“In healthcare you have to detach and shut down emotionally to protect yourself. Until one day you become a stone. It is in that moment that you need to leave before you can no longer find yourself again.” ~ Hospital Nurse (Personal ethnographic notes, 2017)
A cloudy overcast and bleak rain set the mood for what was otherwise a relatively emotionally positive ward in the hospital. Most days in the Intensive Care Unit were surprisingly met with bright and happy dispositions from the helpful and attentive healthcare staff. Nurses in the ward often spoke of life aspirations and exciting future plans, whereas the physicians shared thrilling stories with the interning medical students. While a similar positive ambiance occupied most of the ward on this rainy day, a nurse’s mood was being haunted and challenged by the fading life of her patient.
This nurse, let us call her Anne, is typically pleasant in both mood and conversation, although now she was wearing her emotional armor. Her facial expression was unmoving, and her mood seemed irritable and angry. I believe that Anne’s demeanor was emotional armor that has been put in place to help manage and protect her from the difficult emotions that were tied to the failing health of her patient. Anne’s patient had suffered an accident that required her to be on life support, which her patient was being removed from. The emotional difficulty for Anne involved two issues: firstly, her patient was conscious and aware of what was taking place around her and her condition left her with no way of communicating. Secondly, the patient was to spend her last few hours without any family or friends. Anne was left with the burden of providing her patient with some form of final human attachment and presence during her death. Anne explained to me that no one should have to die alone, and that she was angry that no one from her patient’s personal life was going to be there. She further explained how difficult it was for her, and that emotions, stress, and trying to remain tough and professional were the worst part of the job. As Anne felt the life leave from her patient’s hand, she ran from her post to find a dark and isolated place to cry. The darkness of the room was a shadowy reminder that she is to grieve alone, once again. Dealing with the emotions that healthcare workers encounter is difficult, whether they try to detach from them or confront them. This often creates a hidden inner battle for healthcare workers that is sadly ignored or overlooked by their patients, and leaves them to deal with their emotional trauma in isolation.
The story of Anne can be understood through the perspective of Irving Goffman’s (1959) dramaturgy. The theory suggests that people have a frontstage and backstage when presenting themselves to their audience. The frontstage is where individuals present themselves in a way that they are pressured or expected to, or in a way that they wish to be viewed. The backstage is where individuals plan their acts, wardrobe, and communication with others, and is where much of our true selves and identities exist. The frontstage is essentially our external outward projection of ourselves, and the backstage is our internal thoughts, feelings, and conversations that we have with ourselves. Producing the ability to align our projected selves and behavior with the ways we are expected to feel in certain situations is described as emotion work (Hochschild, 1983). Emotion work is very prominent in the workplace, as employees are expected to act and feel in ascribed ways that are not always attuned to their underlying backstage feelings. Understanding how we are expected to act in our job roles and in certain contexts allows us to manage the way we act, either by evoking or suppressing various feelings. Such understandings of these often covert expectations of how me must conduct and express ourselves emotionally are known as feeling rules (Hochschild, 1983). Through my research, these feeling rules have become apparent to me in healthcare roles.
I find physicians, and nurses like Anne, are expected to manage their feelings according to hospital and professional expectations. These roles have prescribed ways of acting and feeling that are not clearly stated on a job description. Nurses for example are expected to be caring and nurturing, which are characteristics that clearly involve emotional aspects. For example, acting happy to cheer up patients, or knowing when to feel empathy to better understand and respond to the needs of patients. We think primarily of nurses as being female because the characteristics and emotions expected of nurses are often associated with females. In this case, emotional work and feeling rules are very much gendered (Hochschild, 1983). Learning how to act emotionally for a healthcare role is not always found in training documents or textbooks, it is also found through the ward culture (Charmaz & Olesen, 1997). Hospitals and wards can be seen as micro communities, where healthcare workers have their own shared values, rules and expectations. When new nurses or physicians arrive to these micro cultures, they begin to observe and adopt their new surrounding work culture, and with it comes expected ways of managing emotions.
Nurses and physicians have explained to me that they must be strong, and are not supposed to be emotional. There are social pressures to feel certain ways under certain contexts, such as knowing which emotion to feel and how much of it should be felt and expressed. My conversations with healthcare workers align with Berry (2007) in the sense that certain ways of feeling by healthcare workers, such as expressions of sadness, are considered unprofessional. Physicians and nurses present themselves in a way that appear to others as superhuman, while I contend that acting in such a way removes their humanity. Presenting a frontstage self that is strong can cause others to fail to see that a seemingly pleasant healthcare worker is internally sad, angry, frustrated, or broken. It is disturbing to witness healthcare workers save their emotional release for when they are alone, causing them to suffer in silence.
I’ve noticed that there is so much to be lost when we fail to recognize that healthcare workers are not superhuman and that they, like everyone else, feel. Patients can see them as indifferent or not caring, causing them to feel as if they are being neglected or blaming healthcare workers for their failing health. Healthcare workers who suppress their emotions can become detached from them, further detaching them from their patients and their relationships outside of work. They also suffer from emotional burnout, which can lead to alternative and sometimes harmful ways of coping with the emotions and stresses from their work. Workers who take compassion leave often unintentionally place all the burden of repair on their loved ones, only to eventually return to an isolating and vulnerable environment that will likely reproduce their suffering. We need to recognize that even our superheroes can be sad, cry, and grieve. Emotions are at the foundation of what makes us human, and for healthcare workers to not be allowed to be emotional is to expect them to no longer be human.
Berry, P. (2007). The absence of sadness: Darker reflections on the doctor-patient relationship. Journal of Medical Ethics, 33: 266-268
Charmaz, K. and Olesen, V. (1997). Ethnographic research in medical sociology: Its foci and distinctive contributions. Sociological Methods and Research, 25(4): 452-494
Goffman, E. (1959). The presentation of self in everyday life. New York, NY: Random House
Hochschild, A. (2012 ). The managed heart: Commercialization of human feeling. Los Angeles, CA: University of California Press.