Emotional Labour in Health Care

The unmanaged heart of nursing

Catherine Theodosius

• Publisher: Routledge
• Year: 2008
• Print ISBN:
  9780415409537
• eBook ISBN:
  9781134130726
• Topic: Medicine
• Subtopic: Health Care Delivery

Do nurses still care? In today's inflexible, fast-paced and more accountable workplace where biomedical and clinical models dominate health care practice, is there room for emotional labour?

Based on original empirical research, this book delves into personal accounts of nurses' emotion expressions and experiences as they emerge from everyday nursing practice, and illustrates how their emotional labour is adapting in response to a constantly changing work environment.

The book begins by re-examining Arlie Hochschild's sociological notion of emotional labour, and combines it with Margaret Archer's understanding of emotion and the inner dialogue. In an exploration of the nature of emotional labour, its historical and political context, and providing original, but easily recognisable, typology, Catherine Theodosius emphasises that it is emotion – complex, messy and opaque – that drives emotional labour within health care. She suggests that rather than being marginalised, emotional labour in nursing is frequently found in places that are hidden or unrecognised. By understanding emotion itself, which is fundamentally interactive and communicative, she argues that emotional labour is intrinsically linked to personal and social identity. The suggestion is made that the nursing profession has a responsibility to include emotional labour within personal and professional development strategies to ensure the care needs of the vulnerable are met.

This innovative volume will be of interest to nursing, health care and sociology students, researchers and professionals.

Part I
Understanding emotional labour in nursing

A theoretical approach

Vignette 1 ‘Half measures’ Catherine: What would you describe as good care that gives you satisfaction? Paris: Good care: obviously clinically I would be able to look after my patients properly. But, psychologically, I could spend time with them and see what their fears are, what their worries are; to give them good pain control so that they are not in pain. I don’t think we do it half the time. We are running the ward, and it is one of the most stressful wards as far as the patients are concerned because the majority of them, they come for major surgery. They come for aneurysm repair, bypass, they come for cancer. How many times do we get to tell them about their operation? How many times? We count it on our hand. I don’t do it enough. I admit you I don’t, because I am too conscious about not letting the next lady dehydrate and not leaving the other man in pain. You constantly want to see that everybody’s need has been met halfway. Because I feel if I could go and give proper pre-op care, and sit with the patient for half an hour and the wife and the son and the daughter and answer their questions and make sure that psychologically they are cared for, then I have neglected somebody else’s pain or somebody else’s dressing or somebody has dehydrated because the fluid has been behind for six hours. What I do, which I am not happy about, is I try and meet everybody’s needs halfway. So I know that he is moderately hydrated and that the IV is not behind three or four hours. I know that this patient has had all his oral analgesia, the dressing has been done, so he is not in pain because of his wound. But that is not good enough because the psychological care has gone out of the window. When I was a third year student – because I had more time, because I didn’t have responsibilities and accountabilities – I had time to spend with the patient. Every cancer patient, Catherine, the doctor who went and told them about their diagnosis and prognosis, I remember, every single one of them. I pulled the curtain around and I sat with them, and I said, ‘Did you understand what he said?’ I asked what their worries were. I went through with them what was going to happen, what was their after care. What their referrals were. They would say, ‘Who is Dr Smitt?’ you know, and I would tell them. And then I would leave them and then go back twenty minutes, half an hour later to see how they were coping, if they had any more questions to ask. I’d call the Macmillan nurse, call this and call that. I haven’t done that since I qualified. I don’t remember, maybe as a D grade I did a few, but not since I made E grade. So many times I have just burst into tears because of this situation and we do get involved a lot, especially if they

are young. I have done this, six or seven times in handover, because the lady was dying. But it didn’t help her. I think: ‘So what? I got emotional but did it help her? Did I sit and talk to her about how she feels?’ No, I didn’t. As long as the patients are washed and they are in clean beds, that is all that matters now. They can be having the most difficult time of their life, thinking about what the doctors have told them without any nurses going to see how they feel, if they have any questions. That is not nursing care, it is total crap.

1
Emotion management and emotional labour

The work of Arlie Russell Hochschild

The term emotional labour was first coined by the American sociologist Arlie Russell Hochschild (1975, 1979, 1983, 1990). She carried out extensive research in the airline industry, particularly focusing on the emotion work of flight attendants. Hochschild’s work is considered to be groundbreaking in understanding the significance of emotion to everyday life for individuals, families and in the workplace. Most research examining emotional labour draws on her original ideas and concepts. To understand how emotional labour in nursing and health care has developed, it is necessary to explore Hochschild’s work first and then consider how it relates to health care. The aim of this chapter therefore is to introduce and explore Hochschild’s work; unpacking and discussing what she means by emotion management, feeling rules, surface acting, deep acting and emotional labour. The chapter is written so the relationship between Hochschild’s ideas can be clearly followed as they develop. As the concepts are introduced, their relevance to nursing is directly applied to Vignette 1 ‘Half measures’. This narrative is taken from my interview with Paris, an F grade junior sister on Ward B. The applications of Hochschild’s ideas are considered at the end of each section: their relevance is identified without interrupting the account of her work. Thus, this chapter explores Hochschild’s work and considers whether her key ideas are reflected within nursing experience.

Hochschild’s background

As a child, Hochschild was fascinated by the work of her parents, who were US Foreign Service diplomats. Her interest in emotion management began as a child when she was invited to pass drinks and nibbles around the visiting foreign dignitaries. Every gesture and smile was closely monitored and interpreted for hidden meanings. She writes:

Afterwards I would listen to my mother and father interpret various gestures. The tight smile of the Bulgarian emissary, the averted glance of the Chinese consul, the prolonged handshake of the French economic officer, I learned, conveyed messages not simply from person to person but from Sofia to Washington, from Peking to Paris and from Paris to Washington. Had I passed the peanuts to a person, I wondered, or an actor? Where did the person end and the act begin? Just how is a person related to an act?

(Hochschild 1983: ix)

This fascination led Hochschild to explore the relationship between emotions that are really felt and the ones that are acted out for the benefit of others. For her, this is an inherently social act, because in order to work out what emotions individuals should perform, they need to be able to understand the social context in which they are actors. For example, it is socially acceptable to cry at a funeral and laugh at a party even if the person feels hysterical at the funeral and sad at the party. Thus, the social context, funeral or party, dictates what emotion they should act out even if this is different from what they really feel.

Later, as a graduate student at Berkeley, University of California, Hochschild read C. Wright Mills’ influential book White Collar (1951). He argued that in the world of sales, the sales process is as much about the personality of the sales person as it is about the product being sold. In fact, Mills argued that in the sales process the sales people were actually selling their personality. Mills felt that this could be detrimental to the sales people because it resulted in them becoming estranged from themselves. These ideas appealed to Hochschild. However, she felt that there was something missing in his account. In the preface to her book The Managed Heart, she notes:

Mills seemed to assume that in order to sell personality one need only have it. Yet simply having a personality does not make one a diplomat, any more than having muscles makes one an athlete. What was missing was a sense of the active emotional labour involved in selling.

(Hochschild 1983: ix)

Hochschild directly identifies the importance of knowing how to use one’s personality, or more specifically, one’s emotions in the selling process. In essence, Hochschild’s work brings together these ideas about emotion management, acting, the social context and selling one’s personal emotions in the labour market as if they were a product.

Emotion management

Hochschild (1983:7) defines emotion management as ‘the management of feeling to create a publicly observable facial and bodily display’. Children learn how to do this through socialisation processes as they grow up. For example, pictures often show young children learning how to express surprise or being taught to control their tears when they are unhappy. Emotion management requires emotion work, because learning how to do it takes effort. For example, when little Johnny feels disappointment at receiving a hand-knitted cardigan from his grandmother instead of the shiny red toy truck he was hoping for, his mother teaches him to show pleasure and gratitude instead of tears and a tantrum. She may have to take him aside, allowing him time to control his feelings, then explain that he should go up to his grandmother, give her a kiss and say thank you for his lovely cardigan. In this way, Johnny learns not only how to control his emotions, but also what emotions he ought to be expressing in this situation (feeling rules). Thus, he learns that he should manage his disappointment and instead display pleasure and gratitude which he enacts for the benefit of his grandmother and his mother.

In learning this, Johnny also realises that there is a difference between his real private feelings and what he can express publicly. The difference between the private and public sphere is fundamental to Hochschild’s differing notions of emotion management and emotional labour. Here she draws on the work of Erving Goffman (1956, 1959, 1961, 1967, 1969, 1974), who examined how people know how to behave and how they present themselves to others in everyday public life. He drew on the analogy of the theatre in order to help explain everyday interaction. One of the important distinctions Goffman (1959) made is the difference between front stage and back stage. The front stage is where performance takes place, where a show is put on. An example given here is the role of the waitress being pleasant and polite to the customers, enquiring what they want to eat and if she can help them in anyway. When she returns to the kitchen, in the back stage, she might bad mouth them to her colleagues working behind the scenes. Hochschild uses this distinction in her work, seeing emotion work as belonging in the private realm (at home or back stage) and emotional labour as belonging in the public realm (in the workplace or front stage). This private/public distinction, however, is not as clear cut as Hochschild presents it (Wouters 1989a, 1989b, 1991). For her, where and why emotion management occurs creates the fundamental difference between the two. In the private realm, emotion work is considered as being a part of our private lives and takes place in the home; whereas emotional labour is sold for a wage as a commodity and takes place at work. It is an important distinction for Hochschild because it represents the exploitation to which she feels emotional labourers are subjected. However, as is seen in the illustration of Johnny and his mother and grandmother, front and back stage life can coexist together in the private realm, and as seen in the example of waitress, in the public one. In many ways, the distinction is really one of a difference of self, between what individuals consider belongs to them, representing their ‘real selves’, and what is socially acceptable and for public consumption. Hochschild’s notion of feeling rules is much more helpful in this respect.

Emotion management in ‘Half measures’ (Vignette 1) The basic principle of emotion management can be identified in Paris’ vignette ‘Half measures’. Paris tells us what it is that she is really feeling in respect to her dying lady. She is upset and this causes her to cry. When she is with her patient (front stage), she manages her feelings and displays a more appropriate face. This is emotion management. However, she tells us that she did cry in handover (back stage). On the ward there are areas that are accessible only to the nursing staff. This represents their ‘back stage’ areas. Handover on Ward B took place in the nurses’ staff room. It is here that Paris feels free to display her real emotions. Paris implies that ...

Table of contents

• Critical Studies in Health and Society
• Contents
• Illustrations
• Table of vignettes
• Preface
• Acknowledgements
• Introduction Challenging current conceptualisations of emotional labour
• Part I Understanding emotional labour in nursing
• Part II Developing emotional labour in nursing
• Bibliography
• Index