emotional labour and the clinical settings of nursing care: the perspectives of nurses in east...

Nurse Education in Practice (2009) 9, 253–261

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Educationin Practice

Emotional labour and the clinical settings ofnursing care: The perspectives of nursesin East London

Benjamin Gray *, Pam Smith

CCCU, 6B Park Road, Wivenhoe, Essex CO7 9NB, UKCentre for Research in Nursing and Midwifery Education, University of Surrey, Surrey, UK

Accepted 24 August 2008

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KEYWORDSEmotional labour;Nursing;Clinical settings

71-5953/$ - see front mattei:10.1016/j.nepr.2008.08.00

* Corresponding author. Tel.E-mail address: btgray@ho

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: +44 12tmail.co

Summary Emotions in health organisations tend to remain tacit and in need ofclarification. Often, emotions are made invisible in nursing and reduced to partand parcel of ‘women’s work’ in the domestic sphere. Smith (Smith, P. 1992. TheEmotional Labour of Nursing, Macmillan, London) applied the notion of emotionallabour to the study of student nursing, concluding that further research wasrequired. 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 emotional labour and in particular the ways in which emotionallabour was orientated to different clinical settings. Data were collected from 16 in-depth and semi-structured interviews with nurses based in East London (UnitedKingdom). Findings illustrate emotional labour in three different settings (primarycare, mental health and children’s oncology). Findings show the different ways inwhich emotional labour is used and reflected upon by nurses in these three clinicalareas. This is important in improving nurse training and best practice as well as help-ful in offering an initial synopsis of the culture of care in nursing; investigating sev-eral clinical settings of nurses’ emotional labour; looking at changing techniques ofpatient consultation; and beginning to explore the potential therapeutic value ofemotional labour.

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Introduction: definitions of emotionallabour

Hochschild (1983) says that emotional labour in-volves the induction or suppression of feeling in or-der to sustain an outward appearance that

rved.

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254 B. Gray, P. Smith

produces in others a sense of being cared for in aconvivial safe place (Smith and Gray, 2000, 2001).

Emotional labour is particularly typified by threecharacteristics: face-to-face or voice contact withthe public; it requires the worker to produce anemotional state in another; it allows the employerthrough training and supervision to regulate a de-gree of control over the emotional activities ofworkers (Hochschild, 1983; Smith, 1992, p. 7;Smith and Lorentzon, 2007). The term ‘emotionallabour’ highlights the similarities as well as differ-ences of emotional and physical labour. Emotionallabour requires an individualized but trained re-sponse that assists in the management of patients’emotions in the everyday working life of healthorganisations (James, 1993, pp. 95–96; Smith andGray 2000, 2001; Smith and Lorentzon, 2007; Allanand Smith, 2005).

Emotional labour has traditionally been identi-fied with women’s work and the role of the motherin the family. This is especially significant giventhat images of nursing still reverberate with thatof the caring female, particularly with the proto-type of Florence Nightingale (Smith, 1992). Theportrayal of emotional care as an entirely naturalactivity is certainly related to the devaluation ofemotional labour in cultural, gender and economicterms (Persaud, 2004; Oakley, 1974; Totterdell andHolman, 2003; Glomb et al., 2004).

Although there is a growing shift towards thepsychological and social aspects of patient care(Brotheridge and Lee, 2002; Diefendorff and Rich-ard, 2003), an important gap in understanding isthe centrality and therapeutic value of emotionallabour in the lives of patients.

The task of looking at emotional labour in thehealth setting involves the assessment of the strat-egies of emotional regulation that are available tohealth professionals. This includes the analysis ofhow nurses manage their own and the patient’semotions and how nurses come to terms with thedifficult processes that are often an unavoidablepart of patient care. Such research will have toexplicitly deal with uncomfortable and sometimesconflicting emotions that nurses, health profession-als and patients have to face.

The therapeutic potential of nurses’ interper-sonal involvement with patients is certainly a cen-tral feature in what is widely known as the ‘newnursing’. Many say that the ‘new nursing’, if prop-erly overseen, will generate positive outcomes forstaff and patients (Hunter and Smith, 2007; Allanand Barber, 2005; Staden, 1998). Critics suggestthat the ‘new nursing’ may be flawed in some re-spects and may place too many demands on thenursing role (Brotheridge and Grandey, 2002; Mack-

intosh, 1998; Aldridge, 1994). Certainly, the ‘newnursing’ still remains a bone of interprofessionalcontention and therefore a central point of reviewin the future. It is part of the task of the presentstudy to begin such a review, relating the ‘newnursing’ to how nurses deal with emotions andhow emotional labour is shaped by seniors and col-leagues (Allan and Smith, 2005; Williams, 1999;Smith, 1992; Barnes et al., 1998).

If, as Staden (1998, p. 154) says, ‘‘a language tocommunicate care work does not exist’’, then re-search must investigate the ways that emotionsare dealt with in a variety of clinical and non-clin-ical settings. By making emotional labour explicitrather than tacit in nursing practices, there is roomto cope more adequately with the emotional pres-sures, stresses and strategies involved in caring forpatients.

From an evidence-base of research, the contri-bution of emotional labour to nursing practice,training and health policy is clearer. This meansthat recommendations for research and develop-ment can be made in light of important initiativesand guidelines for improvement in nursing (UKCC,1999a; UKCC, 1999b; DoH, 1999).

The main purpose of the study was to investigatethe tacit and uncodified emotions of nurses in sev-eral different clinical settings in order to make theskills, dispositions and aptitudes required for emo-tional labour more explicit and better documentedby empirical and evidence-based research. Emo-tional labour is often ‘swept under the carpet’,associated as a natural facet of nursing or partand parcel of ‘women’s work’. This study aimedto demystify these taken for granted emotions,which will help in documenting the techniques,skills, therapeutic value or otherwise and impor-tance that nurses attach to their emotional labour.Making emotional labour explicit in this way hasramifications for policy, training and nurse practicein different clinical areas as well as perhapsimproving and sustaining standards of patient care.

Methods

The research will present narratives/ stories thatare transcribed from interviews with nurses. Theseare taken from a twelve month pilot investigationconducted in East London in the United Kingdom,in an urban and multi-racial location. Nurse narra-tives involve the clinical settings of:

� Primary care.� Mental health.� Children’s oncology.

Emotional labour and the clinical settings of nursing care: The perspectives of nurses in East London 255

These settings emerged naturally from the databut have a surprising resonance with the clinicalsettings in Smith’s (1992) original study.

The qualitative data of the study were collectedfrom a variety of sources, primarily from sixteenin-depth and semi-structured interviews withnurses. Interviews lasted between 45–90 minutes.Meetings with nurses, nurse managers, directorsand lecturers at several research seminar groupswere also held at the beginning and end of the re-search, in order to present the research, get feed-back on what issues it should examine and also forcomments, ideas and criticisms as regarded theproject’s main findings. There were also researchmeetings with staff, mentors, student nurses,administration, management, the Student Councilfor Nursing and local nurse representatives in orderto have a more holistic and participatory researchapproach and to get a broad spectrum of opinionson the value or otherwise of emotional labour. Allof these methods assisted in the investigation ofaspects of nurses’ emotional labour and helped togain a reflective and participatory focus uponwhich to begin to explore the different clinical set-tings of emotional labour.

Nurses were recruited to the study via the re-searcher’s attendance at several pre- and post-reg-istration classes held at the local East Londonhospital. The researcher particularly attendedclasses on ‘images of nursing’ and those that taughtaspects of sociology and psychology. It was thoughtthat nurses attending these classes would be espe-cially interested in the social, psychological andemotional aspects of nursing and thus want to takepart in the project. The researcher would presentthe project on emotional labour at the start ofthe class and then sit-in for the duration. Nursesand student nurses were then free to approachthe researcher after the class (either in the semi-nar room or more often than not in the informalenvironment of the canteen).

The majority of participants were female (12 ofa total of 16) and ethnically quite diverse (sevendescribed themselves as White, six as Black andthree Asian).

The study draws from the traditions of empiricalqualitative data collection and ethnography, whichlooks at how people make sense of the worldaround them, their experiences of social relation-ships and other people (Garfinkel, 1967). Ethnogra-phy focuses on participants’ meanings (or‘‘members’ meanings’’) and perspectives in orderto better understand social and emotional relation-ships. Feminist studies in health were also impor-tant (Oakley, 1974; Smith, 1992, 1999: James,1989; Oakley, 1981) and especially relevant given

that on average 84% of nurses in the local trustwhere the research took place were women. Afeminist perspective allows what Smith (1999)terms ‘the logging of emotions’ and brings a focusboth on the politics of emotions and on the gen-dered divisions of (emotional) labour in societythat may be unconsciously reproduced in thehealth services.

The purpose of the sixteen in-depth and semi-structured interviews was to discuss the experi-ences of nurses in relation to their feelings andemotional labour and to ask them to reflect upontheir practices and emotions in different clinicalsettings. This allowed the research to address, dis-cuss, reflect upon and so better understand the ta-cit and uncodified emotions often associated withnurses’ practices and emotional labour. Data anal-ysis was conducted by the main researcher and pro-ject leader who would meet regularly to discussaspects of the research on emotional labour andto discuss transcripts of the interviews. Topics,themes and salient issues from the nurse interviewswere identified by reading and re-reading tran-scripts and discussion. Three feedback sessions (fo-cus groups) were held at the local hospital withstudent and registered nurses to discuss prelimin-ary findings and get a participatory focus on mainthemes, what issues were important, what quota-tions to use from interviews in any report or publi-cation and any possible gaps in the research.

The research was subject to the ethical reviewand assent of both the Local Research Ethics Com-mittee and the University’s Research Ethics Com-mittee. In order to ensure informed consent,participants were told about the research, its aimsand what the interviews involved as well as theirrights as research participants to anonymity andconfidentiality. Participants were assured that theywould not be named and that great care would betaken to protect their identity. Because the studyinvolved emotions and discussion of topics of a sen-sitive nature, participants were told that theycould halt interviews at any time and withdraw atany stage of the research. The precise location ofthe study in East London has been omitted for eth-ical reasons and to protect the identities and con-versations of a highly personal and sensitivenature with nurse interviewees.

In addition, an important local issue raised dur-ing conversations and meetings with nurse lectur-ers, managers and directors of nursing involveddifficulties relating to the recruitment and reten-tion of nurses, with reported high levels of staffburnout and high attrition rates with nurses leavingthe profession. This was suggested by lecturers,managers and directors to be partly related to


the emotional pressures and stresses of nursing.The study of emotional labour was therefore con-sidered to be topical, valuable, important and veryrelevant to the local hospital and in the planningand staff recruitment and retention strategies ofthe local trust.

Findings- the clinical settings ofemotional labour: studies of hownurses care

Three clinical settings were mentioned by nurseinterviewees, emerged naturally from the dataand involve different types and orientations ofemotional labour. The three contexts have differ-ent sorts of patients, emotions, nurse narratives,attitudes, dispositions, clinical guidelines andreflection on emotions as well as different waysof managing emotions in patient care. The settingsinvolve different cultures of care and the variedtechniques of emotional labour that were used indifferent situations by nurses.

Primary care, mental health and children’soncology will be briefly surveyed as case examples.The intention is to demonstrate the ways in whichnurses engaged in emotional labour in differentclinical settings. The case examples indicate theusefulness of collecting a rich evidence-base onemotional labour. A concrete evidence-base is par-ticularly necessary given that emotional labour istacit in the nursing profession and needs to bemade more explicit. The contexts of emotional la-bour need to be codified in order to assist nurses intheir day-to-day interactions with patients, rela-tives and other members of staff as well as facili-tating the potential therapeutic value ofemotional labour (Smith, 1992, 2005; Zapf andHolz, 2006).

Primary care

According to one nurse at interview who worked inprimary care as a nurse practitioner:

I have baby clinic once a month at the surgery.All the babies are screaming and screaming, whichisn’t at all good for my head and is, you know,really painful for a four or five hour clinic. The ba-bies are frightened. . . and the mothers are worriedand upset... Sometimes the mothers will scowl atme because I’m hurting their babies. I have to givethe babies their injections. I might even be inter-rupting a feed... All the time I’ve got a headacheand keep things going. I have to keep the babiesand the mothers happy, and have to smile to reas-

sure them and really resist the temptation just toget out of the room.

Several important features of emotional labourcould be suggested as being accomplished by thenurse in this excerpt. These features could be sug-gested to be integral to the management ofemotions:

(1) The nurse was providing emotional labour inso far as she was managing her own and oth-ers’ emotions. Emotional labour makes moth-ers and children feel more comfortable in thebaby clinic.

(2) The nurse was engaged in ‘‘dealing with otherpeoples’ feelings, a core component of whichis the regulation of emotions’’ (James, 1989,p. 15). Appearing caring was a core compo-nent in what Hochschild (1983) terms ‘themanaged heart’. The nurse resists her ownfeeling to ‘‘just to get out’’ of the babyclinic. Instead, surface gestures (such as asmile) were performed in order to ‘‘keepthings going’’ at the clinic (see also Smithet al., 1998, p. 32; Grandey et al., 2005).

(3) In a similar way to Hochschild’s study thatfocused on flight attendants, acting tech-niques were used by the nurse as a strategyfor managing interpersonal relations. Thenurse said she had a personal and work selfthat helped her to orientate herself towardsthe mother and the baby. This was a presen-tation of the nursing self (an image of thenurse as a carer, supporting with a smileand by being there) (see also Smith et al.,1998, p. 32; Grandey et al., 2005; Smith andLorentzon, 2005).

(4) The emotional labour of the nurse helped tosolidify the interpersonal relationship withthe mother. The emotional labour of thenurse worked to create a relatively comfort-able environment for patients and relativesin an emotionally pressured, difficult andstressful situation.

(5) This maintained a functioning work environ-ment and made the baby clinic a consistentatmosphere for those coming into it. Thenurse maintained good relations irrespectiveof her own feelings (see also Smith et al.,1998, p. 32; Allan and Barber, 2005; Smithand Lorentzon, 2005).

Alternatively, on a more critical and cautionarynote as discussed in much research (Aldridge,1994; Smith and Lorentzon, 2005; Larson 2005; Per-saud, 2004; Brotheridge and Grandey, 2002; Hunterand Smith, 2007), it could be argued that the nurse


in the above extract was behaving unethically andwithout authenticity in covering up her ‘true’ emo-tions from her ‘professional’ and ‘work-self’ emo-tions. According to Persaud (2004) the two keytasks required in consultations are to hide negativeemotions and to display positive emotions evenwhen the practitioner feels the opposite. Persaudalso notes that this can cause emotional dissonance(a disparity between genuine and displayed emo-tions) and suggests that many psychologists believethat constantly hiding difficult emotions with col-leagues and patients is stressful enough but if com-bined with forcing positive emotions may pushpractitioners close to burnout. There is also thepossibility that colleagues and patients may seethrough such superficial care.

Mental health

According to a nurse who had over fifteen years ofexperience in mental health:

It’s almost impossible not to take the way youfeel home with you. We do get some chance to talkabout patients at work but I usually end up takingwork home with me and feeling very stressed... Italk things over with my family, minus the details,you know... One of the most emotionally difficultthings about mental health nursing is trying to getto know the patient and feeling that they mightdo something like try and hit you at any moment.

There are two points to draw out in this nurse’saccount. First, stress and ‘‘taking work home’’were seen as a direct result of not enough reflec-tion with colleagues (Cropanzano et al., 2003;Brotheridge and Grandey, 2002). Similar findingswere mentioned in a study of the emotional labourof nurses who worked in orthopaedics (Smith et al.,1998, p. 32). No doubt the nurse’s ‘‘taking workhome’’ with him might cause problems away fromwork with the mental health nurse’s family.

Second, there was the issue of ‘‘trying to get toknow the patient and feeling that they... might tryand hit you at any moment’’. Physical aggression,and labelling difficult patients as ‘mad’ and‘bad’, have certainly been stereotypes of thosewith mental health problems in the health servicesand in public life too.

Patients were divided into ‘‘good’’ and ‘‘bad’’categories by many of the nurses at interviewsand during participant observation in student nurseclasses (Stockwell, 1972). The division of ‘‘good’’and ‘‘bad’’ patients was partly based on the socialcontrol elements of nursing work, with the ‘‘good’’patients being viewed as more compliant thanthose categorised as ‘‘bad’’ (see also Lawler,

1991, p. 147; Zapf and Holz, 2006; Stockwell,1972). For example, a ‘‘bad’’ patient was someonewho had ‘‘brought the illness on themselves andcan’t really be helped’’. Mental health patients,alcoholics, paedophiles and drug users were allseen as ‘‘bad patients’’. Quite patently, dividingpatients in such a way places severe limitationson interpersonal contact and makes all sorts of de-mands on nurses. The therapeutic ideal of equalityin patient treatment sometimes conflicted withpersonal feelings about ‘‘bad patients’’ (see New-ton, 1995; Persaud, 2004). According to anothermental health nurse:

Nurses are called on to deal with all sorts of pa-tients. Just there and then and you’ve got to beready to go and help them (patients). Some pa-tients can be really horrible and even disgusting,which means you have to really emotionally la-bour... I suppose you could say there are goodand bad patients who you treat differently, eventhough you’re not supposed to, and you’re reallysupposed to treat everyone the same.

Taboos of intimacy with patients were formed todeal with perceptions of appropriate and inappro-priate contact (Grandey et al., 2005; Fox, 1980;Lawler, 1991; Stockwell, 1972). In the case of‘‘bad patients’’, emotional distance was encour-aged. With ‘‘good patients’’ the reverse was trueand informal intimacies were said to be acceptableand encouraged. However, the nurse in the aboveexcerpt noted that ‘‘you’re really supposed totreat everyone the same’’. This shows that thetherapeutic ideal of equality was still ingrained inher professional view. There was room for discus-sion, perhaps with a mentor, modern matron, wardsister/ charge nurse, nurse management or tea-cher, of how conflicts between her public role asa nurse and her private feelings about ‘‘bad pa-tients’’ may be resolved. Reflection on conflictingemotions about ‘‘bad patients’’ or even patientsin general and managing difficult events in clinicalpractice areas were essential to professional devel-opment and reflexive nurse practice (Williams,1999; Grandey et al., 2005; Zapf and Holz, 2006).

What was particularly of note was the stress thatwas caused by difficulties that the first nurse hadwith the care and social control elements of hiswork. ‘‘Trying to get to know the patient’’ sits insharp contrast to the image of mental illness asphysical aggression. Studies by Handy (1990) aswell as Cropanzano et al. (2003), show that themandate to both care for and control patients withmental health problems leads to unresolvedconflicts and emotional distresses for all involved.This was said to reproduce distress and inequalitiesin health, especially where discrepancies arise


between daily practices and therapeutic ideals, aswas also recognised by the nurse in the second ex-cerpt (Handy, 1990, 1991; Cropanzano et al., 2003;Newton, 1995, pp. 94–96).

The emotional labour involved in children’soncology and bone marrow transplant

In the children’s oncology setting, nurses have todeal with issues of dying, death, bereavementand managing a ‘good death’. The case of chil-dren’s oncology was a justifiably emotive andupsetting clinical area in which there was often lit-tle hope of a cure and only the possibility of palli-ative care. Nurses, in particular, have to learn howto manage a ‘good death’ and emotional labourwas a key component for doing this.

As a specialist cancer care nurse said of emo-tions in the children’s oncology and bone marrowtransplant setting:

You get attached to the patient and attached tothe family. The last little boy I looked after wasdiagnosed as leukaemic, had chemotherapy andhad bone marrow transplant. The transplant failedand by the time we met him he’d had lots of prob-lems at school and also with his family. He was dy-ing and his parents just wanted him to be anordinary little boy. They were encouraged to dothat by (a specialist cancer centre). I think that’swhat all caring agencies promote, that’s normaland maintained as much as possible. But I think to-wards the end of that little child’s life, it was takento an extreme by health and social services and theparents. The little boy was apparently having night-mares and could see ghosts, but because the littleboy’s parents had been told to maintain the normthey didn’t know when to step away from the normand show their emotions. The doctors and parentshad in a sense stopped listening. I said that it wouldbe good to move the little boy in with the parents,into their bedroom in the last week, but nobodywanted to take on board the fact that the littleboy was so poorly and needed to be closer toeveryone.

The nurse said that she felt ‘‘anger’’ and ‘‘des-pair’’ in the situation, which mirrored the emotionsof the parents and also related to the issue that thenurse had her own children. She said that her feel-ings were not dealt with and supported: ‘‘You can’tshow your frustration if you’re a nurse and you justhave to sit on your anger’’. This dissonance be-tween genuinely felt and displayed emotions waslinked with the formation of the ‘‘hard nurse’’and with high rates of ‘‘burnout’’ (Cropanzanoet al., 2003; Brotheridge and Grandey, 2002).

Such an evocative narrative certainly adds fur-ther weight to the argument that we need to ex-tend an appreciation of emotional labour so as toallow a more explicit focus on systems of socialand emotional support. James writes:

Cancer is a particularly apt disease to review inorder to analyse the management, control and ‘la-bour’ of emotions in health organizations (James,1993, p. 96).

Children’s oncology was a protracted and painfulevent for all those involved. As the nurse said atinterview:

People can go through years and years and yearsof hoping that someone close to them might live,but knowing in the end that they are going to die.I don’t know how nurses and relatives can copewith that, really. They just get on with things andhave to get on with things.

Nurses, patients and relatives were all involvedin emotional labour and engaged in reflections ofhow to manage medical and emotional demands.All involved had at some level to manage their feel-ings. In some cases, this meant having to work atmaintaining the belief that everything was normalin the patient’s life and in other cases it meantbeing faced with the uncomfortable task of disclo-sure or even having to manage a ‘good death’ (Die-fendorff and Richard, 2003; Zapf and Holz, 2006;James, 1993). James writes:

The person with cancer and professionals haveto regulate their feelings. Even the diagnosis. . . ofcancer is surrounded by its own language- ‘disclo-sure’, ‘communication’ and ‘insight’ in healthstaff’s terms; ‘telling’ and ‘knowing’ in lay terms.At a personal level cancer generates disbelief,fear, lies and chaos which are controlled throughinformation, optimism, routine living and socialexpectation. (James, 1993, p. 97).

The above quotation supports the case that thetask of research on emotional labour in the chil-dren’s oncology setting should involve an assess-ment of the strategies of emotional regulationthat were available to nurses. This includes lookingat how nurses manage their own and the patient’semotions, how nurses come to terms with the diffi-cult processes that were an unavoidable part ofchildren’s oncology, and looking at examples ofsuccessful mechanisms of support and disclosurefor patients, relatives and staff.

Systems of support and ways to cope were cen-tral, especially given the rates of burnout and theobvious emotional difficulties involved (Huy,1999; Persaud, 2004). As the nurse said during herinterview:

I think if you emotionally burnout, you don’t giveanything emotionally and patients soon cotton onto


that fact. There are lots of nurses who are burnt-out and who don’t know how to cope and do erecta wall. But then if you continually give and give andgive and give, all the things I might be saying mightbe the right things, and I might have learnt to sayall the right things, but they might not really meananything to me anymore. Although I was doing whatI was supposed to be doing, medically at that point,my emotions weren’t engaged at that point and Ihad to get out.

Conclusion

Despite pressures on resources and problems ofrecruitment and retention in nursing in the UnitedKingdom, this article has shown that nurses contin-ued to provide emotional labour in a variety of dif-ficult as well as everyday circumstances. Despitethe great internal and external pressures of work-ing in the health services, emotional labour wasused to support relationships with patients, rela-tives and colleagues. By doing this, healthcareorganisations were literally kept running by the dif-ferent techniques of emotional labour that nursesuse from day-to-day.

The task remains to identify successful policiesand examples of good nursing practice that rein-force emotional labour and the support of patientsand relatives. There was certainly room to developthe role of emotional labour in policy as well as innurse practice and training. Making emotional la-bour in nursing explicit is certainly in line with cur-rent nursing philosophy, pre-registration and post-registration nursing courses. Indeed, present nurs-ing philosophy is based on the principle that nursesmust have a flexible, reflexive and conceptuallydriven education. This is seen to allow nurses towork in a variety of clinical and non-clinical set-tings in rapidly changing healthcare services, dur-ing a time of constant change and some wouldsay constant crisis in nursing. Nurses are educatedso as to be able to monitor, reflect upon and assesstheir practice, an important element of which in-volves emotions. This leads some to argue- in quitedifferent ways- that nursing is becoming more aca-demic and research-based (Zapf and Holz, 2006;Aldridge 1994; Smith, 1992, 2005).

Future research in the health services should en-gage other professions, patients, voluntary andadvocacy groups. Gender, cultural, personal andprofessional barriers to emotional labour shouldbe more fully studied and noted. The ways thatthese barriers influence health practices shouldalso be investigated. Further comparative researchon different types of emotional labour in nursing

and in other organisations should also be carriedout so as to gain a fuller and broader picture ofhow emotions maintain institutional relationships(i.e. by looking at the different emotional labourin the work of doctors, occupational therapists,nurses and other health staff) (see Firth-Cozensand Payne, 1999). Certainly, as suggested in litera-ture and shown in the research application of thepresent study, there was an ample evidence-baseupon which to form a fuller picture on emotionallabour in healthcare organisations.

Above all, the emotional labour shown in thethree different settings in this study indicated thetherapeutic value and importance that nurses at-tach to their emotional labour. In each of the threesettings discussed, emotional labour was reportedby nurses to bring added value and help in sustain-ing a caring environment between nurses and theirpatients. This gave nurses space to engage with,reflect upon and manage their own and others’emotions, which nurses suggested greatly improvedpractice and the standard of care. Reflection andsupervision of emotions were important methodsof preventing burnout and emotional stresses,which nurse lecturers, managers and directors sug-gested might also be related to local recruitmentand retention issues, with high rates of attritionand nurses leaving the profession in the local trust.

Emotional labour was stereotypically portrayedas female, wrapt up as part and parcel of ‘women’swork’ and associated with caring in the domesticsphere. The notion of emotional care as an entirelynatural activity is certainly related to the devalua-tion of emotional labour in cultural, gender andeconomic terms (Persaud, 2004; Oakley, 1974; Tot-terdell and Holman, 2003; Glomb et al., 2004).Gender stereotypes often meant that femalenurses were ‘invisible carers’ (taken for grantedwith emotions represented as a ‘natural’ activity)while male nurses were ‘forgotten carers’ (Arber,1989; Duncombe and Marsden, 1998). Both maleand female nurses were constrained by stereotypedgender roles and gendered divisions of emotionallabour, particularly as concerned the expressionof emotions and taboos of distance and intimacywith patients. For example, in the mental healthsetting, male nurses were suggested to perform apatriarchal role in controlling ‘dangerous’ or alleg-edly ‘bad’ patients. Moreover, because nurses inthe mental health setting have both a duty of careand social control elements to their work, this wassuggested to cause unresolved emotional pressuresand stresses in patient care. The mandate to bothcare for and control the mental health patientwas reported as leading to distress and inequalitiesin health, especially when discrepancies arose


between daily practices of social control and ther-apeutic ideals (Handy, 1990, 1991; Cropanzanoet al., 2003; Newton, 1995, pp. 94–96).

Emotional labour was regarded by participantsas vital to nurses and an integral part of the cultureof care in the health services. Examples from pri-mary care, mental health and children’s oncologydemonstrate different situations in which emo-tional labour techniques were required and quitevital to care for patients, support reflexive learningand facilitate best nursing practice. Care and emo-tional labour, as originally and more recently out-lined by Smith (Smith, 1992, 1999, 2005; Allanand Smith, 2005; Hunter and Smith, 2007; Smithand Lorentzon, 2007), was thought by nurses to re-main at the very heart of nursing.

The research also had several limitations. First,the research was conducted in one hospital in theEast of London. Findings are context-bound to EastLondon and limited, meaning that broader UnitedKingdom and international research on emotionallabour would be advisable and fruitful. Most ofthe sixteen participants were female and the sam-ple was quite ethnically diverse. Broader researchthroughout the United Kingdom and internationallyis required to reach more conclusive, generalisableand internationally relevant findings. More re-search also needs to pay attention to the emotionalaspects of cultural beliefs. There may be an under-lying assumption in this study that emotional la-bour manifests itself in similar ways in differentcountries and different cultures, but this may notbe the case given cultural differences, divergencesin the structure and set-up of health services anddifferent patterns of nurse education and supervi-sion outside the United Kingdom. It might be usefulfor further research to do a scoping study and sys-tematic literature review that takes into accountthe geographical and cultural variations involvedwith regard to emotional labour. Second, accountsby patients involving their emotions and the emo-tional labour of nurses and other health staff needto be researched to provide a balance of perspec-tives. Third, concepts that run parallel to emo-tional labour (such as emotional intelligence,critical companionship, attachment and clinicalempathy) need to be explored in the United King-dom and international health services context.Fourth and finally, the exhortation of Finemancould be reworked as both a criticism of the limitednature of the present study as well as a call formore research:

What is missing are the definitions and redefini-tions, interlayering of feelings, feelings about feel-ings, over time and in experiential depth (Fineman,1991, p. 216).

Acknowledgements:

Special thanks to Geraldine Cunninham, SteveSmith, Trudi James, Joyce Gray, Mark Steed andall the nurses who took part in the study.

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