This report will be exploring my elective placement with the community nursing team for children with disabilities, analysing the impact of organisational culture on the functioning of a multi-disciplinary team.
The community children’s nurses that I worked with manage a caseload of children and young people with a variety of complex health needs, including tracheostomy care, enteral feeding, oxygen therapy, venepuncture and platelets, palliative and end of life care. There was also a community Asian link nurse, who provides ongoing support and clinical nursing care to children and young people from the Asian community with clinical nursing care. Within the caseload, they provide emergency equipments, supplies and necessities in order for the child to be able to be cared for appropriately and comfortably in their home thereby avoiding and reducing hospital admissions. Additionally, the team also support clinic nurses by providing support for consultant sessions. Examples include: Neurodevelopment (including botulinum therapy), ophthalmology, neonatal, by carrying out nursing assessments (weighing, height measurements, and baseline observations e.t.c.) and they also carry out venepuncture clinic which is predominantly nurse-led. Oxford Dictionary of Nursing (2003) describes venepuncture as ‘the puncture of a vein for any therapeutic purpose’ for example, to extract blood which is then sent to the laboratory for testing p510. Community Nurses on this placement, also carry out assessment and interventions that monitor and enable children with special needs to enable individual progress developmentally and make referrals to other health or social care professionals involved in the care of the child in order to promote continuity of care and provide a holistic care approach.
The organisational culture that will be analysed is emotional labour, which was first described by Hochschild who studied flight attendants. Emotional labour was chosen as theory because it is an aspect of nursing that is experienced every time in nursing practice but not as recognised and is an unseen aspect of work compared to physical labour.
Emotional labour was defined as ‘labour that requires one to induce or suppress feeling in order to sustain the outward countenance that produces the proper state of mind in others [such as] the sense of being cared for in a convivial and safe place. This kind of labour calls for a coordination of mind and feeling, and it sometimes draws on a source of self that we honour as deep and integral to our integral to our individuality. It is sold for a wage and therefore has exchange value’ (Hochschild, 1983, p.7).
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Hochschild (1983) found that flight attendants were recruited and trained to sell the flight company (Delta airline) through a carefully prescribed image to encourage the passengers to feel relaxed, safe and comfortable on their journey. This image was portrayed through physical ‘a modest but friendly smile’ p.96 and emotional work carried out was expected to ‘projecting a warm personality’ p.97. This implied that the basis of emotional labour was commodified by the airline, part of the product being sold specifically to increase their profits; which was achieved by the manipulation of emotions according to the rules of the airline. This however, highlighted that Hochschild’s (1983) work on flight attendants mainly reflected that emotional labour is for competitive, commercial purposes. Which James (1992) argued that under these circumstances reactions may not be sincere; in flight attendants’ case they have been conditioned and trained to respond to the clients’ perceived emotional requirements.
In order for the flight attendants to be considered a job, they had to go through a learning process that was acquired and portrayed during their training stages, Hochschild (1983) illustrated that they had to learn that the passengers were always right and also learn how to control their emotions. In essence, being selected for the job was as a result of the ability to act well without showing the effort involved, this is therefore less authentic (Hochschild, 1983). Under these circumstances reactions may not be sincere but appears so because they have been trained to respond to the clients’ perceived emotional requirements (James, 1992).
It could be said that in order to cope with emotional labour feelings rules are needed, which are the principles that deals with emotion and feeling (Hochschild, 1979). Hochschild (1979) explained that there are two views of emotion, the organismic view relates to biological aspect of emotion i.e. “instinct” or impulse” p. 554, which was said to present the concept of feeling rules and the consideration that there is no justification of what the rules impinge on or what capacity of the person’s self wants to try to obey a feeling rule. Moreover, Hochschild (1983) defined feeling rules as a guide for carrying out emotional labour by creating the right that regulates emotional relationships and highlighted that feeling rules ‘represent what emotions people should express and the degree of that expression according to their social roles’p.18.
One can compare Hochschild’s theory of emotional labour represented by the flight attendants to that of nursing. Emotional care is seen as part of a nurses’ role, according to the Nursing and Midwifery Council code of conduct (2004) nurses must ‘make the care of people your first concern, treating them as individuals and respecting their dignity’ p.1. This suggests that nursing work requires nurses to consider the feelings and emotions of their patients, making sure they ensure their safety and comfort thereby caring and protecting their dignity (Theodosius, 2008). Nurses themselves acknowledged that emotional labour is central to the concept of caring within their job role. Gray (2009) who conducted an in-depth semi structured interview with 16 nurses found that all of the nurses identified emotional labour as ‘a chief part of the nurse’s role in making patient’s feel ”safe”, ”comfortable” and ”at home”’ p.170, concluding that they perceived themselves as natural carer. The participants referred to emotional labour as ”breaking down emotional barriers” between nurse and patient which helped in creating ”more informal” relationships p.171. Which supports Theodosius’s (2008) statement that ‘nurses are seen as being kind considerate, patient; they are cheerful, loving, friendly, good listeners and empathetic’p.31 which is a part of their image and identity. These sum up a nurse’s desire to care which upholds the representation of emotional labour in nursing.
Without a doubt, nursing care involves organisation, physical labour and emotional labour (James, 1992). Theodosius (2008) suggested that this is type of care is holistic care and explained that it comprises of an individual nurse being responsible for the total care of individual patients. It was added that nurses had to use their knowledge and physical capabilities to care for their patients, which demands time and continuity of care thus improving nursing practice. The relevance of Hochschild’s description that ’emotional labour is sold for a wage and therefore has exchange value’ is seen in nursing today, as there is a demand for emotional labour from nurses to delivered as a commodity. For example, the introduction of patient complaints has put more pressure on nurses. This challenges the belief that the nurse is caring conveying that the actions are scripted and performed, therefore are inauthentic (Theodosius, 2008).
Emotional labour in nursing although ‘sold for a wage’ as Hochschild would describe it, is a freely given emotional exchange, which involves interactive development in the relationship between the nurse and patient. The emotions of the nurse and patient contributed in this exchange forecasts the relationship between them, but is regulated by the presence of feeling rules as they understand each other’s role (Theodosius, 2008). In a similar vein, James (1992) clarified that although emotional labour is about action (doing) and reaction (being), it can be demanding and requires skilled work. Moreover, the expectation is to respond to another person and be responded to in a personal way but only develops from the social relationship between the patient and nurse which is determined through emotional labour.
For nurses, feeling rules is based on the principle that nurses are naturally caring and for this care to occur the patient must allow the nurse to care for their physical body, through the communication of ‘personal and private information about their feelings, thoughts and way of life’ p.34 (Theodosius, 2008). On the other hand, Gray (2009) identified that emotional labour adds value to care which is maintained through the caring atmosphere between nurses and their patients. But suggested that rather than using feeling rules as a guide to cope with emotional labour; emotional labour is seen as a chance to reflect on and manage the nurse’s own and others’ emotions. This in turn will aid in improving practice and the standard of patient-centred care. Similarly, Theodosius (2008) made it clear that a nurse needs to manage his or her emotions to benefit the patient as this maximises the ability to carry out skills confidently. But for this to occur the nurse must acknowledge their own feelings, the patient’s feelings and be aware how these feelings might impact on patient interaction which may ultimately influence the accomplishment of nursing goals. A nurse must therefore withhold her personal feelings and thoughts as emotional labour is used to listen, care, offer advice and comfort the patient.
Emotional labour is believed to be a woman’s work (Theodosius, 2008). This is understandable as nurses are predominantly females, but this gender inequality has brought about the stereotypical image that the participants in Gray’s study (2009) believed to be present barriers to emotional labour in health. On the other hand, Theodosius (2008) added that nurses are seen as ‘the image of the girl born to nurse and devoted to caring for the sick’ p.31 which originated from Florence Nightingale. And according to Gray (2009) stereotypes like this was because emotional labour was not recognised as part of a professional occupation, and instead was depreciated as women’s work. Care giving, emotional labour and intimacy were seen as natural roles of women; this perception produced a further barrier in nursing as general nursing was perceived as being only for women and mental health for men (Gray, 2009).
Lack of emotional labour is considered to reflect social status and power that the health professionals have over those who are vulnerable and sick (Theodosius, 2008). There is a need for a balance of power between the nurse and the patient when emotional labour is given. Theodosius (2008) described that this balance is expected because care is given by the nurse and appreciation is shown by the patient. Trust is therefore required from the nurse and the patient in order to stabilise power in emotional labour, this is negotiated through the freely given emotional exchange. For a nurse to carry out procedures a patient has to trust the nurse and in return for the nurse’s skill, the patient shows appreciation to the nurse who then feels pleased for doing something valuable (Theodosius, 2008).
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Furthermore, it is said that the clinical aspect of nursing is linked to a higher status which is seen to be more masculine and also linked with medicine; because of this it is then prioritised. This is linked to the expression of emotions; Theodosius (2008) clarified that being able to suppress emotion is more important because of the power that comes with a higher position. But expressed that in nursing, patients are allowed to express their freedom at the expense of the nurse’s reduction in power.
A concern with the studies into emotional labour was that they were qualitative studies. The difficulty with this approach is it has a subjective nature. This is mainly because data collected can be easily influenced by the researcher’s personal view, which increases the likelihood of bias (Ogier, 2002 and Holloway and Wheeler, 2002). The misinterpretation of data collected can lead to incorrect conclusions, which could then affect the validity and reliability of the results by reducing it (Ogier, 2002). The sample size is also affected in this approach as small samples are usually used, which can introduce sampling bias because the population chosen is often not representative of the population; this reduces the generalisability of the results (Ogier, 2002).
Hochschild (1983) used an ethnographic approach to how people (flight attendants) manage their emotions by exploring the idea that emotion functions as a messenger from the self, specifically to find out how a person acts on their feeling or stop acting on it, or stop feeling; to discover what it was that was acted upon. This approach focused on understanding the views of the people being studied with observations in a natural occurring condition rather than in an artificial condition (Ogier, 2002, p.48). While, James (1992) used a participant observation (the researcher is part of the situation) observing the formula ‘care = organisation, physical labour and emotional labour’ to identify the components of nursing care at a hospice. Gray (2009) and Theodosius (2008) used interviewing method, with Gray re-examining the role of the emotional labour of nursing and Theodosius (2008) examining and observing emotional labour taking place within a nursing context.
Although there are disadvantages to this research type, it is evident that this is inevitable whatever approach is used. Importantly, each study was carried out with the notion of trying to understand the interpretations and motivations of people instead of searching for the cause and explanation of behaviours and experiences (Cormack, 1996) because qualitative approach is a ‘form of social inquiry that focuses on the way people make sense of their experiences and the world in which they live’ (Holloway and Wheeler, 2010, p.3).
It must be acknowledged that nurses’ emotional labour is different from that of the flight attendants. Theodosius (2008) suggested that a flight attendant is more private than customer-oriented. What I have observed whilst on placement is that the role of the community nurse for children with complex health or special needs is carried out because they are getting paid or because the NHS would get a good image that would encourage clients to use their services like that of the flight attendants because as Theodosius (2008) described that emotional labour is founded on the basis of a freely given gift which in this instance is the quality care which is an essential essence of care as it adds life to the child’s years and not years to the child’s life, in order to enable a pain free last moments of life which is and should be perceived as a good death (Goldman, Hain and Liben, 2006) rather than just the fact that it is an aspect of their work requirements or with the aim to enhance the identity of the NHS, this challenges the authenticity of their care.
During my elective placement I had the opportunity to observe a consultation involving a 10 year old boy who had intermediate (type II) spinal muscular atrophy with his aunty who was his carer. According to the Jennifer trust (2010), spinal muscular atrophy (SMA) is a condition that affects the nerves in an area of the spinal cord called the anterior horn, which become damaged; breaking the link between the brain and the muscles. The muscles therefore can’t be used so become wasted or atrophied. This consultation was to discuss his progress and well being with him and to clarify his deterioration with his aunty.
His intelligence was above average and was attending a mainstream school but because of the muscle wasting he was confined in a wheel chair. From my observation it was obvious that he was very frustrated that he was physically dependent but intellectually capable and was aware of his decline in health. This was equally hard for me to listen to and deal with because I perceived that he was fed up with the endless appointments, especially having to meet new people, so instead he had a nonchalant attitude towards people although I was aware that this was not as a result of his condition. I had to suppress my emotions in order to deal with this and not let it affect my communication and interaction with him. This was supported by Theodosius (2008) who clarified that being able to suppress emotion is more important because of the power that comes with a higher position and that patients are allowed to express their freedom at the expense of the nurse’s reduction in power. Similarly, it was also said that emotional labour may involve enhancing, faking, or suppressing emotions to change emotional expression but are managed in response to the display rules for that particular job (Grandey, 2000).
And with regards to the worsening of his condition, his carer was seen by herself and I was allowed to observe and listen. It was discussed that at the stage he was at, his chances of survival were unknown with the likelihood of fatality quite high because generalised weakness and wasting of the muscles occurs especially the respiratory muscles which leads to respiratory infections and problems (Jennifer trust, 2010). This was a difficult time as she was very tearful, this affected my emotions too but I had to control my emotions in order to be able to console and support her in that period. Bolton (2000) explained that nurses work hard on their emotions in order to present the ‘detached face of a professional carer, but also to offer authentic caring behaviour to patients in their care’ p. 580. This is also supported by Theodosius’s (2008) work which made it clear that a nurse needs to manage his or her emotions to benefit the patient as this maximises the ability to carry out skills confidently and that for this to occur the nurse must acknowledge their own feelings, the patient’s feelings and be aware how these feelings might impact patient interaction which ultimately influences the achievement of nursing goals. So, a nurse must therefore withhold her personal feelings and thoughts as emotional labour is used to listen, care, offer advice and comfort the patient.
Hochschild’s theory of emotional labour explained the work and learning that had to take place in order to induce or suppress to control emotions, which although was derived from flight attendants could be applied to nursing.
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