"It's more than connecting tubes": a qualitative inquiry into nurses' emotional labor in dialysis units

Hemodialysis units are highly technical and emotionally charged environments where nurses care for the same patients multiple times per week over many years. While clinical and technical aspects of dialysis nursing are well documented, the emotional labour required to sustain compassionate, safe care in this context remains underexplored. This study aimed to explore how hemodialysis nurses experience and manage emotional labour in everyday practice within dialysis units.

A qualitative study using reflexive thematic analysis (RTA) was undertaken to examine how hemodialysis nurses manage emotional labour in King Faisal University-affiliated dialysis units in Saudi Arabia. Eighteen registered nurses with ≥ 1 year of dialysis experience were purposively recruited. In-depth semi-structured interviews were conducted in Arabic and/or English, audio-recorded, transcribed verbatim, and translated where required. Data were analysed reflexively following Braun and Clarke's six-phase approach, supported by NVivo 14 for data management. Rigour was strengthened through reflexive journaling, peer debriefing, an audit trail, and rich contextual description.

Four interrelated themes were identified: Caring on a knife's edge (remaining calm during clinical instability while containing patients' fear); The mask of professionalism (hiding distress and "smiling through" personal struggles to appear strong and competent); When patients become "like family" (developing deep, long-term bonds that intensify grief when patients deteriorate or die); and Carrying the load: coping and seeking support (leaning on faith, colleagues, humour, and micro-breaks while calling for organisational recognition, debriefing, psychological support, and adequate staffing).

Emotional labour is central to dialysis nursing, shaping both the quality of patient care and nurses' well-being. Supporting this invisible work requires integrating emotional skills into education, fostering emotionally safe unit cultures, and implementing organisational strategies that recognise and resource nurses' emotional needs.

Not applicable.