the unspoken work of general practitioner receptionists: a re-examination of emotion management in...
TRANSCRIPT
lable at ScienceDirect
Social Science & Medicine 72 (2011) 1583e1587
Contents lists avai
Social Science & Medicine
journal homepage: www.elsevier .com/locate/socscimed
Short report
The unspoken work of general practitioner receptionists: A re-examination ofemotion management in primary care
Jenna Ward a,*, Robert McMurray b
aUniversity of York, York YO10 5GD, United KingdombDurham University, United Kingdom
a r t i c l e i n f o
Article history:Available online 29 March 2011
Keywords:GP receptionistsEmotion managementGeneral practiceEmotional neutralityEmotionCareEnglish NHSEmotion switchingUK
* Corresponding author.E-mail addresses: [email protected] (J. Ward), rob
(R. McMurray).
0277-9536/$ e see front matter � 2011 Elsevier Ltd.doi:10.1016/j.socscimed.2011.03.019
a b s t r a c t
Dealing with illness, recovery and death require health care workers to manage not only their ownemotions, but also the emotions of those around them. While there is evidence to suggest that coreoccupations such as nursing are well versed in the nature of and need for such work, little is knownabout the requirements for emotion management on the part of front-line administrative staff. Inresponse, findings from a three-year ethnographic study of UK general practice, suggest that as a first-point-of-contact in the English health care system GP receptionists are called upon to perform complexforms of emotion management pursuant to facilitating efficacious care. Two new emotion managementtechniques are identified: (1) emotional neutrality, and (2) emotion switching, indicating a need toextend emotion management research beyond core health occupations, while at the same time recon-sidering the variety and complexity of the techniques used by ancillary workers.
� 2011 Elsevier Ltd. All rights reserved.
Introduction
Receptionists have become central to the functioning of generalmedical practices, so much so that Arber and Sawyer (1985) notethat it is no longer appropriate to talk of a dyadic relationshipbetween doctor and patient, this having been superseded by thetriumviri of doctorereceptionistepatient in primary care. Whiledoctors have been observed to benefit from this change in terms ofassistance with service co-ordination and demand moderation(Arber & Sawyer, 1985; Copeman & Van Zwanenberg, 1988;Gallagher, Pearson, Drinkwater, & Guy, 2001) the response frompatients has been more ambivalent; with the receptionist asadministrative intermediary being stereotyped as an uncaringbarrier to much needed health care (Arber & Sawyer, 1985). Theabove implies that there is little recognition of the place andperformance of emotional labour (Mann, 2005) in such front-linehealth care. This is potentially significant given that receptionistsare administrative gatekeepers to General Practitioners (GPs) who,in the English health care system, continue to be the primarymedical gatekeepers to NHS care e a position recently strength-ened by reform (DH, 2010). This paper considers the extent to
All rights reserved.
which GP receptionists are required to perform emotion manage-ment and the implications this has on the patient journey throughprimary care. We begin with a brief review of the extant literatureon emotion management.
In her landmark thesis Hochschild (1983) compares the instru-mental use of flight attendants’ emotions in the service sector withthat of labourers in the secondary sector. She notes that in theformer case the ‘the emotional style of offering’ is part of the serviceitself as flight attendant’s emotions are commodified by the airlinein exchange for a wage, just as manual workers are paid for theirphysical labour power by factory owners (Hochschild, 1983: 5).Emotion management is therefore defined as the ability ‘to induceor suppress feeling in order to sustain the outward countenance thatproduces the proper state of mind in others’ (Hochschild, 1983: 7).
This work has been usefully extended by Korczynski’s (2003,2009) distinction between empathetic and antipathetic emotionmanagement (often emotional labour where performed fora wage). Korczynski classifies empathetic emotional labour as thatwhich is intended to produce a positive emotional state in others,such as the sense of happiness, safety or care thatmay be associatedwith the work of nurses, cabin crew or hairdressers. By contrast,antipathetic emotional labour is intended to produce a negativeemotional state in others, as in the fear and insecurity potentiallyemployed by debt collectors, or prison guards
In 2009, Korczynski developed the empatheticeantipatheticdichotomy to propose that service roles should be differentiated on
J. Ward, R. McMurray / Social Science & Medicine 72 (2011) 1583e15871584
the basis of what he calls the ‘substantive nature of the emotionalbearing enacted by the worker to the customer’ (2009:957, emphasisadded), that is to say the degree to which the worker’s privateemotions are intertwined with the customer. Similar to Rafaeli &Sutton’s (1987) faking in good and bad faith, Korczynski (2009)suggests a ‘continuum’ of ‘emotional bearing’, with the twoextremes being a ‘purely instrumental approach’ and a ‘caringapproach’. The instrumental approach requires workers to have littleemotional engagement with the customer beyond the commercialinteraction, whilst the ‘caring approach’ is characterised by a “deeplevel of humanity enacted by workers towards service-recipients(Bolton & Houlihan, 2005)” (Korczynski, 2009: 958).
Thus, Korczynski’s work begins to move us towards the possi-bility of considering emotionmanagement as a relational process ofcommission, performance and consumption; the experience ofwhich can be positive or negative. Moreover it serves as a usefulbackdrop to emergent debates on emotional labour’s relationshipwith health care generally, and our concern with the service role ofreceptionists specifically.
In spite of some significant contributions to the emotional labourliterature stemming from research in health care (notable examplesinclude James (1989); Smith (1992); Bolton (2005); Theodosius(2008)), at present there is no equivalent of this research for thoseworking inhealth administration. The result is a narrowpicture of theplace and performance of emotional labour within the health caresector as a whole (Mann, 2005). It is in response to this lack that thepresent paper considers the emotional labour of GP receptionists.
Method
Design and approach
A qualitative ethnographic study was undertaken between2005e2008. The approach was multi-method, with a view tomilitating against the socially desirable response bias that has beenobserved in emotional labour research, particularly where there isan over reliance on interviews (Czarniawska, 2004). To this endnon-participant observations (N w 300 h) and impromptu inter-views undertaken during observations-(N w 50), semi-structured-(n ¼ 4) and group interviews (n ¼ 1) were all employed.
Participants & place
Three English general practice surgeries agreed to participate inthe study. One served a largely middle class ageing population (siteA), the second, an area of high social and economic deprivation (siteB), and the third an inner-city population of mixed economic andsocial status (site C). All 28 staff involved in receptionwork across thethree sites took part in the study. All were women, aged between 23and 66 years. Local NHS ethics and research governance approvalswere sought and obtained prior to the initiation of the research.
Procedure
Non-participant observations began with six continuous days ateach of the practices. The lead author observed and documented thenature of the work, allowing for the direct identification of emotionmanagement. In total, a further 30 days of observation wereundertaken at different points of the study (by both researchers),across all sites, to assess the extent to which the nature of receptionwork may have altered over time. Because observer interpretationsmay differ from those of participants, in-situ interviews were usedduring observations to ask receptionists to comment on theirexperiences, feelings and motivations. These impromptu interviews(Fox, 2004) lasted anywhere between 2 and 20 min.
Four of the receptionists (1 from site A; 2 from site B; 1 from siteC) who had been observed, volunteered to take part in in-depthinterviews which lasted for up to 90 min and centred on partici-pant’s reflections on: recently observed events, how they negotiatepatient interactions, what makes for a good receptionist, and therole of emotional performances.
The final part of the multiple method strategy involved thefacilitation of a group interview, in which both researchers encour-aged reception staff to share experiences so as to compare percep-tionsof relatedphenomenon(Murphy,Dingwall,Greatbatch, Parker,& Watson, 1998). Seventeen receptionists from across all sites vol-unteered their time to be involved in the group interview facilitatedat site C.
Analysis
Handwritten notes of observations and in-situ interviews weretranscribed, whilst all other data was digitally recorded and tran-scribed in the same way. In this sense the in-depth interview dataand that elicited from the group interview were verbatim writtenaccounts. Both researchers employed a process of intuitivecomparative analysis collaboratively. Building on thework of Glaserand Strauss (1967) a constant comparative method was employedwith a view to examining and comparing the actions, processes andinterpretations of those engaged in reception work, in such a waythat would allow the analysis to construct an account of emotionallabour and any competing logics operating through such work. Ouraim was to identify the range of processes engaged with andexperienced by receptionists, and not their prevalence. There aretherefore no ‘counts of frequency’ or attempts to generaliseprobabilistically.
A thematic analysis was used to analyse and compare theinterview accounts with observations made by the researchers(observations having been rendered as textual data followingtranscription). To ensure methodological rigour, the researchers’interpretations and analyses were re-presented to a small numberof volunteer participants (n¼ 6) during further reflexive interviews(not included in the data set), in which views were exchanged onresearcher interpretations of events. Any factual inaccuraciesidentified during this process were corrected.
No details of patient identity were used or recorded during thestudy. While age and length of tenure are indicated for receptionists,pseudonyms are employed to designate data extracts. Emergentthemes of empathy, neutrality and switching are considered in turnfollowing a brief comment on the nature of receptionists’ work.
Results
The role of the GP receptionist in England is to be the first point ofcontact for users, determining appropriate access to health staff (asadministrative gatekeeper), while maintaining records and relateddocumentation. Observation revealed that much of the receptionwork undertaken at the three practices was similar in kind to thatwitnessed in other GP contexts (Hewitt, 2006). We watched as theGP receptionists dealt with an almost continual flow of patients,requiring them to carry out routine tasks such as checking-in,booking appointments, filing, coding and directing. Supplementingthese were more complexly ‘relational-focused’ processes (Hewitt,2006) such as attending to individual patient needs and problemsstemming from osteoporosis, language barriers, psychological andmental health problems, emergencies, death and common colds.Mornings were often frenetic, filled with phone calls for appoint-ments and patient arrivals, trailing off at lunch times (wherereceptionists would catch up on administrative tasks), before
J. Ward, R. McMurray / Social Science & Medicine 72 (2011) 1583e1587 1585
building again to deal with those attending routine clinics andemergency appointments
The overall impression was of work rendered demanding bymultiply-recursive flows of people, tasks, regulations, proceduresand relations, as Gabby (23, 7 months tenure) joyfully explains:
“We’ve got demanding patients saying what they want ‘now!’(Laughter); you’ve got to multi-task because sometimes we’vegot the phone going and patients at the desk. You’ve got to tryand do it all”
GP receptionists work in the knowledge that relations areongoing: framed by past encounters and casting a shadow on thefuture. The nature of these relationships led to routines of caringdesigned to produce a positive affect (empathetic) in others.
Empathy
At points during our observations we witnessed receptionistsgoing beyond the basic greeting, booking and administering ofpatients. They exhibited a ‘caring approach’ (Korczynski, 2009)designed to invoke a sense of interested well-being in patients, andinformed by the recursive nature of their service work. Oneexample involved a patient with apparent learning issues who hadbrought a children’s book along with him to the surgery. As hestood at the desk he proceeded to describe the contents of the bookto Liz (47, 2 years tenure). She spent time asking him questions,listening to his often-incomprehensible description; attempting tomake him feel cared for. Once the patient had left Liz sat back downat her seat and continued with her work, commenting, “We do thatevery week. trouble is it’s the same book!”
This ritual clearly encroached on Liz’s task-focused work(Hewitt, 2006), and is therefore illustrative of the receptio-nistepatient relationship. Specifically, Liz’s ability to induce orsuppress feelings in order to sustain the outward countenance thatproduces the proper state of mind in others (Hochschild, 1983), inthis case empathy (Korczynski, 2003) was representative ofa ‘caring approach’.
Despite the sincerity of the caring approach the emotionsenacted or suppressed remain a performance intended to producea particular frame ofmind in patients. As Lorna (53,13 years tenure)noted, dealing with issues of illness, loss and disease could bedraining, as could dealing with situations of open hostility andconflict from patients:
“.you can’t keep up a level of empathy that maybe you wouldlike to do all of the time because it would be emotionallydraining. the way that we wind down after - if we geta particularly difficult one [patient] - is to let off steam betweenourselves, and we might joke about it and might even say “thatstupid idiot” just between ourselves, it’s human nature. That’sthe way we let it out between ourselves, in private. You justcouldn’t do it all of the time.”
This admission that maintaining performances of ‘empatheticemotional labour’ (Korczynski, 2003) is impractical, due to theintense and emotional nature of the work being carried out forprolonged periods of time, raised the question of what otheremotion management techniques are used to facilitate patientsthrough the journey of care. One such technique was the deploy-ment of what we have called emotional neutrality.
Neutrality
Particular incidents served to highlight situations or interactionswhen empathetic emotional labour would not have been an
appropriate way of interacting with a patient. One such incidentwas when an apparent mix-up over appointment times led toGabby being racially abused by an elderly patient. In this situation itwould have been difficult to respond with empathy; instead shemanaged to remain composed despite feeling angry and upset.
“It probably is the receptionist role that makes you think you’renot going to get anywhere by shouting and I mean, obviously,she was totally out of order.but . they are obviously annoyedat some reason to do with their health”
Even in such personally distressingwork situations, we continueto see a ‘performance’. Gabby actively suppressed her own emotionsin order to maintain an emotional performance congruent with herrole as receptionist, and also avoid exacerbating the unwantedbehaviour and annoyance of the patient. Instead of showing her realfeelingsewhich in-situ questioning revealed to centre on anger andsadness e she performed what we call emotional neutrality: a tech-nique used to suppress emotions felt whilst displaying unemotionalbehaviour, wherein the suppression of the emotion is the perfor-mance itself.
Initially, emotional neutrality was overlooked in our observa-tions of receptionistepatient interactions, as, by its very character,it was perceived to lack emotional content. However, followingreflection and further conversations with receptionists themselves,it became clear that the apparent absence of emotional display onthe part of workers could constitute a mode of emotional perfor-mance. Some of the most common scenarios in which emotionalneutrality was employed included: when patients attempted to usewhat receptionists felt to be emotional blackmail to obtain a moresuitable appointment; when dealing with ‘known’ patients whowere unpredictable in behavioural terms, and; when listening topatients re-repeat their medical histories.
There were of course times where emotion threatened to cometo the surface, as a strained voice or impatient sigh spoke ofreceptionist’ frustration. In the main however, frustration wasmasked with neutrality, as on the occasion when receptionistShirley (57, tenure unknown) sought to explain to a patient that hecould not see ‘his GP’ because ‘his GP’ had left. As the patientimplored that “she is the only onewho can treatme!” Shirley calmlyinterjected onmore than one occasionwith a polite “Sowhat do youwant to do Mr Frank?” After almost 10 min Mr Frank agreed to the4pm appointment with another doctor. Despite the frustrationShirley later voiced in private, there was no outward display ofempathy or antipathy on her part as work to get the patient tocalmly accept the need to see someone else.
Emotional neutrality emerges then as a newly identifiedemotional labour technique alongside empathetic and antipatheticperformances (Korczynski, 2003). Characterised by the suppressionof internal and external emotional states, its apparently dispas-sionate display is intended to evoke a sense of calm or acceptance inothers. In relation to Korczynski’s (2009) ‘continuum’ of emotionalbearing, emotional neutrality offers a new dimension, giving theappearance of an ‘instrumental approach’ with little apparentemotional engagement, which we argue, serves to mask thecomplexity of caring for those who can be reluctant to accept it.Therefore, performances of emotional neutrality may embody bothextremes, often being instrumental in their delivery but caring inapproach. Thus, the dichotomous nature of Korczynski’s (2009)continuum of emotional bearing may represent just one dimen-sion of the emotion management carried out by front-line servicestaff. Indeed, we observed that one of the defining characteristics ofGP reception work was a requirement to engage in emotionallabour which was both instrumental and caring and the flow of thiswork requires them to shift along the continuum in a process wecall emotion switching.
J. Ward, R. McMurray / Social Science & Medicine 72 (2011) 1583e15871586
Emotion switching
The concept of emotion switching arose from watching GPreceptionists deal with the unknown and the unexpected. Forexample, we witnessed one receptionist on the front desk joyfullycongratulate a first time mum on the birth of her healthy baby boy,make her an appointment for his first set of immunisations, onlythen to find the next person in the queue was informing the surgeryof the death of her husband. This juxtaposition of antitheticemotions on the part of other and self is a central characteristic of GPreceptionists’ work. It is a characteristic that we name emotionswitching: the process of sequentially managing and performingantithetic emotions with a view to matching and managing theemotions of others.
Observations of daily interactions across the surgeries suggestthat ‘switching’ serves to ensure that patients are treated withcompassion and care specific to their individual circumstances,which, while being unique to the patient, are experienced byreceptionists as a complex flow of emotional changes. We werewitness to a particularly poignant example of ‘emotion switching’ inwhich Jane (65; 30 years tenure) and Elizabeth (66; 30 years tenure)discussed how a local woman had been killed when she had fallenfrom her horse. The conversation was particularly sombre, Janenoting that “being in this job, especially for a long time, you get toknow so many people and you know.it really does affect you!” Justas Jane drew breath to continue explaining how death and illnesswas a big part of her job the telephone rang. She picked up thereceiver and in a buoyant and cheerful tone commenced a routineappointment booking. Jane’s sadness and grief at the young wom-an’s death had to be suppressed as she exudedwarmth, enthusiasmand kindness in her interaction with the next patient. Although itwas just a routine appointment booking, Jane employed a positiveempathetic performance in an attempt to engender a sense ofwarmth and caring in the caller.
Therewere other examples, on ourfinal afternoon of observationsAlison (44; tenure unknown) answered the telephone as part of hernormal routine. A few seconds into the call it became clear that thiscall was anything but ‘routine’ as she sought to calm a patient withwho was threatening to use boiling water to scold germs off theirbody. While making signs of despair to the other receptionists as herconcern for the patient’s safety escalated, Alison tried to explain thatcoolwater and soapwould bemore effective. Aftera further 20minofreassurance Alison persuaded the patient to put the phone downwith the promise that someonewould come to help him. Thiswas anextreme example of a receptionist managing her own emotions,switching between neutral voiced instruction and caring concern, inan attempt to evoke a sense of calm in a patient pursuant to care.Moreover, within minutes of these dramatic and emotional eventsthe receptionists go back to work, greeting patients, handlingadministrative duties and answering the phone pursuant toa continuous standard of service delivery, regardless how apparentlyurgent or trivial the presenting issues appear.
Here we see it is not just the ‘the emotional style of ‘offering’(Hochschild, 1983: 5) that is part of the service provided by GPreceptionists, but also the ability to tailor that offering to the needsof individual clients. Receptionists demonstrate an ability to switchrapidly between antithetic emotional performances with a view tomatching (where appropriate) or managing (where necessary) onepatient after another (e.g. empathising to show concern, and thenworking to neutralise aggression). These performances arise out ofthe multiply-recursive nature of the work with respect to flows ofpeople, tasks, regulations, procedures and relations, as well as thecommitment of individual receptionists to delivering care that isusually associated with higher status health care occupations(Bolton, 2005).
Concluding discussion
This paper has sought to explore whether GP receptionistsengage in emotion management as front-line health care staff. Theanswer, from a three-year-long ethnographic study of generalpractice, is unequivocally yes. They are called upon to engage inemotion management as part of wider caring processes, and do soin contexts that are both immediately unpredictable and relation-ally recursive. This gives rise to two emotion management tech-niques that have not been recognised in the extant literaturebefore: emotional neutrality and emotion switching.
It is our contention that through the deployment of suchtechniques GP receptionists can and do play a key role in ‘facili-tating the patient journey’ (Mann, 2005: 304), thereby contrib-uting to the provision of quality carein a manner normallyassociated with core health care occupations such as medicine andnursing (Smith, 1992). Specifically, we found that the episodicrapidity of GP reception work with its constant flow of differentpatients, tasks and situations requires tremendous flexibility inemotional performances, something we identify as emotionswitching: the process of sequentially managing and performingantithetic emotions in a given context. An essential and subtle skillin successful GP reception work, this was observed to involverapid switching along the ‘continuum of emotional bearing’(Korczynski, 2009) through performances of empathetic labour(Korczynski, 2003) and what we have identified as ‘emotionalneutrality’.
Defined as a technique used to suppress emotions felt whilstdisplaying unemotional behaviour, wherein the suppression of theemotion is the performance itself, emotional neutrality wasobserved to perform two main functions. First, as an effectivetechnique for ‘gate-keeping’ and dealing with the emotionalresponse this evokes in clients. Second, to furnish receptionistswiththe ability to remain apparently unmoved in the face of extremeemotion, whilst, simultaneously allowing them to narrate them-selves as part of the community of care.
While the study undertaken here was in-depth, weacknowledge that its scope was limited in terms of the range ofresearch sites. Observation of daily work processes suggestsparallels with accounts rendered elsewhere (Hewitt, 2006) butallowance must be made for the particularities of both local andnational context. The requirements to perform emotionalneutrality may, for example, be less pronounced where recep-tionists do not have the same gate-keeping role; where there isa requirement to pay (e.g. USA or private medicine); or the statusof the patient encourages adjustment to expectations ofemotional performance and affect (e.g. in cases of learningdisability).
The very act of observation may have encouraged receptioniststo work harder at their emotion management, avoiding the displayof negative responses to patients (though this would not invalidatethe existence of emotional neutrality and switching). In addition,the restrictions of ethics approval meant that researchers were notpermitted to explore with patients their experience of the GPreceptionist’s emotional labour performances. To this end, weacknowledge the need for further research into the possibility thatdisplays of emotional neutrality have the potential to producea negative emotional state in others due to an apparent absence ofempathy.
Allowing for these limitations, the study does nonethelessprovide an insight into the ‘emotional roller coaster’ that can be theeveryday work of GP receptionists. Called on to deal with death, joy,anger, aggression, sadness and disillusionment e potentially in thespace of an hour e they have been observed to employ emotionswitching and emotional neutrality as emotion management
J. Ward, R. McMurray / Social Science & Medicine 72 (2011) 1583e1587 1587
techniques in a manner that suggests instrumentality but alsopoints to a deeper caring approach (Korczynski, 2009). GP recep-tion work thus emerges as a complex service role in which thetailoring of one’s own emotions in the management of patientinteractions is key.
To be clear, we are not suggesting receptionists are advancingnew occupational claims in recognition of the emotional nature oftheir work. Rather, it is we who are suggesting that active atten-tion to these newly identified techniques of emotion switchingand emotional neutrality might serve as useful starting points forthe reconsideration of the emotional performances required insuch front-line work. This suggests two avenues for futureresearch in social science and medicine. The first arises from theextension of emotional labour research beyond core occupations,to consider how ancillary workers might contribute to patientjourneys and care. The second calls for more in-depth researchinto the processes through which emotional labour is performedacross the piece, so that the full variety and complexity of tech-niques might be appreciated, and their relative contributions tothe health service experience (for worker, patient, carer andothers) be identified.
Acknowledgements
We would like to thank the general practices for their open-minds and enthusiasm for the project, the receptionists for lettingus sit in the corner of their offices day-after-day scribbling notesand asking questions and the Social Science & Medicine reviewersfor their assistance in developing and refining this paper.
References
Arber, S., & Sawyer, L. (1985). The role of the receptionist in general practice:a ‘Dragon Behind the Desk’? Social Science & Medicine, 20, 911e921.
Bolton, S. C. (2005). Emotion management in the workplace. Basingstoke: PalgraveMacmillan.
Bolton, S. C., & Houlihan, M. (2005). The (mis)representation of customer service.Work, Employment and Society, 19(4), 685703.
Copeman, J., & Van Zwanenberg, T. (1988). Practice receptionists: poorly paid andtaken for granted? Journal of Royal College of General Practitioners, 38, 14e16.
Czarniawska, B. (2004). Narratives in social science research. London: Sage.Department of Health. (2010). Equity and excellence: Liberating the NHS. Cm7881.
London: The Stationery Office.Fox, R. C. (2004). Observations and reflections of a perpetual fieldworker. Annals of
AAPSS, 595, 309e326.Gallagher, M., Pearson, P., Drinkwater, C., & Guy, J. (2001). Managing patient
demand: a qualitative study of appointment making in general practice. BritishJournal of Medical Practice, 54, 280e285.
Glaser, B., & Strauss, A. (1967). The discovery of grounded theory. Chicago: Aldine.Hewitt, H. (2006). Front desk talk: A study of interaction between receptionist and
patients in general practice surgeries. Edinburgh: University of Edinburgh.Hochschild, A. R. (1983). The managed heart: Commercialization of human feeling.
London: University of California.James, N. (1989). Emotional labour: skill and work in the social regulation of feel-
ings. Sociological Review, 37(1), 15e42.Korczynski, M. (2003). Communities of coping: collective emotional labour in
service work. Organization, 10, 55e79.Korczynski, M. (2009). The mystery customer: continuing absences in the sociology
of service work. Sociology, 43, 952e967.Mann, S. (2005). A health-care model of emotional labour. Journal of Health Orga-
nization and Management, 19, 304e317.Murphy, E., Dingwall, R., Greatbatch, D., Parker, S., & Watson, P. (1998). Qualitative
research methods in health technology assessment: A review of the literature.Alton: Core Research.
Rafaeli, A., & Sutton, R. (1987). Expression of emotion as part of the work role. TheAcademy of Management Review, 12, 23e37.
Smith, P. (1992). The emotional labour of nursing. London: Palgrave Macmillan.Theodosius, C. (2008). Emotional labour in health care. London: Routledge.