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The emotional labour of nursing – Defining and managing emotions in nursing work
Nurse Education Today (2009) 29, 168–175
Nurse Education Today www.elsevier.com/nedt
The emotional labour of nursing – Defining and managing emotions in nursing work Benjamin Gray
*
6B Park Road, Wivenhoe, Essex CO7 9NB, United Kingdom Accepted 6 August 2008
KEYWORDS
Summary Emotions in health organisations tend to remain tacit and in need of clarification. Often, emotions are made invisible in nursing and reduced to part and parcel of ‘women’s work’ in the domestic sphere. Smith (1992) applied the notion of emotional labour to the study of student nursing, concluding that further research was required. This means investigating what is often seen as a tacit and uncodified skill. A follow-up qualitative study was conducted over a period of twelve months to re-examine the role of the emotional labour of nursing. Data were collected primarily from 16 in-depth and semi-structured interviews with nurses. Key themes elicited at interviews touch upon diverse topics in the emotional labour of nursing. In particular, this article will address nurse definitions of emotional labour; the routine aspects of emotional labour in nursing; traditional and modern images of nursing; and gender and professional barriers that involve emotional labour in health work. This is important in improving nurse training and best practice; investigating clinical settings of nurses’ emotional labour; looking at changing techniques of patient consultation; and beginning to explore the potential therapeutic value of emotional labour. c 2008 Elsevier Ltd. All rights reserved.
Emotional labour; Nursing
Introduction: definitions of emotional labour Hochschild (1983) says that emotional labour involves the induction or suppression of feeling in order to sustain an outward appearance that
* Tel.: +44 01206 823828. E-mail address: [email protected]
produces in others a sense of being cared for in a convivial safe place. Emotional labour is particularly typified by three characteristics: face-to-face or voice contact with the public; it requires the worker to produce an emotional state in another; it allows the employer through training and supervision to regulate a degree of control over the emotional activities of workers (Hochschild, 1983; Smith, 1992: 7; Smith and Lorentzon, 2007). The term ‘emotional labour’ highlights the similarities as well as differences of
0260-6917/$ - see front matter c 2008 Elsevier Ltd. All rights reserved. doi:10.1016/j.nedt.2008.08.003
The emotional labour of nursing – Defining and managing emotions in nursing work emotional and physical labour. Emotional labour requires an individualized but trained response that assists in the management of patients’ emotions in the everyday working life of health organisations (James, 1993, pp. 95–96; Allan and Smith, 2005; Smith and Lorentzon, 2007). Emotional labour has traditionally been identified with women’s work and the role of the mother in the family. This is especially significant given that images of nursing still reverberate with that of the caring female, particularly with the prototype of Florence Nightingale (Smith, 1992). The portrayal of emotional care as an entirely natural activity is certainly related to the devaluation of emotional labour in cultural, gender and economic terms (Oakley, 1974; Totterdell and Holman, 2003; Glomb et al., 2004; Persaud, 2004). Although there is a growing shift towards the psychological and social aspects of patient care (Brotheridge and Lee, 2002; Diefendorff and Richard, 2003), an important gap in understanding is the centrality and therapeutic value of emotional labour in the lives and well-being of patients. The task of looking at emotional labour in the health setting involves the assessment of the strategies of emotional regulation that are available to health professionals. This includes the analysis of how nurses manage their own and the patient’s emotions and how nurses come to terms with the difficult processes that are often an unavoidable part of patient care. Such research will have to explicitly deal with uncomfortable and sometimes conflicting emotions that nurses, health professionals and patients have to face. The therapeutic potential of nurses’ interpersonal involvement with patients is certainly a central feature in what is widely known as the ‘new nursing’. Many say that the ‘new nursing’, if properly overseen, will generate positive outcomes for staff and patients (Staden, 1998; Allan and Barber, 2005; Hunter and Smith, 2007). Critics suggest that the ‘new nursing’ may be flawed in some respects and may place too many demands on the nursing role (Aldridge, 1994; Mackintosh, 1998; Brotheridge and Grandey, 2002). To be sure, the ‘new nursing’ still remains a bone of interprofessional contention and therefore a central point of review in the future. It is part of the task of the present study to begin such a review, relating the ‘new nursing’ to how nurses deal with emotions and how emotional labour is shaped by seniors and colleagues (Smith, 1992; Barnes et al., 1998; Williams, 1999; Allan and Smith, 2005). If, as Staden (1998, p. 154) says, ‘‘a language to communicate care work does not exist’’, then research must investigate the ways that emotions
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are dealt with by nurses so as to make emotional labour explicit rather than tacit in nursing practices. This will create room to cope more adequately with the emotional pressures and strategies that are used in caring for patients. From an evidence-base of research, the contribution of emotional labour to nursing practice, training and health policy is clearer. The contribution of emotional labour in sustaining high quality standards of patient care and patient-centred medicine is also made more visible. This means that recommendations for research and development can be made in light of important initiatives and guidelines for improvement in nursing (DoH, 1999, 2004, 2006, 2008; UKCC, 1999a, 1999b).
Methods The qualitative data of the study were collected from a variety of sources, primarily from sixteen in-depth and semi-structured interviews with nurses. Interviews with two GPs were conducted to allow some degree of interprofessional comparison. Interviews lasted between 45–90 min. Meetings with nurses, nurse managers and lecturers at several research seminar groups were also held. There were also research meetings with staff, mentors, student nurses, administration, management, the Student Council for Nursing and local nurse representatives. The researcher also attended during ten student nurse classes on the Common Foundation Programme, meaning that there was some amount of participant and non-participant observation. All of these methods assisted in the investigation of aspects of nurses’ emotional labour and helped to gain a reflective and participatory focus upon which to begin to explore the emotional labour of nursing. Nurses were recruited to the study via the researcher’s attendance at several pre- and post-registration classes held at a local East London hospital where the research was based and conducted. The majority of participants were female (12 of a total of 16) and ethnically quite diverse (7 described themselves as White, 6 as Black and 3 Asian). 10 of the student nurses were under 23 and there were 6 qualified nurses in the age range of 30–50 working in a variety of clinical settings such as primary care, children’s oncology and mental health. The study draws from the traditions of empirical qualitative data collection and ethnography, which looks at how people make sense of the world around them, their experiences of social relationships and other people (Garfinkel, 1967).
170 Ethnography focuses on participants’ meanings (or ‘‘members’ meanings’’) and perspectives in order to better understand social and emotional relationships. Feminist studies in health were also important (Oakley, 1974, 1981; James, 1989; Smith, 1992) and especially relevant given that on average 84% of nurses in the local trusts where the research took place were women. The research was subject to the ethical review and assent of the University’s and Healthcare Trusts’ Ethics Committees.
B. Gray was a surprising frankness on emotions and emotional labour that struck the researcher. This keenness to discuss emotional labour was explicable by many nurses’ views that they had to be ‘‘tuned in’’ to their own and perhaps more importantly the patient’s emotions. ‘‘Talking about emotions’’, as one nurse said, ‘‘is a key part of the job that helps you to understand what to do’’.
The emotional routine of nursing
Findings Key themes elicited at interviews touch upon diverse topics involving the emotional labour of nursing. This article will address nurse definitions of emotional labour; the routine aspects of emotional labour in nursing; traditional and modern images of nursing; and gender and professional barriers that involve emotional labour in health work.
Emotional labour and the nurse Nurse definitions of emotional labour Several nurse respondents echoed Hochschild’s (1983) definition and said that emotional labour was ‘‘continuous contact’’, ‘‘feeling like you’re on-call twenty four hours a day and always available to the public’’ and ‘‘giving the patient the feeling of being safe and warm’’. All of the nurses identified emotional labour as a chief part of the nurse’s role in making patient’s feel ‘‘safe’’, ‘‘comfortable’’ and ‘‘at home’’. As a student nurse said: I feel that emotional labour is the way that nurses look after people so they feel comfortable and their relatives feel that they are safe... A part of nursing is to show you care for them, even if you’re having a terrible day and are fed up yourself and with everyone else. You have to give them that extra support they need... Clinical and emotional skills come with the experiences of the job and you have to get in contact with your emotions and how the patient feels. Against some of the more critical literature on emotional labour in nursing, none of the nurse respondents discounted emotional labour from the work that they did in clinical and non-clinical settings (Aldridge, 1994; Mackintosh, 1998; Zapf and Holz, 2006; Hunter and Smith, 2007). There
As a nurse said at interview: It’s just sitting with the patient and feeling that there’s a link. I’ll just sit on the corner of their bed and take their hand so they feel a little better... I try to do that each day that I’m on duty with the less independent patients... Nurses sometimes don’t see how important it is just to show you care. I make the patients comfortable and part of the ward. It helps with the running of the ward and everyone getting to know each other... It’s not something that everyone can immediately see, so a lot of the feelings and work you do with the patient just goes unnoticed. You can’t put feelings of intimacy in the patient’s notes or record. I don’t think that’s possible. You can communicate with the patient just by looking at them or taking their hand. Just showing that you’re attached and that you care. The patient will feel better about talking about their worries. They won’t be so afraid if they need to ask for help or talk things through with you. Emotional labour was reported as making nurse and patient contact easier and ‘‘moving things along’’. All the nurses interviewed said that emotional labour made working with the patient much smoother and helped in ‘‘oiling the wheels’’ of nursing work (Saks, 1990). In the above extract, the social and psychological aspects of emotional labour work as almost invisible bonds that the nurse cultivates with the patient. Intimacy and more informal relations are said to help in the running of daily life on the ward (Savage, 1995; Smith et al., 1998; Allan and Barber, 2005). The emotional labour of the nurse is reported to help the patient to manage disclosures of a sensitive and emotional nature. This could certainly be suggested to increase information sharing as well as opening up more democratic partnerships by working with patients and their families, for example in patient-centred practice and the production of holistic care plans (James, 1989, 1993; Smith and Lorentzon, 2005, 2007).
The emotional labour of nursing – Defining and managing emotions in nursing work
Images of nursing Patient expectations were thought by nurse respondents to be shaped by conventional images of nursing. Student nurses felt that they were obliged to put emotions into nursing work because nursing was portrayed as the work of an ‘‘angel’’, ‘‘Florence Nightingale’’ and part of the domestic work of ‘‘mothering the patient until they feel better’’. Certainly, the images associated with nurses’ emotional labour are predominantly female (James, 1989; Smith, 1992; Cropanzano et al., 2003; Zapf and Holz, 2006). As a first year student nurse said: My mother is a nurse... You have a very close involvement with patients... You’ve got to clean, bathe and wash patients like your own children. You have to talk to them, listen to their troubles and worries like your mothering your own kids. Traditional images of nursing were seen as twoedged, particularly by student nurses. On the one hand, the image of the nurse as a natural carer was seen to ‘‘put patients at ease’’ with a familiar ‘‘mother figure’’. Some student nurses linked the nursing of patients to a mother nursing her child. The image of nurses as natural carers was said to be an automatic help in ‘‘breaking down emotional barriers’’ between nurse and patient and assist in establishing ‘‘more informal’’ relations necessary to nursing. On the other hand, many thought that the prototypes of the natural carer and Florence Nightingale made the establishment of nursing as a profession more difficult. In two separate classroom discussions with student nurses, images of nurses as an ‘‘angel’’ or a ‘‘good little woman’’ were vehemently rejected as ‘‘sexist’’ (Smith, 1992; Diefendorff and Richard, 2003). Almost all in the classroom discussions agreed that stereotypical images of nursing devalued emotional labour and the experiences that nurses have to accumulate throughout a career in nursing. Gender issues and barriers to emotional labour were certainly chief among the minds of these student nurses in classroom debates. The gender stereotype of the female carer, especially the mother figure, touches on personal and public perceptions of nursing care. Perceptions of the female carer are present in society and reproduced in the personal views of student nurses. The gender stereotype of nursing is certainly double-edged and creates a tension in the views of student nurses. The female stereotype is thought by student nurses as useful in making patients feel
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at ease, as well as simultaneously being thought as devaluing to nursing as a profession. Williams (1999) as well as Allan and Smith (2005) say that there are conscious and unconscious connections made by students about the activities associated with nursing. With guidance on selfawareness and reflection, Williams suggests that teachers will be able to assist student nurses in making connections between past and present events. In other words, reflection on the student nurse’s past and family role models will help in making present relationships with peers, patients and seniors more explicit. The emotional labour connected to these groups will also be rendered visible and better appreciated by reflection and discussion with the teacher.
Barriers to emotional labour Stereotypical images of nursing, which portray nurses as ‘‘angels’’ and natural care givers, touch on the nature/nurture debate and form gender inequalities in the health services. Stereotypical images of nursing were noted by interviewees to present barriers to emotional labour in health, in so far as the emotional labour of nurses was not recognised as a professional occupation and was instead depreciated as part of ‘‘women’s work’’. All the nurses interviewed had at one time or other experienced barriers to emotional labour that are embedded in the gender inequalities of wider society and largely reflected in health services (James, 1989; Lawler, 1991; Allan and Barber, 2005). Peculiarly, both older nurses and recently enrolled student nurses agreed that emotions were seen as a ‘‘weakness’’ by other staff, senior nurses and doctors. Certainly, there were gender and professional barriers as regarded the recognition of emotional labour. According to one student nurse: Some people see general nursing as being for women and women’s work. That’s why a lot of men go into mental health... It’s very hard to show that you care for a patient sometimes as you’re told not to get too close to the patient by some of the older staff and doctors on the wards. But that makes it impossible to empathise with the patient and try to feel what they’re feeling... Nurses should feel able to care and to get close with their patients. It comes with the job, really. Perceptions of emotional labour as part and parcel of ‘‘women’s work’’ were said to influence the choice of clinical placement and practice area.
172 Stereotypes of male and female labour in wider society, which regard women as natural care givers and men in more patriarchal roles, were influential in perceptions of appropriate and inappropriate patient contact. It was felt in discussion with classes and during interviews that intimacy was perceived in society and the health services as the role of women. Patient contact and intimacy were said to be more acceptable for women than for men. According to one male student nurse: Patients might feel uncomfortable about a male nurse washing, cleaning and looking after them. Especially a female patient. Care giving, emotional labour and intimacy were seen as the natural roles of women. This perception gave rise to a further perceived barrier, in so far as general nursing was perceived as being exclusively for women and mental health was said to traditionally be exclusively for men. There was heated debate between male and female student nurses in classroom discussions that sometimes became very polemical. There are taboos of closeness and distance (Lawler, 1991; Persaud, 2004; Allan and Barber, 2005) with the patient that are largely tacit in the health services and not evaluated in open discussion. In the above quotation of a student nurse, gender stereotypes and sexual taboos involving close contact and physical intimacy shape appropriate and inappropriate forms of patient care. Gender stereotypes and professional taboos effect the quality of emotional labour and types of consultation that are available to nurses and other health professionals.
Gender stereotypes There were many gender stereotypes that were mentioned by nearly all of the nurses. General nursing was seen as feminine work that involved washing and close physical contact with the patient. Mental health nursing was viewed as being more masculine and the occupation of the majority of male nurses. Female nurses were seen as natural carers and emotional labourers of the patient’s body. Male nurses in mental health sometimes had to deal with ‘‘physical aggression’’, had to be ‘‘physically stronger’’ and remedy disturbances of the patient’s mind. The respondents certainly touched upon gender divisions of body/mind and female/male that have implications for the emotional labour of nursing. As a female student nurse said:
B. Gray I’d like to go into mental health but it’s seen as being work for men, even though it’s been one of the most emotionally hard placements that I’ve done as a student nurse in the last three years. Emotional labour with the body was seen as largely the responsibility of women. In nursing, women were seen to be essential in the duties of cleaning, bathing, maternity and obstetrics. Male nurses were frequently perceived to be an inappropriate presence in these areas. Gender stereotypes also made many male nurses feel uncomfortable with close physical and emotional contact. Mental health was perceived by nearly all respondents as part of male nursing. Women were natural emotional labourers in general nursing, while men contained the emotional disturbances and physical aggression of mental health patients. Gender barriers presented problems in nurses’ specialism, in so far as stereotypes of male and female nurses related to the clinical practice areas. Classroom debate said that male nurses in perceived female clinical settings (general nursing, obstetrics and midwifery) could be labelled as ‘‘gay’’ (see Lawler, 1991, p. 213; Allan and Barber, 2005). Female nurses in perceived male clinical settings (mental health) were said to be physically and sexually at risk from aggressive mental health patients. Male nurses would have to fulfil a patriarchal role and ‘‘look after’’ female nurses in the mental health setting (Handy, 1990, 1991).
Professional differences There were also interprofessional barriers to emotional labour. Some of the nurses had very strong opinions regarding the poor quality of interpersonal contact that doctors provided to their patients. This was more than what one participant termed ‘‘doctor bashing’’ and interprofessional rivalry, in so far as gender divisions between the emotional labour of nurses and doctors emerged during interviews. As one nurse working in primary care said: I think that doctors are trained early on that they’re not supposed to talk about their feelings with staff and patients... It’s a much more private profession than nursing and doctors are much much less accessible to patients. Feelings are put to one side for the ‘real work’ of medicine. It’s just diagnosis and medical cure, which doesn’t stand up to scrutiny, really, as it isn’t possible to heal with some cases like terminal patients. There’s an unwritten rule that nurses
The emotional labour of nursing – Defining and managing emotions in nursing work care for patients and that we’re the ones responsible for the patient’s feelings while they’re here. It’s left up to us, really. Doctors are detached from that sort of thing and leave nurses to pick up the emotional pieces. This nurse’s view was largely confirmed by the GP who ran the practice: Feelings can get in the way if you’re trying to make a diagnosis of a patient. You’ve got to try and remain objective. It might be an embarrassing illness or personal examination of some kind. It’s better to get on with the medicine and let the nurses deal with the emotions... My practice works as a team of doctors and nursing staff much like a family. All I can really do is patch people up physically and send them home. Divisions of emotional labour certainly influence the perceptions of the emotional work that may be carried out by nurses, doctors and other healthcare staff. The model of the primary healthcare team as a functioning ‘‘family’’ is employed in the above excerpt. The image of a ‘‘family’’ is used to reinforce the gender stereotype of the subjective female (nurse) and objective male (doctor) that is widespread in society. To be sure, there are limitations placed on both doctors and nurses in terms of how these professions are supposed to labour emotionally. This has a direct effect on how the professions consult patients and attend to the emotional needs of patients in medical encounters.
Conclusion The findings of this study of emotional labour in the contemporary health services has shown that the emotional labour between nurses, student nurses, lecturers, patients and clinical staff is a vital part of the quality of care that is within the NHS. Emotional labour informs interpersonal relationships and sustains the quality of nurse-patient care. Emotional labour is potentially of great therapeutic value. The findings reported here and elsewhere suggest that emotional labour needs to be made more explicit and codified in order to incorporate it into policy and practice. The potential for exploiting staff and patients’ emotions needs to be countered by education and training, informed by research that makes emotional labour explicit, and which develops methods, systems and techniques as part of an evidence base on emotional labour that informs best practice.
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This research highlights four main issues: (1) Emotional labour is largely implicit in the minutiae of nursing practice as well as missing more broadly in health and social care policy at the national level. There is room for the development of emotional labour in policy, training, education and nurse practice (Smith, 1992, 2005; Cropanzano et al., 2003; Allan and Smith, 2005). (2) Gender and professional differences are present in wider society and reflected in the structures of health services (James, 1989; Smith, 1992; Diefendorff and Richard, 2003; Allan and Barber, 2005). Women and men should not feel discouraged from providing emotional labour and support (both to patients and colleagues). The portrayal of emotion as a ‘‘weakness’’ to the nursing profession needs to be strongly discouraged. If it is not, divisions of labour will be a continuing facet in nursing and in other health professions (i.e. barriers to women going into mental health nursing; limitations to the emotional labour of GPs and doctors, which effect patient consultation, as highlighted in this research). (3) There is the task of grounding the emotional labour of nurses in a formal and systematic way (Smith, 1992, 1999; Smith and Lorentzon, 2005; Allan and Smith, 2005). Clarification is required in nurse training, leadership and education. This will be based on sociological, psychological and psychotherapeutic models of emotional labour. In addition, the potential for abusing staff and patient’s emotions needs to be countered by education and training. (4) More research on emotional labour in nursing and other professions needs to be done. This will make emotional labour explicit and develop the techniques of care available in the health services. There is great scope for evidence-based research leading to informed practice on emotional labour (Smith, 1992, 2005; Hunter and Smith, 2007). Above all, the emotional labour in this study indicates the therapeutic value and importance that nurses attach to their emotional labour. Emotional labour brings added value and sustains a caring environment between nurses and their patients. This gives nurses space to engage with, reflect upon and manage their own and others’ emotions, which greatly improves practice and the standard of patient-centred care.
174 This paper makes the argument that emotional labour is rife with gender divisions that are also present in wider society. A case is therefore made for a feminist perspective on the labour of emotions in the health services that could be accused by detractors as being biased. More robust research is required, as the present study was limited to 16 interviews with nurses (the majority 12 of whom were female) and 2 interviews with GPs. Further study should more fully explicate the gendered nature of emotional labour and the ways in which allegedly ‘patriarchal professions’, such as doctors, are increasingly being called to use emotional labour in their training, consultations and daily practices. Emotional labour continues to be regarded as vital to nurses and an integral part of the culture of care in the health services. Emotional labour techniques are quite vital to care for patients, support reflexive learning and education as well as facilitating best nursing practice. Care and emotional labour, as originally and more recently outlined by Smith (Smith, 1992, 1999, 2005; Allan and Smith, 2005; Hunter and Smith, 2007; Smith and Lorentzon, 2007), remains at the very heart of nursing.
Acknowledgements Special thanks to Pam Smith, Geraldine Cunningham, Steve Smith, Trudi James, Joyce Gray, Mark Steed and all the nurses who took part in the study.
References Aldridge, M., 1994. Unlimited liability? Emotional labour in nursing and social work. Journal of Advanced Nursing 20, 722–728. Allan, H., Barber, D., 2005. Emotional boundary work in advanced fertility nursing roles. Nursing Ethics 12 (4), 391–400. Allan, H., Smith, P., 2005. The introduction of modern matrons and the relevance of emotional labour: developing personal authority in clinical leadership. Journal of Work Emotions and Organisations 1 (1), 20–34. Barnes, E., Griffiths, P., Ord, J., Wells, D. (Eds.), 1998. Face to Face with Distress: The Professional Use of the Self in Psychosocial Care. Butterworth-Heinemann, Oxford. Brotheridge, C.M., Grandey, A.A., 2002. Emotional labor and burnout: comparing two perspectives of ‘people work’. Journal of Vocational Behavior 60, 17–39. Brotheridge, C.M., Lee, R.T., 2002. Testing a conservation of resources model of the dynamics of emotional labor. Journal of Occupational Health Psychology 7, 57–67. Cropanzano, R., Rupp, D.E., Byrne, Z.S., 2003. The relationship of emotional exhaustion to work attitudes, job performance and organizational citizenship behaviors. Journal of Applied Psychology 88 (1), 160–169. Department of Health (DoH), 1999. Making a Difference, London: DoH.
B. Gray Department of Health (DoH), 2004. The NHS Improvement Plan: Putting People at the Heart of Public Services, London: DoH. Department of Health (DoH), 2006. Our Health, Our Care, Our Say: A New Direction for Community Services, London: DoH. Department of Health (DoH), 2008. High Quality Care for All: NHS Next Stage Review Final Report, London: DoH. Diefendorff, J.M., Richard, E.M., 2003. Antecedents and consequences of emotional display rule perceptions. Journal of Applied Psychology 88, 284–294. Garfinkel, H., 1967. Studies in Ethnomethodology. Prentice Hall, Englewood Cliffs, NJ. Glomb, T.M., Kammeyer-Mueller, J., Rotundo, M., 2004. Emotional labor demands and compensating wage differentials. Journal of Applied Psychology 89, 700–714. Handy, J., 1990. Occupational Stress in a Caring Profession. Avebury, Aldershot. Handy, J., 1991. The social context of occupational stress in a caring profession. Social Science and Medicine 32 (7), 819– 830. Hochschild, A., 1983. The Managed Heart. University of California Press, Berkeley. Hunter, B., Smith, P., 2007. Emotional labour – just another buzz word? International Journal of Nursing Studies 44 (6), 859–861. James, N., 1989. Emotional labour: skill and work in the social regulation of feelings. Sociological Review 37 (1), 15–42. James, N., 1993. Divisions of emotional labour: disclosure and cancer. In: Fineman, Stephen (Ed.), Emotion in Organizations. Sage, London. Lawler, J., 1991. Behind the Screens: Nursing, Somology and the Problem of the Body. Churchill Livingstone, London. Mackintosh, C., 1998. Reflection: a flawed strategy for the nursing profession. Nurse Education Today 18, 553– 557. Oakley, A., 1974. Housewife. Penguin, Middlesex. Oakley, A., 1981. Interviewing women: a contradiction in terms. In: Roberts, Helen (Ed.), Doing Feminist Research. Routledge and Kegan Paul, London. Persaud, R., 2004. Faking it: the emotional labour of medicine. British Medical Journal 329, 87. Saks, K., 1990. Does it pay to care? In: Abel, E., Nelson, M. (Eds.), Circles of Care: Work and Identity in Women’s Lives. SUNY Press, New York, pp. 111–136. Savage, J., 1995. Nursing Intimacy: An Ethnographic Approach to Nurse–Patient Interaction. Scutari Press, London. Smith, P., 1992. The Emotional Labour of Nursing. Macmillan, London. Smith, P., 1999. Emotional labour and the politics of emotions and logging emotions: a logbook of personal reflections. Soundings, 11. Smith, P., 2005. Participatory evaluation: navigating the emotions of partnerships. Journal of Social Work Practice 19 (2), 195–209. Smith, P., Barnes, S., Jennings, P., 1998. The secret ingredient. The Nursing Times 94 (6), 32. Smith, P., Lorentzon, M., 2005. Is emotional labour ethical? Nursing Ethics 12 (6), 638–642. Smith, P., Lorentzon, M., 2007. The emotional labour of nursing. In: Spouse, J., Cox, C., Cook, M. (Eds.), Common Foundation Studies in Nursing, fourth ed. Elsevier, Edinburgh. Staden, H., 1998. Alertness to the needs of others: a study of the emotional labour of caring. Journal of Advanced Nursing 27, 147–156.
The emotional labour of nursing – Defining and managing emotions in nursing work Totterdell, P., Holman, D., 2003. Emotional regulation in call centres: testing a model of emotional labour. Journal of Occupational Health Psychology 8, 55–73. UKCC, 1999a. Fitness for Practice, London: UKCC. UKCC, 1999b. Nursing Competencies, a Circular of the UKCC (ncomp), London: UKCC.
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Williams, S., 1999. Student carers: learning to manage emotions. Soundings 11, 180–186. Zapf, D., Holz, M., 2006. On the positive and negative effects of emotion work. European Journal of Work and Organizational Psychology 15, 1–28.
Available online at www.sciencedirect.com
Nurse Education Today www.elsevier.com/nedt
The emotional labour of nursing – Defining and managing emotions in nursing work Benjamin Gray
*
6B Park Road, Wivenhoe, Essex CO7 9NB, United Kingdom Accepted 6 August 2008
KEYWORDS
Summary Emotions in health organisations tend to remain tacit and in need of clarification. Often, emotions are made invisible in nursing and reduced to part and parcel of ‘women’s work’ in the domestic sphere. Smith (1992) applied the notion of emotional labour to the study of student nursing, concluding that further research was required. This means investigating what is often seen as a tacit and uncodified skill. A follow-up qualitative study was conducted over a period of twelve months to re-examine the role of the emotional labour of nursing. Data were collected primarily from 16 in-depth and semi-structured interviews with nurses. Key themes elicited at interviews touch upon diverse topics in the emotional labour of nursing. In particular, this article will address nurse definitions of emotional labour; the routine aspects of emotional labour in nursing; traditional and modern images of nursing; and gender and professional barriers that involve emotional labour in health work. This is important in improving nurse training and best practice; investigating clinical settings of nurses’ emotional labour; looking at changing techniques of patient consultation; and beginning to explore the potential therapeutic value of emotional labour. c 2008 Elsevier Ltd. All rights reserved.
Emotional labour; Nursing
Introduction: definitions of emotional labour Hochschild (1983) says that emotional labour involves the induction or suppression of feeling in order to sustain an outward appearance that
* Tel.: +44 01206 823828. E-mail address: [email protected]
produces in others a sense of being cared for in a convivial safe place. Emotional labour is particularly typified by three characteristics: face-to-face or voice contact with the public; it requires the worker to produce an emotional state in another; it allows the employer through training and supervision to regulate a degree of control over the emotional activities of workers (Hochschild, 1983; Smith, 1992: 7; Smith and Lorentzon, 2007). The term ‘emotional labour’ highlights the similarities as well as differences of
0260-6917/$ - see front matter c 2008 Elsevier Ltd. All rights reserved. doi:10.1016/j.nedt.2008.08.003
The emotional labour of nursing – Defining and managing emotions in nursing work emotional and physical labour. Emotional labour requires an individualized but trained response that assists in the management of patients’ emotions in the everyday working life of health organisations (James, 1993, pp. 95–96; Allan and Smith, 2005; Smith and Lorentzon, 2007). Emotional labour has traditionally been identified with women’s work and the role of the mother in the family. This is especially significant given that images of nursing still reverberate with that of the caring female, particularly with the prototype of Florence Nightingale (Smith, 1992). The portrayal of emotional care as an entirely natural activity is certainly related to the devaluation of emotional labour in cultural, gender and economic terms (Oakley, 1974; Totterdell and Holman, 2003; Glomb et al., 2004; Persaud, 2004). Although there is a growing shift towards the psychological and social aspects of patient care (Brotheridge and Lee, 2002; Diefendorff and Richard, 2003), an important gap in understanding is the centrality and therapeutic value of emotional labour in the lives and well-being of patients. The task of looking at emotional labour in the health setting involves the assessment of the strategies of emotional regulation that are available to health professionals. This includes the analysis of how nurses manage their own and the patient’s emotions and how nurses come to terms with the difficult processes that are often an unavoidable part of patient care. Such research will have to explicitly deal with uncomfortable and sometimes conflicting emotions that nurses, health professionals and patients have to face. The therapeutic potential of nurses’ interpersonal involvement with patients is certainly a central feature in what is widely known as the ‘new nursing’. Many say that the ‘new nursing’, if properly overseen, will generate positive outcomes for staff and patients (Staden, 1998; Allan and Barber, 2005; Hunter and Smith, 2007). Critics suggest that the ‘new nursing’ may be flawed in some respects and may place too many demands on the nursing role (Aldridge, 1994; Mackintosh, 1998; Brotheridge and Grandey, 2002). To be sure, the ‘new nursing’ still remains a bone of interprofessional contention and therefore a central point of review in the future. It is part of the task of the present study to begin such a review, relating the ‘new nursing’ to how nurses deal with emotions and how emotional labour is shaped by seniors and colleagues (Smith, 1992; Barnes et al., 1998; Williams, 1999; Allan and Smith, 2005). If, as Staden (1998, p. 154) says, ‘‘a language to communicate care work does not exist’’, then research must investigate the ways that emotions
169
are dealt with by nurses so as to make emotional labour explicit rather than tacit in nursing practices. This will create room to cope more adequately with the emotional pressures and strategies that are used in caring for patients. From an evidence-base of research, the contribution of emotional labour to nursing practice, training and health policy is clearer. The contribution of emotional labour in sustaining high quality standards of patient care and patient-centred medicine is also made more visible. This means that recommendations for research and development can be made in light of important initiatives and guidelines for improvement in nursing (DoH, 1999, 2004, 2006, 2008; UKCC, 1999a, 1999b).
Methods The qualitative data of the study were collected from a variety of sources, primarily from sixteen in-depth and semi-structured interviews with nurses. Interviews with two GPs were conducted to allow some degree of interprofessional comparison. Interviews lasted between 45–90 min. Meetings with nurses, nurse managers and lecturers at several research seminar groups were also held. There were also research meetings with staff, mentors, student nurses, administration, management, the Student Council for Nursing and local nurse representatives. The researcher also attended during ten student nurse classes on the Common Foundation Programme, meaning that there was some amount of participant and non-participant observation. All of these methods assisted in the investigation of aspects of nurses’ emotional labour and helped to gain a reflective and participatory focus upon which to begin to explore the emotional labour of nursing. Nurses were recruited to the study via the researcher’s attendance at several pre- and post-registration classes held at a local East London hospital where the research was based and conducted. The majority of participants were female (12 of a total of 16) and ethnically quite diverse (7 described themselves as White, 6 as Black and 3 Asian). 10 of the student nurses were under 23 and there were 6 qualified nurses in the age range of 30–50 working in a variety of clinical settings such as primary care, children’s oncology and mental health. The study draws from the traditions of empirical qualitative data collection and ethnography, which looks at how people make sense of the world around them, their experiences of social relationships and other people (Garfinkel, 1967).
170 Ethnography focuses on participants’ meanings (or ‘‘members’ meanings’’) and perspectives in order to better understand social and emotional relationships. Feminist studies in health were also important (Oakley, 1974, 1981; James, 1989; Smith, 1992) and especially relevant given that on average 84% of nurses in the local trusts where the research took place were women. The research was subject to the ethical review and assent of the University’s and Healthcare Trusts’ Ethics Committees.
B. Gray was a surprising frankness on emotions and emotional labour that struck the researcher. This keenness to discuss emotional labour was explicable by many nurses’ views that they had to be ‘‘tuned in’’ to their own and perhaps more importantly the patient’s emotions. ‘‘Talking about emotions’’, as one nurse said, ‘‘is a key part of the job that helps you to understand what to do’’.
The emotional routine of nursing
Findings Key themes elicited at interviews touch upon diverse topics involving the emotional labour of nursing. This article will address nurse definitions of emotional labour; the routine aspects of emotional labour in nursing; traditional and modern images of nursing; and gender and professional barriers that involve emotional labour in health work.
Emotional labour and the nurse Nurse definitions of emotional labour Several nurse respondents echoed Hochschild’s (1983) definition and said that emotional labour was ‘‘continuous contact’’, ‘‘feeling like you’re on-call twenty four hours a day and always available to the public’’ and ‘‘giving the patient the feeling of being safe and warm’’. All of the nurses identified emotional labour as a chief part of the nurse’s role in making patient’s feel ‘‘safe’’, ‘‘comfortable’’ and ‘‘at home’’. As a student nurse said: I feel that emotional labour is the way that nurses look after people so they feel comfortable and their relatives feel that they are safe... A part of nursing is to show you care for them, even if you’re having a terrible day and are fed up yourself and with everyone else. You have to give them that extra support they need... Clinical and emotional skills come with the experiences of the job and you have to get in contact with your emotions and how the patient feels. Against some of the more critical literature on emotional labour in nursing, none of the nurse respondents discounted emotional labour from the work that they did in clinical and non-clinical settings (Aldridge, 1994; Mackintosh, 1998; Zapf and Holz, 2006; Hunter and Smith, 2007). There
As a nurse said at interview: It’s just sitting with the patient and feeling that there’s a link. I’ll just sit on the corner of their bed and take their hand so they feel a little better... I try to do that each day that I’m on duty with the less independent patients... Nurses sometimes don’t see how important it is just to show you care. I make the patients comfortable and part of the ward. It helps with the running of the ward and everyone getting to know each other... It’s not something that everyone can immediately see, so a lot of the feelings and work you do with the patient just goes unnoticed. You can’t put feelings of intimacy in the patient’s notes or record. I don’t think that’s possible. You can communicate with the patient just by looking at them or taking their hand. Just showing that you’re attached and that you care. The patient will feel better about talking about their worries. They won’t be so afraid if they need to ask for help or talk things through with you. Emotional labour was reported as making nurse and patient contact easier and ‘‘moving things along’’. All the nurses interviewed said that emotional labour made working with the patient much smoother and helped in ‘‘oiling the wheels’’ of nursing work (Saks, 1990). In the above extract, the social and psychological aspects of emotional labour work as almost invisible bonds that the nurse cultivates with the patient. Intimacy and more informal relations are said to help in the running of daily life on the ward (Savage, 1995; Smith et al., 1998; Allan and Barber, 2005). The emotional labour of the nurse is reported to help the patient to manage disclosures of a sensitive and emotional nature. This could certainly be suggested to increase information sharing as well as opening up more democratic partnerships by working with patients and their families, for example in patient-centred practice and the production of holistic care plans (James, 1989, 1993; Smith and Lorentzon, 2005, 2007).
The emotional labour of nursing – Defining and managing emotions in nursing work
Images of nursing Patient expectations were thought by nurse respondents to be shaped by conventional images of nursing. Student nurses felt that they were obliged to put emotions into nursing work because nursing was portrayed as the work of an ‘‘angel’’, ‘‘Florence Nightingale’’ and part of the domestic work of ‘‘mothering the patient until they feel better’’. Certainly, the images associated with nurses’ emotional labour are predominantly female (James, 1989; Smith, 1992; Cropanzano et al., 2003; Zapf and Holz, 2006). As a first year student nurse said: My mother is a nurse... You have a very close involvement with patients... You’ve got to clean, bathe and wash patients like your own children. You have to talk to them, listen to their troubles and worries like your mothering your own kids. Traditional images of nursing were seen as twoedged, particularly by student nurses. On the one hand, the image of the nurse as a natural carer was seen to ‘‘put patients at ease’’ with a familiar ‘‘mother figure’’. Some student nurses linked the nursing of patients to a mother nursing her child. The image of nurses as natural carers was said to be an automatic help in ‘‘breaking down emotional barriers’’ between nurse and patient and assist in establishing ‘‘more informal’’ relations necessary to nursing. On the other hand, many thought that the prototypes of the natural carer and Florence Nightingale made the establishment of nursing as a profession more difficult. In two separate classroom discussions with student nurses, images of nurses as an ‘‘angel’’ or a ‘‘good little woman’’ were vehemently rejected as ‘‘sexist’’ (Smith, 1992; Diefendorff and Richard, 2003). Almost all in the classroom discussions agreed that stereotypical images of nursing devalued emotional labour and the experiences that nurses have to accumulate throughout a career in nursing. Gender issues and barriers to emotional labour were certainly chief among the minds of these student nurses in classroom debates. The gender stereotype of the female carer, especially the mother figure, touches on personal and public perceptions of nursing care. Perceptions of the female carer are present in society and reproduced in the personal views of student nurses. The gender stereotype of nursing is certainly double-edged and creates a tension in the views of student nurses. The female stereotype is thought by student nurses as useful in making patients feel
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at ease, as well as simultaneously being thought as devaluing to nursing as a profession. Williams (1999) as well as Allan and Smith (2005) say that there are conscious and unconscious connections made by students about the activities associated with nursing. With guidance on selfawareness and reflection, Williams suggests that teachers will be able to assist student nurses in making connections between past and present events. In other words, reflection on the student nurse’s past and family role models will help in making present relationships with peers, patients and seniors more explicit. The emotional labour connected to these groups will also be rendered visible and better appreciated by reflection and discussion with the teacher.
Barriers to emotional labour Stereotypical images of nursing, which portray nurses as ‘‘angels’’ and natural care givers, touch on the nature/nurture debate and form gender inequalities in the health services. Stereotypical images of nursing were noted by interviewees to present barriers to emotional labour in health, in so far as the emotional labour of nurses was not recognised as a professional occupation and was instead depreciated as part of ‘‘women’s work’’. All the nurses interviewed had at one time or other experienced barriers to emotional labour that are embedded in the gender inequalities of wider society and largely reflected in health services (James, 1989; Lawler, 1991; Allan and Barber, 2005). Peculiarly, both older nurses and recently enrolled student nurses agreed that emotions were seen as a ‘‘weakness’’ by other staff, senior nurses and doctors. Certainly, there were gender and professional barriers as regarded the recognition of emotional labour. According to one student nurse: Some people see general nursing as being for women and women’s work. That’s why a lot of men go into mental health... It’s very hard to show that you care for a patient sometimes as you’re told not to get too close to the patient by some of the older staff and doctors on the wards. But that makes it impossible to empathise with the patient and try to feel what they’re feeling... Nurses should feel able to care and to get close with their patients. It comes with the job, really. Perceptions of emotional labour as part and parcel of ‘‘women’s work’’ were said to influence the choice of clinical placement and practice area.
172 Stereotypes of male and female labour in wider society, which regard women as natural care givers and men in more patriarchal roles, were influential in perceptions of appropriate and inappropriate patient contact. It was felt in discussion with classes and during interviews that intimacy was perceived in society and the health services as the role of women. Patient contact and intimacy were said to be more acceptable for women than for men. According to one male student nurse: Patients might feel uncomfortable about a male nurse washing, cleaning and looking after them. Especially a female patient. Care giving, emotional labour and intimacy were seen as the natural roles of women. This perception gave rise to a further perceived barrier, in so far as general nursing was perceived as being exclusively for women and mental health was said to traditionally be exclusively for men. There was heated debate between male and female student nurses in classroom discussions that sometimes became very polemical. There are taboos of closeness and distance (Lawler, 1991; Persaud, 2004; Allan and Barber, 2005) with the patient that are largely tacit in the health services and not evaluated in open discussion. In the above quotation of a student nurse, gender stereotypes and sexual taboos involving close contact and physical intimacy shape appropriate and inappropriate forms of patient care. Gender stereotypes and professional taboos effect the quality of emotional labour and types of consultation that are available to nurses and other health professionals.
Gender stereotypes There were many gender stereotypes that were mentioned by nearly all of the nurses. General nursing was seen as feminine work that involved washing and close physical contact with the patient. Mental health nursing was viewed as being more masculine and the occupation of the majority of male nurses. Female nurses were seen as natural carers and emotional labourers of the patient’s body. Male nurses in mental health sometimes had to deal with ‘‘physical aggression’’, had to be ‘‘physically stronger’’ and remedy disturbances of the patient’s mind. The respondents certainly touched upon gender divisions of body/mind and female/male that have implications for the emotional labour of nursing. As a female student nurse said:
B. Gray I’d like to go into mental health but it’s seen as being work for men, even though it’s been one of the most emotionally hard placements that I’ve done as a student nurse in the last three years. Emotional labour with the body was seen as largely the responsibility of women. In nursing, women were seen to be essential in the duties of cleaning, bathing, maternity and obstetrics. Male nurses were frequently perceived to be an inappropriate presence in these areas. Gender stereotypes also made many male nurses feel uncomfortable with close physical and emotional contact. Mental health was perceived by nearly all respondents as part of male nursing. Women were natural emotional labourers in general nursing, while men contained the emotional disturbances and physical aggression of mental health patients. Gender barriers presented problems in nurses’ specialism, in so far as stereotypes of male and female nurses related to the clinical practice areas. Classroom debate said that male nurses in perceived female clinical settings (general nursing, obstetrics and midwifery) could be labelled as ‘‘gay’’ (see Lawler, 1991, p. 213; Allan and Barber, 2005). Female nurses in perceived male clinical settings (mental health) were said to be physically and sexually at risk from aggressive mental health patients. Male nurses would have to fulfil a patriarchal role and ‘‘look after’’ female nurses in the mental health setting (Handy, 1990, 1991).
Professional differences There were also interprofessional barriers to emotional labour. Some of the nurses had very strong opinions regarding the poor quality of interpersonal contact that doctors provided to their patients. This was more than what one participant termed ‘‘doctor bashing’’ and interprofessional rivalry, in so far as gender divisions between the emotional labour of nurses and doctors emerged during interviews. As one nurse working in primary care said: I think that doctors are trained early on that they’re not supposed to talk about their feelings with staff and patients... It’s a much more private profession than nursing and doctors are much much less accessible to patients. Feelings are put to one side for the ‘real work’ of medicine. It’s just diagnosis and medical cure, which doesn’t stand up to scrutiny, really, as it isn’t possible to heal with some cases like terminal patients. There’s an unwritten rule that nurses
The emotional labour of nursing – Defining and managing emotions in nursing work care for patients and that we’re the ones responsible for the patient’s feelings while they’re here. It’s left up to us, really. Doctors are detached from that sort of thing and leave nurses to pick up the emotional pieces. This nurse’s view was largely confirmed by the GP who ran the practice: Feelings can get in the way if you’re trying to make a diagnosis of a patient. You’ve got to try and remain objective. It might be an embarrassing illness or personal examination of some kind. It’s better to get on with the medicine and let the nurses deal with the emotions... My practice works as a team of doctors and nursing staff much like a family. All I can really do is patch people up physically and send them home. Divisions of emotional labour certainly influence the perceptions of the emotional work that may be carried out by nurses, doctors and other healthcare staff. The model of the primary healthcare team as a functioning ‘‘family’’ is employed in the above excerpt. The image of a ‘‘family’’ is used to reinforce the gender stereotype of the subjective female (nurse) and objective male (doctor) that is widespread in society. To be sure, there are limitations placed on both doctors and nurses in terms of how these professions are supposed to labour emotionally. This has a direct effect on how the professions consult patients and attend to the emotional needs of patients in medical encounters.
Conclusion The findings of this study of emotional labour in the contemporary health services has shown that the emotional labour between nurses, student nurses, lecturers, patients and clinical staff is a vital part of the quality of care that is within the NHS. Emotional labour informs interpersonal relationships and sustains the quality of nurse-patient care. Emotional labour is potentially of great therapeutic value. The findings reported here and elsewhere suggest that emotional labour needs to be made more explicit and codified in order to incorporate it into policy and practice. The potential for exploiting staff and patients’ emotions needs to be countered by education and training, informed by research that makes emotional labour explicit, and which develops methods, systems and techniques as part of an evidence base on emotional labour that informs best practice.
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This research highlights four main issues: (1) Emotional labour is largely implicit in the minutiae of nursing practice as well as missing more broadly in health and social care policy at the national level. There is room for the development of emotional labour in policy, training, education and nurse practice (Smith, 1992, 2005; Cropanzano et al., 2003; Allan and Smith, 2005). (2) Gender and professional differences are present in wider society and reflected in the structures of health services (James, 1989; Smith, 1992; Diefendorff and Richard, 2003; Allan and Barber, 2005). Women and men should not feel discouraged from providing emotional labour and support (both to patients and colleagues). The portrayal of emotion as a ‘‘weakness’’ to the nursing profession needs to be strongly discouraged. If it is not, divisions of labour will be a continuing facet in nursing and in other health professions (i.e. barriers to women going into mental health nursing; limitations to the emotional labour of GPs and doctors, which effect patient consultation, as highlighted in this research). (3) There is the task of grounding the emotional labour of nurses in a formal and systematic way (Smith, 1992, 1999; Smith and Lorentzon, 2005; Allan and Smith, 2005). Clarification is required in nurse training, leadership and education. This will be based on sociological, psychological and psychotherapeutic models of emotional labour. In addition, the potential for abusing staff and patient’s emotions needs to be countered by education and training. (4) More research on emotional labour in nursing and other professions needs to be done. This will make emotional labour explicit and develop the techniques of care available in the health services. There is great scope for evidence-based research leading to informed practice on emotional labour (Smith, 1992, 2005; Hunter and Smith, 2007). Above all, the emotional labour in this study indicates the therapeutic value and importance that nurses attach to their emotional labour. Emotional labour brings added value and sustains a caring environment between nurses and their patients. This gives nurses space to engage with, reflect upon and manage their own and others’ emotions, which greatly improves practice and the standard of patient-centred care.
174 This paper makes the argument that emotional labour is rife with gender divisions that are also present in wider society. A case is therefore made for a feminist perspective on the labour of emotions in the health services that could be accused by detractors as being biased. More robust research is required, as the present study was limited to 16 interviews with nurses (the majority 12 of whom were female) and 2 interviews with GPs. Further study should more fully explicate the gendered nature of emotional labour and the ways in which allegedly ‘patriarchal professions’, such as doctors, are increasingly being called to use emotional labour in their training, consultations and daily practices. Emotional labour continues to be regarded as vital to nurses and an integral part of the culture of care in the health services. Emotional labour techniques are quite vital to care for patients, support reflexive learning and education as well as facilitating best nursing practice. Care and emotional labour, as originally and more recently outlined by Smith (Smith, 1992, 1999, 2005; Allan and Smith, 2005; Hunter and Smith, 2007; Smith and Lorentzon, 2007), remains at the very heart of nursing.
Acknowledgements Special thanks to Pam Smith, Geraldine Cunningham, Steve Smith, Trudi James, Joyce Gray, Mark Steed and all the nurses who took part in the study.
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