healthcare

Article
The Effect of Emotional Labor on the Physical and Mental
Health of Health Professionals: Emotional Exhaustion Has a
Mediating Effect
Chien-Chih Chen 1 , Yu-Li Lan 2, * , Shau-Lun Chiou 3, * and Yi-Ching Lin 3

1 Department of Future Studies and LOHAS Industry, Fo Guang University, Yilan 262307, Taiwan
2 Department of Health Administration, Tzu Chi University of Science and Technology, Hualien 970302, Taiwan
3 Department of Rehabilitation, Taiwan Adventist Hospital, Taipei 10556, Taiwan
* Correspondence: yuhli@ems.tcust.edu.tw (Y.-L.L.); frank26480967@gmail.com (S.-L.C.)

Abstract: (1) Background: Workers who perform emotional labor for an extended period are prone to
emotional exhaustion; in particular, when the work exceeds the range of one’s emotional resources,
it will produce job burnout. This study investigated the effects of emotional labor and emotional
exhaustion on the physical and mental health of health professionals. (2) Methods: This study
was cross-sectional and the sampling criteria were health professionals from August 2020 to July
2021, including rehabilitators, nutritionists, clinical psychologists, radiologists, respiratory therapists,
pharmacists, medical examiners and audiologists. A questionnaire was used to collect data on
participants’ emotional labor, emotional exhaustion, physical health and mental health. A total of
120 valid questionnaires were obtained. (3) Results: Significant positive correlations were found
between emotional labor and emotional exhaustion, physical and mental health and anxiety. A
hierarchical regression analysis found that the effect of emotional labor on physical and mental health
increased the predictive power to 59.7% through emotional exhaustion, and emotional exhaustion
had a mediating effect on the relationship between emotional labor and physical and mental health.
(4) Conclusions: This study provides a reference for managers of medical institutions to care for
employees’ work stress and physical and mental health, which will help institutions build a friendly
Citation: Chen, C.-C.; Lan, Y.-L.;
and healthy workplace.
Chiou, S.-L.; Lin, Y.-C. The Effect of
Emotional Labor on the Physical and
Keywords: emotional labor; emotional exhaustion; physical and mental health; medical professional
Mental Health of Health
Professionals: Emotional Exhaustion
technicians
Has a Mediating Effect. Healthcare
2023, 11, 104. https://doi.org/
10.3390/healthcare11010104
1. Introduction
Academic Editors: Carlos Laranjeira
As the population ages rapidly, the need for chronic disease care and the severity
and Ana Querido
of disease increases. In addition to having a wealth of knowledge and experience in
Received: 21 October 2022 managing ever-changing medical technologies, medical staff also need to deal with hospital
Revised: 22 December 2022 evaluations and maintain a good doctor–patient relationship. Their work performance
Accepted: 25 December 2022 behaviors can have a massive impact on patient outcomes and safety [1].
Published: 29 December 2022 Healthcare work involves elevated levels of physical and psychosocial stress, resulting
in low employee job satisfaction, burnout, turnover intentions and poor health [2–5]. In
particular, during the COVID-19 pandemic, fear rose in medical staff and caused more
health problems to surface, which not only had a huge impact on their psychological
Copyright: © 2022 by the authors.
Licensee MDPI, Basel, Switzerland.
well-being, but also tested their resilience and ability to cope with stress. Therefore, the
This article is an open access article
psychological and physical effects of COVID-19 on medical personnel have been the focus
distributed under the terms and
of attention [6].
conditions of the Creative Commons The object of medical care services is the patient. During the extensive medical service
Attribution (CC BY) license (https:// process, it is necessary for health professionals to suppress their true feelings, so they are
creativecommons.org/licenses/by/ often required to maintain a good attitude and manage their emotions to provide quality
4.0/). healthcare services. Emotional labor is an individual’s commitment to the management

Healthcare 2023, 11, 104. https://doi.org/10.3390/healthcare11010104 https://www.mdpi.com/journal/healthcare

Healthcare 2023, 11, 104 2 of 9

of emotions to create appropriate facial expressions and body movements in front of the
public [7]. Emotional labor is divided into two levels of expression: surface and deep.
Surface acting involves masking actual emotions such as using a fake smile to hide one’s
true feelings, whereas deep acting involves trying to feel and express desired emotions
such as modifying one’s feelings to suit the situation [7,8].
Empirical studies on emotional labor have found that the frequency of deep emotional
performance of nursing staff correlates with higher emotional labor and a less ideal state of
mental health [9]. Workers who perform emotional labor for an extended period are prone
to emotional exhaustion [10,11]; in particular, when the work exceeds the range of one’s
emotional resources, it will produce job burnout [12].
If employees have negative emotions or cannot control their emotions rationally, and
support and methods to eliminate emotional problems are not available, employees may
experience job burnout and reduced job performance, which can result in emotional exhaus-
tion [13]. When emotional exhaustion occurs, employees will feel that they are emotionally
disconnected; their physical and emotional energy are exhausted, and they have negative
emotions such as anxiety, tension, depression and irritability. Moreover, they will display
discontentment toward work and lose their jobs. Lack of interest and enthusiasm [14,15],
and then symptoms such as physical problems, lack of energy, deteriorating health and
exhaustion follow [16]. Therefore, emotional exhaustion is one of the important indicators
of physical and mental health [15].
Previous studies have demonstrated that emotional labor directly affects organiza-
tional outcomes and employee well-being [17–22]. However, few studies have investigated
the relationship between emotional labor and physical and mental health. As for medical
personnel, past research has focused on the emotional labor of nursing staff, and research
on the effects of emotional labor and emotional exhaustion on physical and mental health of
health professionals does not exist. Therefore, this study is expected to provide a reference
for managers of medical institutions to care for employees’ work stress and physical and
mental health, which will help institutions build a friendly and healthy workplace.

2. Materials and Methods

2.1. Study Design and Participants
This study was cross-sectional and used purposive sampling. From August 2020 to
July 2021, questionnaires were distributed to health professionals, including rehabilita-
tors, nutritionists, clinical psychologists, radiologists, respiratory therapists, pharmacists,
medical examiners and audiologists. The eligible sampling conditions included health
professionals working in the hospital who were willing to participate in the study as in-
dicated by their signed consent. The exclusion criteria included those employees who
had submitted their resignation. A total of 120 valid questionnaires were obtained. In
terms of gender, women and men accounted for 80% (96) and 20% (24), respectively. Ages
30–40 accounted for 41.7% (50), followed by 40–50 at 27.5% (33). More than half (56.7%,
n = 68) of the participants were married, and 41.7% (50) were unmarried. Those without
children were the majority, accounting for 54.2% (65), followed by those with two children,
accounting for 26.7% (32). Most participants had a university degree, accounting for 67.5%
(81), or had completed graduate school or more, accounting for 20.0% (24). In terms of occu-
pation, rehabilitator accounted for 24.2% (29), followed by medical examiners, accounting
for 20% (24) (Table 1).

Table 1. Descriptive statistics of participants (n = 120).

Variable Item n (%) Variable Item n (%)

Gender Male 24 20 None 65 54.2
Number of children
Female 96 80 One 19 15.8
Healthcare 2023, 11, 104 3 of 9

Table 1. Cont.

Variable Item n (%) Variable Item n (%)

20–30 15 12.5 Two 32 26.7
Number of children
31–40 50 41.7 Three or more 4 3.3
Age 41–50 33 27.5 Rehabilitator 29 24.2
51–60 17 14.2 Nutritionist 5 4.2
61–70 5 4.2 Clinical psychologist 8 6.7
College 15 12.5 Radiologist 20 16.7
Education University 81 67.5 Professional Respiratory therapist 8 6.7
Master’s degree 24 20 category Pharmacist 23 19.2
Unmarried 50 41.7 Medical examiner 24 20
Marital Married 68 56.7 Audiologist 3 2.5
status Divorce 1 0.8
Widowed 1 0.8

2.2. Measures
A structured questionnaire was used as the research tool. Five experts and scholars
were invited to evaluate the content validity of the questionnaire. They rated each item on
the questionnaire with regard to “importance,” “text clarity,” and “appropriateness.” The
reliability was analyzed using Cronbach’s alpha. The questionnaire included the following
measures. Emotional labor items were rated using a five-point Likert scale [23], which
included 7 items on surface acting and 4 items on deep acting. After factor analysis, two
eigenvalues greater than 1 were extracted, the eigenvalues of a single factor were 3.42
and 4.12, respectively, and their sum explained 71.37% of the variance. The factor loading
of each item is greater than 0.6, indicating that the item validity is good (Table 2). The
reliability of deep effect and surface effect were 0.904 and 0.893, respectively, the Cronbach’s
alpha of emotional labor was 0.885, and the content validity was 0.881.

Table 2. Factor analysis results of emotional labor (n = 120).

Varimax Factor One Varimax Factor Two

Emotional Labor
Factor Loadings Factor Loadings
Surface acting
I will feign appropriate emotion when serving patients. 0.800
I will pretend to be in a good mood when serving patients. 0.854
I treat patients like a play. 0.852
When serving patients, I will feign job-appropriate emotions. 0.879
In order to express the emotions required by the job, I will wear a mask to hide
0.842
what I really feel inside.
There is a gap between the emotions I express to the patient and what I
0.621
feel inside.
I would feign appropriate emotions to treat patients. 0.836
Deep acting
I try to feel the emotions that need to be expressed when serving patients. 0.809
I try to empathize with the emotions that have to be expressed in
0.880
serving patients.
I try to feel the emotions that need to be expressed to the patient. 0.898
I try my best to serve patients with empathy. 0.843
Percentage of variation explained (%) 49.87 21.50
KMO (Kaister–Meyer–Olkin) 0.880
χ2 = 920.927
Bartlett’s test of sphericity
p < 0.001

Emotional exhaustion was assessed using the Maslach Burnout Inventory (MBI-
GS) [24] which contains five items that are responded to using a five-point Likert scale, with
a good-enough reliability of 0.88. In this study, Cronbach’s alpha was 0.919 and content
Healthcare 2023, 11, 104 4 of 9

validity was 0.933. In terms of physical and mental health, the China Health Questionnaire
(CHQ-12) revised by Williams [25] in 1986 was used. On the basis of the 30 questions in the
General Health Questionnaire (GHQ) [26], various questions about Chinese culture were
added. The Cronbach coefficient of the scale was 0.83–0.92. The measure included 4 ques-
tions about physical health, 4 questions about anxiety, and 4 questions about depression
and poor family relationships. The Cronbach’s alpha of this study was 0.839 and content
validity was 0.890.

2.3. Data Collection

After the study was approved by the Taiwan Adventist Hospital Institutional Review
Board (108-E-21), the researcher explained the purpose of the study and relevant infor-
mation to eligible participants. After the participant signed the written consent, they put
their completed questionnaire and consent form into a secured box that was allocated
for questionnaires.

2.4. Differences in Physical and Mental Health according to Demographic Characteristics

Differences in physical and mental health due to gender (t = 0.358, p > 0.05) and marital
status (t = −0.298, p > 0.05) were evaluated using a t-test, and there were no significant
differences. One-way analysis of variance was used to explore the differences in physical
and mental health according to age (F = 0.291, p > 0.05), education (F = 0.691, p > 0.05), and
profession (F = 1.658, p > 0.05). There were no statistically significant differences found
among the groups.

3. Result
3.1. Descriptive Analysis for Each Scale
Table 3 shows the results for the average scores on the measures. The average score
for emotional labor was 3.70 (1–5 points). The average score for surface acting was 3.42,
and the average score for deep acting was 4.11. The average score for emotional exhaustion
was 2.71 (1–5 points). Cutoff scores for the above were as follows: low group < 1.35, middle
group 1.35–3.65, high group > 3.65. The average score for physical and mental health was
2.01 (1–4 points). Among them, the average scores were 1.72 for physical condition, 1.87
for anxiety, and 2.38 for depression and poor family relations. The average score for poor
sleep was 2.13. Cutoff scores for the above were as follows: low group < 1.08, middle group
1.08–2.92, high group > 2.92.

Table 3. Descriptive analysis for each scale (n = 120).

Measurement Constructs/Items Number of Items Mean Item Score Range

Emotional labor 11 3.70 1–5
Surface acting 7 3.42 1–5
Deep acting 4 4.11 1–5
Emotional exhaustion 5 2.71 1–5
Physical and mental health 12 2.01 1–4
Physical condition 4 1.72 1–4
Anxiety 3 1.87 1–4
Depression and poor family relations 4 2.38 1–4
Poor sleep 1 2.13 1–4

Therefore, the health professional’s surface acting is moderate, deep acting is high,
emotional exhaustion is moderate, poor physical condition is moderate, anxiety is moderate,
depression and poor family relationships are moderate, and poor sleep is moderate.

3.2. Differences in Emotional Labor, Emotional Exhaustion, and Physical and Mental Health
among Health Professionals
Kruskal–Wallis analysis was used to explore the differences in emotional labor (includ-
ing surface acting and deep acting), emotional exhaustion, and physical and mental health
Healthcare 2023, 11, 104 5 of 9

in the different professions. The results show that surface acting (p < 0.05) and emotional
exhaustion (p < 0.05) were significantly different among the health professionals categories
(F = 3.491, p < 0.05).
The surface acting of the examiner and audiologist is the highest, and the surface
acting of the clinical psychologist is the lowest. Emotional exhaustion was highest for
examiner and pharmacist and lowest for radiologist and nutritionist.

3.3. The Relationship between Emotional Labor, Emotional Exhaustion, and Physical and
Mental Health
Pearson correlation coefficients were used to analyze the relationships between the
variables. Significant positive correlations were found between emotional labor and emo-
tional exhaustion (r = 0.336, p < 0.001) and physical and mental health (r = 0.184, p < 0.05).
The more surface acting (r = 0.918, p < 0.001) and deep acting (r = 0.659, p < 0.001), the more
emotional labor. Emotional labor was also significantly positively correlated with anxiety
(r = 0.225, p < 0.05), indicating that the greater the degree of anxiety, the more emotional
labor. Emotional labor, physical condition, and depression and poor family relations did
not reach a statistically significant difference, indicating that physical condition as well
as depression and poor family relations have no correlation with emotional labor. Emo-
tional exhaustion was significantly positively correlated with physical and mental health
(r = 0.597, p < 0.001) and surface acting (r = 0.404, p < 0.001). This shows that the worse
the physical and mental health and the more surface acting, the greater the emotional
exhaustion. Deep acting and emotional exhaustion did not reach a statistically significant
difference, indicating that there is no correlation between them. Emotional exhaustion
was significantly positive with physical condition (r = 0.482, p < 0.001), anxiety (r = 0.596,
p < 0.001), and depression and poor family relations (r = 0.294, p < 0.001). This shows that
the worse the physical condition, the more anxiety and the more depression and poor
family relations, the greater the degree of emotional exhaustion. Physical and mental
health, surface acting and deep acting did not reach a statistically significant difference,
indicating that there is no correlation between them. Physical and mental health and
physical condition (r = 0.857, p < 0.001), anxiety (r = 0.878, p < 0.001), and depression and
poor family relations (r = 0.600, p < 0.001) had a significantly positive correlation. This
means that the worse the physical condition, the more anxiety, and the more depression
and poor family relations, the worse the physical and mental health (Table 4).

Table 4. Correlations between emotional labor, emotional exhaustion, and physical and mental health.

Variable Emotional Labor Emotional Exhaustion Physical and Mental Health

Emotional labor 1
Emotional exhaustion 0.336 *** 1
Physical and mental health 0.184 * 0.597 *** 1
Surface acting 0.918 *** 0.404 *** 0.135
Deep acting 0.659 *** 0.044 0.166
Physical condition 0.167 0.482 *** 0.857 ***
Anxiety 0.225 * 0.596 *** 0.878 ***
Depression and poor family relations −0.070 0.294 *** 0.600 ***
*: p < 0.05; ***: p < 0.001.

3.4. The Mediating Effect of Emotional Exhaustion on the Relationship between Emotional Labor
and Physical and Mental Health
A hierarchical regression analysis was used to explore emotional exhaustion as a
mediator in the relation between emotional labor and physical and mental health. The
results show that Model 1 (F = 4.138, p < 0.05), Model 2 (F = 14.996, p < 0.001) and Model 3
(F = 32.447, p < 0.001) were all statistically significant. The R2 of emotional labor on physical
and mental health was 18.4% (β = 0.184, p < 0.05), and the R2 of emotional exhaustion on
physical and mental health was 33.6% (β = 0.336, p < 0.001). The effect of emotional labor
on physical and mental health increased the predictive power to 59.7% through emotional
Healthcare 2023, 11, 104 6 of 9

exhaustion, and emotional exhaustion had a mediating effect on the relationship between
emotional labor and physical and mental health (β = 0.603, p < 0.001) (Table 5).

Table 5. The mediating effect of emotional exhaustion in the relation between emotional labor and
physical and mental health.

Physical and Mental Health

Predictor
Model 1 Model 2 Model 3
Predictor
Emotional labor 0.184 * −0.019
Emotional exhaustion 0.336 *** 0.603 ***
R2 0.184 0.336 0.597
4 R2 0.184 0.152 0.261
F 4.138 * 14.996 *** 32.447 ***
*: p < 0.05; ***: p < 0.001.

4. Discussion
This study found that the higher the emotional labor of health professionals, the greater
the emotional exhaustion. Similar to the discussion by scholars such as Hochschild [7],
when employees are required to regulate their emotions at work to match the changes in the
external environment, the appropriate external emotional performance may be inconsistent
with the employee’s true inner feelings; the external and internal emotions are alienated.
This alienation cannot be maintained for a long time, which leads to stress overload and
emotional exhaustion. Therefore, workers with high emotional labor are more likely to have
emotional disorders and emotional exhaustion. Given the correlation between emotional
labor and emotional exhaustion [27], the higher the emotional labor undertaken by an
individual, the more there will be an increase in the frequency of emotional exhaustion [28].
The results of this study show that surface acting was positively correlated with emo-
tional exhaustion, while deep acting had no significant relation to emotional exhaustion.
The plausible reason is that surface acting only modifies the external emotional expression
to achieve the purpose of emotional camouflage, which would make it easy to create conflict
between inner and external emotions, resulting in emotional imbalance. Therefore, the
higher the level of surface acting, the heavier the emotional labor required, which is akin
to the view put forward by Grandey [29,30]. When an individual’s inner emotions are
repressed and desired emotions are expressed, the surface effects exhibited can deplete per-
sonal energy and affect employee well-being [30–32]. For example, nurses are more likely
to experience emotional exhaustion when they engage in superficial performances [33].
Surface behavior is positively correlated with emotional exhaustion [31,34]. Conversely,
deep performances tend to resolve the initial emotional dissonance, resulting in the same
internal feelings and external performance [30,31]. Employees will experience positive
emotional experiences to express positive emotions, and these experiences may provide
relief of fatigue [35]. A prior study found that deep acting leads to better mood, better job
performance and higher job satisfaction [29].
Long-term and constant emotional labor may damage an individual’s physical and
mental health [36,37]. This study found that the emotional labor of health professionals
was significantly and positively correlated with anxiety and physical and mental health.
Previous studies also found that surface acting emotional labor was positively associated
with depression [38,39]. A study on nursing staff found that emotional labor can explain
21% of the variance in mental health status, showing that the greater the emotional labor of
nursing staff, the less ideal was their mental health [9]. Additionally, a recent study found
that episodic emotional labor was a strong predictor of depressive symptoms in nursing
home health care workers two years later [40].
Past studies have discovered that in the process of performing medical care, nurses
must suppress their emotions to provide professional services. Such emotional services
can lead to work stress, deterioration of physical and mental health and emotional ex-
Healthcare 2023, 11, 104 7 of 9

haustion [41], and directly affect the quality of patient care and the occurrence of medical
negligence, which can even prompt them to leave the workplace [42]. Emotional labor
can predict employee job satisfaction and emotional exhaustion. Nursing staff who use
superficially disguised emotional labor are more likely to experience emotional exhaustion
and have lower job satisfaction because they need to hide their true emotions and disguise
unfelt emotions, increasing the degree of emotional dysregulation [43].
Moreover, the present study observed that surface acting emotional labor and emo-
tional exhaustion were positively correlated, and the latter had a mediating effect on the
relation between emotional labor and physical and mental health. Similar to previous stud-
ies, nurses are more likely to experience emotional exhaustion when they use surface acting
emotional labor. As a way of regulating emotions, performances can help employees regain
emotional resources and reduce emotional exhaustion [44]. In addition, Rogers et al. [38]
found positive correlations between the surface acting emotional labor of doctors and
work-related burnout and depression. There was a negative correlation between deep
emotional labor and burnout, and work-related burnout mediated the relationship between
surface emotional labor and depression.
The above literature suggests that the higher the level of emotional labor, the more
serious the degree of emotional exhaustion, and the less ideal one’s physical and mental
health. Conversely, it also indicates the lower the emotional labor, the lower the degree
of emotional exhaustion and the better one’s physical and mental health. Therefore, it is
inferred that there will be significant differences between emotional labor and emotional
exhaustion and physical and mental health of different degrees.
This study adopted a cross-sectional data collection method to explore the emotional
labor, emotional exhaustion, and physical and mental health of health professionals. It is
suggested that future research conduct longitudinal studies to examine causal relationships
and effects over time. In addition, the study included health professionals at one particular
hospital, and there may be different results due to differences in the background variables
of the research participants.

5. Conclusions
This study confirms that the emotional labor and emotional exhaustion of health
professionals are quite serious. Emotional labor was significantly positively correlated with
emotional exhaustion, physical and mental health, and anxiety. Emotional exhaustion was
significantly and positively correlated with physical and mental health, physical condition,
anxiety, and depression and poor family relationships. The predictive power of emo-
tional labor on physical and mental health was improved through emotional exhaustion;
emotional exhaustion had a mediating effect in the relation between emotional labor and
physical and mental health.
We hope to inspire others to study how emotion management can help the health and
well-being of healthcare professionals, thereby improving the quality of care healthcare
professionals provide to patients. Therefore, developing emotional management skills
necessary for health professionals to work effectively is essential to improve the quality of
patient care and treatment outcomes, and to ensure that patient care is not compromised by
the health professional’s own emotional and health conditions. There is indeed a great need
for channels to relieve and de-escalate their emotional labor to prevent emotional exhaus-
tion from occurring. Related studies have found that social support through colleagues,
supervisors and organizations in the workplace may reduce the negative effect of emotional
labor [45,46]. Therefore, the implications of this study suggest that in addition to improving
the working environment (including providing social support) to reduce the emotional
labor of employees’ surface acting behavior, hospital managers can provide supportive
psychological counseling to reduce employees’ emotional labor and emotional exhaustion.
This in turn will improve the physical and mental health and well-being of employees.
Healthcare 2023, 11, 104 8 of 9

Author Contributions: Conceptualization, C.-C.C., Y.-L.L. and S.-L.C.; methodology, C.-C.C. and
Y.-L.L.; software, C.-C.C. and Y.-L.L.; validation, C.-C.C., Y.-L.L., Y.-C.L. and S.-L.C.; formal analysis,
C.-C.C. and Y.-L.L.; investigation, Y.-C.L. and S.-L.C.; resources, Y.-C.L. and S.-L.C.; data curation,
C.-C.C. and Y.-L.L.; writing—original draft, C.-C.C. and Y.-L.L.; writing—review and editing, C.-C.C.
and Y.-L.L.; project administration, C.-C.C., Y.-L.L., Y.-C.L. and S.-L.C. All authors have read and
agreed to the published version of the manuscript.
Funding: Taiwan Adventist Hospital provided funding for this research project.
Institutional Review Board Statement: The study was conducted according to the guidelines of
the Declaration of Helsinki and approved by the Institutional Review Board of Taiwan Adventist
Hospital (108-E-21).
Informed Consent Statement: Informed consent was obtained from all participants involved in
the study.
Data Availability Statement: Data is available upon request from the corresponding author. Data
are not publicly available due to privacy and ethical constraints.
Conflicts of Interest: The authors declare no conflict of interest.

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