Enhance the Emotional Dimension of Caring

INTRODUCTION The health and illness experiences of children and their families are often characterized by intense emotions that reflect suffering and vulnerability. Across children's different development stages, illness and clinical procedures pose emotional challenges that may cause considerable distress.1,2 Consequently, pediatric nursing care involves specific strategies and tools to help children regulate their emotional responses, distinguishing it from the care provided to adults and older clients. Evidence from psychology, psychiatry, and neuroscience underscores the fundamental role of affection in supporting healthy and harmonious child development; therefore, pediatric nursing emphasizes emotionally attuned and sensitive practices grounded in a culture of affection.2-4 Building on this understanding, nurses who care for children and their families—with the therapeutic aim to alleviate emotional burdens and support emotional regulation—consider emotional needs equally as important as physiological and other health care requirements. Moreover, nurses place significant value on positively transforming the child's and family's health care experiences, recognizing these moments as opportunities for learning and development.1 Emotional care involves understanding children's emotions across developmental stages, recognizing how these emotions are shared within families, and supporting adaptive emotional regulation.2 However, nurses frequently absorb the intense emotionality and suffering of their clients, which can impact their well-being and contribute to emotional exhaustion.2,3,5,6 The last global pandemic, Coronavirus Disease 2019 (COVID-19), has exacerbated these challenges, generating profound emotional experiences—marked by anxiety, fear, distress, anger, loneliness, and isolation—for children and their families. This situation further underscores the crucial importance of emotional nursing care in pediatric settings, as well as the necessity for nurses to manage their own emotions effectively.5 The emotional dimension of nursing is grounded in a holistic and integrative approach to the human being.2 Children and their families are multidimensional individuals who experience a wide range of emotions that significantly influence their well-being, reinforcing the necessity of rejecting Statement of Significance What is known or assumed to be true about this topic? Pediatric nursing is often marked by significant emotional complexity, which requires nurses to engage in emotional management. Providing compassionate care relies on understanding the emotional experiences of clients, including children and their families, as well as the nurses' ability to handle those emotional responses. Establishing practice guidelines based on nursing research and theoretical frameworks is essential for enhancing clinical outcomes, health services, and health care economics. What this article adds? Health care institutions and nurses must recognize and value the emotional aspects of nursing. By doing so, the emotional labor involved in nursing can be integrated into reflective practice and supported by scientific evidence. It is essential to develop models of care that guide and empower nurses in addressing emotional challenges specific to pediatric nursing and health care. The application of the Emotional Labor Model in Pediatric Nursing has the potential to encourage discussions, research, and changes in practice among pediatric nurses, administrators, researchers, and nursing education programs.fragmented or reductionist perspectives. A humanized approach to care—rooted in the ethical principle of human dignity—emphasizes emotionally attuned and compassionate support.3 In light of these principles, the notion of emotional neutrality in nursing practice is increasingly challenged. Contemporary nursing science recognizes the centrality of human emotions in health care.3,5-7 Consequently, care provision demands an attentive and emotionally responsive approach, with the nurse-client relationship playing a pivotal role in facilitating both the expression and management of emotions.1-3,7 Emotional labor in nursing8 represents the operationalization of this emotional dimension. It is defined as an autonomous intervention and/or a set of strategies or tools aimed at facilitating clients' emotional regulation, managing nurses' own emotions, expressing emotions appropriately, and cultivating the capacity to provide emotional care.9,10 To achieve this and enhance care quality, emotional labor should be integrated into nursing education and training programs,1,8-10 fostering the development of nurses' emotional competencies. Research on emotional labor in nursing has yielded several conceptual models and frameworks to guide understanding and practice, including the Healthcare Model of Emotional Labor,11 the Four Typologies of Emotional Labor,12 the Emotional Labor Process Model,13 and the Authentic Emotional Labor Model.14 However, in pediatric care, the unique characteristics of clients and nurse-client interactions require a distinctive model.2,11,15 Considering this gap, this paper introduces the Emotional Labor Model in Pediatric Nursing (ELMPN), outlining its foundation, key care categories, expected outcomes, and applicability in strengthening the emotional dimension of pediatric care. THE ELMPN: A MODEL OF CARE The ELMPN is characterized by its comprehensive approach to conceptualizing and operationalizing emotional labor within the field of pediatrics. The model encompasses 5 categories of care, each imbued with an affective-emotional dimension and designed to consciously facilitate the management of emotionality among clients (children and families) and nurses. These categories are as follows1: Promote a safe and affectionate environment. Nurture care with affection. Facilitate clients' emotional management. Build stability in the relationship. Regulate own emotional disposition to care (see Figure 1) Figure 1.: Schematic representation of the ELMPN: relationship among the 5 care categories.1 The 5 care categories of the ELMPN are adaptable to different pediatric settings and children's developmental stages, making the model a flexible framework for enhancing nursing practice with children and families. Its distinctiveness lies in the management of both clients' and nurses' emotions, supporting nurses' personal and professional development, promoting emotional well-being and humanized care, and embodying the concept of triple centrality. Here, triple centrality refers to the emphasis placed on 3 interrelated domains: (1) the child/family, (2) the nurse, and (3) the child/family-nurse relationship. In domain (1), centrality is reflected in care categories such as Promote a safe and affectionate environment, Nurture care with affection, and Facilitate clients' emotional management. In domain (2), it is represented by the category Regulate own emotional disposition to care. In domain (3), centrality is evident in the category Build stability in the relationship. The ELMPN serves as both a conceptual and practical framework for pediatric nurses, guiding the management of emotionality throughout the health-disease continuum. It emphasizes the emotional well-being of pediatric clients, acknowledges nurses' own emotional responses, and promotes the regulation of emotions during nurse-client interactions. The model highlights the potential for emotional experiences to be transformed into opportunities for positive growth and personal development, thereby enhancing the quality of care and fostering a more humanizing health care environment. When applying the ELMPN, pediatric nurses tailor their interactions according to the children's developmental stage. For example, within the category Facilitate clients' emotional management, 2 primary emotional management strategies are employed: anticipatory and reactive. In anticipatory emotion management, nurses take proactive steps to prevent emotional distress during care procedures. For infants, this may involve approaching the crib slowly, using gentle touch, maintaining a calm tone of voice, and smiling to convey safety. Nurses may also ask the mother to hold the baby with affective restraint during procedures such as medication administration, minimizing fear or irritation. Toddlers, who are beginning to assert independence and engage in symbolic play, often benefit from imaginative approaches. For instance, if a toddler is playing with a toy stroller, the nurse might join the game, comment on the stroller's color, or introduce the procedure by saying something like, "We're going to energize your stroller with a magic liquid through this little tube," to explain intravenous medication. Preschoolers, who are more verbal and imaginative, can be engaged by initiating conversations about their drawings, pets, or favorite games. Treatments or procedures may be framed as part of a play scenario—such as checking a doll's temperature or giving medicine to a teddy bear—to promote cooperation through storytelling and role-play. School-aged children, possessing increased cognitive abilities and curiosity, benefit from clear, age-appropriate explanations. Nurses can use simple vocabulary, books, or illustrations to explain procedures and encourage questions. In addition, nurses promote trust and reduce anxiety by showing openness and honest responses. Adolescents, capable of abstract thinking and often emotionally sensitive, require verbal explanations. Nurses create space for questions, clarify doubts, and support emotional expression, while also observing emotional lability, which is common during this stage. The ELMPN has been demonstrated to foster stability within the nurse-child-family relationship, thereby creating an environment characterized by safety, empathy, and affection. This, in turn, positively influences the emotional management of all parties involved.1,2,6 Moreover, the application of the ELMPN promotes professional performance among nurses through education, training, and supportive debriefing. These processes enable nurses to incorporate presence, availability, emotional involvement, and positivity into their care, balancing caring for others while protecting themselves from emotional exhaustion. The ELMPN has been officially registered as intellectual property with the General Inspection of Cultural Activities (IGAC) in Portugal, bearing registration number 1349/2019 as of May 15, 2019. METHODS A Grounded Theory study16 was conducted as part of a doctoral thesis entitled "Work with the Emotions in Pediatric Nursing: A Process of Metamorphosis of the Emotional Experience in the Act of Caring".17 This study provides insights into how nurses manage emotions in their care for children and families, and how such emotional management is transformed into a therapeutic intervention that enhances pediatric clients' well-being through the re-signification of their experiences. The research also highlights often invisible, unconscious, and undervalued nursing interventions that promote health gains, underscoring the critical importance of the emotional dimension in nursing practice. This qualitative research aligns with the naturalistic (interpretive) paradigm, aiming to explore the complexity of human experiences directly and holistically. An exploratory, descriptive approach was adopted, involving the collection and analysis of narrative and subjective data within a pediatric ward. Participants included nurses (n = 12), children (from infants to school-aged, n = 10), adolescents (aged 11 and 16 years, n = 2), and family members (mothers, fathers, and grandparents, n = 21). Participants were recruited by the head nurse or shift manager, and informed consent was obtained from both nurses and families. To explore phenomena in depth and collect richness, descriptive data, 3 methods were employed: interviews, observations (participant and nonparticipant), and written narratives. In-depth interviews were conducted with 24 nurses, 5 parents (mothers and fathers), and 1 adolescent. Observations focused on various interactions, including: mother-father-nurse (1), child-grandmother-nurse (2), child-mother-nurse (5), adolescent-nurse (1), mother-nurse (2), adolescent-mother-nurse (1), mother-father-grandmother-nurse (1), child-nurse (3), and child-mother-father-nurse (2). Additionally, written narratives were obtained from 4 nurses. Data analysis was conducted using NVivo software. The study demonstrated how emotions are employed therapeutically in pediatric nursing, showing that emotional management can be structured into interventions that enhance client well-being. The development of a logical, systematic, and explanatory model emerged from this middle-range theory16,17 and is grounded in the nursing body of knowledge, particularly the concept of emotional labor.8,9 The model was subsequently validated in other pediatric contexts through research and reflective practice.1 Consequently, it serves as a theoretical framework derived from inductive research rooted in nursing practice. It functions not merely as a representation of reality but also as a practical guide for pediatric nurses and an educational resource. According to the pioneers of Grounded Theory,16 the model represents the operational aspect of the middle-range theory and is considered a practice model, in contrast to a conceptual model, which possesses a higher level of abstraction.18 A practice model, or model of care, is defined as a schematic representation that is directly applicable, specific, and concrete.19-21 Models are developed to represent theories; thus, a middle-range theory can give rise to a diagrammatic representation that reveals relationships between concepts.22 The middle-range theory underlying this study produced the ELMPN, illustrating the interconnections among 5 care categories and explaining emotional nursing phenomena derived from inductive reasoning.23 In summary, the ELMPN evolved from the middle-range theory developed in the author's doctoral thesis (2005-2010),17 as well as quantitative and qualitative studies conducted in diverse pediatric contexts to validate the model,1 and through reflective practice with expert pediatric nurses and discussions with researchers and academic peers.2,3,5 CONCEPTUAL FRAMEWORK The ELMPN is grounded in several theoretical foundations. First, it reflects the nursing metaparadigm, which encompasses the concepts of environment, person, health, and nursing intervention.24 Second, it incorporates the transformative nursing paradigm,25 with caring as its central concept, drawing on Watson's Theory of Human Caring7 and related theorizing on caring.26 Third, it integrates the concept of "personal knowledge" within the context of nursing knowledge patterns.27,28 Finally, it embraces a holistic7 and humanistic29 perspective in health care. This conceptual framework is based on the concept of emotional labor in nursing, a construct that has received substantial scholarly attention.8,9,30 It is precisely this concept of emotional labor that underpins the designation of the ELMPN. In addition, the model incorporates principles of family-centered care and atraumatic care in pediatric nursing. THEORETICAL CONCEPTS Based on the nursing metaparadigm,24 the ELMPN is grounded in 5 fundamental concepts. - The Person-Client is defined as the child or family member who experiences intense emotionality within the context of health-disease processes. This emotionality is both inherent to the children's developmental stage and shaped by the care experience itself, which may exacerbate suffering and increase vulnerability. The Person-Client is understood as a complex, unique, sensitive, and vulnerable being—one who may attribute negative emotional meanings to illness and health care experiences. However, this individual also possesses the capacity for emotional reorganization and for mobilizing both internal and external resources to cope and adapt positively. Whether this adaptive ability is activated depends significantly on the conditions and environment surrounding the individual, as well as the presence of supportive care and meaningful relationships. - The Person-Nurse is adept at recognizing and interpreting the emotional needs of each child and family (Person-Client) and is attuned to their emotional responses to health challenges and the care process. This nurse is committed to supporting and empowering the client's emotional management in a manner appropriate to the children's developmental stage. The Person-Nurse demonstrates empathy and emotional closeness, thereby fostering a deeper understanding of the client's emotional state. The emotional responses elicited through interactions with clients experiencing distress and suffering contribute to the development of emotional competence in the nurse. However, it is essential that nurses also have the capacity for introspection and articulation of their experiences—particularly within the context of teamwork and their own emotional well-being. Regular reflection on practice and the use of supportive debriefing are recommended strategies within the ELMPN to sustain nurses' emotional well-being and foster professional growth. - The Pediatric Environment is understood as a relational and emotionally homely atmosphere that begins at the point of reception and continues throughout the continuum of care. It is characterized by interactions grounded in trust, affection, calmness, and comfort for all individuals involved. The creation of this therapeutic environment is facilitated by engaging the child's imagination and emotional world through affection, singing, appropriate language, and play. This environment is affective and secure, thoughtfully adapted to the children's developmental stage, and intentionally designed to support emotional regulation and reduce distress throughout the care experience. - The nurse-client relationship is characterized by emotional connection and caring; it serves as a space for expression and sharing, where clients experience intense emotionality and nurses respond empathetically to the suffering of those in their care. Managing this emotional flow is essential to the therapeutic process. Therapeutic relationships are built on empathy, trust, compassion, proximity, and emotional reciprocity. For these relationships to be effective, both communication and emotional regulation strategies must be carefully adapted to the children's developmental stage, ensuring that emotional needs are addressed in a developmentally appropriate and supportive manner. - The concept of emotional labor in pediatric nursing is defined in both general and specific terms. General Definition: Emotional labor in pediatric nursing refers to the intentional management of emotionality—both of clients (children and families) and nurses—to positively transform emotional experiences, interpersonal relationships, and the care process itself. This transformation seeks to relieve suffering, enhance well-being, and support the personal growth of all individuals involved. To protect themselves from emotional exhaustion, nurses employ individual strategies (eg, reflective writing, meditation, relaxing walks) as well as collective strategies (eg, case analysis, supportive debriefing, group recognition, and praise). These practices are designed to promote emotional well-being and resilience. Specific Definition: Emotional labor in pediatric nursing involves a set of therapeutic strategies and tools mobilized by nurses—individually and collectively—during the care process. These are operationalized through the 5 care categories of the ELMPN: Promote a safe and affectionate environment; Nurture care with affection; Facilitate the management of clients' emotions; Build stability in the relationship; Regulate own emotional disposition to care. These strategies aim to promote the emotional well-being and health of children and families, as well as the emotional balance and professional satisfaction of nurses. THE 5 CARE CATEGORIES OF ELMPN Nurses recognize the profound emotional experiences faced by pediatric clients, understanding these as intrinsic to nursing practice.1-3,5 They actively seek to transform these experiences positively and therapeutically through the application of 5 care categories (Figure 1), which reflect the intentionality of emotional care. The following examples illustrate these categories in practice: - To cultivate a secure and nurturing atmosphere, nurses introduce themselves by name and communicate in a tone that is both compassionate and reassuring. They often wear colorful uniforms to create a friendly environment and guide children through the playroom to foster a sense of safety. Additionally, they initiate conversations and moments of play, using characters from fairy tales or cartoons to engage the child's imagination and promote emotional comfort (Figure 2). Figure 2.: Defining characteristics of the care category "Promote a safe and affectionate environment".1 - To nurture care with affection, nurses demonstrate their warmth through various expressive and relational behaviors. First, their smiles, calm and gentle tone of voice, soft gaze, and comforting speech—often enriched by affectionate language or nickname and accompanied by soothing head movements—reveal their ability to provide tenderness and reassurance. Second, this affection is also conveyed through physical expressions of care, such as gentle stroking, light touches, hugs, and offering a lap for comfort and emotional containment (Figure 3). Figure 3.: Defining characteristics of the care category "Nurture care with affection".1 - To facilitate the management of clients' emotions, nurses adopt a calm and compassionate demeanor, instill hope, and reassure families of their availability and support. They use a range of strategies and tools to prepare children for treatments or procedures, including visual aids such as puppets or books to enhance understanding. Additionally, nurses teach children simple relaxation techniques, such as deep breathing, whistling, blowing, and guided imagery, to help reduce anxiety and promote emotional regulation. Children are also encouraged to keep comfort objects—such as a stuffed toy or blanket—during procedures and are supported in expressing their emotions through conversation or drawing. Parents are encouraged to be present during all procedures and are actively invited to participate in the care process (Figure 4). Figure 4.: Defining characteristics of the care category "Facilitate clients' emotional management".1 - To build stability in the relationship, particularly during the initial encounter, nurses strive to establish rapport with children by asking about the identity of their doll or teddy bear, engaging in conversations about shared interests—such as close friends, school experiences, or pets—and creating a foundation of trust. This trust is fostered through physical and emotional proximity, expressions of affection, transparent communication, and a collaborative approach to decision-making with parents or other family members (Figure 5). Figure 5.: Defining characteristics of the care category "Build stability in the relationship".1 - To regulate their own emotional disposition to care, nurses can draw on resources available within the team context. These include group support, reflective practice, sharing emotional management strategies, and facilitating discussion groups or forums focused on emotions related to health care. In addition to team-based strategies, individualized emotional regulation resources are developed through workshops and webinars. These include relaxation techniques, reflective writing, meditation, mindfulness, dance, and yoga—all of which support positive emotional regulation during highly affective care experiences (Figure 6). Such formative strategies—particularly training and supportive debriefing—are essential components of the ELMPN and play a crucial role in fostering the development of emotional competencies among nurses. Figure 6.: Defining characteristics of the care category "Regulate own emotional disposition to care".1 The 5 care categories are inherently interrelated, with nurses' emotional regulation being essential to their presence and availability in providing affectionate care. The following example illustrates how the ELMPN care categories enhance the provision of emotional care: When a child exhibits signs of distress related to fear of hospitalization, and the mother displays anxiety and apprehension about her child's health, the nurse recognizes the emotional vulnerability of both clients. Demonstrating empathy, affection, and availability in communication, the nurse fosters a supportive environment that promotes emotional well-being. To create a therapeutic atmosphere, the nurse warmly introduces the child and mother to the bedroom and playroom, adopting a friendly and welcoming demeanor. The therapeutic relationship is marked by hopeful dialogue and positive interactions, facilitating the emotional management of both child and mother, and nurturing feelings of trust, respect, and consideration. The nurse's approach is multifaceted: empowering the mother by providing essential information and involving her in the child's care; offering the mother a safe space to express her emotions and find meaning in the experience; and providing opportunities for the child to engage in play, painting, and recreational activities, including interaction with hospital clowns. During treatments, the nurse teaches the child deep breathing techniques and guides them through positive imagery to alleviate fear and stress. To ensure continuity of care and knowledge sharing, nurses hold practice analysis meetings to disseminate emotional management strategies used in their care. They also participate in mindfulness exercises and listen to soothing music to foster calm and reduce stress. Collectively, these strategies have proven effective in helping families cope with the emotional challenges associated with their children's health conditions. A PRACTICAL CASE—REFLEXIVE RECORDING OF NURSE-CHILD INTERACTION IN THE CONTEXT OF PEDIATRIC ONCOLOGY During the morning, while James (a fictitious name) was alone in the room after his mother had left the ward, I considered it appropriate to approach him. Before this interaction, James had been playing a game of Four in a Row with his mother. Upon approaching him, I invited him to continue the game, which he graciously accepted. James has had cancer since the age of 2 and has undergone multiple chemotherapy protocols. He is now 5 years old. His facial expression reflects the prolonged time he has spent in the hospital and does not easily lend itself to smiling. Over time, he has developed strong defense mechanisms that shield him from external influences. As a result, interpersonal interactions—both verbal and nonverbal—pose a significant challenge. Table 1 demonstrates how ELMPN can be applied, as described in a nurse's reflective journal. Table 1. - Description of the Nurse-child Interaction and Correlation With the Categories of ELMPN. Nurse-child interaction Emotional changes Strategies and tools employed in the ELMPN ELMPN categories of care The investment of time in interpersonal relationships has been shown to facilitate the overcoming of communication barriers. The game began following a negotiation regarding the color of the pieces. During play, Jim's gaze occasionally fell upon me, particularly when he anticipated risky moves. In response, I displayed subtle signs of internal deliberation, reflecting a state of uncertainty in my decision-making process. In turn, he exhibited a playful expression, suggesting the presence of a hidden strategy. - Fear - Play and playthings - Facilitate clients' emotional management - Feeling - Presence - Empathy uncomfortable - Friendly relationships - Inhibition - Openness to emotional expression - Promote a safe and affectionate environment I looked at him, perplexed, and responded in a playful manner: "James, what is the meaning of that expression? I am certain you are attempting to deceive me". He smiled in return, but making an effort to suppress his laughter, aware that any overt display of amusement might be interpreted as an indication of intimacy in the relationship—something he did not yet feel sufficiently confident to convey. - Shame - Affectionate humor - Build stability in the relationship - Active listening - Feeling uncomfortable - Openness to emotional expression - Promote a safe and affectionate environment - Confidence building In some instances, the correct move was chosen, while in others, a deliberate mistake was made to elicit a response from the child during the interaction. When the outcome was favorable, the child exhibited a positive response in the form of laughter and increased engagement. Conversely, when I won, the child displayed a smile that was partially forced but still restrained. - Happiness (albeit restrained) - Humor- Affectionate humor - Nurture care with affection - Facilitate clients' emotional management - Empathy At one point, a recreation specialist entered the room with a DVD player and a selection of movies, in response to a prior request made by Jim. I then asked Jim whether he would prefer to watch the DVDs or continue playing "Four in a Row" with me, and he chose to continue the game. This response demonstrated that these moments of play with the nurse were a source of pleasure and enjoyment for him. Given the challenging nature of the hospital environment and the prolonged duration of hospitalization, the ability to provide a moment of tranquility and enjoyment for a child is undoubtedly beneficial for facilitating em