Theoretical Article

Pensar Enfermagem / v.29 n.01 / Jan-Dec 2025 / DOI: 10.71861/pensarenf.v29i1.436 / e00436

Emotional labor in pediatric nursing: Experience report with

therapeutic instruments

Rita Barros1*, Sofia Seabra2, Paula Diogo3

1 Enfermeira Especialista em Enfermagem de Saúde Infantil e Pediátrica, Neonatologia do Hospital Lusíadas Lisboa; Centro de Investigação,

Inovação e Desenvolvimento em Enfermagem de Lisboa (CIDNUR), Escola Superior de Enfermagem, Universidade de Lisboa, Lisboa, Portugal;

orcid.org/0009-0002-3311-9828

2 Enfermeira, Unidade Médico Cirúrgica de Adultos, Hospital Doutor Manoel Constâncio Abrantes; Estudante de Mestrado em Enfermagem de

Saúde Infantil e Pediátrica, Escola Superior de Enfermagem de Lisboa (ESEL); orcid.org/0009-0006-9360-3434

3 Professora Coordenadora, Departamento de Enfermagem da Criança e do Jovem, Escola Superior de Enfermagem de Lisboa (ESEL); Centro de

Investigação, Inovação e Desenvolvimento em Enfermagem de Lisboa (CIDNUR), Escola Superior de Enfermagem, Universidade de Lisboa,

Lisboa, Portugal; orcid.org/0000-0003-4828-3452

* Corresponding author: ritavieirabarros@gmail.com

Received: 02.05.2025

Accepted: 1.1.2025

Editor: Helga Henriques

How to cite this article: Barros R, Seabra S, Diogo P. Emotional labor in pediatric nursing: Experience report with therapeutic instruments. Pensar Enf

[Internet]. 2025 Jan-Dec; 29(1): e00436. Available from: https://doi.org/10.71861/pensarenf.v29i1.436.

Abstract

Children and their families experience health and illness intensified by several factors, including exposure to

unfamiliar, threatening environments and disrupted routines. Given this impact, nurses should stay attuned to

children’s and families’ emotional needs and facilitate the intentional management of emotions by deploying

therapeutic instruments anchored in the Emotional Labor Model in Pediatric Nursing. This practice orientation

aims to positively transform intense emotional situations, potentially distressing for children, families, and

nurses.

This experience report examines how these instruments were deployed across three practicum settings

(neonatology, pediatric emergency department, and pediatric inpatient unit) over four months in public

hospitals in Lisbon and surrounding areas.

During the practicums, master’s students in child and pediatric health nursing deployed therapeutic instruments

such as humor and therapeutic play, which were pivotal in reducing the negative impact of hospitalization.

Additionally, we observed the applicability of the Emotional Labor Model in Pediatric Nursing and underscored

its relevance as a structured framework for these instruments.

Keywords

Emotions, Pediatric Nursing, Emotional Labor, Clinical Apprenticeship, Advanced Nursing Practice,

Experience Report.

Introduction

Children and their families frequently experience intensely emotional and potentially distressing states associated

with health and illness processes that, when hospitalization is required, may constitute crises for the entire

family.1,2 In neonatal hospitalization, an abrupt and unexpected separation occurs between the newborn and the

parents, an experience often described as an “emotional roller coaster.”3 In the context of sudden illness, seeking

care in the pediatric emergency department is a source of emotional stress for both the child and the family.4

When inpatient care is needed, pain and fear are compounded by disrupted routines and the desire to return

home, contributing to a deeply emotional experience.5 In this sense, emotions are inherent to nurse–child and

family interactions and inseparable from a holistic, humanized approach to pediatric care.1,6 The pediatric client

includes children and adolescents across developmental stages and their families, who should not be separated

from the nursing care process.2

Nurses, attuned to emotional needs and pursuing therapeutic outcomes, deploy therapeutic instruments tailored

to each child and family.1,7,8 These instruments help operationalize emotional labor in nursing.9,10,11 Centering

this concept, the Emotional Labor Model in Pediatric Nursing (ELMPN) proposed by Diogo,1 provides a

Theoretical Article

Pensar Enfermagem / v.29 n.01 / Jan-Dec 2025 / DOI: 10.71861/pensarenf.v29i1.436 / e00436

practice orientation for pediatric settings that enables the positive transformation of intense emotional situations

that can be unpleasant or distressing.1

ELMPN is a pedagogical resource integrated into the curriculum of the Master’s Program in Child and Pediatric

Health Nursing (CMESIP) at the Nursing School of Lisbon. It served as part of the theoretical framework for

CMESIP practicum projects, in articulation with the EmoS&PraxEnf Project within the Lisbon Center for

Nursing Research, Innovation, and Development (CIDNUR). The first two authors’ enrollment in CMESIP

was motivated by recognition of the importance of evidence-based practice and the continuous improvement

of pediatric nursing care, aiming for advanced nursing practice.

Accordingly, this article is an experience report on the CMESIP students’ clinical practicums, whose educational

projects focused on the emotional dimension of care and on ELMPN. The practicums in neonatology, pediatric

emergency department, and pediatric inpatient care took place over four months in different public-sector

hospitals in central Lisbon and surrounding areas.

This experience report discusses the importance of experiential learning and reflective practice as core

methodologies in the clinical practicum and in competency development. It also outlines the theoretical

orientations that guided the process, including reference authors such as Jean Watson. Next, we define the

concept of therapeutic instruments in nursing to support the presentation and reflection on the instruments

used to promote emotional labor in pediatric nursing during the practicums. Finally, we synthesize the

therapeutic instruments developed by the students and relate them to the model’s five care categories, followed

by a concluding reflection. The objective is to examine how therapeutic instruments that promote emotional

labor in pediatric nursing were deployed across the three contexts mentioned, while also highlighting the

importance of nursing practice models and the applicability of the ELMPN.1

Development

Experiential learning and reflective practice in the clinical practicum

The clinical practicums across different hospital care settings exposed us to the complexity, uncertainty, and

instability of health and illness as experienced by children and their families. This contact deepened knowledge

grounded in experiential learning and reflective practice.

Experiential learning arises from contact with experience, from which knowledge is derived and where it is

tested; learning unfolds through a cycle that involves an experience, reflective observation, and

conceptualization, followed by a new experience.12

Reflective practice likewise underscores the importance of experience and reflection on it.13 In practice,

professionals reflect on novel situations through reflection-in-action and, subsequently, reflection-on-action,

enabling the analysis and critique of their own knowledge and the improvement of practice.13 Thus, by

systematically reflecting on and articulating specific care situations, it is possible to acquire competencies - that

is, the effective, intentional application of knowledge and specific skills in each situation.14,15 Within this iterative

process, competence can be understood as knowledge-in-action.14

Throughout the practicums, contact with multiple care situations prompted reflections conducted in

coordination with healthcare teams, clinical and academic supervisors, and peers. Allied with existing scientific

evidence, these reflections took place in the care settings themselves, in classroom sessions, and through written

work. Reflection in and on practice is represented in learning journals, field diaries, and other written reflections,

with particular focus on the topic under study.

Theoretical orientations and practice models

According to Lacerda et al.,16 the theoretical framework is the foundation for building knowledge in nursing as

a discipline and a science. It enables the reasoned transformation of professional practice, promoting greater

recognition and strengthening of the discipline. Nursing theories are crucial for advanced nursing practice,

which is characterized by practice grounded in its own knowledge base and focused on delivering holistic,

nursing-specific care.16,17 This does not imply that nursing knowledge cannot be informed by knowledge from

other disciplines.16 Such contributions are often important, yet they should be meaningful for transforming the

discipline itself. The discipline advances through reflective practice that both questions and is supported by its

own theoretical framework and by scientific evidence.16 Accordingly, it is essential to outline the concepts and

theoretical frameworks that underpinned the students’ educational projects and trajectory, as well as this

experience report.

Theoretical Article

Pensar Enfermagem / v.29 n.01 / Jan-Dec 2025 / DOI: 10.71861/pensarenf.v29i1.436 / e00436

Since the dawn of humanity, caring has been a fundamental need, indispensable for human survival.6,18

Throughout life, people receive care intended to promote and maintain the best possible health across all

dimensions, and the nursing profession is central in this regard.6,18

The concept of caring is central to Jean Watson. In developing the Theory of Human Caring, she described

shifts in nursing’s language, with the concept of caring moving to carative and, later, to caritas.6,19 This designation

was considered broader and more representative of the caring-affective dimension inherent in the concept, as

well as its development over time.6,19 In addition to caring for the person as a whole, Watson emphasizes the

nurse’s attention to the self, engaging in self-care and introspection to enhance the delivery of humanized care.19

Swanson’s Middle Range Theory of Caring likewise adopts a person-focused approach grounded in respect for

individuals’ experiences and abilities, enabling the delivery of humanized care and the nurse’s own growth.20,21

Her theory underscores the need to know the person well, to show respect and empathy, and to recognize the

person as a unique individual with experiences, abilities, beliefs, perceptions, and emotions related to the

moment being experienced - elements that should be considered in the care process.20,21 Thus, caring in nursing

entails a holistic approach that is inseparable from emotions and from the relationship established with the

patient and family.1,6,20 Care extends beyond the health problem itself and is characterized by transpersonal

moments, as it transcends time, place, and even physical presence.1,6,18,20

Within a clinical practice grounded in these theories, nurses are equipped to provide care in which the emotional

dimension is regarded as fundamental, alongside the physiological, aesthetic, and cultural dimensions.1 To

support the intentional management of emotions by the child and family, the nurse deploys a set of therapeutic

instruments that promote emotional labor in nursing.1,10 Their value in care delivery - and their inclusion in

both basic and advanced nursing education - are essential; consequently, theoretical frameworks and

intervention models are needed to guide practice.1,10

Emotional labor in pediatric nursing

The concept of emotional labor was introduced into nursing by Pam Smith in response to the undervaluation

of the emotional dimension of care observed in practice.10 The concept focuses on the emotional experience

of patients and nurses, aiming to provide emotional support and effective continuity of care through often

invisible competencies such as empathy, support, and therapeutic presence.10 This conception differs from

others in asserting that emotional labor does not entail subordination to professional rules, as suggested in

Hochschild’s initial sociological approach to the concept.22 Badolamenti et al. emphasize the concept’s complex,

multidimensional nature, concluding that it refers to managing the expression and display of emotions.22

For Smith, nurses adapt their approach in each situation within a continuous learning process.10 She argues for

formal training in this emotional dimension from the outset of professional education and throughout it;

accordingly, the existence of practice models is essential.1,10

The ELMPN emerged from Diogo’s research program over more than two decades, grounded in the author’s

experience caring for children with cancer and their families.1 Her research focused on the emotional dimension

of nursing care; findings from the author’s primary studies led to a middle-range theory whose maturation gave

rise to the model.1 Ongoing development and validation across pediatric care contexts followed, conferring

theoretical robustness alongside clinical applicability.1 Validation of its applicability occurred continuously

through research,1,23 and through reflection on practice - an essential learning tool. This process enabled the

master’s students to enhance their practice of emotional labor and, at the same time, reinforced the ELMPN’s

applicability across child and family care contexts.1

In this model, emotional labor in pediatric nursing is defined as:

“the intentional management of the emotionality of care recipients (children, adolescents, and families) and of

nurses, with the aim of positively transforming the emotional experience, relationships, and care, promoting relief

of suffering and enhancing well-being, as well as the growth of those involved in the interaction; nurses deploy

strategies that prevent emotional exhaustion—individually and within teams—promoting their emotional well-

being”1(p111)

Through affective-emotional nursing interventions, intensely emotional and potentially distressing situations

experienced by pediatric patients during health and illness are positively transformed.1 This occurs through the

model’s five care categories, which present nursing interventions in a systematic, organized way.1 The categories

are named by intent: 1) Promote a safe and affectionate environment; 2) Nurture care with affection; 3)

Facilitate clients’ emotional management; 4) Build stability in the relationship; and 5) Regulate own emotional

disposition to care.1

Throughout clinical practicums, the master’s students recognized that nursing care is intrinsically linked to

human emotions and that the nursing interventions developed in this domain are systematized in the ELMPN.1

For this reason, the model was a key resource in their educational trajectory, during which they deployed and

developed therapeutic instruments that promote emotional labor.

Theoretical Article

Pensar Enfermagem / v.29 n.01 / Jan-Dec 2025 / DOI: 10.71861/pensarenf.v29i1.436 / e00436

Therapeutic instruments in nursing

A nursing intervention is considered therapeutic when it yields actual or potential benefits for the patient - that

is, improved well-being and quality of life - with implications beyond the physiological dimension.7 The term

refers to an action that is useful, restorative, and beneficial for the person, taking their specific characteristics

into account.7

The therapeutic effect of nursing interventions is achieved, notably, through interaction with the patient and

the relationship established with them - the nurse being the therapeutic instrument.7,8 It also occurs by meeting

needs through physical interventions, as appropriate to the person’s situation.7,8 Therapeutic results may further

be attained by modifying the care environment, through caring relationships, and via comfort measures.7,8 To

achieve therapeutic outcomes - promoting well-being and/or relieving suffering - nurses develop interventions

using therapeutic instruments such as humor, music, therapeutic presence, and emotion management, among

others.8

Clarifying and further developing these concepts is essential, contributing to recognition of the “small things,”

that is, nursing interventions that are often invisible yet have fundamental therapeutic potential.1,7,8,10

To develop affective-emotional interventions, the nurse deploys therapeutic instruments that promote

emotional labor in pediatric nursing, which is a process systematized in the ELMPN.1

Current evidence offers several examples of therapeutic instruments through which nurses intervene to

promote pediatric patients’ emotional well-being, reducing stress and increasing self-efficacy,24 as follows:

• Welcoming

• Information sharing

• Support groups

In intensive care contexts, under a family-centered care (FCC) approach,25 stress is reduced through the

following:

• Information sharing

• Parental involvement and participation

In situations such as venipuncture, the preoperative period, or seeking care in the pediatric emergency

department, therapeutic instruments that alleviate anxiety, stress, fear, and pain include the following:26, 27, 28, 29,

• Music

• Humor

• Therapeutic play

• Facilitated expression of feelings

• Information sharing

• Procedure-preparation strategies

The deployment of these instruments follows an atraumatic care approach, underscoring the importance of

adapting to the child’s needs and characteristics.26 In addition, providing conditions that allow the child to play

and handle materials safely is essential.28,29,30

Therapeutic instruments promoting emotional labor in pediatric nursing

Across the three practicum settings, the master’s students deployed therapeutic instruments that promote

emotional labor in pediatric nursing, aiming to support the intentional management of children’s and families’

emotions.1

Some interventions continued work already underway by nurses in each setting, whereas others - identified

below - were created by the students.

In the neonatology practicum, care was provided to high-risk newborns - those with higher morbidity and

mortality than average - and to their families.31 This hospitalization is associated with an abrupt, unexpected

separation between the family and the newborn.3 It entails intensely felt and often contradictory emotions, such

as the happiness of the child’s birth alongside anxiety and fear related to the child’s health status.3

In response to the intense emotionality experienced by parents, multiple interventions using therapeutic

instruments were deployed. These included steps to keep the environment familiar and comfortable in a setting

that can be particularly frightening, thereby promoting a safe, caring environment.1 In the same vein, the

students prepared decorative cards for each infant’s bedside marking monthly milestones and major holidays.

Theoretical Article

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Journals titled “Hope Album” were created so parents could record moments with their child through

photographs and writing; at parents’ request, the team often contributed to these records as well.

In this context, actions such as soothing speech, gentle touch, and holding - which nurture care with affection

- were performed frequently, both alongside interventions such as positioning or feeding and in spontaneous

moments.1

Responding to families’ emotional experiences, nurse-facilitated support groups held periodically were an

important, highly valued resource that provided opportunities to share experiences and feelings. In this setting,

FCC-based interventions using therapeutic instruments - such as information sharing, support groups, and

involvement in care - are essential for families of hospitalized newborns.

In the pediatric emergency department practicum, we accompanied children and families who sought

hospital care for sudden health problems or exacerbations of chronic conditions.4 From the first interaction,

particularly at triage, we adopted an welcoming approach that conveyed calm and confidence, since any visit to

the pediatric emergency department may carry a high emotional burden.4 In doing so, we fostered a safe, caring

environment and nurtured care with affection.1,32

In this context, an atraumatic care approach was fundamental, given the frequent performance of painful

procedures that cause discomfort and fear, compounded by the stress of an unfamiliar environment.

Accordingly, it was essential to implement interventions systematically, notably through procedure-preparation

strategies and by minimizing separation between the child and the family.4,32

Invasive procedures such as blood draws or nebulized therapy generated pain, fear, and distress in children. It

was important to intervene with procedure-preparation strategies, notably through therapeutic play using the

“Ouchie Kit” (Kit Dói-Dói) available in the treatment room. The kit contained several stuffed animals and

practice supplies for venipuncture without needles, as well as stickers and adhesive bandages, allowing the

procedure to be explained to the child calmly and safely. If the child preferred, they could try the procedure on

their own toy.

At the end, the child could choose from several stickers and received a bravery diploma as praise for their

behavior - even if they cried - creating a moment of repair. This positive reinforcement conveys to the child

that their worth is not contingent on how they behaved during the procedure.33 In addition, it helps strengthen

the nurse–child/family relationship.33 Music and videos selected by the child were also used frequently in the

treatment room with therapeutic intent.

Given their emotional state, some families exhibited aggressive behavior (verbal and, in some cases, physical)

toward healthcare professionals. These situations are more frequent in emergency departments, since anxiety

and despair about the child’s health and prolonged waiting times hinder emotion regulation.34 Accordingly, it

was essential to intervene through information sharing tailored to the family’s level of understanding.34 We also

deployed developmentally appropriate and culturally responsive communication strategies, facilitating emotion

management and building stability in the relationship.1,4

In this way, by deploying therapeutic instruments such as therapeutic play and information sharing, the intent

was to positively transform the child’s and family’s emotional experience.1

Pediatric inpatient care is a potentially stressful and fear-inducing environment, associated with painful

procedures, medical equipment, an unfamiliar and threatening setting, and disrupted routines.5,35 For parents,

this experience entails changes in parental roles and adjustments in the family’s usual functioning.36

For children with chronic conditions, hospital stays can be long and frequent, limiting daily activities and

potentially compromising growth and development.37 Children report melancholy, discouragement, and apathy,

feeling insecure and unable to cope with their emotions.38 These children and families particularly need

emotional support to mitigate negative experiences and reduce anxiety.39

In the pediatric inpatient practicum, we noted that care delivery was grounded in FCC and atraumatic care.

These practice frameworks were reflected in the promotion of parental participation and continuous

information sharing, as well as parental collaboration in their child’s care. In addition, children were prepared

for procedures, performed in the treatment room rather than in the hospital room. Within the scope of

intentional emotion management, a welcoming approach was provided to the child or adolescent and their

family. Combined with expressions of affection, this action contributed to a positive transformation of the

hospitalization experience, promoting calm, relief of suffering, and increased confidence.1

The deployment of therapeutic instruments was particularly important for the unaccompanied hospitalized

child, since addressing affective and emotional needs is essential to minimize the negative effects of this

experience.40 The nurse used affection with therapeutic intent to mitigate the absence of a companion, without

seeking to replace the parent/caregiver’s role.41

During painful procedures, alongside pharmacological measures, therapeutic instruments such as therapeutic

play and music were deployed, fostering a safe, caring environment.1 It was important to give the child

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autonomy to choose the music and toys. These interventions facilitated emotional regulation, promoting calm

and well-being, as well as emotional self-regulation.1

All interventions, grounded in FCC and atraumatic care, included maintaining parental presence and

participation, as in the other practicum settings. This involvement was beneficial, lowering parental anxiety and

stress, facilitating their emotional regulation, increasing confidence, and protecting family relationships.1,42

In collaboration with the multidisciplinary team, one of the master’s students developed a therapeutic

instrument that promotes emotional labor in pediatric nursing: the “Emotions’ Thermometer.” Two

thermometers were created to allow children to express their emotional state through colors and illustrations -

an essential step toward children’s emotion regulation.

In providing care to the child and family, nurses are also susceptible to intensely emotional experiences driven

by factors such as excessive workload or team conflict.1 To sustain their engagement and ability to care,

professionals use strategies such as analysis of experiences and sharing feelings, among others - elements that

are also part of the ELMPN.1,43 For this reason, it was essential for the master’s students to conduct experience

analyses and reflections with clinical and academic supervisors, as well as written reflections (learning journals).

Across the practicum settings, team training on emotional labor in pediatric nursing was likewise important and

focused on the therapeutic instruments that promote it. Accordingly, the students conducted in-service training

sessions and created a document compiling scientific evidence and practical examples of interventions to

deploy, systematized in the ELMPN by developmental stage.1

The therapeutic instruments used in each setting are summarized in Table 1.

Table 1. Therapeutic instruments used in practicum setting

In response to children’s emotional needs, we intervened using several therapeutic instruments that promote

emotional labor in pediatric nursing, some of which were implemented in these settings, such as the “Emotions’

Thermometer.” Tailored to the context and to each child’s specific situation, nurses deploy instruments such

as affection, information sharing, therapeutic play, music, and humor. However, the instruments highlighted in

each setting are not exclusive to that setting; they are used as appropriate to each child’s needs to reduce the

negative impact of hospitalization.

These instruments are the means by which nurses perform emotional labor, including the strategies they use to

regulate their emotional readiness to care.

Practicum settings

Therapeutic instruments that promote emotional labor in pediatric nursing

Neonatology

Care-environment modification

“Hope Album”

Gift of affection

Facilitated expression of feelings

Support groups

Information sharing

Involvement and participation

Experience analysis

Reflection

Pediatric emergency department

Pediatric inpatient care

Gift of affection

Information sharing

Procedure-preparation strategies

“Ouchie Kit”

Stickers and bravery diplomas

Involvement and participation

Humor

Therapeutic play

Music

Experience analysis

Reflection

Gift of affection

Information sharing

Procedure-preparation strategies

Involvement and participation

Humor

Therapeutic play

Music

“Emotions’ Thermometer”

Experience analysis

Reflection

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During the practicums, these interventions were observed and mapped to the ELMPN’s five care categories,

as depicted in Figure 1.

Final reflection

Providing nursing care to children is inseparable from emotions, and nurses’ interventions are essential to

facilitate their intentional management.1,6 In response to children’s and families’ emotional needs, nurses

intervene using therapeutic instruments that promote emotional labor in pediatric nursing, even when not

explicitly labeled as such.

Nurses’ interventions are systematized and organized in the ELMPN, which serves as both a pediatric practice

framework and a pedagogical resource. Consequently, it served as an essential guide during the practicums,

enabling students to internalize the importance of these interventions and to demonstrate its applicability and

relevance.

Practicums across the three pediatric contexts enabled us to care for and support children and their families

through experiences that included sudden health problems, frequent or prolonged hospitalizations, and even

the child’s death. These experiences carry significant emotional impact, and nursing work was guided by the

deployment of therapeutic instruments that promote emotional labor in pediatric nursing. Because these

situations are also emotionally intense for nurses, regulating the emotional disposition to care became

fundamental.1 To sustain engagement and the ability to care, actions such as experience analysis and sharing

feelings - particularly with colleagues - were crucial.

As for limitations, the practicums followed the program’s schedule, which restricted the development of

additional therapeutic instruments. Moreover, the dynamics of each practicum context constrained the

Figure 1. Schematic representation of how the therapeutic instruments deployed in hospital practicum settings map onto the ELMPN’s

five care categories.

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development of specific instruments. The ELMPN is at an early stage of implementation, so further research

on its therapeutic instruments is needed.

Authorship and Contributions

RB: Data collection, analysis and interpretation; Manuscript writing; Critical review of the manuscript; Approval

of the final version of the manuscript and assumption of responsibility for it.

SS: Data collection, analysis and interpretation; Manuscript writing; Critical review of the manuscript; Approval

of the final version of the manuscript and assumption of responsibility for it.

PD: Study conception and design; Manuscript writing and critical review; Approval of the final version of the

manuscript and assumption of responsibility for it.

Conflicts of interest and Funding

No conflicts of interest were declared by the author(s).

Sources of support / Financing

The study was not subject to funding.

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