This study aimed to elucidate, through qualitative analysis, the cognitive processes by which experienced oncology nurses regulate their emotions when facing anxiety and emotional conflict in communication with patients.
We employed a qualitative exploratory design using semi-structured individual interviews with six certified oncology nurses in Japan. Participants were recruited via snowball sampling and provided written informed consent. Interviews were conducted in Japanese using a pre-tested interview guide; audio data were transcribed verbatim. Data were analyzed with the Steps for Coding and Theorization (SCAT) method. Metacognitive theory—distinguishing metacognitive knowledge and metacognitive regulation—guided interpretation of the findings.
Analysis of 38 theoretical descriptions yielded two overarching themes: (1) anxiety and conflict in communication with cancer patients, and (2) metacognitive emotion-regulation strategies. The latter comprised two subthemes: (a) patient-oriented cognitive strategies (e.g., linguistic adjustments, trust-building, facilitating patients’ self-regulation), and (b) self-oriented cognitive restructuring (e.g., reframing dilemmas, monitoring and modulating one’s own emotional responses). These processes reflected deliberate monitoring and regulation of thinking and feelings to sustain constructive engagement with patients.
Experienced oncology nurses use metacognition to recognize, interpret, and flexibly regulate emotions in challenging interpersonal situations. Educational implications include integrating structured metacognitive reflection alongside empathy and mindfulness training to cultivate durable, transferable coping skills. Future studies should examine this approach in diverse clinical contexts, include larger and cross-cultural samples, and evaluate longer-term outcomes in nurses’ emotional resilience and clinical practice.
For nurses engaged in cancer care, communication with patients is one of the most routine tasks, yet it also constitutes a significant source of difficulty.
To address these challenges, recent years have seen the promotion of training programs aimed at enhancing empathic capacity.
Building on this theoretical distinction, metacognition provides a broader perspective on how nurses regulate their emotions. Defined as the awareness and regulation of one’s own cognitive and emotional processes, metacognition comprises both knowledge (recognition of tendencies in thinking and emotions) and regulation (monitoring and adjusting these processes).
Based on the distinction between antecedent- and response focused strategies, the survey by Suzuki and Furuse offers a complementary view.
Although strategies such as empathy, mindfulness, and attentiveness to emotions can support coping.
Clarifying how oncology nurses confront and overcome the anxiety and conflict they encounter in relationships with patients holds both practical and educational significance. Especially in daily care situations, where nurses are susceptible to emotional influence, the ability to appropriately regulate emotions and reconstruct thoughts and actions becomes a vital competency that enables more meaningful nursing practice. Because these psychological and cognitive processes are difficult to observe directly, exploring them requires methodologies that capture nurses’ conscious articulation and reflection on their experiences. A qualitative exploratory approach is therefore particularly suited to capturing these nuanced experiences. Beyond contributing to theory, such insights can inform training programs that cultivate nurses’ capacity to reframe anxiety as a learning opportunity, enhance resilience in emotionally demanding communication, and support policy initiatives that promote advanced educational strategies for nursing practice.
The objective of this study is to elucidate the cognitive processes by which experienced oncology nurses regulate emotions when faced with anxiety and emotional conflict in communication with patients.
This study adopted a qualitative exploratory design to elucidate how experienced oncology nurses regulate their emotions in response to challenging clinical situations. Given the aim of gaining an in-depth understanding of the participants’ internal and often implicit experiences and cognitive processes, data were collected through semi-structured interviews.
Participants were oncology nurses holding nationally recognized specialty certifications in Japan, either as Cancer Nursing Clinical Nurse Specialists (CNS) or as Certified Nurses in Cancer Chemotherapy Nursing. The inclusion criteria stipulated a minimum of five years of clinical experience in oncology nursing to ensure that the participants could provide mature, practice-based reflections rather than accounts of novice-level anxieties.
Recruitment was conducted using snowball sampling. Initial participants were identified through professional oncology nursing networks, and subsequent participants were introduced via peer referrals. In each case, the researcher directly contacted referred nurses, provided study information, and obtained informed consent. A total of six participants were recruited between October and November 2019.
Prior to the interviews, participants received written information outlining the study purpose, data management procedures, and their right to withdraw at any time. Written informed consent was obtained from all participants. This study was approved by the Research Ethics Committee of the Japan Advanced Institute of Science and Technology.
Interviews were conducted with a total of six nurses
Interview data were analyzed using the Steps for Coding and Theorization (SCAT), which involves (a) extracting notable words or phrases, (b) paraphrasing, (c) identifying underlying concepts, and (d) developing themes. Themes were subsequently woven into storylines, from which theoretical descriptions were derived.
The adequacy of the sample was assessed through the concept of information power.
The first author (YI), a registered nurse with extensive oncology experience, conducted all interviews and analyses. While this professional background provided valuable interpretive insight into participants’ narratives, it also carried the potential risk of researcher bias. To address this, reflexive memos were maintained throughout the study to monitor the influence of the author’s assumptions and perspectives.
A total of 38 theoretical descriptions were generated through SCAT method. These were subsequently organized into two overarching themes: (1) anxiety and conflict in communication with cancer patients, and (2) metacognitive emotion-regulation strategies. The latter theme included two subthemes: (a) patient-oriented cognitive strategies”, and(b) self-oriented cognitive restructuring. Quotations are cited with participant number, gender, age, and years of oncology nursing experience.
Despite receiving specialized oncology nursing education and having more than five years of clinical experience, all participants described frequent experiences of anxiety and emotional difficulty in their interactions with cancer patients. The following are illustrative examples:
“I had a patient who needed to continue working to afford treatment, but the side effects would impair his sense of taste, making it difficult to work as a chef. I felt anxious about how to engage with him without diminishing his motivation for treatment.” [Participant 1, female, 30s, 16–20 years of experience]
“Undergoing stoma surgery would have allowed her to eat again, but as a young woman, she was concerned about the impact on her appearance. On the other hand, placing a central venous port would preserve her physical appearance but not fulfill her wish to eat. I struggled with how to face her treatment-related conflict without imposing my values.” [Participant 4, female, 50s, over 21 years of experience]
(a) Patient-oriented cognitive strategies
Participants engaged in cognitive-level interventions to respond to patients’ suffering. These included avoiding expressions that could evoke negative emotions and using language that supported the patients’ self-regulation of anxiety.
“When a patient complained, ‘I can't eat,’ I avoided saying ‘But you are eating,’ because I thought it might upset them. Instead, I chose to agree and empathize. Since the patient was concerned about weight loss, I tried to avoid reinforcing negative perceptions.” [Participant 3, female, 40s, over 21 years of experience]
“Patients often don’t know who to talk to about the struggles they experience during treatment. Even if they find it hard to speak directly to doctors, I tried to be someone they felt they could trust to connect them with the right support.” [Participant 4, female, 50s, over 21 years of experience]
(b) Self-oriented cognitive restructuring
Experienced nurses also described actively reinterpreting their own anxiety and inner conflict during difficult communication, using cognitive restructuring to regulate their responses.
“I find it difficult to deal with topics like treatment policy, where dilemmas can’t be fully resolved. Still, I try to be someone who can think things through together with the patient, so that they don’t feel alone.” [Participant 3, female, 40s, over 21 years of experience]
“It was initially very hard for me to face patients who expressed anger when treatment wasn’t going well. But just avoiding those situations won’t help me grow. I try to reinterpret the situation, telling myself that their anger must be grounded in some deeper reason.” [Participant 2, male, 40s, 16–20 years of experience]
This study qualitatively examined how experienced oncology nurses regulate their emotions in response to challenging clinical situations, and select responses in the face of difficult patient communication. The findings revealed that participants did not rely solely on reactive or situational coping; rather, they employed metacognition to recognize, interpret, and reconstruct their emotions. This enabled them to flexibly manage anxiety and conflict in interpersonal settings.
One illustrative case (Participant 2) was that of a nurse who reported initial difficulty in dealing with patients who expressed anger when treatment was not progressing as expected. However, he consciously reinterpreted the patient’s anger, telling himself that there must be a reason behind it. Through this reinterpretation, he broadened his capacity to respond, not by suppressing his own emotions, but by seeking a more structured understanding. Another nurse (Participant 3) reflected on dilemmas surrounding treatment decisions and described striving to be someone who could “think together with the patient” so that the patient would not feel alone. These instances illustrate a metacognitive redefinition of the nurse’s role through the reorganization of relational dynamics. Such processes align with the concepts of “monitoring” and “regulation” in the metacognitive frameworks.
Previous qualitative studies on nurse emotion regulation have emphasized empathy, mindfulness, and communication skills training as strategies for managing stress and anxiety.
Research on emotional labor further highlights the risks of relying on surface acting and expressive suppression, which may help nurses maintain professional appearance but are consistently linked to emotional exhaustion and burnout.
Our findings extend these insights by showing that experienced oncology nurses engage in metacognitive reorganization—actively monitoring their own distress, reframing its meaning, and reorganizing their role in relation to patients. This goes beyond techniques such as cognitive reappraisal, which is often taught as a discrete strategy.
The findings of this study enrich existing models of nurse emotion regulation by emphasizing the central role of metacognition in managing clinical anxiety. While previous models have largely prioritized response-focused strategies (e.g., mindfulness, empathic communication),
Situating these insights within Gross’s process model of emotion regulation clarifies that effective professional practice involves not only responding to emotions once they arise but also proactively shaping how they are appraised.
The findings of this study highlight the potential for educational programs to incorporate structured reflection on nurses’ own anxiety as part of communication training.
Embedding such metacognitive reflection into ongoing professional education may help experienced nurses transform unavoidable emotional strain into constructive engagement with patients.
Although this study focused on oncology nurses, the findings are relevant to other domains of healthcare where professionals face frequent emotional challenges, such as palliative care,
It is also important to recognize that certain contextual factors constrain transferability. The present findings were derived from experienced oncology nurses, who had both specialized knowledge and opportunities for long-term relationships with patients. The applicability of these processes is limited in settings where emotional intensity is lower, or where nurses have fewer chances to engage in sustained patient relationships. Furthermore, novice nurses require different forms of support, as their emotional regulation is often shaped by inexperience rather than by complex relational dilemmas.
The limitations of this study lie in both its scope and sample. The findings were derived from a small number of experienced oncology nurses with nationally recognized certifications in Japan.
Although guided by metacognitive theory, the present findings cannot confirm whether similar processes operate in other professions. Future research should examine practitioners in roles that also involve high levels of emotional strain—such as palliative care, psychiatry, or emergency medicine—to explore how they recognize and reframe their own anxiety in challenging encounters. Such investigations would clarify whether the mechanisms identified here reflect a broader professional capacity for metacognitive regulation under emotional pressure.
This study examined how experienced oncology nurses regulate their emotions in response to challenging clinical situations, particularly in patient communication. The findings demonstrate that experienced oncology nurses utilize metacognitive processes—rather than relying solely on reactive coping—to reinterpret anxiety and reorganize their professional role in challenging patient communication.
Future research should examine not only whether similar metacognitive processes are observed among healthcare professionals in other emotionally demanding contexts (e.g., palliative care, psychiatry, or emergency medicine) and at different levels of professional experience but also evaluate the effectiveness of educational interventions that explicitly integrate structured metacognitive reflection into training programs.
The author would like to express sincere gratitude to Professor Mitsuru Ikeda of the Japan Advanced Institute of Science and Technology for his valuable advice on the development of the interview guide.
This study was supported by JSPS KAKENHI(Grant Number: JP23K19820).
The author declares that there is no conflict of interest.
Appendix A. Detail of the participants and Appendix B. Interview Guide