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Impressions and Comments Arising from the Meeting on Emotional Labour: Ritsumeikan University, July 31st, 2008

　SMITH Pam & COWIE Helen　March 19, 2009
ABE Akira & ARIMA Hitoshi (eds.)　Care and Emotional Labor
Report Issued by Research Center Ars Vivendi of Ritsumeikan University, Vol.8, 2009. 247p.
ISSN 1882-6539　pp.128-140

Japanese Page

　
Abstract
　　The purpose of the meeting was to review the concept of emotional labour both from a theoretical perspective and as a conceptual device for examining the role of emotions in care and nursing. The meeting also explored a range of perspectives on the concept of emotional labour, each of which identified different aspects that influence the extent to which emotions are permitted, encouraged or deemed appropriate to be expressed in healthcare settings. Participants also looked at the theoretical links between the emotional labour literature and the workplace bullying literature with specific reference to the emotional health and wellbeing of staff and service users, and to the quality of the care being provided. The seminar also discussed the role of effective leadership, team working and the management of change in creating a workplace culture which facilitates effective management of emotions and at the same time promotes high standards of quality care.

Introduction
　　Hochschild defines emotional labour as: the induction or suppression of feeling in order to sustain an outward appearance that produces in others a sense of being cared for in a convivial safe place. She describes jobs with high emotional labour components as sharing three characteristics:

1. Face to face or voice contact with the public.
2. They require the worker to produce an emotional state in another e.g. gratitude, fear.
3. They allow the employer through training and supervision to exercise a degree of control over the emotional activities of their employees.

　　Hochschild suggests there are two kinds of emotional labour achieved through surface and deep acting. In surface acting we consciously change our outer appearance in order to make our inner feelings correspond to how we appear. Deep acting requires us to change our inner feelings by a variety of methods so that they become our authentic feelings which we freely present to the outside world. In surface acting we may experience feelings of dissonance but this is not the case with deep acting because of the degree of authenticity achieved. A critical issue explored in the meeting concerned the extent to which professionals should be trained to manage negative feelings in ways that lead to good quality of care while at the same time preserving the authenticity of their experience.

Theoretical perspectives
　　Recent theoretical developments of emotional labour over the last decade (Bolton 2000, 2001, Bolton and Boyd, 2003) propose a typology of workplace emotions and a range of motivational factors at individual and organisational level. In the context of her study of gynaecology nurses, Bolton (2000) argues that emotional labour is a gift given for ‘philanthropic’ reasons. For example, the gynaecology nurses described how the therapeutic use of humour gave the patients the opportunity to have a laugh in an ‘emotionful place’ that was a ‘woman’s world’. This interpretation is in line with Smith’s (1992) view that emotion management is shaped by clinical context. A ward sister confirmed: ‘The essential basis of nursing is caring. You can’t be a nurse if you don’t care’ (Bolton 2000: 583). Bolton adds a helpful dimension by demonstrating how there may be an interaction between the different levels of emotion management: as individuals they were prepared to give patients extra time if they required it but at the same time worked hard to enact professional feeling rules to present the image of a professional carer.
　　Theodosius (2006, 2008) claims that the concept of emotion management, although innovative in its time, ignored the unconscious processes taking place during patient-nurse interaction. She also argues that working with emotions is integral to the way in which nurses construct their personal identity and proposes that unconscious process may underlie their decision to become nurses in the first place (Theodosius 2006: 899). Theodosius’s (2006) methodology attempted to recover these unconscious emotions from patients, nurses and other health care professionals by using diaries, interviews and participant observation. Theodosius was concerned that the early emotional labour research of nursing (James 1992, Smith 1992), rather than exposing emotion work and making it visible, had marginalised it and driven it underground. On the contrary, it could be argued that at the time when the topic was first being researched and written about, emotions and nursing were highlighted to reveal a hidden world of nursing and learning to be a nurse. Subsequently emotional labour as a concept has become ‘normalised’ and part of the everyday language of nursing and care work being incorporated into the current discourse of compassion and dignity (Smith 2008) 　
　　Theodosius (2008) has extended the analysis of emotional labour to examine the nature of emotions that nurses feel and how they form a part of their social identity which goes beyond the presentational symbolic forms expressed through the emotion management framework first inspired by Hochschild (1983). She also suggests ways that nurses can be supported to learn to incorporate and manage complex, messy emotions as part of who they are in terms of both their personal and professional self and draws on Acher’s work on personal and social identity mediated through reflexive ‘inner dialoue’ to develop these theoretical perspectives (Archer 2000, cited by Theodosius, 2008: 91). Theodosius demonstrates her approach through a series of powerful vignettes in which she sums up that ‘therapeutic’ emotional labour (which she distinguishes from ‘instrumental’ emotional labour) ‘is still an important component to nursing care, that is still central to the nursing identity and that society in the form of those nurses care for - still needs and believes in it’ (Theodosius 2008: 172). In the vignettes Theodosius deals with and describes complex and challenging situations where nurses are working at the extremes: from loving care to complaints; from trust and reciprocity with patients to feeling to be working at ‘half measures’ and being bullied by colleagues. Theodosius’ in depth analysis can best be appreciated in reading it in its entirety but in summing up she highlights the essential nature of two way relationships between nurses, patients and their carers which contribute to the emotional labour process.

Organisational perspective
　　In the context of the management of emotions in the organisation, some emotional display rules are taught to employees through induction, training and supervision. Others, however, are implicitly learned through a process of observation of organisational rituals and processes. Where the situation is ambiguous, employees make their own judgements of what is allowed with the result that some rules are adopted while others are ignored. In health and social care settings, the negative consequences of inappropriate emotional expression - whether towards staff or service users - can have a serious impact on the quality of care. In the care home or hospital, where inappropriate emotions have become the norm, nurses are less able to give of themselves emotionally to the people in their care who are, as a result, more likely to experience parallel emotions such as fear, anxiety and helplessness.
　　This is where the literature on workplace bullying is of relevance to the emotional labour literature. Recent studies of violence in the United Kingdom (UK) National Health Service (NHS) have found significant levels of colleague on colleague bullying (e.g. Quine, 1999) but also of aggression on the part of patients towards healthcare professionals. The latest report on staff in the UK NHS by the Healthcare Commission (Healthcare Commission 2008) found that 23% of NHS staff reported being bullied by patients, 18% by patients’ relatives, 8% by managers and 13% by colleagues. Paradoxically, although the majority of staff knew how to report such episodes, a substantial minority never did so. This finding confirmed Einarsen’s (2004) proposal that the culture of the workplace acts as a form of filter through which a range of behaviours come to be accepted or even tolerated, despite the fact that most employees experience a high degree of role conflict when they observe aggressive behaviour and report a poor quality of environment in these circumstances. In the specific context of care for older people who are particularly vulnerable, the consequences of inaction can be extreme, since many people become desensitised to others’ suffering the longer they are exposed to situations where intervention does not take place.
　　Braverman (2002) suggests that organisations should manage specific incidents by training their staff to find solutions that respect the emotions of the recipients of care. At a wider policy level, however, the organisation must consider appropriate systemic interventions to take consistent account of the power of emotionally sensitive individuals to use their own and others’ emotional states to prevent problems and find solutions to bullying and abuse. Such policies should emphasise the importance of interpersonal skills, teamwork and leadership in promoting an open culture that counteracts the tendency to scapegoat and blame individuals (for example, the older person with a continence problem) rather than adopt a systemic analysis.

Practitioners’ perspectives
　　Empirical studies undertaken since Hochschild first published her ground breaking study have shown that there is a variation in how different types of emotional labour are valued and recognised within the healthcare workplace. For example the emotional labour of cancer care is dependent upon whether the person with cancer is being actively treated or has reached the palliative care stage (James, 1992, Kelly et al. 2000).
　　An example of the complex interplay of emotions in contexts of patient care is described by Eyers and Adams (2008) in their study of carers and nurses working with older people with dementia. In their study, they document the observation that carers and nurses may need to detach themselves from emotions such as revulsion at unpleasant smells and body fluids in order to survive. Eyers and Adams (2008) refer to ‘emotional labour tools’ which they say workers use when dealing with situations such as toileting, washing and dressing which potentially can be distressing and embarrassing to carer and service user alike. These ‘tools’ such as listening and gentle persuasion are regularly used to preserve the older person’s dignity and privacy. However, they can also be implemented as a means of manipulating an older person to be more ‘co-operative’ within the limited time available to the carer. Where care staff and nurses are not trained and supported to manage emotions in this way, there is clearly potential for vulnerable and challenging service users to be subject to bullying and elder abuse.

Impressions from participation in everyday life in Japan
　　Observations at a Kyoto clinic for the promotion of older people’s continence indicated that the giving of emotional labour was a key part of their philosophy of care. As one professional commented, ‘you need to imagine what it would be like to be that older person as the recipient of your care.’ She added that since attending the authors’ presentation she was now more able to understand the significance of emotions in her work with older people. She gave the example of an older person who might react angrily towards a carer and be perceived as difficult or ‘grumpy’ when in fact the underlying reason was that this person was wearing uncomfortable incontinence pads. In such circumstances, the carer might not be aware of the physical discomfort and shame being experienced unless they had the conceptual emotional labour tools to reflect on their practice.
The observations in the clinic were interesting when comparing the work of Adams and Eyers (2008) who described the experience of carers of older people who may need to detach themselves from emotions such as revulsion at unpleasant smells and body fluids in order to survive. In the clinic to promote continence much effort was taken to deal technically and aesthetically with smells and bodily fluid by offering 400 examples of beautiful designed incontinence pads and pants and state of the art commodes. These technical solutions helped considerably, but, as the leader of the clinic observed, the professional still needed to understand that the patient’s own experiences could not be similarly ‘flushed away’ but rather their feelings needed to be understood.
　　Another impression of significance was the respect and dignity transmitted by the efficient and effective organisation of the railways. On completion of the ticket inspection ticket collectors bowed to their passengers before leaving the carriage. Young women in beautifully designed pink and green uniforms and smart hats walked quietly up and down the carriages collecting passengers’ rubbish into a trolley with pink bin liners. These were just two examples of the impression management and emotional labour of seemingly routine and even ‘dirty’ tasks to make them appear pleasant and pleasing to the public and transmit a feeling of respect.

Reflections
　　A number of conceptual questions remain about the nature of care, each of which is fraught with contrasts and contradictions.
　　Care is a right so can it be professionalised?
　　Is it morally right to control or manage emotions?
　　Who decides what is appropriate and what is permissible?
　　Are emotions controlled by the needs of the organization?
　　Does ‘impression management’ mean that emotions are controlled by society?
　　How do we keep the balance between rationality and emotion?
　　How can we create a culture founded in care, respect and compassion?
　　Can the practice of emotional labour lead to a confusion of identity?
　　Is it labour or is it love?
　　Is it natural or is it a skill?
　　Is it about feelings or tasks?
　　Does it come from the heart, the head or the hand?
　　Is it guided by mind or body?
　　Or should caring be seen as an integrated whole?
　　During a recent interview, a nurse leader was clear that the integration of care was not helped by the ‘check box’ culture with its emphasis on clinical competencies in which ‘you get to the point that you only measure and have interest in the things you can tick, then what happens to qualities such as judgement and integrity? You can’t tick either of those because they’d take some maturing and it’s about how the practitioner feels about what they are doing and have the opportunity to reflect on their practice’.
　　It is perhaps because of the heightening awareness of the need for nurses to be able to be given emotional spaces to think and feel about their practice that there have been some criticisms of Hochschild’s work which have described emotional labour as a ‘technical fix’, perpetuating the body-mind dichotomy and potentially separating out emotions from the technical and physical aspects of care. Pat Benner, an American Professor of Nurs-ing, applies a philosophical approach to the concept of care, which she says transcends the body-mind split and enables connection and concern between nurse and patient. Emotions are seen as the key to this connection because ‘they allow the person to be engaged or involved in the situation .... The alienated, detached view of emotions, as unruly bodily res-ponses that must be controlled actually cuts the person off from being involved in the situation in a complete way’ (Benner and Wrubel, 1989). Views such as these represent a trend over the past decade amongst nurses in the USA and Europe to move to a more holistic approach to care and away from ‘a nation’s blind embrace of high tech medicine’ (Gordon, 1988).
　　This trend has continued over the intervening decades with increasing attention to the role of emotions in nursing and caring. Three characteristics of this trend can be noted. The first characteristic illustrated by Theodosius’ work is the role of the unconscious and psychoanalytic and psychodynamic approaches to emotions. Phenomenology and embodiment as characterised by Benner’s work continues to be acknowledged as important for nursing. The symbolic interactionist and Marxist stance of the cognitive approach to emotions characterised by Hochschild’s work has attracted increasing theoretical critiques in particular the risk that emotions become marginalised and normalised and detracts from what is given ‘freely’ as part of who one is and what one is paid to do (McClure and Murphy 2007). The traditional solution reverses the changes that have taken place in women’s entry into the workforce and places them very firmly back in the home, absolving men from any of the responsibility to care. The post modern solution demands the removal of the central image of the caring mother figure, leaving men and women in the workforce and the need for all sectors of society to learn to live without care. Cold modern institutionalises all forms of human care while the warm modern model values care at the individual, family and public level.
Recent empirical work refutes this view as one that potentially encourages nurses and women to give over and above what they are supported to do both personally and professionally. The emotional labour analysis pays attention to the division of labour within the health service and the gendered nature of care. Hochschild’s most recent analysis of the four models of care is important in this respect which she describes along a cultural continuum from ‘traditional’, ‘post modern’, ‘cold modern’ and ‘warm modern’ solutions to the care deficit which at its extreme is to learn to live without care and the need to go beyond the individual to systems and processes in which nurses and others operate (Hochschild 2003).

◆Useful References
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Benner, P., and Wrubel, R., 1989. The Primacy of Caring: Stress and Coping in Health and Illness. Addison-Wesley, Menlo Park CA.
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◆Role of the funding source
Financial support was provided by the DAIWA Anglo-Japanese Foundation and by Hiroshima University and the University of Surrey during Helen Cowie’s one year visiting professorship at Hiroshima University and Pam Smith’s two week research visit to Japan.
This gave the authors time to present their ideas, discuss them with colleagues in health and education from UK and Japan, and prepare the manuscript for submission to IJNS.

◆Contributors
HC and PS shared equally in the writing of this article.

◆Conflict of Interest
None

◆Acknowledgements
Dr. Yuichi Toda, Osaka University of Education and Dr. Haruo Sakiyama, Ritsumeikan University and their colleagues for their helpful commentaries on the ideas presented in this paper.

□SMITH Pam & COWIE Helen March 19, 2009“Impressions and Comments Arising from the Meeting on Emotional Labour: Ritsumeikan University, July 31st, 2008”　ABE Akira & ARIMA Hitoshi (eds.) Care and Emotional Labor, Report Issued by Research Center Ars Vivendi of Ritsumeikan University, Vol.8, 2009. 247p. ISSN 1882-6539，pp.128-140.

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