‘Symbiotic niceness’: constructing a therapeutic relationship in psychosocial palliative care

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Social Science & Medicine 58 (2004) 2571–2583

‘Symbiotic niceness’: constructing a therapeutic relationship in psychosocial palliative care Sarah Li St. George’s Hospital Medical School, Kingston University, Kingston Hill Campus, Kingston Hill, Surrey KT2 7LB, UK

Abstract The concept of symbiotic niceness illustrates a mutually shared advantage in the nurse–patient relationship. This relationship is premised on the co-production of niceness through the doing of psychosocial care. This paper presents an account of ‘symbiotic niceness’ produced in palliative care nurses’ talk. The data are collected from two hospices and one general hospital for the dying. The analysis of talk demonstrates how psychosocial care can be understood as the collaborative practice of ‘niceness’ in the daily activities of participants, and how they collaboratively achieve reciprocal and therapeutic relevance for their talk. Participants co-engage in a ‘selling game’. Through the activities of selling, a set of personal assets that constitute their personal Curriculum Vitae (CV) are revealed. It suggests that nurses’ assets, when combined with patients’ assets, function as marketable ‘products’ to produce an impression of nice patients and professionals. This in turn leads to the production of an impression of ‘nice’ organisations. Impression management is presented as a key strategy for the production of marketable niceness. Through the co-performance of niceness in talk, both nurses and patients are constructed as people who are somewhat charismatic, friendly, informal, understanding and concerned. This paper argues that underpinning the co-enactment of symbiotic niceness is the sharedness of patients’ and nurses’ experiences and a reciprocal notion of therapeutic help. It serves as a means of managing relations between palliative care nurses and dying patients. Symbiotic niceness thus represents a core component of professional and patient identity which works to maintain social orderliness as well as to advance personal, professional and organisational aspirations. r 2003 Elsevier Ltd. All rights reserved. Keywords: ‘Symbiotic niceness’; Nurse–patient relationship; Psychosocial care; Palliative care nursing

Introduction This paper is about how palliative care nurses and dying patients collaboratively form symbiotic and reciprocal relationship through enactment of psychosocial care in talk in their daily practices. The aim here is to relate the doing of psychosocial care in terms of ‘symbiotic niceness’ to broader notions of nursing as a form of emotional labour. A selection of verbal interactions, looking at one specific theme of symbiotic niceness, that is, ‘marketable niceness’, is analysed. The analysis of talk reveals that participants co-engage in a ‘selling game’. Through the activities of selling, a set of personal assets which constitutes their personal Curriculum Vitae (CV) are revealed. It suggests that nurses’ E-mail address: [email protected] (S. Li).

assets, when combined with patients’ assets, function as marketable ‘products’ to produce an impression of nice patients and professionals. This in turn leads to the production of an impression of nice organisations. Impression management is presented as a key strategy for the production of ‘marketable niceness’. Through the co-performance of niceness in talk, both nurses and patients are constructed as people who are charismatic, friendly, informal, understanding and concerned. Symbiotic niceness thus represents a core component of professional and patient identity which works to maintain social order as well as to advance personal, professional and organisational aspirations. Symbiotic niceness may be objectified as a skill for certain groups of professionals to learn to do better, in particular, in situations in which they may have to deal with

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interactional problems (Li, 2002). I argue that psychosocial care is not a specialist project even though it is dressed up in the technical language of psychology, psychiatry and medicine. Psychosocial care means psychological and social care. These form two of the four care components that constitute ‘holistic care’ (Clark, 1994; Sheldon, 1997; Twycross, 1995). The remaining two components are physical and spiritual care. Holistic care means meeting patients’ physical, psychosocial, social and spiritual needs. It is the conventional wisdom in the frameworks of care for sick and dying patients (Saunders & Baines, 1983). In Saunders and Baines’ (1983) book, the psychosocial care component is central to the management of dying patients in palliative care. A formal definition of palliative care1 is: ‘the active, total care of patients whose disease is not responsive to curative treatment. Control of pain, of other symptoms and of psychosocial, social and spiritual problems is paramount. The goal of palliative care is achievement of the best possible quality of life for patients and their families’ (WHO, 2002). There is no shortage of literature in palliative care which recognises the importance of meeting a dying person’s needs not only at a physical level but also at psychosocial and spiritual levels. Recurrence of certain themes in psychosocial literature such as personality, family involvement, family support, personal relationships and effective communication in care of the dying suggests that these are important nursing agenda for meeting dying patients’ psychosocial needs. For example, in what is regarded by professionals in palliative care as the only ‘official’ definition of the psychosocial care component, the NCHSPCS’ (1997) discussion paper states that: ‘psychosocial care is concerned with the psychosocial and emotional well-being of the patient and their family/carers, including issues of self-esteem, insight into and adaptation to the illness and its consequences, communication, social functioning and relationships’ (NCHSPCS, 1997: 6). The NCHSPCS’ paper (1997) offers some useful suggestion in how psychosocial care can be given in context, in that it outlines a model of psychosocial palliative care which is claimed to be efficient in responding to the ‘total pain’ experienced by the dying patient, this being the patient’s spiritual, psychosocial, practical and physical aspects of pain. Central to the understanding of the concept of psychosocial care is the 1 The definition of palliative care can also be located in NHO (1994: 29).

importance of attending to a dying patient’s physical and psychological state of mind and body. This also includes the management of social relationships in interaction and communication.

Psychosocial care as the practice of ‘niceness’ James (1986) observed that the relationship between nurses and patients was reciprocal in nurses’ accounts on care of the dying in a hospice. This relationship was balanced by a notion of ‘give and take’. For example, she reported that sometimes patients offered caring to nurses by maintaining a nice front in the face of dying. Patients’ positive personal qualities such as dignity and having a sense of humour were considered important because they made nurses feel that they were making special efforts. The idea of the collaborative production of nice and reciprocal relationship can be seen in the work of Strauss, Fagerhaugh, Suczek, and Wiener (1982). Strauss et al. observed that sentimental work was collaboratively worked at by both patients and nurses in chronic illness. For example, participants monitored each other’s behaviour by observing the moral rules of respect and tact in terms of the rules of explaining, pacing and obtaining consent. They also tried to maintain a professional face of self-control by presenting themselves as supportive and helpful people. Strauss et al. called these activities composure and interactional work. Composure work also served to help patients maintain their composure. The authors also observed that nurses constantly tried to keep certain information from patients believed by staff to be harmful to them. The withholding of information served as a strategy to help patients maintain their composure. Strauss et al. called these activities awareness context work. Then there was rectification work which served to restore patient’s shattered composure, the causes of which may be due to a rudeness from staff members or disagreement between staff members and patients. It also served to reassure patients. Evidence of identity construction and the co-enactment of niceness in the context of death and dying can be located in Copp’s (1996) thesis. Copp demonstrated how participants in her study actively engaged in a constant and mutual game of monitoring each others’ psychosocial needs. She observed that dying patients sometimes tried to put on a brave face so as to mask their own suffering and present themselves as very nice people. Patients sometimes responded to nurses’ efforts by praising them for their kindness and support. Nurses too made attempts to protect patients from further embarrassment, distress and grief as they face imminent dying by playing down the seriousness of a crisis or an event.

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Hockey (1986) who conducted an observational study in a residential home for elderly patients and a hospice for dying patients in the UK, observed that elderly patients tried to please the nursing staff by making an effort to appear good-natured and caring in exchange for being accepted by care staff. When elderly patients required assistance, they would approach the nurses cautiously and politely. Hockey (1986) also noted that joking with patients served to deepen the level of involvement between patients and nurses in the nurse– patient relationship. Discussion of the literature above reveals that giving psychosocial care involves the emotional labour of being nice to each other. Niceness is not just about presenting a good professional front, it also concerns the wider implications of social interaction. It may be regarded as a mechanism for constituting moral identities and for maintaining social order.

General concept of niceness The idea of niceness can be found in Goffman’s (1967, 1976b) concepts of deference and demeanour. Goffman says that our face-to-face interactional order is guided and governed by ceremonial rules which involves presentational rituals. For him, presentational rituals are regarded as types of deference and demeanour (Goffman, 1967, 1976a). Goffman (1976a) says that demeanour refers to: ‘that element of the individual’s ceremonial behaviour typically conveyed through deportment, dress, and bearing, which serves to express to those in his immediate presence that he is a person of certain desirable or undesirable qualities’ (p. 489). Goffman (1976a) argues that deference takes two forms, presentational and avoidance rituals. The former concerns obligation, showing sentiment of regards for others, affection, belongingness, paying compliments to each other and showing signs of sympathy and concern. The latter concerns preserving ones’ privacy by keeping a distance from the recipient so as not to intrude into or violate one’s social spaces. For Goffman, joking and sharing a sense of humour may also represent a way of making people popular and ‘nice’ (Goffman, 1967: 17). Goffman (1967, 1976b, 1974) suggests that individuals’ demeanour and deference have implications for the wider society in which they live. The ability to perform as competent individuals involves rules of proper conduct. Such rules are ‘bindings of society’ which serve to bind the actor and the recipient together. To break the basic rules of conduct may lead to the break down of social order. So individuals are more or

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less obliged to conceal bad conduct, and only to reveal appropriate behaviour. Goffman (1967) thus regards conduct such as failure to perform in the proper manner as bad demeanour. The ability to perform as competent individuals constitutes the basic kind of face work and rules of common courtesy. The notion of niceness can also be found in Hochschild’s (1983) study of flight attendants’ work. For Hochschild (1983), being nice serves to preserve interactional order. Hochschild observed that flight attendants’ work was concerned very much with the paid emotional labour of being nice to passengers. She observed that in the airlines’ recruitment manual, certain qualities were required of the would-be flight attendants, for example, a pleasant appearance and a smiling face, friendly, enthusiastic, poise and calm. Hochschild suggested that as well as having to look nice, flight attendants had to present themselves as friendly and enthusiastic people. Friendliness was seen as an important attribute of niceness. According to Hochschild, flight attendants had to constantly give the appearance of being warm and pleasant in the course of their duty. Thus, Hochschild regarded warmth as an aspect of ‘ordinary niceness’ which was used by the organisation as ‘an instrument of service work’. She suggested that ‘warmth’ served to present airlines as ‘powered by charm’ (p. 95). In the palliative care literature, Hunt (1991) has observed that niceness is associated with being friendly and informal. It is presented as a joint activity between symptom control nurses and dying patients in the latter’s homes in her study. For Hunt, being friendly means polite greetings, exchanging pleasantries, talking about the most mundane things like the weather, cracking jokes or sharing a sense of humour with patients. Being friendly and informal are devices which function to enable symptom control nurses to gradually introduce their planned business agenda to their patients and to gradually draw their business encounter politely to a close. So being friendly and informal implies promoting a nice relationship with people. Hunt’s view echoes Jarrett’s (1996) finding. Jarrett found that being friendly and informal served to create opportunities for both nurses and dying patients to build a therapeutic relationship in which ‘comfortable communication’ could occur (p. 201). She argued that ‘comfortable communication’, which involved being available, helpful, optimistic and knowledgeable, enabled dying patients and their carers to deal with their ever changing circumstances. On the other hand, Street (1995), in a study of paediatric nursing in a children’s hospital in Melbourne, observed that in one paediatric ward, nurses engaged in an act of self-advertising. For example, nurses presented their ward as a caring unit. Being caring meant being nice. Being nice meant smiling a lot, speaking in a

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manner that displayed sympathy, not making a fuss and not complaining. Nurses also perceived the other ward staff as nice and friendly. Like Hochschild’ s flight attendants, Street suggested that nurses in her studies had to act in artificial ways in order to maintain the unit culture of perpetual niceness. Street bemoaned that this kind of niceness was forced upon nurses and that their genuine feelings were compromised and submerged underneath the unit’s facade. Hence she called this ‘the tyranny of niceness’ (p. 30, 31). Street deplored those nurses who, in trying to be nice all the time, neglected other aspects of caring, for example, the need to reassure parents when their children were in hospitals. She argued that genuine niceness/caring exist beyond the tyranny of niceness and that it required much thoughts, not just technical competence. Street’s (1995) view echoes Aranda’s (1998, 2001) idea of the ‘tyrannies of palliative care’. Aranda argues that palliative care is in danger of suffering from ‘ideological stagnation’ (Aranda, 2001: 572) in terms of a similar veneer of niceness found in Street’s work. Aranda claims that this veneer of niceness could hamper effective peer appraisal which could make it difficult for nurses to resolve conflict or ease tension in interaction. Yet, it is not clear how ‘genuineness’ manifests itself in the nurse–nurse and nurse–patient relationships. Street appears to accept uncritically that ‘genuine’ niceness exists. However, I argue that it is unhelpful to say that we can get at the ‘genuine’ or ‘spontaneous’ characteristics of another person by claiming that we can apparently access his/her internal thought processes, a view also endorsed by Brown and Levinson (1978). The discussion of the concept of niceness in the literature reviewed above reveals that niceness concerns the wider implications of social interaction. Being nice is a collaborative effort between participants in interaction. Maintaining a nice professional front and character-building are thus central in the nurse–nurse and nurse–patient relationships. It may be regarded as a mechanism for constituting moral identities and for maintaining social order. The overall aim of the research (Li, 2002) is to investigate how palliative care nurses enact psychosocial care in their natural settings, particularly with reference to their talk. The aim of this paper is to examine one account of symbiotic niceness, namely, ‘marketable niceness’ in which I will explore how nurses and dying patients collaboratively construct a therapeutic relationship in psychosocial palliative care through doing symbiotic niceness, how nurses and dying patients collaboratively construct moral characters in interaction, what strategies are used by participants in enacting symbiotic niceness, and what function symbiotic niceness serves.

Methods As I was interested in how palliative care nurses enact symbiotic niceness through the doing of psychosocial care in talk, I needed to locate myself in settings where I could observe nurses who went about their business of caring for dying patients. For the research as a whole (Li, 2002), two hospices (H1 and H2) and one general hospital (HP1), which had a palliative care service unit, were purposively selected for comparative analysis. All three settings were located in South England. H1 and H2 were charity organisations but were partly funded by the National Health Service (NHS). HP1 setting was a palliative service unit which served a large teaching hospital. Admission was by referrals from General Practitioners (GPs) or from community palliative care teams. In all three settings, most patients had a diagnosis of cancer. Patients suffered from various forms of cancer at different stage of the disease. However, most came in when their disease was at the terminal stage. The types of cancer diagnosed in these patients were: breast, gastric, oesophagus, pancreas, lungs, rectum, bladder, liver, breast, colon, brain secondary and ovarian cancer. There were also non-cancer admissions, one in H1, namely, diabetes; three in H2, namely motor-neurone disease (MND), Parkinson’s Disease and Alzheimer’s Disease. In HP1, there were two non-cancer admissions, namely, MND and diabetes. However, patients who suffered from diabetes had also a diagnosis of cancer. The age of the patients ranged from 28 to 102 yr. The average stay for patients was about 1 week. Patients came into H1, H2 and HP1 for symptom control, continuing care, terminal care and respite care. The study design Within a grounded theory approach (Glaser and Strauss, 1967) an ethnometholdogical–ethnographical perspective on psychosocial care was adopted (Li, 2002). Different methods were combined: (a) content analysis, used to generate analytic categories; (b) the constant comparative method used to identify emerging themes generated from one setting and compare them with the remaining two settings to see whether the themes support one another; (c) theoretical sampling (Coffey & Atkinson, 1996) which enabled me to continually reflect on findings that determined further data collection strategies; (d) inductive approach which involved using the analytic tools of conversation analysis (CA) because such tools were considered to be contextsensitive (Silverman, 1985). It also enabled me to analyse my data systematically and to guard against the ad hoc use of common-sense interpretation (Silverman, 1985, 1997); (e) identification of deviant cases which may reveal data which might contradict research findings

ARTICLE IN PRESS S. Li / Social Science & Medicine 58 (2004) 2571–2583 Table 1 Staff observed Staff profile H1 H2 HP1

Female

9 10 5

Male

1 2 1

Total

10 12 6

Average years of experience in the setting 5 4 10

(Seale, 1999; Silverman, 1985); (f) simple counting and some statistical calculation; and (g) field-notes and research diary which helped reflection. The subjects Palliative care nurses were my primary focus. Patients, relatives and other professionals were ‘incidental’ although they may engage in talk with nurses or enter nurses’ discussion. A total of 28 palliatives care nurses from all three settings were observed. Table 1 shows the number of palliative care nurses observed and their experience. Consent Permission was formally obtained from the Ethical Research Committee in three settings. Verbal consent was obtained from a series of introductory meetings with participants over a period of 10 months. Information sheets for both palliative care nurses and patients were provided. These were displayed on patient’s notice boards in the wards. Written consent was also obtained from palliative care nurses. The ethical guidelines of each setting were followed throughout the research. Method of data collection I began fieldwork in H1 setting, followed by HP1 and H2. Initially I conducted short spans of observation lasting 15 min at various times during the day, twice a week, and on different days of the week. I observed periods of high activity; medium activity; low activity and quiet times to obtain an overall picture of the working culture of each setting. As time went on, the length of observation increased from 2 h to an entire shift on occasions. I spent 3 months of observation in H1 for a total of 35 h, H2 for a total of 40 h; and 6 months in HP1 for a total of 63 h. The main methods of data collection was participant observation. It included: (a) tape-recording of nurses’ hand-over meetings whereby one shift replaced another and multidisciplinary meetings, (b) observing and recording nurses’ activities at work. This involved shadowing palliative care nurses when they carried out what they described as a round of

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‘giving care’ to their patient, and taking part in the nursing care for some patients (20 in all), both male and female. Data analysis I transcribed and imported each episode of my observation into the QSR NUDIST2 program. Transcripts were repeatedly read until a sense of emerging themes or categories that might be of interest emerged. A set of analytic categories were then created. This stage is called ‘sensing the data’. A systematic and rigorous content analysis on recorded field-note data was carried out. I then identified data which showed nurses talking about patients whom they wanted to help feel better, and moments where nurses gave physical care or talked about patients’ psychological, social, spiritual conditions. Specific words or phrases spoken by palliative care nurses were identified and counted. This established how frequently such categories occurred in nurses’ talk in one setting when compared with the two other settings. ‘Word count tables’ were constructed to show the number of times a word occurred in the nurses’ talk, e.g., ‘nice’, ‘good’, ‘lovely’, ‘sad’ or ‘difficult’. The constant comparative method was used to reveal systematic differences or similarities in the enactment of psychosocial care in each of the three settings. Because I was interested in how nurses constitute their own, their patients’/relatives’ and other professionals’ moral characters, I deepened my data analysis by adopting some of the analytic tools of CA to reveal and make visible participants’ activities in nurses’ talk Fig. 1.

Results The data analysis demonstrated the construction of four analytic categories of dying patients in nurses’ psychosocial care talk. These were: ‘trouble-free patients’ who are presented as patients who are nice as well as free from pain and other symptoms and who deserve ‘care+niceness’; ‘troubled patients’ who are troubled in both body and mind; ‘potentially troubled patients’ whose fluctuating physical and mental conditions depended on whether pain and other symptoms were brought under control; and lastly, the ‘undeserving patients’, presented in nurses’ talk as those who deserve ‘obligatory care’ but ‘minus niceness’ (Li, 2002: 240, 242, 248). I also identified eleven analytic categories of 2

This stands for Qualitative Solutions and Research: Nonnumerical Unstructured Data Indexing Searching and Theorising. It has a facility to split data into lines of a defined length. It also numbers the lines of data. It has specific tools to do word or string search.

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Researcher in the field

‘Sensing data’ The ‘noticings’ forming impressions of themes and categories

‘Quantifying data’ Counting instances & constructing ‘frequency’ tables’

‘Sensitising myself to the data’ Identify words & phrases Construct ‘indicator tables’

Contextualising data Application of CA tools Constructing psychosocial care’ Constructing ‘niceness’

Theorising Constructing moral identities Fig. 1. The process of data analysis (Li, 2002;119)

symbiotic niceness produced in nurses’ talk which included seven instances when niceness was abandoned. However, it is beyond the scope of this paper to discuss these findings. Tables 2 and 3 summarise them. (Li, 2002: 151, 174). For the purpose of this paper, I shall present analysis of one type of symbiotic niceness, which is ‘marketable niceness’. Marketable niceness’ refers to a type of niceness which is co-constructed in participants’ talk whereby personal qualities such as having a good sense of humour, being caring, kind, calm and displaying professionalism are reconstructed as ‘marketable assets’. These ‘personal assets’ are in turn re-constructed as ‘team’ or ‘institutional assets’ which serve to produce an impression of ‘nice’ organisations. The nature and quality of the nurse–nurse and nurse–patient relationship are revealed and made visible. The following data analysis demonstrate that ‘marketable niceness’ is coconstructed by participants in talk through strategies of paying compliments and using humour.

Analysis Paying compliments: ‘Personal assets’ reconstructed as ‘team’ and ‘company’ assets The processes of construction and reconstruction of marketable niceness involve a series of conversational sequences: (1) introduction of the topic; (2) the ceremonial ‘appointment’ of an individual;

Table 2 Operational definition of patient categories Troubled patients

This refers to a group of patients who are presented in nurses’ talk as troubled, because their minds and bodies are troubled. Some are unable to maintain their own niceness because they are becoming troublesome themselves.

Trouble-free patients

This refers to a group of patients whose niceness is constituted from a mixture of elements in nurses’ talk, including behaviour and moral character, as well as freedom from troubling symptoms, or at least a controlled response to troubling symptoms. They are presented in nurses’ talk as charming and worthy people who do not let their troubles get on top of them.

The potentially troubled patients

This refers to some patients who apparently ‘sit’ on the ‘troubled free-troubled’ continuum. This means that they are potentially trouble-free but may become troublesome because their physical and mental troubles are beginning to trouble them. Because they are already nice, they do not become troublesome for the nurses. They still deserve nurses’ sympathy and niceness.

The undeserving patients

This is a group of individuals who are sometimes presented in nurses’ talk as unpleasant and unlikeable people. Nurses present themselves as often struggling to maintain their composure. They may sometimes be unable to do so and so niceness may be abandoned in these moments. Nurses may sometimes prefer not to have these individuals around. Such patients are painted as neither charming, worthy, nor deserving in spite of suffering from very ‘troubled minds and bodies’.

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Table 3 Analytic categories of niceness Symbiotic niceness

It means that the ‘niceness’ of nurses simultaneously requires, feeds on and ‘grows’ from the ‘niceness’ of nurses themselves and of patients and nurses. It is a symbiotic existence. It is mutually benefiting and sustaining

Marketable niceness

A type of niceness which is co-constructed in participants’ talk whereby personal qualities are constructed as personal assets. These assets are re-constructed as team or institutional assets which serve to produce an impression of nice organisations

Team niceness

It is a type of niceness performed by an individual who also involves the team to which he or she belongs. In my sense, niceness produced by the individual not only may enhance an individual’s professional status but also team status. Thus whenever ‘I’ and ‘we’ appear in any one instance of talk by the same person, it constitutes ‘team niceness’

Institutional niceness

Refers to a type of niceness collectively performed by the team from the standpoint of ‘we’. ‘We’ means everyone in the team. Collective niceness is demonstrated in successful patient outcome such as discharge or getting better

Personal niceness

A type of niceness performed by the individual which may help to enhance his/her professional status and image. The personal aspect is represented by the self-referencing ‘I’

Inverted comma niceness

It is a type of niceness apparently done directly or indirectly quoting, or paraphrasing another person’s speech

Super niceness

This represents a supreme kind of niceness. This means that niceness is performed to make nice people even nicer, for example, trouble-free patients who already have striking and likable personalities

Niceness as a bonus

Refers to a type of niceness produced in nurses’ talk which presents ‘troubled patients’ as nice because they have fighting spirits and they constantly strive to get better. These qualities add bonus to nurses’ effort

Disclaimed niceness

Refers to a type of niceness done by a particular person who sometimes do not use the selfreferencing term ‘I’ or collective noun ‘we’

Unstable niceness

Refers to a type of niceness which may potentially be threatened by patients’ changing illness conditions. Achievement of niceness may be determined by whether nurses are able to maintain patients’ disease processes in a stable state

Undeserved niceness

Refers to a type of niceness which, in the context used, can be interpreted as meaning that certain patients, because of their own unpleasantness, are perceived by PCNs as deserving of obligatory care but minus nurses’ niceness

The ‘censored talk’

Refers to parts of talk which are ‘edited out’ from the parts that are ‘edited in’ or ‘approved’. This type of talk is strictly sanctioned by participants in the settings. They have not given me their permission to record an instance of talk

PCN = palliative care nurse.

(3) construction of a personal CV3; (4) construction of a team and organisational CV. Data excerpts (a) and (b) below are two instances of talk recorded during palliative care nurses’ ‘unofficial’ 3 In my study, CV is not used in its everyday meaning, that is to say, a CV for academic/job interviews. It is used in a specific sense in that it is a negotiated CV which is jointly constructed by participants in talk (Li, 2002: 187).

coffee break in H1 setting. The talk took place on the same day but at different times, once in the morning (excerpt a) and once in the afternoon (excerpt b). During these breaks, nurses sometimes talked about special events happening at the hospice such as hospital fetes or charity events. This kind of talk was usually conducted in a friendly and informal manner. For example, laughter (line b: 246) is regarded by Arminen (1998) as a resource which works to echo the ‘sharedness’ (p. 109) of the event.

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Data Excerpt (a) 21 The subject of a ‘‘Royal Visit’’ (N1 gestured a quotation marks with two 22 fingers above both sides of her head) was also talked about. The Duchess of 23 Norfolk was visiting the ‘Hospice’ today. 24 The nurses were deciding who was to present flowers and escort her 25 around the hospice. They suggested that ‘N2 should do 26 it’ because they said’ she0 s got the right qualities’ 27 They made references to her ‘look’; her ‘warm personality’ and her ‘blonde 28 hair’: (H1:1:21–27) Data Excerpt (b) 240 N took me (SL) into the interview room where staff gather to have 241 their cups of tea. 242 During their ‘coffee break’ they spoke about what had been done, 243 what needed to be done 244 N took the opportunity to tell the staff that N2 245 was going to do the ‘‘Royal tour’’. 246 There was a lot of laughter again. They made reference to her ‘persona’ and 247 her ‘demeanour’: (H1:1:240–247) In these two instances of talk, the topic of conversation, the ‘Royal Visit’, is first introduced. Arminen (1998) suggested that topic construction served as ‘a flexible resource for members to link individual and communal experience’ (p. 88). In this instance of talk, the event is happening the next day. The ‘specialness’ of this visit is indicated by the double quotation marks (lines a: 21–2; b: 245) which represent N’s hand gestures. Then comes the ceremonial ‘appointment’ of an individual who would be the best person to take the Duchess of Norfolk round the ‘Royal tour’. The nurses decided that N2 should be the person. These two instances of talk represent a nurse’s CV which is concerned with a set of personal assets (expressed through the use of first name ‘N2’, ‘she’ and ‘her’ at lines a: 25–7) endorsed by palliative care nurses to be ‘right’ (line a: 26) and thus creditable qualities for carrying out this important task. The notion of such qualities is embodied in the words ‘persona’ (line b: 246) and ‘demeanour’ (line b: 247). Just what these ‘right’ qualities are can be seen in the nurses’ statements at lines a: 27–8, for example, N’s ‘look’, ‘warm personality’ and ‘blonde hair’. These appear to support some of the key features that constitute the concept of demeanour identified by Goffman (1967). In these two instances of talk then, N’s personal assets, look, warm personality, blonde hair’ (line a: 27– 8) and ‘demeanour’ (line b: 247) can be regarded as properties which encompass marketable values and the kinds of qualities which are required by the job of escorting the Duchess during her ‘Royal tour’ (line b: 245). Following Hochschild (1983), just as personal assets such as warmth or friendly smiles represent the airlines’ charm, so N’s personal assets represent both the hospice’s and palliative care nurses’ charm and niceness, something which Fineman (1993) would describe as ‘pernicious features of personality market’ (p. 18) and a

recipe for ‘corporate success’ (p. 12). The production of niceness in N benefits other nurses. It could also lead to the production of niceness in the professionals, and the production of a nice organisation where they work. In this sense, through the strategy of paying nice compliments to other colleagues, personal assets are reconstructed as marketable ‘team’ and ‘company’ assets expressed in the use of a collective noun ‘hospice’ at line a: 23. In this sense, niceness is symbiotically produced and shared by palliative care nurses themselves. Sometimes nurses may actively engage in selling the products (CV) of another palliative care nurse. Displayed in the excerpt below is an elaboration of the features of a nurse’s CV. Excerpt (c) on facing page is an instance of talk between N2 and N1, recorded after an episode of shadowing N1. Here the topic of conversation is about N2 with whom N1 has been working during the early morning shift. N1 and N2 have been assigned to look after P on this particular morning. Involved in N1’s talk is an image of an awkward patient, displayed at lines c: 189–190, who is presenting particular management problems for the nurses. In this instance of talk, the impersonal pronouns ‘this’ and ‘that’ (line c: 190) refer to the two ‘holes’ on P’s abdomen, colostomy and ileostomy. The collective pronoun ‘them’ (line c: 189) refers to the nurses who have been looking after him. N1’s statement then at line c: 192 indicates a notion of a negative self-evaluation. It implies her inability to deal with P’s situation. Mulkay (1984), in examining the nature and distribution of compliments in Nobel Prize ceremonies, showed that this form of negative selfevaluation served to downgrade the prize winners’ own achievements (p. 537). Simultaneously it served to function as a courteous ceremonial response to positive evaluation given to them by other Laureates at the

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Data Excerpt (c) 185 9.00 AM 186 I (SL) joined some of the nurses for coffee. N1 had just 187 finished helping N2 with P. N1 commented that she ‘was very 188 impressed with the way N2 (first name was used here) handled P’. N1 said: ‘she was so 189 gentle and so patient despite P telling them not to touch 190 this, not to touch that’. N1 said that ‘N2 (first name was used here) was a 191 professional; has a real professionalism’: N1 said that she 192 ‘couldn’t have done what N1 did or the way she did it’. N1 193 said that N2 ‘took the dressing off and re-dressed it and 194 she made him comfortable’: (H1:9: 185–194)

ceremonies. In this instance of talk, N1’s negative selfevaluation serves to display her appreciation of N2’s ability, namely the ‘whats’ and ‘hows’ to manage P’s particular situation as perceived by N1. N1’s appreciation of N2’s special qualities is displayed in the full compliment she pays personally (here she used N2’s first name) to N2. Watson (1981) suggests that the choice of first names is not a ‘trivial interactional alternative’ (p. 101), but a ‘recognitional device’ (p. 98) which works to select a personalised relationship between two speakers. It also works as a solution to solve an interactional problem. In this instance, the use of first name by N5 serves to divert the hearer’s attention from N5’s own embarrassment which is expressed and displayed in her statement at line c: 192: ‘couldn’t have done what N1 did or the way she did it’. Involved in N1’s statements is an extreme appreciation of N2’s competence: ‘very impressed’ (lines c: 187–8), ‘so gentle’ (lines c: 188–9), ‘so patient’ (line c: 189), and an extreme upgrading of N2’s status displayed in the positive descriptor ‘real’, at line c: 191. As shown by Bergman (1992) and Gumperz (1992: 495), the notion of extreme

Data Excerpt (d) 193 194 195 196 197 198

Braithwaite (2000), Dingwall (1977) and Freidson (1993), the concept of professionalism concerns nurses’ capacity to perform certain kind of work which is often associated with the notion of expert knowledge, skills, competence and social behaviour. It also concerns autonomy, commitment to the task, a system of ethics and maintenance of standards. In this instance, N2’s account constructs N1 as a ‘nice professional’, being gentle, patient and competent in dressing P’s wounds. In constituting N1 as possessing ‘nice’ personal assets, an impression of being a ‘nice’ professional in N2 is achieved, and an instance of symbiotic niceness is accomplished between N1 and N2. Thus the niceness of professionals represents the CV (‘marketable assets’) for their organisations in which they work. Paying compliments to PCN by a patient: displaying ‘personal assets’ Excerpt (d) below is an instance of observation recorded in H1 setting.

We (SL & N) went into another room. I was introduced to P. He looked very pleased to see us. He told me what was important for me to learn, ‘To be charming; smiling like N’ (here first name is used). He took N0 s hand and kissed it: N and I laughed. More jokes from the patient followed. (H1: 1: 193–98)

upgrading is indicated by the use of maximal descriptive characters: ‘very’, ‘so’ and ‘real’. In this instance, constituted in N1’s talk is representation of N1’s orientation to the nursing philosophy of how a ‘real’ professional should behave even under difficult circumstances, that is, as a person who exhibits professionalism. As suggested by Finlay (2000), Southon and

In this instance, SL was shadowing N on her morning round just after the hand-over between night and early shifts. P pays a full compliment to N. Displayed in this instance of observation is an image of patient who presents himself as being friendly and informal through his use of N’s first name at line d: 196. The image of a polite, respectful, courteous and pleasing individual,

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who appreciates the nurses for ‘smiling’ is displayed at lines d: 196, and he presents himself as a gentleman by kissing N’s hand (line d: 197). In presenting himself as a gentleman of the ‘court’ (Elias, 1978), he is also presenting N as a ‘lady’ who is accorded his respect, who has special qualities, such as charm and smiles, which he values. In this sense, the production of ‘niceness’ in P leads to the production of niceness in N and by implication, in institutions. P’s statement then constitutes him as a person who actively engages in the process of ‘selling’ the ‘seller’s’ (palliative care nurses) products, and his own ‘personal assets’ are also displayed. So charm and smiles may be regarded as ‘marketable assets’ for both palliative care nurses and patients to co-perform niceness. Joking and laughing (line f: 198) may also be regarded as stage props (Goffman, 1969) which serve to bolster the co-enactment of niceness. This represents another instance of symbiotic niceness.

Discussion The production of one account of ‘symbiotic niceness’ in nurses’ talk functioned to preserve a nice, friendly, informal and pleasant atmosphere in interaction. ‘Symbiotic niceness’ was accomplished through paying compliments, self-compliments and the use of humour. It was constructed from a set of rules, sequential arrangement of talk and the use of pro-terms, such as ‘I’, ‘you’ and ‘we’, which instructed how statements made by participants were to be interpreted and heard. Both patients’ and nurses’ moral identities were defined by a set of ‘personal assets’ which participants drew on to enact ‘symbiotic niceness’. These assets which included humour were reconstructed in nurses’ talk as ‘marketable assets’ which served to produce an impression of a nice organisation. It demonstrated palliative care nurses’ ‘personal assets’ which, when combined with patient assets, mirrored ‘team assets’. The assets presented served to benefit the team and produce a nice team image. ‘Team assets’ in turn mirrored organisational assets. Moreover, this meant that the niceness of nurses and patients reflected on and benefited the organisations where they occupied or worked. Palliative care nurses’ ‘personal assets’ (CV) consisted of qualities of personality and behaviour such as warmth, a smiling face, self-control (ability to maintain composure), being patient, kind, gentle, competent, knowledgeable and having the ability to show concern expressed in the display of sympathy and empathy. They also consisted of physical attributes (an attractive appearance), style of clothes and age. The data analysis seemed to show that nurses’ personal assets represented nurses’ notion of what a ‘real’ professional ought to be. Patients’ CV (assets) also consisted of good manners,

being courteous, having a good sense of humour, making jokes about themselves, sharing jokes with nurses, showing appreciation and generally being pleasant, polite and having an appearance of general physical wellness. Nurses’ personal assets and patient assets thus represented essential elements for the construction of symbiotic niceness, what Goffman (1967) would call deference and demeanour. They also represented important features of emotional labour (Li, 2002: 278). See Table 4. The findings support Goffman’s (1967) notions of deference and demeanour in that participants in this study engage in what Goffman describes as ‘presenting a nice front to others that are of certain desirable qualities’ (Goffman, 1967: 77). Those ‘others’ may include relatives, visitors and SL. Nurses and patients may be conscious of the fact that their actions may be judged by others who are present. In Goffman’s view, such actions are consciously ‘staged’ or managed. Through demeanour or deference, Goffman says that ‘an individual creates an image of himself meant not for his own eyes but for others’ (p. 78). What his study offers is one account of symbiotic niceness co-constructed by participants and how it is revealed through talk. However, we cannot know the answer to whether genuine niceness exists in the nurse– patient relationship as suggested by Street (1995), and the flight attendant–passenger relationship observed by Hochschild (1983). As suggested by Goffman (1967), there is no such thing as the ‘real self’. For him, the self is an actor or performer who has learned the parts well, that is, the scripts which are written specifically for these parts. Indeed, Kuzmics (1991), in his critique of Goffman’s work, argued that in Goffman’ world, there was only ‘play-acting’ (p. 22) in which ‘there are only actors, but no authenticity’ (p. 24). The self was thus subject to self-regulation and self-control. Kuzmics’ (1991) suggested that Goffman neglected the social and cultural demands that were forced upon individuals (p. 18). Yet Goffman’s ‘acted’ self may be seen as the consequences of responding to such forces that were imposed on individuals. The findings in this paper also support Wouters’ (1989) argument that it is difficult to make a distinction between a ‘real’ and a ‘false’ self (p. 97). Nevertheless, the idea of ‘staged’ actions such as those apparently presented by palliative care nurses and patients in this study is relevant to the idea of surface acting suggested by Hochschild (1983). Surface acting refers to actions which are not acted from the heart. They represent the ‘masks’ (p. 18) which are required by flight attendants to ‘put on’ in the course of their duty. For example, smiles are consciously put on just to please their customers because they are paid to do so. They become valuable company assets to promote ticket-sales (Hochschild, 1983: 108). In Hochschild’s view, smiles

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Table 4 Features of emotional labour displayed in palliative care nurses’ talk Author

Context

Nature of emotional labour

Sarah Li (2002)

Three palliative Public performance and care settings (UK) maintenance of niceness Co-production of niceness Co-performance of niceness

Actively engage in selling each other’s personal assets Give care + niceness Give obligatory care minus niceness

Strategy

Outcome of emotional labour

Impression management

A ‘scripted’ performance of symbiotic niceness: Rewarding Productive

Constructing patients’ disease processes as resources via enactment of psychosocial care

Collaborative Reciprocal relationship Resistance to performance of niceness

Withholding/withdrawing niceness Manage interactional conflicts Preserve interactional order Maintain neutrality Preserve anonymity Mothering Adjust nurses’ own demeanour and deference Preserve acceptable ‘front’ Maintain, preserve and display professional competence, knowledgeability and skills Maintain general sense of psychosocial and physical well-being Minimise distress

can be regarded as a commodity for the airline companies, therefore smiles can be said to belong to the companies. The present study departs from the work of Hochschild (1983) in two ways. Firstly, Hochschild claims that flight attendants do not sell themselves, instead they sell their company, albeit reluctantly. However, in this study, being a nurse is found to be different from being a flight attendant. Palliative care nurses not only ‘sell’ themselves, they also engage in ‘selling’ their hospices and hospital. Sometimes nurses and patients co-engage in the selling game, selling nurses’ personal and patients assets for themselves and the organisations. Mutual fun appears to characterise the ‘selling game’. Secondly, in her study, Hochschild does not seem to pay attention to the part customers play in selling the CV of flight attendants apart from reporting that the customers sometimes send ‘orchid letters praising an attendant for good service’ (p. 116). In this study, patients also engage actively in selling the nurses’ personal and professional assets.

Conclusion This paper argues that the nurse–patient relationship is a reciprocal one. It is premised on a therapeutic existence of symbiotic niceness in that both parties engage in the process of mutually feeding, absorbing, and benefiting niceness work. This serves as a means of managing relations between palliative care nurses and dying patients, especially in situations in which nurse have to manage patients who present behavioural problems, perceived by palliative care nurses as symptoms of patients’ disease progression. Symbiotic niceness thus represents a core component of professional and patient identity which works to maintain social order as well as to advance personal, professional and organisational aspirations. It suggests that the niceness of patients has implications for the nurses’ own performance of niceness, which is in turn a key component of the emotional labour that contributes to psychosocial care. Symbiotic niceness can thus be analysed as a skill available for everyone in ordinary everyday interaction.

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It is suggested that health care professionals learn how to ‘do’ niceness better. This learning process is particularly relevant in situations in which interactional difficulties may arise, for example, when niceness is threatened, withheld, withdrawn or when niceness completely breaks down.

Acknowledgements My sincere thanks to the doctors, nurses and patients of the two hospices and one general hospital, without their generosity, this project would not have been possible. My thanks to Professor Clive Seale (Goldsmith’s College, University of London) for reading my earlier and final drafts and for his valuable comments, to Angie Frontin (Senior Lecturer, Kingston University) who have diligently read my earlier drafts and made very useful comments.

Appendix A Transcription symbols PCN: N: P: SL: Dots between words:

Palliative care nurse Nurse Patient Researcher ‘I amy..oky’: Pauses in seconds Underlined words: Draws readers’ attention to particular words or sentences used by participants in the analysis Single quotation marks ‘P is frightened’: in the data: Represents an instance of a Nurse’s talk HP1: 16: 86–87: Indicates a particular setting, the number of a full data transcript and the location of the line position of the same data transcript

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