Introduction
In the Iranian healthcare context, compassion and emotional labor are fundamental to nursing, particularly in oncology units, where nurses provide care for patients facing long-term suffering and end-of-life challenges [1]. Compassion is a core value in nursing practice, deeply embedded in Iranian cultural and ethical expectations. Oncology nurses are expected to deliver empathetic, patient-centered care, often forming strong emotional connections with their patients and their families [2]. However, this high level of emotional involvement comes at a psychological cost, leading to increased emotional burden and burnout among healthcare providers [3].
Cancer incidence in Iran has been rising significantly, with 131,191 new cancer cases reported in 2020. The most common types include breast cancer (28.1% of female malignancies), stomach cancer, and colorectal cancer. Projections indicate that by 2025, cancer cases in Iran will increase by 42.6%, with both population structure (28.7%) and changing risk factors (13.9%) contributing to this surge [4]. This escalating burden of cancer care places increasing emotional and physical demands on oncology nurses, further exacerbating emotional labor and burnout [5].
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Studies show that oncology nurses in Iran experience higher levels of stress, anxiety, and emotional exhaustion compared to those in other specialties [6]. Research conducted by Mazhari & Khoshnood (2021) identified the emotional and psychological challenges faced by Iranian nurses caring for cancer patients, emphasizing the need for emotional resilience training and organizational support [7]. Similarly, Raingruber (2015) found that meaningful nurse-patient relationships in oncology settings, while crucial for patient care, increase emotional burden, making nurses more susceptible to burnout [8].
Emotional labor is the process of managing emotions to meet professional expectations, often requiring nurses to suppress their own distress, frustration, or grief while expressing compassion, patience, and reassurance [9]. Oncology nurses frequently witness patient deterioration, loss, and family suffering, which intensifies their emotional burden. Emotional burden differs from caregiver burden, which primarily refers to the physical workload of caregiving, whereas emotional burden arises from the psychological strain of constantly managing emotions in a high-stress environment [10]. Research shows that Iranian oncology nurses experience higher levels of emotional exhaustion compared to nurses in other specialties due to the continuous cycle of patient deterioration and death [11].
When emotional burden remains unaddressed, it can lead to burnout, a negative consequence of prolonged emotional labor. Burnout in oncology nurses manifests as emotional exhaustion, depersonalization, and reduced personal accomplishment, leading to lower job satisfaction, decreased quality of care, and higher turnover rates. Studies in Iran have highlighted the increasing prevalence of burnout among oncology nurses, which negatively impacts both individual well-being and healthcare system performance [12]. Nurses experiencing burnout are more likely to develop mental health issues, feel disconnected from their patients, and consider leaving their profession. Given the projected rise in cancer cases in Iran, addressing nurse burnout and emotional burden is crucial to ensuring sustainable, high-quality oncology care [13].
Several interventions have been explored to mitigate burnout and emotional burden among oncology nurses [14]. A quasi-experimental study conducted in Kerman, Iran, evaluated the effectiveness of aesthetic care training on oncology nurses’ perceptions of end-of-life care. The study, which involved 100 nurses, showed that aesthetic care training significantly improved emotional resilience and nurses’ ability to manage the psychological demands of oncology care [15]. Another study by Bolton (2005) found that nurses who receive emotional regulation training experience lower stress levels and better coping mechanisms in high-intensity oncology environments [16]. Kinman & Leggetter (2016) further highlighted that nurses with structured emotional support programs show improved psychological well-being and reduced burnout symptoms [17].
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While these studies demonstrate the potential benefits of structured emotional support programs, further research is needed to comprehensively explore emotional labor and its individual and organizational consequences for Iranian oncology nurses. There remains a gap in understanding how emotional burden progresses into burnout and how nursing interventions can be optimized to protect nurses’ mental well-being while maintaining high-quality patient care.
Given these challenges, this study aims to explore the perceptions of Iranian oncology nurses regarding emotional labor, focusing on its impact on nurses’ well-being, job satisfaction, and patient care quality. By examining the interplay between emotional burden, compassion, and burnout, this research seeks to provide practical recommendations for improving nurses’ emotional resilience and workplace support systems, ultimately contributing to better patient outcomes and nurse retention in oncology settings.
Methodology
Design and setting
This is a phenomenological qualitative research project conducted in the year 2024. Qualitative research is the effective design for exploring the experiences of healthcare professionals who are directly involved in patient care and engage in face-to-face communication. It is especially good for showing things known but not deeply and precisely understood [18].
This study employed a phenomenological qualitative approach to explore the lived experiences of oncology nurses regarding emotional labor. This approach was chosen to capture the emotional complexities faced by oncology nurses, allowing for a deeper exploration of their emotional burden, coping mechanisms, and professional challenges. Through semi-structured, in-depth interviews, participants shared their experiences, which were analyzed using conventional content analysis to identify recurring themes. This method provided a rich, interpretative understanding of the emotional demands in oncology nursing, offering insights that quantitative methods may not fully capture.
The participants for the present study are selected by the researchers based on a purposeful sampling method. The purposeful sampling method allows for the in-depth investigation of rich information cases [19]. Data collection was done up to saturation levels, where the researcher felt no more information would be added with the addition of new participants.
The sample population included 18 oncology nurses working in four public and private hospitals in Mashhad, Iran.
Oncology nurses are specialized healthcare professionals trained to care for cancer patients across different stages of diagnosis, treatment, and palliative care. Their responsibilities often include administering chemotherapy, managing side effects, providing emotional and psychological support, and coordinating with interdisciplinary teams to enhance patient outcomes. The scope of practice for oncology nurses can differ between countries. In some healthcare systems, they primarily focus on direct patient care, while in others, they may have extended roles in treatment planning, symptom management, and survivorship care programs. In Iran, oncology nurses work in hospital-based oncology wards, chemotherapy units, and palliative care centers, where they engage in both clinical and emotional labor to support patients and their families.
Participants responded voluntarily and had at least three years of experience in oncology units. The nurses were informed about the research before the interviews and gave consent.
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Data collection
Before the data collection process began, all the participants were informed about the objectives of the study, that participation in this research is on a purely voluntary basis, and that confidentiality was guaranteed through anonymization. Three oncology nurses who were interviewed initially used broad, open-ended questions to specify the discussion of the study topic. An interview guide has been drawn upon based on the preliminary interviews and a literature review on the matter. Further interviews were conducted using this semi-structured interview guide.
Each interview started with questions such as: “Please briefly introduce yourself,” “What is your level of education?” and “How many years have you worked in this unit?” The interview then proceeded with open-ended questions such as: “What has changed in your personality since you started working as a nurse?” “How do you describe your relationship with patients and their relatives?” “What does emotional labor mean to you?” “What is the purpose of emotional labor in your view?” “What do you think are the individual effects of using emotional labor for oncology nurses?” “What do you think are the organizational outcomes of using emotional labor in oncology nurses?” and “What has your emotional engagement been like in the oncology unit?” Interview guide added to supplementary files.
All interviews were audio-recorded with the consent of the participants using a digital recorder, and simultaneously notes were taken. These tasks were managed by one researcher.
According to this method, 18 face-to-face in-depth personal interviews with oncology nurses continued until data saturation was reached. In other words, oncology nurses were interviewed until no new information was obtained. Each interview took approximately 30 to 60 min and at the time and place most suitable for the participant. The interviews took place between April and May of the year 2024.
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Data analysis
The data analysis method that was conducted is conventional content analysis; this is one of the most commonly used methods in order to identify, analyze and report themes in qualitative data [20]. Data analysis was performed using the MAXQDA software. The audio-recorded content for each interview was first transcribed verbatim and repeatedly read for an in-depth understanding of the themes and concepts. The data were coded, and primary codes were extracted from the data. Then, the identification of the main and sub-themes was carried out. Two researchers independently analyzed the codes; in case of discrepancy, materials were referred to a third researcher for review.
To ensure rigor and reliability with regard to the qualitative data itself, four criteria were addressed as put forward by Guba and Lincoln: credibility, dependability, confirmability, and transferability [21]. Credibility pertained to the length of time one was engaged with the studied phenomenon. Dependability took into consideration feedback from experts, participants, and colleagues with regard to the findings to explain ambiguities and resolve them. Reliability was ensured by having interviews coded by two different researchers, while transferability was enhanced through purposive and heterogeneous sampling and expert review comments.
Results
The demographic data for the interviewees are summarized in Table 1. From the results, the average age of the respondents was 28.8 years, with an average length of service in the oncology unit being 3.8 years. In addition, 77.8% of the respondents were female, while 88.9% had a bachelor’s degree (Table 1).
Table 1
Demographic characteristics of interviewees
Demographic characteristic | Number | Percentage (%) |
|---|---|---|
Gender | ||
Male | 4 | 22.2 |
Female | 14 | 77.8 |
Education Level | ||
Bachelor’s Degree | 16 | 88.9 |
Master’s Degree | 2 | 11.1 |
Work Experience (Years) | ||
3–5 Years | 5 | 27.77% |
6–10 Years | 9 | 50% |
More than 10 Years | 4 | 22.22% |
Average Age | 28.8 Years | |
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The concepts, categories, and subcategories extracted are presented in Table 2. The emotional labor of the oncology nurses as narrated by the participants has been placed under three broad themes, “Individual Effects,” “Organizational Outcomes,” and “Relationships with Patients.” Further, these were divided into seven subthemes as depicted in Table 2.
Table 2
Individual and organizational effects of emotional labor of oncology nurses
Theme | Sub-theme | Code |
|---|---|---|
Individual effects | Quality of life | • Demoralization • Not enjoying life • Fear of getting yourself and your family sick |
Experience intense sadness | • Experience intense sadness • Mental confusion • Compassion for patients • Trying to keep distance from patients • Unreasonable expectations of the patient’s companions | |
Organizational effects | Work commitment | • Sincerity in providing services • Do extra effort • Selfless service |
Job satisfaction | • Fatigue from work • Decreased motivation • Decreased individual success • Officials’ lack of attention to material and spiritual needs • Willingness to change sectors | |
Hospital performance | • Increasing the quality of services • Improving the process of treating patients • Reducing medical errors • Increasing patient satisfaction | |
Communication with patients | Empathy with patients | • Dependence on patients • Companionship with patients • Attention to patients • Put yourself in the shoes of patients |
Psychological support for patients | • to give hope • Motivate the patient • Increase morale • Appropriate behavior with the patient • Gaining the trust and cooperation of patients |
Concept 1: individual effects
Individual effects of nurses’ emotional labor may be described in the light of quality of life and encountering extreme sorrow. Regarding quality of life, oncology nurses testified that “their spirits have weakened,” “they don’t enjoy life,” and “they fear getting cancer themselves or having their families get cancer.” All but one participant stated that they witness patients deteriorate from a healthy physical appearance to the terminal stages of their disease, which depletes their morale: “Usually, patients come to the ward in good physical condition, but as their illness gets worse, their appearance deteriorates too, and it ruins our morale. It makes us unable to enjoy life.” (Interview 1 & 11). “I have become depressed because in this ward there is little hope for life; this is the last stop and whoever comes here eventually expires, it destroys you. No matter how you are under the influence of chemotherapy, its side effects affect you, too. Our morale has gotten weaker.” (Interview 2). Other participants reported, “My perspective on life has changed. I’m always nervous about myself and my family, whether those symptoms or sicknesses are unduly suspicious for cancer. Generally speaking, I’ve become more depressed.” (Interview 3 & 15). “The thing that really affects a person here is the feeling that you yourself could get this disease in the future. I have become very sensitive, and my emotions are easily triggered.” (Interview 5). “My spirit has weakened a lot. I think of death more and that it could be very close to me or my family. It has considerably affected my mind, and I think that one day I could end up here myself.” (Interview 8).
Participants summarized the experience of intense grief: “We experience intense sorrow here, “psychologically, we’re falling apart, “we feel a lot of sympathy for the patients, “we try to keep our distance from the patients, " and “some patients’ companions have unreasonable expectations.” All participants had experienced deaths of patients and described it as an incident causing deep sorrow and psychological distress: “Whenever we tried to build a friendly connection with someone, they passed away and it made us more upset. Many have left memories with us. Seeing people your age or younger pass away and getting close to them really ages you.” (Interview 2 & 17). Another participant shared, “I had a patient who was 22 years old and had two children. She was doing fine and was on chemotherapy. One night, she dreamed they came to take her away, which meant this world was no longer for her. She said she was a little scared, but felt fine in the following days. The next day, she was intubated and transferred to the ICU. I went to see her in the ICU, and she was in terrible condition, and at 3:30 that day, she passed away. I was deeply saddened and upset for days.” (Interview 4). Professional distance from patients means that nurses don’t grieve as intensely for their dying patients. “In my first year, I was much closer to my patients and more emotionally involved with them, but when they passed away, it really broke me. For a long time, I would dream about my patients. These days, I don’t even ask for my patients’ names anymore, so that they won’t stay in my memory too much if something happens to them. I’ve learned that the more distance I keep from the patients, the less their deaths affect me.” (Interview 7).
Sometimes the families of the patients, being in their psychologically and emotionally grave state, become quite unreasonable, bringing into play the aggressive behavior that distresses the nurses. “There were many patients, especially the younger ones, whom we had good relations with, and we even cried for some who were intubated. I had a patient during CPR when I was crying while performing it. Even though the doctor had called off the CPR, I knew this patient was innocent, the father of two children, and I knew all of this, so I continued CPR for an hour and a half. In the end, that patient expired, and afterward, a big fight broke out in the ward. The patient’s companions came in and attacked us, without showing any gratitude for our efforts. Given their tough situation, we were really distressed as well.” (Interview 11).
Main concept 2: organizational outcomes
The organizational effects of nurses’ emotional labor were reported in both positive and negative aspects that are encapsulated in three themes, namely, “work commitment,” “job satisfaction,” and “hospital performance.” Participants described the positive organizational outcomes of emotional labor as going the extra mile, selfless service, and dedication in providing care, which leads to improved service quality, reduced medical errors, better patient recovery, increased patient satisfaction, and enhanced hospital performance. One of the participants highlighted the following in relation to selfless service and dedication: “You give it your all. Despite the workload, you get up and do everything on time, even though there’s so much work, you are underpaid and you don’t have energy or motivation.“.
Most of the participants agreed that emotional labor improves hospital performance. For example, one participant stated, “Emotional labor raises patient satisfaction and will have positive effects on the recovery process of the patient. The stay in the hospital by the patient is reduced as well as complaints against nurses and staff are reduced even when some mistakes are made. Patient satisfaction in our ward improves, and naturally the hospital reputation benefits.“(Interview 3).
Decreased performance, a desire to transfer to another ward, or withdrawal from work were mentioned as the negative organizational effects of emotional labor. Most of the participants mentioned, “We do not have any motivation for working anymore,” “We are tired of working in this ward,” “We want to be transferred to another department,” and “The administration doesn’t pay attention to our material or emotional needs.” Most participants pointed out the negative impacts of emotional labor on the organization. For instance, one nurse mentioned the state of workload and support system as follows: “We have heavy shifts because we are understaffed; five people remain deficient in this ward. Work is tremendous, and we really feel exhausted within this ward, so there is no support for us.” (Interview 9). As one informant put it, “This is a terrible ward, and I’ve struggled very much to get out of it, but I still pity the patients, so I do my utmost to give them optimal care because that might give them two days more to survive. For the patient and relatives, these two days may mean everything where to me it means nothing.” (Interview 7). Most of the interviewees also complained about organizational support: “We get no support at all from the organization. Nothing. Not even a bit of encouragement or reduction of pressure, either financially or emotionally, so as to make our lives a little easier with all the stress we’re under. And I’m here working just like somebody else who is in another department, yet with no differentiation made between us.” (Interview 14). Another participant said, “Besides the psychological and emotional burdens of this ward, the chemotherapy drugs also physically affect the nurses. Unlike radiology technicians who get radiation pay, we get nothing. This place is emotionally overwhelming, and the environment and structure of the ward also contribute to this: there is substandard equipment, ineffective hoods, a lack of patient monitoring devices, and protection gear“(Interview 10).
Main concept 3: relation to patients
The emotional labor of the nurse can be understood to mean the elaboration of a relationship with the patients, such as “empathy with patients” or “emotional support for patients.” All participants defined emotional labor as a relation formed with the patient in a special way. Aspects that some oncology nurses who participated in this study mentioned in relation to their relations with patients include attachment to and accompaniment of patients; showing concerns by putting oneself in the place of the patient; giving patients motivation and hope; treating them well; gaining their trust; and ensuring their cooperation. Most participants pointed to the good relationships they had with their patients: “We usually have a good relationship with all patients. We comfort them and try to always be cheerful. Sometimes, we’ve cried alongside the patients because they’re humans, they’re suffering, and they have problems. But the fact that they can express their pain is very important. Sometimes, due to this emotional relationship, patients have requested a specific nurse at their bedside, and we’ve even given them a placebo injection, and they’ve felt better, which was because of the emotional support. When a patient has a good relationship with his nurse, he knows the nurse is working for him and giving his best effort.” (Interview 7). “I always had a good relationship with my patients. I think that’s our responsibility, to make good relationships with them, show empathy towards them, and understand them because they are in a very vulnerable position. Patients are emotionally fragile, and this helps elevate their mood and encourages them to continue their treatment and cooperate with us.“(Interview 15). Participants emphasized psychological support for the patients: “Psychological support is really important in this ward. Hope and treating the patient well. Since the treatment course is long and they visit quite often, we get to know them, so we try to raise their spirits and help them with the treatment process as well.” (Interview 6). Most participants recognized that, as cancer treatment takes time, nurses and patients become attached to each other: “Because the length of stay is longer in this ward, and the nature of the illness is different. In other words, patients don’t develop a sense of intimacy with the doctors and nurses. They’re here two or three days then discharged, whereas it is different here. Here, in the case of long-time hospitalization, we all get to know each other and become friends, and the extended stay itself brings that attachment. Patients even recognize the nurses by their footsteps and perfume.” (Interview 11).
Discussion
This study contributes to the understanding of emotional labor in oncology nursing, highlighting its individual and organizational consequences. The findings indicate that emotional labor, while essential for building trust and improving patient care, can also lead to emotional exhaustion and burnout when not managed effectively. Oncology nurses must regulate their emotions continuously, often suppressing their own distress to provide a compassionate and reassuring presence for patients. A key approach to enhancing emotional resilience in oncology nurses is the implementation of aesthetic and compassionate care practices [22]. Aesthetic care refers to therapeutic interactions that involve empathetic communication, non-verbal support, and creating a comforting environment for patients [23]. Research suggests that nurses trained in aesthetic care techniques—such as therapeutic touch, music therapy, mindfulness, and guided imagery—can significantly improve patient emotional well-being and pain management [24]. Furthermore, compassionate care emphasizes active listening, presence, and emotional validation, helping nurses strengthen patient trust and reduce psychological distress in cancer wards [25].
In oncology settings, nurses play a vital role not only in delivering direct patient care but also in teaching emotional coping strategies to cancer patients and their families. Some of the key skills and interventions nurses use include [26]:
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**Active Listening and Emotional Validation** – Oncology nurses are trained to recognize patients’ emotional expressions and validate their concerns, providing psychological comfort and reducing anxiety.
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**Guided Emotional Expression** – Nurses help patients articulate fears and emotions through structured conversations, journaling, or art therapy.
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**Relaxation and Mindfulness Techniques** – Techniques such as breathing exercises, progressive muscle relaxation, and guided visualization are commonly taught to cancer patients to reduce stress and enhance emotional stability.
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**Hope-Promoting Communication** – Oncology nurses use motivational communication strategies to instill hope while maintaining honest yet compassionate conversations about treatment and prognosis.
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**Family-Centered Emotional Support** – Teaching patients and their families how to manage emotional distress together strengthens social support systems, leading to better coping outcomes.
A study conducted in Kerman, Iran, evaluated the effectiveness of aesthetic care training in improving nurses’ ability to provide end-of-life emotional support. Findings indicated that structured training in aesthetic and compassionate care significantly enhanced nurses’ emotional resilience, allowing them to better regulate their emotions while providing holistic care [15]. The findings of this study align with existing literature on emotional labor, burnout, and coping strategies among oncology nurses. Several studies have emphasized the impact of emotional labor on nurses’ psychological well-being, highlighting both its positive and negative consequences. A study by Lin (2022) found that emotional labor is essential for high-quality patient care but can lead to emotional exhaustion when not properly managed. This is consistent with the current study’s findings, where oncology nurses reported both professional fulfillment and significant emotional burden [27]. Similarly, Chen et al. (2023) demonstrated that emotional labor in healthcare settings requires constant emotional regulation, which, if unsupported, results in stress and burnout [28]. In the Iranian context, Mazhari & Khoshnood (2021) explored the challenges faced by oncology nurses and noted that the emotional demands of caring for terminally ill patients often lead to increased stress and burnout [7]. This supports the current study’s conclusion that oncology nurses require structured interventions to manage emotional burden effectively. Moreover, Han et al. (2023) highlighted the importance of workplace resources, showing that nurses who received emotional resilience training experienced lower stress levels and improved well-being [29].
Unlike previous studies that mainly focused on general burnout and stress, this study provides a deeper insight into the distinct concepts of emotional burden, caregiver burden, and burnout, showing how these interrelated factors affect oncology nurses. Furthermore, this study adds to the growing body of evidence supporting the need for aesthetic and compassionate care training in oncology settings. Future research should continue exploring long-term interventions that can sustain nurses’ emotional resilience while improving patient care outcomes.
Conclusion
It is a core value in oncology nursing that reinforces nursing practices to bring about sustainable and optimal care and assures good communication amongst the nurses, the patients, and the families of the patients. Emotional labor bears different positive and negative effects on both the individual and the organization. The negative aspects of emotional labor hence need to be checked side by side with the positive ones. Burnout, job satisfaction, and the intention to change units are the negative effects that may be assessed periodically in nurses who interact closely with patients and their families. This is most especially true in sensitive units like oncology where these interactions become most intense. The evaluations then conducted will help in setting suitable regulations to reduce the negative influences of emotional labor.
Acknowledgements
The author thanks all participants in this study.
Declarations
Ethics approval and consent to participate
The Ethics Committee of Mashhad University of Medical Sciences (IR.MUMS.REC.1402.302) has reviewed and approved this study. All procedures performed in this study involving human participants were conducted in accordance with the ethical standards of the institutional and national research committee, as well as the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. All participants received oral and written information about the study. All participants gave their written informed consent to participate. Participants were also free to withdraw during the interview at any moment during the process. Lastly, confidentiality and privacy were observed in the study. The names of the respondents were not mentioned, and audio recordings are kept on a password-protected computer.
Clinical trial number
Not applicable.
Competing interests
The authors declare no competing interests.
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