Flashback to my first day in child psychiatry as a freshly qualified clinical arts therapist – my dream job. I’ve spent hours planning my drama-therapy session, and I’m now with four seven-year-olds and two nurses. ‘Hello,’ I say, but no one listens. Two boys seem to be having a screaming competition. The room fills with their piercing cries. A third boy rocks back and forth. Occasionally, he frowns while a girl talks non-stop about penguins, then kicks me.
Even if I recognise symptoms and psychological processes, I feel overwhelmed. Masking my disarray, I say: ‘Hi, I’m Susanna. I’m going to tell you a story.’ But the children ignore me until one of the nurses speaks. Her soothing yet firm voice changes everything: ‘Hey everybody, let’s listen.’ Miraculously, the children calm down. Into the quiet, I offer direction: ‘Let me show you something.’ I mime holding a precious object in my hands: ‘I have a tiny bird.’ Everyone is watching, so I whisper: ‘My bird is very shy. But wants to meet you.’ The children smile. An hour later, the session is over, and I am exhausted. My face is red, I am sweaty and tense. My reactions feel embarrassing, non-professional. In the following months, I will be spat on, hit, screamed at and triggered. Daily, I will remind myself: This is my dream job.
In The Managed Heart (1979), the sociologist Arlie Russell Hochschild identified and defined this kind of workplace interaction as ‘emotional labour’. Or: ‘the management of feeling to create a publicly observable facial and bodily display.’ Inspired by Erving Goffman’s work on the different roles we play, Hochschild built her case by looking at jobs in the service industry or in care work that require people to control their feelings and exhibit emotional responses that meet the demands of their role. In a restaurant, a waitress must smile at an angry customer; staff in elder care homes should remain considerate with each resident when faced with two hours to change 20 beds. For Hochschild, emotional labour describes a monetary exchange for correctly shaped emotions. It involves the development of (often unrecognised) communication and stress management skills. Over 25 years of hospital work as a therapist, then supervising and training clinical teams, I’ve learnt to present a calm demeanour. Alongside doctors, nurses and teams dealing with suicides, domestic violence, road accidents, insults, manipulation, distress, blood, abandonment, vomit, illness, child abuse, rape, pain and death, I’ve developed skills to comfort and conciliate.
When they work well, hospitals should provide respite and relief. Yet, backstage, this emotional work is messy and grim. It can be classified as ‘dirty work’, a concept developed by sociologists and political scientists, such as Joan Tronto, for work that remains hidden, the underbelly of society. Emotional hospital work is upsetting in the etymological sense – for it overturns, capsizes, the emotions. How do staff bridge this emotional gap?
When I run hospital supervision groups on this topic, I often begin by explaining that, although emotional labour and emotional regulation are never explicitly detailed in a hospital job, implicitly they are required. A young doctor ought to be able to calmly announce the imminent death of a loved one to family without betraying that they’re feeling overwhelmed. An accident and emergency medical receptionist must settle an aggressively drunk woman, even if they feel terrified. Following a road accident, ambulance staff have to retrieve a family’s bodies from a car, manage their own emotional shock, and console the surviving member.
Yet what are these emotions at work here? Our present-day English word ‘emotion’ took shape in the 16th century but, historically, emotions are related to the ancient concepts of pathos and humours, via early modern passions, perturbations and appetites. Today, an emotion is broadly understood to have three parts: a spontaneous subjective state of arousal, experienced as pleasant or unpleasant; an increase in bodily measures such as heart rate or adrenaline; and a communicative element, often non-verbal. In the context of hospital work, this means that, during emotional labour, staff are managing a subjectively experienced, unexpected situation that influences both body and mind. Every single interaction is impalpably different.
Hochschild distinguishes two kinds of emotional labour. Surface acting, or adjusting visible expressions and tone of voice while inner feelings are not changed; and deep acting, where we embody and adopt the emotional role required of us. In hospitals, such emotional labour enhances patient safety, care, diagnostic skills and the efficiency of treatment. The Latin root of the word ‘emotion’ is movere. Emotions move us. All emotional labour involves emotional regulation, as defined by the psychologist James Gross, referring to attempts to influence emotions in ourselves or others. While many sectors necessitate emotional labour, a hospital houses people’s pain and suffering. Inside, the six basic emotions of joy, anger, surprise, fear, sadness and disgust run rife through its corridors. And at its heart is patient care. ‘Care’, as an ethical position described by the hospital philosopher Cynthia Fleury, is what makes an uncomfortable world inhabitable, the miscarriage tolerable, the cancer bearable.
But if emotional labour is role playing a ‘caring’ role, what is happening to hospital employees offstage? How do staff discover how to help and yet not try to save the world; to create boundaries, but not build impenetrable walls; to assume a role, yet be authentic? How can doctors, nurses and paramedical personnel learn the script of care? Or should these emotional and communicative qualities simply emerge intuitively, from professional devotion? Or from having a character and gender suited to the job? Do we expect more empathy from a nurse than a doctor, and why? What happens when staff don’t feel anything, or feel too much?
In a capitalist hospital, crammed with overworked and underpaid staff, is it even legitimate to ask people to be kind professionally, and always available to console?
During a lecture I gave in a French medical school, an experienced oncologist admitted to holding themselves back: ‘At the start of my career, I avoided bedside end-of-treatment and palliative care announcements, leaving it to senior colleagues. I was too scared.’ Months passed, and then, she said: ‘it was my turn. At first, the appointments went badly, but gradually I developed techniques. I realised people need time, so we began to sit on chairs around the bed. No staff member was ever left standing as this meant they could potentially leave the room while a patient learnt of their imminent death. The seated position put us all on an equal standing, encouraging clear communication. Also, I allocated more time to these appointments. The extra 10 minutes changed everything.’ While the professor talked, her voice stumbled slightly: ‘The announcements became deeply personal as we talked about mothers preparing memory boxes for children. After a while, I began to receive letters from families, explaining how these appointments had helped them steer through grief and death.’
Intuitively, the oncologist had developed an informal end-of-treatment protocol. Yet emotional responses cannot be formulaic; and, therefore, part of her protocol, she insisted, was based on her own emotional communication and boundaries. Even for staff, one emotional response cannot fit all.
Will a life-threatening diagnosis make them laugh nervously, produce tears or induce silence?
Another time, a medical student explained to their class: ‘Last summer, I was interning in a geriatric ward. When people died, I didn’t know how to speak, or bear the smells. But I copied care workers, their quiet pitch of voice, vocabulary, how they gently touched the corpse.’ During supervision groups on emotional labour, staff have confided how they coped with their first suicide, the first time someone threw up on them, or when a psychiatric patient in the midst of a psychotic episode punched them in the face. A nurse in a paediatric intensive care unit (ICU) told of staff singing with parents as children died, providing care in the moments of silence after death when, as the writer Jean Mouttapa explains, only poetry and song can convey our grief.
I’m always struck by the highly skilled and yet unacknowledged nature of this work. A hospital is a ‘shelter’ for the needy, linked to the word ‘hospitable’, meaning to be ‘kind and cordial to strangers or guests’. Staff are continually adapting to the subjective experiences of their patients, never knowing if a life-threatening diagnosis will make them laugh nervously, produce tears or induce silence.
Emotional labour is not a psychotherapeutic process, but even an informal kind of transference, in which a person redirects some of their feelings from one person or subject to an entirely different person, is unavoidable. A parent who shouts, upon discovering their daughter has leukaemia, is not angry at the staff, but feeling helpless. Responding appropriately requires ‘reading the room’. When the paediatric nurses sang during an end-of-life moment, it was a suggestion, never an obligation. Over my years with patients, I have learnt to keep quiet and listen. In experienced emotional work, ‘to pay attention’ is, as the poet Mary Oliver wrote in Owls and Other Fantasies (2003), ‘our endless and proper work’.
Staff must also distinguish between empathy and identification. Even while remaining authentic, a hospital worker has to draw emotional boundaries; they cannot feel the pain of each patient, or accept any behaviour dished out to them. Empathy is our ability to put our feet in a patient’s shoes but not to wear them all day. Equally, hospital work obliges us to accept, with great humility, that much of another’s suffering in unknowable. In her book on trauma, Axiomatic (2019), Maria Tumarkin explores these limits, where to begin helping and where to stop? ‘What can be grasped of another person’s suffering has limits,’ she writes.
An acknowledgment of boundaries protects the patient, but it also protects staff. Thus, emotional labour is not just about communicating outwards: it entails staff processing their inner emotions. But how (and should) a nurse hold back tears when a patient dies? Numerous studies show that emotional suppression affects cognition, adds stress and dents our ability to form authentic relationships. Pushing down a negative emotion, for example, has both immediate and delayed consequences for our cardiac systems. Yet, the reality of hospital life means that a nurse in her mid-20s, working in a neonatal intensive care unit, may never see a baby leave the hospital: their patients either move to a high dependency unit or don’t make it home at all. How do staff work with such human tragedy, but also go home from this suffering? Put another way, how do you prevent the battle-weariness from hardening you to life’s comforts?
For early career medical workers, the problem is particularly challenging. ‘When I was younger, I would get incredibly stressed before each operation,’ a heart surgeon from Lyon confides. ‘I had sleepless nights, terrified my hands would shake.’ A nurse manager relates how, despite years of clinical experience, when she began working in a paediatric ICU, she fainted every month, following staff meetings where she had to announce infant death statistics. At the start of my own career, I freelanced in eight different hospitals units. Often, I finished my days humanely enriched, but emotionally drained. For financial reasons, I worked with disturbed teenagers until I was 38 weeks pregnant, until a young man threw a shoe in my face (which I luckily dodged). Looking back, I have often put myself in high-risk situations. As a whole, state hospital workers are an underpaid, highly skilled population that is more likely to suffer mental and physical ill-health. In 2022, more than half of UK doctors experienced or witnessed verbal or physical abuse. Which prompts the question: who cares for the carers?
Backstage, hospital personnel develop methods to deal with their emotions. The objective is not to suppress but to regulate their feelings. In supervised sessions, managers or psychologists hold group debriefings after road accidents or distressing deaths. It helps to narrate the traumatic event, while group support allows staff to understand and process challenging experiences. Formal sharing is also a symbolic sign of institutional respect. An anaesthetist nurse tells me about a debriefing held after a colleague’s tragic death: ‘The very fact that the session was organised and the management team came meant the institution acknowledged something serious had happened. Without it, I would have felt dehumanised.’
Hospital staffrooms offer informal support, of the kind that researchers such as Moïra Mikolajczak identify as an effective strategy for processing negative emotions. Heads nod, hands are squeezed, and humour is key. In 2019, a US study on medical humour showed that levity helps staff release tension, while gallows humour diminishes horror and denies distress. If the philosopher Jean-Paul Sartre described emotions as transformations of the world, then humour offers hospital staff catharsis, takes them from catastrophe to something light. Over time, I’ve come to know when it will be important to make or share in a joke when something is unbearable. For, while the patient is experiencing a once-in-a-lifetime personal tragedy, staff need to be able to face this situation every day.
That said, staff must nevertheless leave the hospital, carrying or discarding the weight of their day. Outside of the institution, the day’s dramas must be forgotten. As the disaster specialist Lucy Easthope writes in When the Dust Settles (2022), the hardest part of an emotionally demanding job is de-mobbing. You might think that family life was the perfect antidote to intense work stress; however, once in our own homes, among family or friends, jokes about blood or suicide anecdotes do not make any sense. The staff member is alone. When the oncologist I interviewed began making end-of-treatment announcements, she said: ‘I couldn’t talk to my children.’ Instead, she’d ‘sit on the sofa, feeling dreadful and watch trash TV.’ Later, she found relief in joining a choir and singing out her stress. The heart surgeon from Lyon said: ‘I began running for two hours before each operation, to clear my mind, and found I developed a new focus.’ An auxiliary nurse working with extremely violent patients in a closed psychiatric unit said: ‘When I go home, I take off my nursing uniform, and it as though the clothes are a kind of costume which has taken the physical blows and the insults. When I take it off, I remove the weight of my day.’ The nurse changes roles.
I felt as if I was spending my days on an emotional battlefield
Other medical workers self-medicate in more traditional ways: some 10 to 15 per cent of healthcare professionals misuse substances in their lifetime, with professionals working in emergency medicine, psychiatry and high-stress specialities at highest risk. A recent study showed that around 60 per cent of French doctors suffer burnout.
When I began working as a clinical arts therapist, I felt as if I was spending my days on an emotional battlefield. Early on, I was, to use Hochschild’s term, surface acting. I observed other staff, learned how to speak slowly, stand steady, anchor myself to the ground. Much of emotional labour is to do with such non-verbal communication. Inside, I might have been a quivering wreck, but in the face of a violent child I appeared calm. I used a quiet voice during a schizophrenic episode; cracked jokes with a furious teenager. While I surface acted, there remained a gap between my own emotions and those I displayed, meaning that I was still haunted by my day: the emotions reached me negatively. But through supervision, reading and training, imperceptibly the role I was playing became integrated into my working practice, and also in myself. I began, in other words, to deep act, and in the process the calm mask became my face.
Critically, deep acting is not permanent. Confronted by complex situations, or acute ones like pandemics, health workers are destabilised and return to surface acting. The trouble is that persistent surface acting is strongly linked to burnout. Because the gap between felt and displayed emotions is difficult to navigate, staff will often crack under the pressure of pretending to care. It’s the kind of emotional exhaustion that leaves people feeling over-emotional or else numbed. There are red lights, warning bells. A decade-hardened geriatric care worker recently told me: ‘I know I have to change jobs. Suddenly, I just can’t cope with seeing the old people die every week. Each time, I want to cry.’ During a post-pandemic supervision group, a nurse manager described a sudden form of surface acting: ‘Despite 30 years of experience, I panicked because my landmarks had gone and I didn’t know how to behave. It was terrifying but I had to put on a brave face.’ No wonder that, following the COVID-19 pandemic, health workers across the world left their jobs in droves.
And yet, not feeling anything is a non-starter. ‘If I didn’t care at all, I couldn’t do the work,’ an anaesthetist explains. Her words accord with many testimonials I heard from hospital personnel. Working across France and internationally, I’ve never met a member of staff who admitted to wanting to stop feeling emotions. ‘I can and do occasionally shed a tear with patients in difficult situations,’ a senior consultant paediatrician offers. ‘It’s not a problem for me because it means that I care.’ Between caring and remaining focused on patient welfare, hospital professionals walk a tightrope. They need to care. But not so much that they cannot sleep at night.
Until very recently, emotional labour in hospitals was profoundly gendered, and also hierarchical. It was traditionally seen to belong to the feminised province of nursing, where caring and giving of oneself was understood as a vocation or calling. Until quite recently, emotional skills have not always been recognised as necessary for doctors and were actively discouraged. In 2003, researchers found that, from early in their training, doctors were taught that ‘technical skills are [considered] fundamental, whereas interactive skills (if encouraged at all) are secondary.’ But expediency plays its role, too. In an increasingly technical profession with a fast turnover, as one woman doctor recently told me: ‘Many doctors begin wanting to care and gradually lose the time, having to prioritise other things.’ All staff are torn by economic pressures: the lack of contact time, understaffing, the demand to feed 10 physically dependent patients in an hour. The challenge is how to provide quality of care. Because the ‘care’ – the held hand, the kind word – is what makes unbearable experiences bearable for the patient, and gives meaning to the carers’ work.
The emotions have not always been separate from rational medicine. The ancient Greek philosopher Gorgias argued that words had a psychotropic influence, allowing patients to overcome their fear (their emotions). For medieval European physicians, the ‘accidents of the soul’ influenced health, alongside air, food, drink and sleep. The extraordinary Islamic bimaristan, or asylum of the sick, such as the Al-Mansuri hospital in 13th-century Cairo, provided models for Western hospitals, with their medical training and focus on care. Here, storytellers and musicians were engaged to keep patients emotionally calm. Even in the midst of the West’s rational Enlightenment, the Romantic period witnessed a resurgence in the role of emotions being valued in ‘authentic’ science. Michael Brown, in Emotions and Surgery in Britain (2022), offers the example of the anatomist Astley Cooper speaking to a surgical class at St Thomas’ Hospital in London in 1815, saying: ‘With regard to operations a few acquisitions are necessary. It has been said that an Operator should have a[n] Eagle’s eye, a Lion’s heart and a Lady’s hand.’ There was a recognition of the perceptual and emotional as embodied qualities required for medical work.
Today’s neuroscience dispels the myth of a clear separation between reason and emotion. In the so-called hand model of the brain – described by Dan Siegel, a clinical professor of psychiatry at the University of California, Los Angeles – high-stress situations cause the rational part of the brain to cede its management of the emotions, which Siegel called ‘flipping your lid’. In this model, if a patient panics during a diagnostic announcement, for example, their cognitive capacities (memory, organisation) diminish, as the prefrontal cortex disconnects from the limbic area, and emotions such as fight, flight or freeze dominate. The very same logic applies to the overworked nurse manager, the distressed surgeon and the exhausted care worker. Inside hospitals, the pressures of ‘emotional labour’ affects staff performance. ‘It is not always easy,’ confides one doctor, ‘to keep a cool head. Not to make mistakes.’
A smile or a listening ear can communicate care across the painful chasms of human suffering
These problems generated by emotional labour cannot be resolved by stress management techniques, meditation or massage chairs. In this particular setting, emotional labour is intractable. If we use the iceberg analogy, care and emotional labour are the hidden, invisible part of the hospital, but – at the same time – they are its foundation. Emotion is what makes the hospital care.
Guenter B Risse, author of Mending Bodies, Saving Souls: A History of Hospitals (1999), calls for greater support for the notion of ‘healing communities’. He recognises that: ‘The need for human contact and community is currently overshadowed by complex and impersonal diagnostic and therapeutic procedures.’ With artificial intelligence now entering hospitals, it’s even clearer that we need to understand emotional labour as profoundly human work. It is the intangible act of giving as hope. A smile or a listening ear can communicate care across the painful chasms of human suffering.
One solution to the problem is a structural recognition of this hidden work. We could, as Fleury prescribes, make this care visible; putting hospitals’ ‘dirty work’ at the top of the agenda, inverting the pyramid, increasing pay, improving working conditions and staff numbers. In 2016, Fleury created the first French research chair in philosophy at Sainte Anne Hospital in Paris. With antennae across France, and ‘creatives commons’ involving staff, patients and academics, the project aims to make hospitals ‘open places for reflection and experimentation’ by creating spaces where staff and patients can think through care.
Although I’ve worked in hospitals for more than 25 years, I often think I walked through the doors by chance. I never planned to have a medical career. But the passion, care and thoughtfulness of staff and patients alike has been one of the greatest gifts of my working life. Today, as a result of developing a clear value system, I have realised how much my hospital work can feel like a political act, almost the opposite of David Graeber’s ‘bullshit job’. While the bullshit job is meaningless, becoming psychologically destructive when paired with a work ethic that associates work with self-worth, hospital work can resist capitalism. Hochschild is correct in describing the exploitative aspects of ‘emotional labour’ – but despite, or perhaps because of, emotional labour, hospitals are nonetheless authentic places to work. They demand belief and integrity from their workers, the alignment of our values with our labour. Every day is different; every relationship requires something new. Deeply human and meaningful, this work changes lives. Such care should not be idealised or sentimentalised, but made visible, recognised, allowing the ‘dirty’ to be held up to the light.
