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A case study: Authentic emotional labour in nursing

Nursing is one of the most demanding and stressful occupations when it comes to emotion management. It scores high in studies of burnout, stress, and other negative consequences of emotional labour (Maslach, 1982; Smith, 1992; McVicar, 2003). Therefore, if we can establish that emotional authenticity is possible in such a demanding job as nursing, it may be possible in other, emotionally less exhaustive professions as well, although this possibility must be established for each profession individually.

Nursing has undergone a profound change in recent decades. The traditional task-oriented view of nursing was focused on meeting patients' biological needs through various treatments, whose techniques, procedures, and informational basis constituted the core of the profession. This core is obviously still there, but it has become equally clear that nursing care cannot be defined in terms of mere treatment, however skilfully administered. Patients are people in need, and insofar as nursing attempts to remove or relieve their suffering and restore their health and well-being, nurses must treat patients as whole persons.

The holistic and patient-oriented view of nursing emphasises the role of empathy and compassion in the nurse-patient relationship. Empathy is necessary for understanding the meaning and implications of illness from the patient's perspective. It involves appreciative and imaginative receptivity to another person's inner reality, to his or her thoughts, emotions, and needs, and thereby conveys vital information for the determination of appropriate therapeutic intervention. However, empathy is not enough because it must be accompanied by compassion, willing participation in another person's suffering that introduces solidarity with the other person and an altruistic motive to help him or her. It is compassion that leads the nurse to initiate informed actions and treatments that purport to empower the patient. Indeed, nursing has been characterised as an inherently moral practice by virtue of its commitment to care and the essential role of empathy and compassion in the service of this value (Benner & Wrubel, 1989; Gastmans, 1999; Benner, 2000; Bolton, 2000; von Dietze & Orb, 2000; Reynolds, Scott, & Austin, 2000; Scott, 2000).

Empathy and compassion are examples of professional virtues that manifest themselves as appropriate emotions and actions at work. Only an emotionally sensitive nurse is capable of effective nursing, since he or she can take the patient's perspective, recognise the patient's needs, and respond in an appropriate manner. Without these emotional propensities, the perception of complex situations vis-avis the patient's condition is likely to be clouded and the therapeutic interventions chosen less than optimal (Benner & Wrubel, 1989; Nordtvedt, 1998; Staden, 1998; Benner, 2000; von Dietze & Orb, 2000; Reynolds, Scott, & Austin, 2000; Scott, 2000; Henderson, 2001; McQueen, 2004). For "a sympathetic, compassionate or kind person is not only apt to perform beneficent acts, but also characteristically perceives more situations as warranting beneficent actions when this is in fact the case, than would a person lacking in sympathy, compassion, or kindness," as Justin Oakley (1992, p. 51) remarks.

In addition to their vital role in nursing care, professional empathy and compassion are delicate skills exemplifying the Aristotelian principle of the Golden Mean. A nurse who faces suffering on a regular basis must learn to cope without losing his or her sensibilities. Thus, nurses must continuously strike and maintain a balance between two dysfunctional opposites regarding affective engagement, the Scylla of detachment and the Charybdis of overinvolvement, for it is the mean that represents functionality (Carmack, 1997) - and professional virtue. To quote Gleichgerrcht and Decety (2012, 254): "In training for empathy, the main objective should be to achieve the optimal balance between being empathic without suffering the costs that come from overstimulating negative emotional arousal." In spite of the rise of holistic and patient-oriented nursing, this balancing skill still seems to belong to the tacit knowledge of nursing; practicing nurses often complain that their professional training did not properly prepare them for the emotional labour of nursing (Smith, 1992; Henderson, 2001). Yet this deficiency is no great surprise if balancing is a virtue in the Aristotelian sense, for virtues are learned only in practice under the tutelage of senior colleagues.

Nevertheless, balancing affective engagement can be learned, given time and experience. Betty Carmack (1997) suggested that having the potential to affect outcomes without needing to control them constitutes the core of this ability. Self-care and self-monitoring, as well as setting limits and boundaries on one's emotional labour also contribute to effective balancing. Omdahl and O'Donnell (1999), in turn, distinguished between emotional contagion and empathic concern in empathy. They found that emotional contagion was positively correlated with burnout, whereas empathic concern, which relates to an affective concern for the well-being of another without sharing emotion, was negatively correlated with burnout. These results are consistent with empirical evidence on down-regulation of empathy that comes with experience in medical settings (e.g. Decety, Yang, and Cheng, 2010). Thus, Gleichgerrcht and Decety (2012, 253) point out that "caregivers' down-regulation of the emotional response dampens their emotional arousal in response to the pain or distress of others and may thus have beneficial consequences in freeing up cognitive resources necessary for being of assistance and expressing empathic concern." Empathic concern manifests then regulated rather than contagious empathy. The role of experience in learning emotion regulation in a professional role suggests that it is a skilful capacity requiring careful observation of many "rights," determined by one's professional feeling and display rules.

Finally, there is some evidence that nurses may experience their emotion work in accordance with professional feeling and display rules as authentic even if this work requires considerable amount of emotion management. An emphatic nurse who perceives that his or her patient is anxious about a forthcoming operation and engages in a reassuring conversation with the patient is a case in point. The nurse's compassionate support of the patient complies with her professional feeling rules. A professional role may become a second nature to a seasoned nurse, who need not engage in conscious manoeuvring in order to evoke and maintain the relevant occupational emotions. However, the nurse still feels those emotions qua professional as his or her emphatic interest in the patient typically differs in its range and depth from the similar interest of a close relative or friend. Yet the differences between private and professional empathy do not render the latter inauthentic, as Louise de Raeve (2002) remarked. Instead of modelling authenticity on the intensity and spontaneity of some private emotions, we should rather see the two "worlds", private and professional, as distinct and meaningful in their own right. This view is consistent with the idea that our identities consist of various private and social roles whose feeling and display rules we have internalised as a part and parcel of those roles.

Nothing said above denies that the professional emotion management of nurses can be hard work - demanding, exhaustive, even sorrowful, as Nicky James (1989) showed in her studies on nursing the dying. However, the argument implies that exhaustiveness alone does not render emotion management in a professional role inauthentic any more than the occasional arduousness of managing emotions in private life. The main problem with emotionally exhaustive jobs seems to be that they must "be designed to be flexible enough to accommodate emotional labour" as James (1989, p. 34) argued. This requires, above all, that emotion work is recognised as a vital aspect of nursing and other professional work. Moreover, organisational mechanisms must be introduced to support coping with the negative effects of professional emotion work. Even so, we may not be able make this work easy. However, if we can show that emotions managed in our professional roles can cohere with our commitments, both private and professional, then we have presented a case for the authenticity of these emotions.

Conclusion

I have rejected Hochschilds and Bolton's view that limits authenticity to spontaneous emotions or emotions managed in accordance with non-institutional social feeling rules as insufficient. Instead, I have argued that the proper, a normative understanding of authenticity as a regulative ideal of coherence between a person's various roles and their constitutive commitments allows us to make conceptual room for the authenticity of emotions managed in a professional role, provided that the constitutive values, virtues, and beliefs of the role are compatible with the worker's other salient epistemic and normative commitments, and that emotions are managed in proper working conditions that include considerable autonomy, participative management style, social support, and a reasonable workload.

This resolution of the paradox of emotional authenticity challenges the prevalent view of emotional dissonance or inauthenticity as a defining aspect of emotional labour. Emotion management in accordance with professional virtues qualifies as emotional labour even if it need not involve experiences of inauthenticity. Moreover, professional emotion management in proper working conditions suggests itself as that benign type of emotional labour whose existence previous empirical research has indicated, without being able to specify it. This hypothesis appears plausible, given the evidence surveyed in this article. However, its testing is a topic for an interdisciplinary rather than merely philosophical study.

 
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