulation of feelings to maintain a caring persona while delivering healthcare services [13]. This theoretical framework has evolved significantly in nursing literature, encompassing three key dimensions: surface acting, deep acting, and the expression of naturally felt emotions [2, 11].
In nursing practice, emotional labor theory has expanded to include concepts of empathy, compassion satisfaction, and compassion fatigue [7]. Research indicates that nurses engage in significant emotional management to maintain professional composure while providing empathetic care, particularly in high-stress situations [5]. This emotional work is especially pronounced in settings dealing with loss and grief, where nurses must balance professional responsibilities with genuine emotional support [14]. Given the cyclical patterns of hope and despair that define RPL, emotional labor can become a prolonged, repetitive process rather than a single high-intensity event.
The context of RPL care presents unique challenges for emotional labor that distinguish it from other high-emotion healthcare settings. Unlike oncology or hospice care, where the trajectory of loss might be more predictable, RPL care involves cyclical patterns of hope and loss as patients return for subsequent pregnancies [3]. This recurring nature of loss creates a distinct emotional dynamic where nurses must repeatedly engage with the same patients through multiple grief experiences while maintaining therapeutic optimism [4].
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The potential for compassion fatigue in RPL care is particularly concerning. Studies suggest that repeated exposure to patient trauma can lead to emotional exhaustion and burnout among healthcare providers [9]. In the context of caring for repetitive pregnancy loss, nurses’ emotional resources can become progressively depleted’, when nurses consistently confront the heartbreak of recurrent miscarriages, their empathy may wane over time, inadvertently compromising both their well-being and the care they deliver [6]. Despite growing recognition of compassion fatigue, most healthcare research focuses on single-event or short-duration scenarios [8]. Few studies address the cumulative emotional toll of recurring patient encounters in RPL care, where nurses repeatedly witness the re-emergence of grief [8].
Rationale and problem statement
The examination of emotional labor in RPL care represents a critical area of investigation with significant implications for both clinical practice and healthcare policy. Research consistently demonstrates that nurses' emotional well-being directly influences the quality of patient-centered care, particularly in sensitive contexts like pregnancy loss [5, 7]. Understanding the nuances of emotional labor in RPL care could inform evidence-based institutional policies for staff support, structured debriefing protocols, and specialized training programs [2].
A significant conceptual gap exists in current literature regarding the intersection of emotional labor and recurrent loss experiences. While research has explored emotional labor in various healthcare contexts, limited attention has been paid to the unique dynamics of caring for patients through multiple, sequential losses [3]. This gap is particularly concerning given the potential for cumulative emotional impact on nurses who repeatedly support the same patients through traumatic experiences [15].
Research questions
This study addresses three interconnected research questions that examine different aspects of emotional labor in RPL care.
RQ1: What are the lived experiences of emotional labor among gynecological nurses caring for patients with RPL?
RQ2: Which coping strategies and resilience-building mechanisms do these nurses adopt to manage the emotional challenges arising from RPL care?
RQ3: How do organizational factors influence gynecological nurses’ emotional labor in the context of RPL, and what are the perceived gaps or supports provided by healthcare institutions?
Significance and contributions
This study offers significant theoretical contributions to emotional labor discourse by exploring the unique dynamics of repeated grief encounters in healthcare settings. The investigation of how nurses manage emotions through multiple loss experiences with the same patients extends current understanding of emotional labor theory. Furthermore, by examining the coexistence of compassion fatigue and satisfaction in RPL care contexts provides valuable insights into the complexity of nursing roles [8].
The practical implications of this research are substantial. Findings will inform nursing education curricula and continuing professional development programs, particularly in areas of emotional resilience and patient communication strategies [11]. Healthcare organizations can utilize these insights to develop or enhance support systems, including structured debriefing sessions and mandatory psychological support resources, ensuring that nurses are better equipped to handle recurrent loss scenarios and maintain their well-being.
Social and ethical considerations are central to this research, acknowledging the profound sensitivity surrounding pregnancy loss and the ethical imperative to protect both patient and nurse well-being. The study recognizes the broader societal impact of supporting healthcare workers in reproductive health services, contributing to improved healthcare outcomes and more sustainable nursing practice [12, 13]. In doing so,, this research aims to enhance understanding of emotional labor in RPL care while providing practical recommendations for supporting nurses in this challenging field.
Methods
Study design
A qualitative, phenomenological design was used to explore the lived experiences of gynecological nurses who care for patients with RPL. Phenomenology is appropriate for capturing the essence of participants’ experiences by focusing on their subjective perceptions and emotions [16].
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In this study, each research question informed a specific facet of the methodology. RQ1 guided open-ended inquiries about nurses’ lived emotional experiences, RQ2 shaped prompts about their coping strategies, and RQ3 underpinned discussions on how organizational factors influence emotional labor. This alignment ensured the phenomenological approach captured the depth and breadth of nurses’ perspectives on RPL care.
Participants
A purposive sampling strategy was employed to recruit registered nurses working in gynecological or early pregnancy units who regularly encountered patients experiencing RPL. The inclusion criteria were: (1) at least two years of clinical experience in gynecological nursing, (2) current employment in an early pregnancy unit or equivalent, and (3) willingness to participate in an in-depth interview.
A total of 12 participants were interviewed for this study. Recruitment was facilitated through the distribution of study flyers in hospital wards and by direct email invitations sent to unit nurse managers. Nurse managers then informed eligible staff members about the study, allowing those interested to contact the researchers directly. The characteristics of the participants are summarized in Table 1. Data collection continued until no new themes emerged from the interviews, indicating conceptual saturation. At 12 interviews, the research team observed thematic redundancy, prompting the decision to conclude recruitment.
Table 1
Participant Profile (N = 12)
Participant ID
Gender
Age Range
Years of Nursing Experience
Primary Unit Setting
Interview Duration (minutes)
P1
F
25–29
3
Urban
60
P2
F
30–34
7
Urban
70
P3
M
35–39
10
Urban
55
P4
F
40–44
12
Rural
65
P5
F
25–29
4
Rural
60
P6
F
45–49
15
Urban
75
P7
M
35–39
10
Urban
50
P8
F
30–34
8
Rural
70
P9
F
25–29
3
Urban
55
P10
F
50–54
18
Urban
60
P11
F
45–49
20
Rural
65
P12
F
40–44
12
Urban
60
F Female, M Male; “Years of Nursing Experience” refers to total professional experience, though all participants had at least two years specifically in a gynecological or early pregnancy setting
Data collection
Semi-structured, in-depth interviews were used to gather rich qualitative data from each of the twelve participating nurses. A semi-structured interview guide was developed specifically for this study based on a preliminary literature review, consultations with experienced gynecological nurses, and feedback from a qualitative research specialist. The English-language version of this guide can be found in Supplementary File. Prior to initiating any interviews, written informed consent was obtained from each participant, and a concise information sheet outlined the study’s objectives, the voluntary nature of participation, data protection measures, and assurances of confidentiality.
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During the interviews, only the lead researcher had access to raw audio recordings, which were stored securely on a password-protected device. Transcripts were anonymized and accessible solely to the core research team. This structure ensured that the discussion covered a spectrum of relevant experiences, from day-to-day responsibilities in early pregnancy units to deeply personal sentiments about RPL. Interviews typically lasted between 60 and 75 min and were conducted either face-to-face in a private location at the hospital or through a secure video-conferencing platform, depending on the participant’s preference. In order to document the interviews accurately, the researchers obtained permission to audio-record each session. Field notes, which included observations about facial expressions, body language, voice modulation, and pauses, added depth to our analysis of the nurses’ emotional expressions and contextualized their verbal accounts of emotional labor.
Development of the interview guide
The semi-structured interview guide was crafted (see Supplementary File) to explore nurses’ experiences with RPL across five main sections: (A) Background Information and Context, (B) Emotional Labor in RPL Care, (C) Coping Strategies and Resilience, (D) Organizational Influences and Gaps, and (E) Closing Reflections. Each section’s questions were designed to address the study’s three research questions (RQs) and to elicit in-depth narratives.
RQ1 (lived experiences of emotional labor) guided the prompts in Section B, where participants were asked, for instance, “Can you describe the emotions you frequently experience when caring for a patient who has just experienced another pregnancy loss?” This allowed nurses to detail the emotional challenges and personal impact of RPL care.
RQ2 (coping strategies and resilience) informed the items in Section C, such as “When you feel distressed or saddened by a patient’s repeated losses, what do you do for yourself to manage those emotions?” These questions targeted the methods—both individual and collective—that nurses use to navigate emotional strain.
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RQ3 (organizational factors affecting emotional labor) was primarily addressed in Section D, which included inquiries about institutional support and managerial policies (e.g., “Could you describe a time when you felt well-supported by your organization?”). By exploring workplace resources, staffing, and training, the guide captured nurses’ views on how external factors shape their well-being.
In addition, Section A gathered background information—such as professional role, years of experience, and frequency of encountering RPL—while Section E offered participants an opportunity to reflect on their motivations, moments of satisfaction, and any final thoughts.
We developed this guide through an initial review of literature on emotional labor, compassion fatigue, and communication in sensitive healthcare contexts, followed by consultations with two experienced gynecological nurses and one qualitative research expert. No formal pilot study was conducted; however, the guide was adjusted after the first few interviews to improve question clarity and include additional probes. For example, after noticing participants referenced feelings of “overwhelm” but struggled to articulate specifics, we introduced more direct follow-up questions (e.g., “How would you describe feeling ‘overwhelmed’ in daily practice?”).
This iterative process ensured the guide was both comprehensive and flexible, allowing participants to freely discuss their experiences while maintaining a focus on the study’s overarching research questions.
Data analysis
The transcribed material, in conjunction with the field notes, formed the basis of an inductive thematic analysis, guided by Braun and Clarke [17]’s six-step framework: (1) familiarization with the data, (2) generating initial codes, (3) searching for themes, (4) reviewing potential themes, (5) defining and naming themes, and (6) producing the report.
Researchers began by repeatedly reading through the transcripts (familiarization) to achieve a thorough understanding of the data, making initial observations on emerging patterns and notable ideas. From these observations, the team developed a coding scheme, labeling segments of the text that captured recurring concepts such as emotional strain, empathy fatigue, boundary-setting, and institutional support (generating initial codes). Once the initial codes were applied to all transcripts, the researchers organized them into potential themes (searching for themes) that reflected larger meanings and relationships within the data.
Through a series of iterative discussions, the team carefully reviewed and refined each candidate theme (reviewing potential themes), ensuring internal coherence within themes and distinctiveness across themes. Following this step, the themes were clearly defined and labeled (defining and naming themes), capturing the essence of the data for the final analysis. Any discrepancies or divergent interpretations among the research team were resolved collaboratively, ensuring that the final set of themes accurately represented the nurses’ shared experiences while preserving individual nuances.
For instance, codes like “feeling helpless” and “emotional exhaustion” were consolidated under the theme “Emotional Burden,” whereas codes such as “peer venting” and “structured debriefings” contributed to a broader theme of “Coping Strategies.” Direct quotes from the interviews were selected to illustrate each theme and to maintain the authenticity of participants’ voices.
Member checking was employed by providing participants with concise summaries of the emerging themes and inviting their feedback, while peer debriefing with external qualitative researchers offered additional perspectives. Furthermore, an audit trail was kept throughout the project, including detailed notes on coding decisions, theme revisions, and reflective memos. This systematic documentation enhanced transparency and dependability, allowing the research team—and external reviewers—to trace how data were transformed into final themes.
Ethical considerations
Ethical approval for this study was obtained from the Institutional Review Board (IRB) at Shanxi Provincial People's Hospital. Written informed consent was secured from all participants before conducting any interviews. Each participant was assigned a pseudonym to maintain anonymity, and any identifying details were removed from transcripts. A counseling referral list was also provided for any participant who felt emotional distress related to discussing RPL.
Results
Overview of findings
The results in this section derive from semi-structured, in-depth interviews with 12 gynecological nurses employed in early pregnancy units. Using an inductive thematic analysis, four central themes emerged that elucidate the complexity of nurses’ experiences in caring for patients with RPL (As shown in Fig. 1). These themes are: (1) The Emotional Burden of Recurrent Loss, (2) Balancing Empathy and Professional Boundaries, (3) Coping Strategies and Resilience-Building, and (4) Organizational Support and Gaps.
Fig. 1
Emergent Themes in Gynecological Nurses' Experiences with RPL
×
In addressing the research questions, the first two themes predominantly illustrate how nurses experience emotional labor (RQ1), the third theme focuses on coping (RQ2), and the fourth theme highlights organizational influences (RQ3). While each theme is distinct, they are interrelated facets of the overall phenomenon of emotional labor in RPL care. Below, we detail the findings related to RQ1, which examines the lived experiences of emotional labor among gynecological nurses in this specific clinical context.
Findings for RQ1
The emotional burden of recurrent loss
Participants frequently described an intensified emotional load from caring for patients with multiple pregnancy losses. Unlike a single instance of miscarriage, RPL compelled nurses to repeatedly witness cycles of grief and hope, which many described as a “compounding sorrow.” One nurse explained,
“After seeing the same patient lose another pregnancy, it’s like a heartbreak that stacks on top of the previous one.” (P2)
In addition, nurses reported feeling a personal bond with recurring patients, having already supported them through previous losses. This bond intensified the emotional stakes. As one participant confessed,
“It’s not just the patient’s grief anymore; it becomes something I carry with me, like I’m grieving with them.” (P6)
This sentiment illustrates how empathy can gradually turn into emotional exhaustion, particularly when multiple losses occur over a short span of time.
Balancing empathy and professional boundaries
While deep empathy emerged as a hallmark of effective care, participants acknowledged the toll of ‘feeling too much.’ Nurses described balancing genuine compassion with the need to protect themselves from overwhelming sorrow:
“I had to learn to keep a part of myself walled off. If I feel everything they’re feeling, I get home and I’m depleted.” (P9)
“I felt awful at first for not letting myself cry with them every time, but I realized that if I don’t draw a line, I’ll be of no help eventually.” (P5)
These accounts align with classical definitions of emotional labor, highlighting the conflict between maintaining empathy and preserving one’s emotional health. Consequently, boundary management emerged as both an ethical and self-care priority in RPL settings.
Manifestations of emotional labor
The interviews further revealed distinct forms of emotional labor that nurses practiced. While some adopted surface-level techniques—maintaining a calm or reassuring facade—the majority discussed deep acting, attempting to genuinely empathize with the patient’s grief. A common thread was emotional masking, wherein internal turmoil coexisted with an external demeanor of composure.
One nurse, for example, described the constant mental effort required to appear strong:
“I’ve become good at looking in control, but inside, I can be all over the place—sad, worried, even angry at the unfairness of it all.” (P3)
“I thought it was my job to be the ‘rock.’ Then, one day, a patient had her third loss, and I completely broke down afterward.” (P4)
Such accounts underscore how sustained emotional performance can increase vulnerability to compassion fatigue or burnout. Nurses often recognized the need to present an empathetic front, yet this facade took a psychological toll that emerged in private moments.
Findings for RQ2
Coping strategies in daily practice
A key pattern emerging from the interview data is the variety of coping strategies that nurses regularly employ to navigate the emotional toll of caring for RPL cases.
Individual reflection and mindfulness
Individual reflection and mindfulness
Many nurses reported deliberate reflection as vital for processing difficult emotions—through journaling or brief solitude:
“If a case really gets to me, I’ll note it in my journal to unpack those feelings later. Writing helps me see the situation more clearly and remind myself I did my best.” (P5)
Mindfulness exercises (e.g., breathing techniques, guided meditations) were highlighted as critical tools for regaining composure between patient interactions. These practices enabled nurses to “reset” emotionally, preventing the buildup of anxiety or distress over the course of a demanding shift.
Peer Debriefing and colleague support
Peer support was another cornerstone of emotional management. One participant noted:
“A quick chat with my colleague in the break room can totally change my outlook on the day. It helps me process what happened and not carry it to the next patient.” (P2)
Where wards had a team-based culture, nurses felt less isolated; those lacking such networks more frequently reported internalizing stress, sometimes leading to extended emotional fatigue.
Resilience-building mechanisms
Beyond immediate strategies, participants highlighted longer-term resilience-building measures, including professional growth, boundary-setting, and formal counseling.
Professional identity and growth
A recurring narrative emphasized how experiencing RPL cases over time transformed nurses’ professional identities. By confronting repeated grief, nurses gained deeper empathy and nuanced communication skills. One participant explained:
“In the beginning, I felt overwhelmed by the tragedy of it all. Over time, I realized I was growing more empathetic, but also more confident in my ability to guide patients through their grief.” (P11)
This growth paradoxically alleviated emotional distress, as nurses developed evidence-based communication and boundary-setting practices.
Formal counseling and self-care routines
Although formal mental health services (e.g., Employee Assistance Programs) were available to some participants, not all felt comfortable accessing them. Those who did described notable benefits, such as learning structured coping skills, receiving objective feedback, and validating their emotional reactions:
“I started going to therapy sessions offered by the hospital. It was a game-changer—helped me figure out why I was getting so affected and how to step back without feeling guilty.” (P6)
Others emphasized self-care routines (e.g., regular exercise, hobbies, family time) as key to sustaining resilience. Overall, a combination of peer support, individual reflection, and personal self-care reduced the likelihood of compassion fatigue.
Findings for RQ3
Perceived organizational support
Participants consistently highlighted how organizational structures and policies either bolstered or undermined their capacity to manage emotional labor. In units with formal debriefing programs or psychological support services, nurses reported a greater sense of safety and validation. One participant noted:
“In my old hospital, we had scheduled debriefs after tough cases. It really normalized talking about what we were feeling. Now, we barely even acknowledge the toll it takes.” (P3)
Workload pressures and resource constraints
A significant organizational barrier mentioned by nearly all participants was workload pressure: large patient volumes, staffing shortages, and demanding administrative tasks left limited time for self-reflection or peer support. Nurses described feeling pulled in multiple directions, making it difficult to pause and “process the emotional reality” of an RPL case before moving on to the next patient. Moreover, some participants felt that budget limitations and lack of staffing rendered emotional support initiatives a low priority. The resultant time scarcity often exacerbated stress, as nurses navigated emotionally heavy scenarios without adequate intervals for decompression.
Need for specialized training and consistency
A recurring recommendation from participants was the institutionalization of specialized training on emotional labor in RPL care. While general mental health resources exist, nurses contended that RPL-specific guidance—covering grief counseling, communication strategies with repeatedly grieving patients, and self-care protocols—would be more relevant and effective:
“We keep getting told to practice self-care, but there’s no structured guidance on how to handle recurrent pregnancy loss specifically. It’s such a unique context that we need more targeted support.” (P8)
Additionally, participants advocated for consistent policy implementation. Even when certain programs existed, they were sometimes applied sporadically or at the discretion of individual ward managers. Consistency in offering psychological support services and ensuring staff coverage for debriefing sessions were frequently cited as practical steps organizations could take.
Overall, nurses emphasized that organizational factors have a profound effect on whether they can effectively cope with emotional labor in the context of RPL. Facilities equipped with structured support programs, reasonable staffing, and specialized training were perceived to foster better nurse well-being and, by extension, patient care outcomes. In contrast, units lacking these institutional supports often left nurses feeling isolated and overburdened, heightening their vulnerability to compassion fatigue or burnout.
Discussion
The present study explored how gynecological nurses caring for RPL navigate the unique demands of emotional labor, the coping strategies they develop, and the influence of organizational contexts on their well-being and professional practice.
Emotional labor in RPL care
Our results confirm that RPL care imposes a profound and cumulative emotional burden on nurses. This aligns with Delgado, et al. [7], who note that repetitive exposure to traumatic or grief-laden scenarios intensifies emotional dissonance in nursing work. While emotional labor theory often discusses single-event traumatic contexts [12, 18, 19], our findings indicate that recurring patient losses create an additional layer of emotional stress. Nurses repeatedly establish empathic bonds with patients, only to witness repeated heartbreak when another loss occurs. This “compounding sorrow,” as one participant described it, parallels the “emotional ambiguities” that Moretti and Pronzato [20] observed among healthcare professionals grappling with complex technologies in their platforms—both contexts amplify mixed emotional states, underscoring that emotional experiences can be simultaneously empathetic, distressing, and ambiguous.
In line with Dunn [21], who documented teachers’ emotional labor following personal miscarriage experiences, nurses in this study navigated a boundary between professional composure and genuine emotional investment. Emotional labor in these RPL settings often demanded “deep acting” rather than simple surface displays [22, 23]. Yet, as Bokek-Cohen and Tarabeih [24] reported in the context of transplant coordinators, excessive deep acting risks burnout if genuine feelings are persistently suppressed or if nurses feel compelled to display emotions contrary to their authentic states [25, 26].
Coping strategies and resilience
Our findings further illustrate how nurses adopt both individual and collective strategies to manage their emotional labor. This resonates with [7], who emphasize that resilience interventions should address the specific emotional demands of nursing work. These personal coping behaviors mirror what Msiska, et al. [27] labeled as students’ “emotion management” in a Malawian nursing setting, and parallel the reflection- and regulation-based approaches described by Dal Santo, et al. [28].
On a collective level, peer debriefing and team-based emotional support served as a crucial buffer against compassion fatigue, echoing Yehene, et al. [29], who found that peer support could both amplify and mitigate secondary trauma depending on the emotional labor strategies used within teams. Additionally, many of our participants acknowledged that over time, these coping practices contributed to a transformation in professional identity—similar to how Jocic, et al. [30] observed young adults with Type 1 diabetes “emotionally laboring” and redefining their self-concept over time. In our study, nurses described evolving resilience, shaped by repeated cycles of emotional distress and reflective self-care.
Recent research on pediatric intensive care staff using diaries (Sansone et al., 2023) also underscores the value of structured collective reflection. Similarly, our findings suggest that both formal and informal debriefings in RPL care can mitigate recurring grief and promote emotional processing. Such interventions could be adapted to focus groups or diary-writing exercises, enabling nurses to externalize and navigate the cumulative sorrow inherent in RPL.
Organizational support and gaps
Consistent with Su, et al. [31] and Yilmaz, et al. [32], participants in our study emphasized the significant impact of organizational factors—staffing levels, availability of structured debriefing, and the presence (or absence) of targeted support programs—on nurses’ capacity to manage emotional labor sustainably. Echoing the perspectives of Wen, et al. [33], who argued that “personal-job fit” influences healthcare workers’ physical and mental health via emotional labor processes, our data indicate that insufficient institutional support intensifies nurses’ risks of burnout and compassion fatigue.
These organizational challenges align with the integrative reviews by Delgado, et al. [7] and Shaqiqi, et al. [34], both of which call for strategic interventions that mitigate nurses’ prolonged exposure to emotional labor stress. Surface acting, in particular, was associated with higher occupational stress and burnout [3, 35]. Our findings demonstrate that if staffing resources are scarce or if managers undervalue emotional debriefing, nurses are left alone to handle complex grief situations, thereby compounding emotional strain [25, 26]. By contrast, units offering structured debriefings, professional counseling, or collegial support had nurses who reported feeling more valued and less emotionally drained.
Theoretical and practical implications
Theoretically, this study reinforces the notion that emotional labor in healthcare is multifaceted [19, 23]. This dynamic reaffirms calls from Dunn [21] and MacIver, et al. [26] to view emotional labor through fluid and context-contingent lenses. Additionally, exploring “emotional ambiguities” [20] extends the discourse beyond fixed emotional states, urging future research to consider how nurses oscillate among conflicting emotions.
Practically, healthcare institutions need to recognize that recurrent loss scenarios demand specialized support infrastructures. Building on recommendations from Delgado, et al. [7] and Zaghini, et al. [3], our findings underscore the necessity of robust resilience training, formal debriefing sessions, and sufficiently staffed units. Interventions aimed at educating nurses on emotional self-regulation, surface vs. deep acting, and compassionate boundary-setting could mitigate negative outcomes like depression [32], high turnover intention [31], and secondary traumatic stress [29]. Moreover, organizational justice—ensuring nurses’ voices are heard and their emotional burdens validated—can play a critical role in reducing emotional distress [31, 33, 36].
Limitations and future directions
Our qualitative approach enabled a deep exploration of nurses’ subjective experiences, but it was context-specific, focusing on early pregnancy units in a limited number of hospitals. The sample’s transferability may therefore be constrained [18]. Future research might employ longitudinal designs to track how nurses’ coping evolves across multiple RPL cases, mirroring the suggestions of Delgado, et al. [7] and MacIver, et al. [26]. Comparative or multi-site studies could assess how differences in organizational culture or resource availability influence emotional labor patterns [28, 37]. Additionally, experimental or interventional research might measure how targeted workshops or digital support tools [20, 38] affect nurses’ emotional well-being and burnout rates in RPL care settings.
Practical implications
Building on the above insights, several practical strategies can enhance nurse well-being and patient care in RPL contexts:
A central strategy involves structured reflection and debriefing, which can be facilitated by tools such as reflective journals or weekly focus groups. Recent work by Sansone et al. (2023) on pediatric intensive care staff demonstrates how diaries and structured collective reflection can promote emotional processing and normalize discussions of grief. In RPL units, hospitals could adapt these methods to enable nurses to discuss recurring challenges, voice their emotional experiences, and share coping techniques in a supportive environment.
A second key consideration is training focused specifically on RPL scenarios. Participants in this study emphasized the unique communication and emotional demands posed by repeated losses, suggesting that workshops or seminars address grief counseling techniques, boundary-setting skills, and evidence-based communication strategies tailored to RPL contexts. By learning how to differentiate surface from deep acting and how to set compassionate yet firm emotional boundaries, nurses may mitigate the risk of burnout and compassion fatigue.
Adequate nurse-to-patient ratios can provide essential time for emotional decompression between patient encounters. Similarly, reduced workloads allow opportunities for nurses to engage in peer debriefing without feeling pressured to rush to the next task, thereby minimizing the need for surface acting. When nurses experience organizational support in these ways, they are more likely to cope effectively and maintain the quality of their caregiving.
Finally, formal psychological support services can supplement these measures, particularly when nurses face ongoing stress without immediate relief. Institutions might offer on-site counseling, specialized Employee Assistance Programs, or partnerships with mental health providers who understand the cyclical nature of RPL grief. Encouraging nurse participation in these services, while actively destigmatizing the need for help, remains crucial for sustaining their well-being.
Conclusion
Our study underscores how RPL care amplifies the inherent tensions of emotional labor for gynecological nurses, requiring them to balance genuine empathy with protective professional boundaries. These findings echo the broader consensus in the literature that emotional labor is both a therapeutic instrument and a potential source of psychological strain [7, 25, 34]. Ultimately, recognizing the cyclical grief of RPL contexts calls for tailored, evidence-based strategies—combining nurse autonomy, social support, and advanced emotional labor training—that ensure both patient well-being and the sustainability of nurses’ mental health.
Drawing on our findings, several targeted measures can strengthen nurse well-being and care quality in RPL contexts. First, standardized RPL-specific communication trainings should be developed to address the recurring grief patterns unique to multiple pregnancy losses. Such trainings could refine nurses’ abilities to deliver sensitive information and recognize their own emotional boundaries. Second, protected time for debriefing—whether through scheduled sessions or informal huddles—allows nurses to reflect on difficult cases, reducing the build-up of emotional distress. Third, fostering peer-support or focus groups can ease feelings of isolation by providing spaces where nurses openly share coping strategies and experiences. Fourth, healthcare institutions should facilitate easy access to counseling services, encouraging staff to seek professional help when needed without stigma. Finally, instituting a continuous evaluation of nurse well-being—through surveys, one-on-one check-ins, or feedback loops—helps identify emerging stressors and ensures timely organizational responses.
Collectively, these recommendations emphasize an integrated approach in which individual coping strategies and robust institutional backing complement each other. By advancing both nurse autonomy and social support, healthcare facilities can more effectively address the cyclical grief of RPL while safeguarding nurses’ emotional health and sustaining high-quality, empathic patient care.
Acknowledgements
The authors would like to thank all the members who participated in this study.
Clinical trial number
Not applicable.
Declarations
Ethics approval and consent to participate
This study was approved by the Institutional Review Board of Shanxi Provincial People's Hospital. Written informed consent was obtained from all participants before enrollment in the study. All methods were performed in accordance with the relevant guidelines and regulations.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
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