Competition has been growing among hospitals as increased disclosure of quality assessments of their services is creating a customer-centered medical environment. As ambulatory care represents the first point of contact between the patient and the hospital, thus determining the image of the hospital, a customer service-orientation strongly emphasized for ambulatory care nurses. Previous studies have showed that kindness is the factor with the greatest influence on hospital satisfaction for outpatients [1,2], and the kindness of ambulatory care nurses is one of the factors considered when customers select hospitals [1]. Many hospitals provide training on expressing kindness and regularly conduct customer satisfaction surveys to improve customer-centered medical services [2], and actively intervene to follow a code of behavior and control the emotional expressions of medical personnel [2,3].

The regulations or strategies of hospitals that standardize and enforce rules regarding the emotional expression of individuals may require their emotional labor [4]. Emotional labor is defined as the regulation of individuals’ experienced emotions and emotional expression in order to achieve the goals of an organization. It refers to an individual’s efforts to control personal emotions in order to adapt to an organization or perform one’s duties effectively in situations where there is a gap between the emotional expression required by the organization and the actual emotions felt by the individual [4,5]. Emotional labor can take the form of either surface, deep acting or emotional dissonance. Surface acting refers to the outward expression of emotions in accordance with organizational regulations, contrary to the actual emotions of an individual. Deep acting, on the other hand, involves attempts to conscious change the actual emotions of an individual towards the desired action. The emotional labor performed by nurses directly affects the development of rapport with patients, and hence, the mental and physical well-being and recovery of patients as well. There is a positive aspect to emotional labor, in that it can be a symbolic emotional expression that provides reassurance to patients [6]. However, ongoing emotional labor can negatively influence service providers in the form of emotional exhaustion, depression or anxiety, additional stress, and negative effects on health, ultimately having a negative effect on the organization in the form of reduced job engagement, reduced motivation to provide quality service, and increased turnover rate [2,7].

Due to the nature of ambulatory care, nurses meet a variety of patients and tend to be focused more on indirect rather than direct care. Additionally, the severity of patients’ conditions has increased due to the decrease in the lengths of hospital stay by patients, and an increase in the number of patients with more complex conditions. Thus, there is an increasing demand for quality services from patients, and nurses are forced to perform emotional labor to overcome the conflict between their professional identity as nurses and the need to fulfill demands regarding quality of service [8]. Job satisfaction increases when the performance of deep acting emotional labor by an individual coincides with the regulation regulation of expression by the organization [4,9].

The purpose of this study is to analyze the impact of surface and deep acting emotional labor on emotional dissonance among ambulatory care nurses in a general hospital. The specific objectives of the study are as follows: 1) to identify the levels of surface acting, deep acting, and emotional dissonance of the study participants; 2) to identify variations in surface acting, deep acting, and emotional dissonance according to the general characteristics of the participants; 3) to define the correlations among surface acting, deep acting, and emotional dissonance of the participants; and 4) to define the factors that influence emotional dissonance of the participants.

This study confirms that the ambulatory care nurses’ emotional labor relatively higher than ward nurses. This study confirms that the surface acting and deep acting of emotional labor effect emotional dissonance in ambulatory care nurses.

The emotional labor scores of the participants in the current study ranged from 3.36 to 3.76 out of 5. This was lower than the emotional labor scores of ambulatory care nurses from metropolitan areas (3.78) [11], but significantly higher than the average score of 3.25 of ward nurses [12]. Since patients have been demanding a higher quality of service from advanced general hospitals, the emotional labor of ambulatory care nurses, who are the first point of contact with patients, is still high. However, it was found that the values for emotional dissonance, which results in the tension, conflict, and stress that are some of the sub-factors of emotional labor, were low. This is seen as the effect of various education programs for nurses. The customer satisfaction education and counseling programs conducted by the medical institution at which this study was undertaken help nurses to control their emotions during the communication process. Further, customer experience management activities may have been effective in helping them understand the points of view of the patients/customers and solve problems.

The surface acting and deep acting scores of the participants were higher than the corresponding scores in a study of nursing hospitals in Seoul [13] and in studies of hospital nurses [3,8]. Therefore, it was identified that the ambulatory care nurses at the medical institution involved in this study function at high levels of deep acting. Although low levels of deep acting result in an increase in emotional exhaustion with increases in surface acting, this does not result with high levels of deep acting [14]. This implies that although the levels of surface acting increase due to the demand of higher quality service from patients, this will not automatically lead to an increase in emotional exhaustion, since there is a high effort to treat the patients with sincerity. Although it may be difficult to decrease the rigor of emotional labor due to the severity of patient conditions and the expectations and demands for higher quality service, there needs to be effort from nurses to attend to patients with sincerity. In addition, organizational support, emphasis on leadership and psychological counseling programs are other measures attempted to overcome the toll of emotional labor and resulted in positive changes.

The results of this study did not show meaningful variations in the emotional labor of ambulatory care nurses according to the general characteristics of the participants. These findings are contrary to studies that showed meaningful variations according to age, job position, clinical career, working unit, and employment status [1,12]. Surface acting and deep acting emotional labor strategies vary according to education level and types of hospital. No variable in the current study showed meaningful results, aside from total clinical career because the participants of this study were either staff nurses or charge nurses who have similar tasks in the ambulatory care unit, and it is recommended that the total clinical career be considered when selecting ambulatory care nurses who have the capacity to manage emotional labor.

It was found that ambulatory care nurses have high levels of emotional dissonance and deep acting while performing the tasks of patient education, counseling, and advocacy. This may relate to nurses’ awareness of the importance of these tasks. When they try to align their emotional states and expressions while they are on the job, they experience emotional dissonance when they are repeatedly exposed to situations where there are too many patients to handle and they always run out of time. Ambulatory care nurses try to change their own emotions, gradually accept the broad responsibilities of a nursing professional, understand the situations of the patients by coming out of the state of conflicting emotions, and experience a unification of their emotions and the expression required by the organization [15,16]. Job satisfaction levels of nurses increase when the nurses are identical to the expression regulations of the organization. Therefore, there needs to be an expansion of roles for ambulatory care nurses related to patient education, counseling, and advocacy for a positive influence on deep acting, support programs such as training in improving communication and counseling programs, and also a support system to regulate regulate factors such as total work hours, work intensity, and job rotation.

The emotional dissonance levels were found to be high or low, and that the level of deep acting was found to be higher than that of surface acting. Further, there were no meaningful variations in emotional dissonance, surface acting, and deep acting according to the general characteristics, and it was found that the factors that influence emotional dissonance are surface acting and deep acting. The results of the study show that ambulatory care nurses are currently trying to align their experienced emotions and expressions, and they feel emotional dissonance while working in the ambulatory care department. Therefore, certain measures, such as job relocation for ambulatory care nurses to expand the positive influence of deep acting in terms of managing emotional labor, training on improving communication to control emotional dissonance, supporting programs such as counseling programs, and regulation of employment factors such as the total work hours, job rotation, and support systems are necessary.

Following from these results, certain recommendations for future studies emerge, as follows: first, future studies should identify the various factors that influence the emotional dissonance of ambulatory care nurses and compare the factors according to the job characteristics of the department. Second, future studies should identify whether it is possible to reduce the negative factors of emotional labor by coordinating the tasks of ambulatory care nurses. Third, future studies should explore the development and application of education and clinical nursing programs for ambulatory care nurses aimed at effectively managing emotional labor.