Mediating role of emotional labor in the association between emotional intelligence and fatigue among Chinese doctors: a cross-sectional study

Fatigue in the workplace comprises both physical and mental constructs, affecting the overall state of workers. Reduced proprioception and strength due to fatigue may lead to low work performance and quality, and high incidence of human errors and accidents [1, 2]. Moreover, fatigue may also result in many adverse health outcomes such as chronic fatigue syndrome, burnout, and work-related musculoskeletal disorders in the long term [3, 4]. Among the groups of healthcare occupations, fatigue has been described as a serious problem, especially doctors [5‐8]. Fatigue is highly prevalent among doctors in China [7, 8]. Due to the shortage of health care professionals, doctors often work overload, and they have to work in an environment with various stressors, which make them prone to suffering from fatigue [6, 9]. It could not only affect the physical health of doctors, but also lead to decline in work performance and increase of mental health problems [7, 8, 10]. At the same time, the decline of work quality and efficiency caused by fatigue could directly impair patients’ satisfaction with health care services and the doctor-patient relationship. These stressors in turn will aggravate physical and mental fatigues, thus forming a vicious circle [11]. Therefore, great attention should be paid to the etiology of fatigue in order to develop appropriate measures to prevent it among doctors.

In workplaces, fatigue may be a consequence of highly demanding work and various psychological and environmental factors. In doctors, in addition to physical fatigue caused by high workload, it is worth paying more attention to mental fatigue caused by adverse occupational psychological environment. Work stress perceived by doctors leads to negative emotional reactions and gradually consumes their energy. What’s more, mental fatigue can facilitate the perception of physical fatigue [12]. Therefore, effective emotion regulation may have an important preventive role on fatigue [13]. Emotional intelligence (EI), its concept was first proposed by Salovey and Mayer in 1990 [14], consisting of the abilities to identify, understand, harness and regulate emotions in oneself and in others. In the processes of diagnosis and treatment, doctors need to show specific and appropriate emotions to their patients in a high-stress environment. Also, doctors have to interact frequently with other people, such as patients’ family members, nurses, and consultants from other departments. Obviously, for doctors, EI is an important internal resource for dealing with interpersonal emotional pressure in those processes. For instance, doctors with higher EI are more likely to relieve their work stress and reduce tiredness by control emotions [15, 16]. A previous research has reported that the doctors who used the practical skills of EI, such as confidence, empathy, adaptability and conflict management, to communicate successfully with patients and colleagues might feel satisfied with their works [16].

Emotional labor is the process of managing feelings and expressions to achieve the professional requirements of emotion when interacting with customers, co-workers and superiors [17]. According to the results of Diefendorff’s research, the performance of emotional labor strategy mainly includes three aspects: surface acting (SA, modifying facial expressions), deep acting (DA, modifying inner feelings) and natural acting (NA). Roles that have been identified as requiring emotional labor include many occupations in the tertiary/service sector [18], particularly within healthcare settings. Therefore, there is a great deal of emotional labor for health care workers who need face-to-face contact with patients for a long time at work [19, 20]. Hu et al. reported that the most frequently adopted strategy by doctors was NA, followed by DA and SA [20]. In addition, as previously mentioned, SA could be more consistently problematic for employees’ well-being than DA. When employees play SA, their self-authenticities are damaged because of the internal and external conflict in emotion, and they will be prone to psychological distress, fatigue and job dissatisfaction [21‐23]. Conversely, DA is an effortful process through which employees change their internal feelings to align with organizational expectations, and it is positively associated with organizational behavioral outcomes and physical and mental well-being. Therefore, health care providers should continuously prioritize and integrate these complex emotions and specific situations.

According to the results of many previous studies, EI has various effects on emotional labor strategies [23‐25]. In some extent, EI can reduce SA, and improve DA and NA. Specifically, the doctor who has high EI could easily understand the emotions of patients in communication with them. In general, they don’t need to pay efforts to change their emotions, and natural emotion outpouring can satisfy organizational expectations. However, when internal feelings are not aligned with organizational expectations, doctors with high EI have adequate abilities to arouse or suppress their emotions [26]. Therefore, EI could play its positive roles by influencing emotional labor strategies. Moreover, EI and emotional labor strategies can be changed through effective intervention to enable them to cope with stressful environments and prevent physical and mental fatigues in workplaces. However, no research has been done to examine the associations of EI and emotional labor strategies with fatigue among Chinese doctors to our best knowledge.

In light of the above concerns, the purpose of the present study was to verify the following three assumptions among Chinese doctors: 1) EI and emotional labor strategies are associated with fatigue, 2) EI is associated with emotional labor strategies, and 3) emotional labor strategies mediate the association between EI and fatigue.

The result of the present study showed that the mean score of fatigue was 8.02 ± 3.39 among Chinese doctors of Shenyang, Liaoning Province, and it was higher than the result of a previous study in the same occupational group of Hainan Province in China [7], and basically consistent with the fatigue level of doctors (8.03 ± 2.87) from Anshan of Liaoning Province [33]. Lin et al. reported a higher fatigue level among Chinese doctors of Zhuhai, Guangdong Province [8]. The fatigue level of doctors in this study was also higher than the results of general population (5.50 ± 3.09) [34] and scientific and technical personnel (7.28 ± 3.37) [28] in China. In the United States, the physical and mental fatigues of doctors are very common. O’Donnell et al. had reported that nearly half of physicians (45.4%) had high levels of fatigue, and there was a strongly positive association between fatigue and dissatisfaction with practicing medicine [5]. Also, doctors in Japan are suffering from prolonged fatigue [6, 35]. The fatigue of doctors is associated with sick leave and injury, and it can increase the frequency of task errors and affect the safety of patients. As a common and serious problem among doctors worldwide, fatigue needs to be paid more attention by themselves and hospital managers.

In this study, EI had a significantly negative association with fatigue, and this result is consistent with findings from other studies [36, 37]. The finding of Zeidner et al. indicated that self-report trait EI was inversely associated with compassion fatigue in health-care professionals [36]. Similarly, Weng et al. found that higher self-rated EI was significantly associated with less burnout among internists [15]. One possible explanation for these findings is that EI could facilitate the development of individuals’ coping resources, such as healthy emotions, adaptive explanations and adequate social support, which help them prevent physical and mental fatigues.

The three emotional labor strategies had different effects on fatigue among Chinese doctors of Shenyang in this study. Our result showed that SA was positively associated with fatigue, whereas there was a negative association between NA and fatigue. Because of the inconsistency between the use of SA and cognitive evaluation and emotional experience, doctors need to passively exert some efforts to maintain their external emotional performance. This not only consumes physiological and psychological resources, but also causes fatigue when these consumed resources can’t be effectively supplemented [38]. However, DA is an internal emotional experience, and it is adjusted through positive thinking and striving [39]. Although DA has considerable positive effects on both individual and organizational outcomes, it still involves a great expenditure of energy to deeply modify one’s feelings in the process of adjustment [40]. For NA, employees do not need to adjust their emotions in cognition, and they naturally come up with the emotions that have been experienced in the workplace. Obviously, NA is a daily, without effort, and not a source of stress. Thus, NA was negatively associated with the level of fatigue among Chinese doctors in this study.

In addition, EI was an important influencing factor of the performance of emotional labor strategy in this study [23‐25], which is mainly reflected in the two strategies: SA and NA. The results indicated that EI was significantly and negatively associated with SA strategy, and positively associated with NA strategy, but did not significantly affect DA strategy [23]. Specifically, doctors with higher EI are more inclined to use NA strategy. Those doctors are naturally able to feel empathic in the face of patients’ various situations, and express the emotions in line with the organization’s requirements. In this case, they almost do not need to pay any emotional effort and cost. However, for doctors with lower EI, they often adopt SA strategy, because they can’t really understand their own feelings, control emotions and act reasonably, resulting in the inability to reconcile their internal emotions with supposed emotions. This study also firstly proved that emotional labor strategies mediated the association between EI and fatigue among Chinese doctors. Specifically, EI could lead to the reduction of SA strategy, and promote the use of NA strategy. Thus, EI directly and indirectly decreased the doctor’s perception of fatigue.

In addition, the study found that the doctors who married/cohabited are more prone to fatigue than those single/divorced/widowed/separated doctors, because the former shoulder the dual responsibilities and pressures from work and family, which aggravates fatigue [9]. There was a significantly negative association between high job rank and fatigue [9]. Although directors have to undertake both medical care and management tasks, they have greater autonomy and higher rewards at work than general practitioners. What’s more, job position is usually proportional to working income, and monthly income was negatively associated with the level of fatigue in this study [6]. Therefore, equitable work income is a protective factor in coping with fatigue. Consistent with some previous research results [6, 9], weekly working time was positively associated with the level of fatigue in this study. Therefore, it is recognized that the rationalization of working time is an effective measure. In addition, the department of doctors was related to the level of fatigue [33]. In particular, surgeons could tend to report a higher fatigue than internists. A reasonable reason is that surgeons often have to spend a lot of physical energy during their surgical operations.

According to the results of this study, fatigue could be reduced from the perspectives of EI and emotional labor strategies. First of all, hospital managers should provide doctors with the opportunities and ways to learn emotional self-regulation, in order to improve their EI levels gradually [41]. Secondly, emotional labor education and training should be carried out to avoid the formation of SA strategy [18, 42], which could reduce the physical and mental fatigues of doctors.

Before conclusions can be drawn, several limitations of this study must be acknowledged. Firstly, due to cross-sectional design, it can not to assess the causal relationships among study variables in the study, which need to be confirmed in longitudinal study. In fact, our research hypotheses were based on solid theoretical and research foundations. Secondly, the present study was only conducted at the secondary and tertiary general hospitals in a provincial capital city, in northeast China. Therefore, further research is needed to improve the generalization of our findings among doctors from hospitals in different levels and regions. Additionally, the associations among study variables might be affected by the unique use of self-report measures. Measurement tools with adequate reliability and validity and the anonymity of respondents were adopted to reduce common-method bias.

There was a high level of fatigue among Chinese doctors. EI was negatively associated with fatigue. SA was positively associated with fatigue, and NA was negatively associated with fatigue. However, DA was not significantly associated with fatigue. EI could indirectly reduce fatigue partially through modifying SA and NA strategies, respectively. Therefore, EI intervention, as well as education and training in emotional labor should be carried out to cope with fatigue among Chinese doctors.