Table Of ContentThe Emotional
Labour of Nursing
Its impact on interpersonal relations, management
and the educational environment in nursing
Pam Smith, BNurs MSc PhD RNT
Director of Nursing Research & Development
District Nursing Adviser's Department,
Bloomsbury and Islington District Health Authority
M
MACMILLAN
© Pam Smith 1992
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First published 1992 by
MACMILLAN EDUCATION LTD
Houndmills, Basingstoke, Hampshire RG21 2XS
and London
Companies and representatives
throughout the world
ISBN 978-0-333-55699-3 ISBN 978-1-349-12514-2 (eBook)
DOI 10.1007/978-1-349-12514-2
A catalogue record for this book is available
from the British Library.
Contents
Foreword vii
Preface IX
Acknowledgements xi
1 Introduction 1
The little things 1
What is care? 4
The emotional labour of care 8
Nursing and care 8
The body-mind dichotomy 10
The politics of care 11
Emotional labour costs 13
Everybody's ideal 16
The nurse as emotional labourer 17
2 Putting their toe in the water: collecting, testing and
expecting nurses to care 20
Research subjects, settings and methods 20
Who train as nurses? 20
Standing up in the City Hospital environment 26
In Nightingale's image 30
3 Nothing is really said about care:
defining nursing knowledge 33
The content of nurse training at City Hospital 35
Nursing process: philosophy, conceptual device or
work method? 37
Affective/psychological nursing and learning to do
emotional labour 40
Informal training for people work: feeling rules and
emotion management 46
iii
Learning to communicate and emotion management:
patients' views 49
4 You learn from what's wrong with the patient:
defining nursing work 52
You learn from what's wrong with the patient: how
medical specialties legitimise nursing work 52
Recognising emotion work 55
When the feelings don't fit 57
There are some patients you'd rather nurse than
others: issues of age, gender and race 60
When emotional labour is the work: the case of
violent patients 63
Dispelling the stereotypes: issues of race 65
5 The ward sister and the infrastructure of emotion
work: making it visible on the ward 68
Emergencies and emotions 70
Everybody's ideal: characteristics of ward sisters and
nurses 74
Producing and reproducing emotional labour in the
ward 80
Reproducing emotional labour, management styles
and the nursing process 86
6 Death and dying in hospital: the ultimate emotional
labour 96
Defining death and dying in hospitals 96
Feelings about death and dying 97
Death's unpredictability 99
Packaging death 100
'You knew exactly what to do': a death well managed 101
The technical and emotional labour of death 103
Death and bereavement 105
The role of the hierarchy in managing death 110
7 The caring trajectory: caring styles and capacity over
time 112
First-year students: 'so good to have around' 112
Third-year students: 'the blues time' 116
iv
Personal emotion work 118
Caring factors 121
Emotional labour: styles and strategies 131
8 Conclusions 135
Concepts of care atid emotional labour 135
At what cost care? 136
The future of nursing theory and practice 137
The effects of emotional care on patient outcomes 143
Methodological appendix 146
Participant observation 146
Grounded theory 147
Feminist sociology 147
Organisation of the research 148
Details of subjects studied 150
Methods of data collection 153
Data analysis 156
Patients' interview guide 160
Ward learning environment rating questionnaire 162
Appendix A: City school of nursing plan of training 166
Appendix B: Student nurse assessment form 168
Appendix C: General course philosophy, aims and
objectives 175
Appendix D: Content analysis of student timetables 178
Appendix E: Findings from the ward learning environ-
ment student rating questionnaire 179
Notes 193
References 208
Index 216
v
Foreword
Christine Hancock,
General Secretary, Royal College of Nursing
Pam Smith's analysis of the socialisation of student nurses is
vivid, moving and challenging. She uses a wealth of personal
anecdotes from student nurses as well as her own, very percept
ive observations to record the changing responses of students to
patients and to their work. At its most extreme, the process of
socialisation reduces the fresh-eyed first-year student who iden
tifies with the emotional needs of patients to a cynical and
disillusioned practitioner preoccupied with getting through the
'real' tasks of bed baths and medication.
Pam Smitch demonstrates that nurse education has failed to
value the emotional labour of nursing and to teach students how
to give emotionally explicit care without burning themselves
out. Because this fundamental aspect of nursing is neglected
within the curriculum, students themselves fail to value it,
tending to believe that 'absolute facts' are more important.
Project 2000 will relieve many of the pressures on student
nurses which come from the weight of responsibility they carry
for direct patient care. However, nurse educators will still need
to respond to the challenge thrown down by Pam Smith's book
and look hard at their teaching programmes in order to prepare
and support student nurses better.
Pam Smith's work confirms that many of the distancing
techniques observed by Isabel Menzies in the 1960s are still
being practised today to help nurses cope with the pain of
nursing. Her study pinpoints the key role of the ward sister in
setting the emotional tone of the ward. The ward sister's
management style determines whether the student's individu
ality is encouraged or repressed, whether the student can resist
the weight of the nursing hierarchy and whether, therefore,
they can learn to harness their own personal resources to meet
the individual needs of patients.
I hope that Pam Smith's book will be widely read by ward sisters
and charge nurses, by managers and by educators. It is a
challenge to us all.
Preface
I clearly remember the incident that finally triggered me to make
an in-depth study of nursing. I was working at the time as a
nurse teacher in elderly care. I had chosen that specialty because
I thought it would be free from the high-tech heroics of the acute
medical and surgical wards. Nurses rather than doctors would
provide care rather than cure and emphasise person rather than
patienthood.
Full of enthusiasm, I redesigned the content of the teaching
programme to reflect patient-centred care based on nursing
rather than medical criteria. I substituted sessions on disease
and treatment with those on interpersonal relationships and
ways of maintaining patients' daily living activities. Some ses
sions were used to look at ways of prioritising care around
patients' needs rather than routines.
Imagine my discomfort when a student told me that she had
been reprimanded by the ward sister* for agreeing to help a
patient bathe and wash her hair in the afternoon rather than the
morning. The student had been so excited at being encouraged
to give patients choice that the sister's displeasure at having her
ward routines disrupted came as quite of a shock.
The incident provoked in me a number of questions. What
was it that compelled the sister to insist that certain tasks were
completed by a regular time? Was it unreasonable to put
patients at the centre of care when human life expectancy
limited the 'triumphs' of modern medicine? Most importantly, I
felt I had let the student down. Was I teaching to strive for ideals
that, although promoted by popular nursing ideologies, were
inappropriate to their everyday realities? Somehow I didn't think
so. But I had to find out why and how.
Eventually I was given the opportunity to seek out some of the
answers to my questions by a progressive nurse manager who saw
the value of an in-depth study of the subjective experiences of
student nurses during training. As a participant observer I had a
*'Ward sister' and 'sister' are equivalent to 'charge nurse'.
unique opportunity to talk to nurses and to be allowed back in to
the world of the ward. I experienced at first hand some of the
contrasts and contradictions of learning to care and was led to feel
it, along with the nurses, as labour of an emotional kind.
Discussions after a sociology seminar with friends brought
Arlie Hochschild's study of flight attendants to my attention. I
would like to thank Anne Karp who told me about that study,
The Managed Heart, which introduced me to the notion of
'emotional labour' as part of work. I would also like to thank
Arlie Hochschild, with whom I discussed the first draft of this
book. Her sociological imagination facilitated me not only in the
writing of the book but also to extending my understanding of
the notion of emotional labour as applied to nursing.
Jane Salvage encouraged my early efforts at transforming a
thesis into a manuscript and Joe Hanlon gave invaluable com
ments on the final drafts. To both my thanks. Also to Dave
Wield, Maureen Mackintosh, Naomi Richman, Teresa Smart,
Nicki Thorogood and many other friends, particularly in the
thesis days, for lots of emotional labour along the way.
I would also like to thank Sally Gee, John Gee and Bridget
Smith, who provided me with comfortable accommodation and
conversation during long days of writing.
My colleagues have also played an important part in showing
interest and support for the book. I am also appreciative of
understanding managers who allowed me to take leave in order
to write both thesis and book.
Finally, thanks to the student nurses, sisters, teachers and
staff nurses in the study for showing me what it means to care.
Since completing the research, changes within the health ser
vice, nurse education and the impact of caring for people with
Acquired Immune Deficiency Syndrome (AIDS) have increased
the emotional load on nurses, but not the resources. Their
caring capacity is stretched to the limit. The detail, but not the
spirit, of my research might have been different if I were
conducting it now. But the message remains the same: caring is
work and requires skill and resources.
Unfortunately, I am not able to thank the people in my study
by name for reasons of confidentiality. But to you all my thanks,
especially the four ward sisters and the director of nursing at
'City' Hospital. This book is dedicated to you.
Pam Smith
20 February 1991
