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Perspectives on emotional labour and bullying: reviewing the role of emotions

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Article  in  International Journal of Work Organisation and Emotion · May 2010

DOI: 10.1504/IJWOE.2010.032923

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Int. J. Work Organisation and Emotion, Vol. 3, No. 3, 2010 227

Perspectives on emotional labour and bullying:

reviewing the role of emotions in nursing and
healthcare

Pam Smith* and Helen Cowie

Faculty of Health and Medical Sciences,
University of Surrey,
Stag Hill, Guildford GU2 7TE, UK
E-mail: P.A.Smith@surrey.ac.uk
E-mail: h.cowie@surrey.ac.uk
*Corresponding author

Abstract: This paper identifies some critical issues about the inappropriate
expression of emotion in a range of healthcare settings. The authors review
the concept of emotional labour both from a theoretical perspective and as a
conceptual device for examining the role of emotions in nursing and healthcare.
The authors explore a range of perspectives on the concept of emotional labour,
each of which identifies different aspects that influence the extent to which
emotions are permitted, encouraged or deemed appropriate to be expressed in
healthcare settings. They also link the emotional labour literature with the
workplace bullying literature with specific reference to the emotional health
and well being of staff and service users.

Keywords: emotional labour; workplace bullying; communities of coping;

care; nursing.

Reference to this paper should be made as follows: Smith, P. and Cowie, H.

(2010) ‘Perspectives on emotional labour and bullying: reviewing the role of
emotions in nursing and healthcare’, Int. J. Work Organisation and Emotion,
Vol. 3, No. 3, pp.227–236.

Biographical notes: Pam Smith is General Nursing Council Trust Professor

of Nurse Education, Centre for Research in Nursing and Midwifery Education
in the Division of Social Care, Faculty of Health and Medical Sciences,
University of Surrey. She is known for her work on the emotional labour of
nursing and the coordination of the Working with Emotions Network. She is
currently seconded to the Nursing Studies Department University of Edinburgh.

Helen Cowie is Research Professor in the Division of Social Care, Faculty of

Health and Medical Sciences, University of Surrey. She is widely known
for her research into school and workplace bullying, on peer support
against bullying and on the emotional health and well being of young people.
She is Director of the UK Observatory for the Promotion of Non-Violence
www.ukobservatory.org and currently heads the UK teams in two EU-funded
projects on cyberbullying and on the creation of a virtual learning centre
for training professionals in strategies for counteracting school violence.
Her contribution to this paper was written during her one-year term as Visiting
Professor in the Graduate School of Education, Division of Learning Science,
Hiroshima University.

Copyright © 2010 Inderscience Enterprises Ltd.

228 P. Smith and H. Cowie

1 Introduction

This paper explores a range of literatures which cover the inappropriate expression of
emotions in healthcare settings, current debates concerning the conceptualisation
of emotional labour and the connection with organisational perspectives. The paper
discusses the theoretical relationship between caring and emotions to raise a number of
questions for future research.

2 Negative consequences of inappropriate emotional expression

in healthcare settings

In health and social care settings, the negative consequences of inappropriate emotional
expression – whether towards staff or service users – can have a serious impact on the
quality of care. In a care home or hospital, if inappropriate emotions have become the
norm, nurses are likely to be less able to give of themselves emotionally to the people
in their care, as Smith et al. (2006) found in their study of international nurses.
The service users, in turn, will be more likely to experience parallel emotions such as
fear, anxiety and helplessness, as Allan et al. (2009) observed in their study of the
emotional responses of international nurses who had been socially excluded or
marginalised by their colleagues, their supervisors and by the organisation itself.
These nurses found that not only were they bullied by supervisors but they received very
little support from colleagues who chose instead to act as if nothing untoward were
happening. Such bystander apathy simply added an extra dimension to the emotional
suffering of the international nurses in this study. The nurses were often forced to seek
out communities of support outside the workplace, for example in their local church.
The findings are confirmed in the literature on workplace bullying (e.g., Einarsen, 2004;
Zapf, 1999) by Mayhew (2002, p.22) who documents a range of reasons why employees
may choose not to report verbal abuse; for example, through embarrassment or because
of pressure from the organisational culture. Hochschild (1983) also writes of emotional
numbness and alienation from the self when employees face constant verbal abuse.
Recent studies of violence in the United Kingdom (UK) National Health Service
(NHS) have found significant levels of colleague-on-colleague bullying (e.g., Quine,
1999) but also of aggression on the part of patients towards healthcare professionals.
The latest report on staff in the UK NHS by the Healthcare Commission (Healthcare
Commission, 2008) found that 23% of NHS staff reported being bullied by patients, 18%
by patients’ relatives, 8% by managers and 13% by colleagues. Paradoxically, although
the majority of staff knew how to report such episodes, a substantial minority never
did so. This finding confirmed Einarsen’s (2004) proposal that the culture of the
workplace acts as a form of filter through which a range of behaviours come to be
accepted or even tolerated, despite the fact that most employees experience a high degree
of role conflict when they observe aggressive behaviour and report a poor quality of
environment in these circumstances.
In the specific context of care for older people who are particularly vulnerable, the
consequences of inappropriate emotional expression can be extreme, since many people
 Perspectives on emotional labour and bullying 229

become desensitised to others’ suffering the longer they are exposed to situations where
intervention does not take place. An example of the complex interplay of emotions in
such contexts is described by Eyers and Adams (2008) in their study of carers and nurses
working with older people with dementia. They document the observation that carers and
nurses may need to detach themselves from emotions such as revulsion at unpleasant
smells and body fluids in order to survive. Eyers and Adams (2008) refer to
‘emotional labour tools’, which they say workers use when dealing with situations such
as toileting, washing and dressing which potentially can be distressing and embarrassing
to carer and service user alike. These ‘tools’ such as listening and gentle persuasion are
regularly used to preserve the older person’s dignity and privacy. However, they can also
be implemented as a means of manipulating an older person to be more ‘cooperative’
within the limited time available to the carer. Where care staff and nurses are not trained
and supported to manage emotions in this way, there is clearly potential for vulnerable
and challenging service users to be subject to bullying and elder abuse.
As we indicate in the next section, the growing literature on emotional labour offers
perceptive insights into the processes at work when inappropriate emotions are expressed
to the detriment of care.

3 Current debates about the concept of emotional labour

Hochschild (1983) documented the institutionalisation of emotion, defining emotional

labour as the induction or suppression of feeling in order to sustain an outward
appearance that presents a socially desirable performance. The self-management of
emotions in this way, just like physical labour, involves effort and hard work on the part
of employees. She describes jobs with high emotional labour components as sharing three
characteristics:
• face to face or voice contact with the public
• they require the worker to produce an emotional state in another e.g., gratitude, fear
• they allow the employer through training and supervision to exercise a degree
of control over the emotional activities of their employees.
Hochschild suggests there are two kinds of emotional labour achieved through surface
and deep acting. In surface acting we consciously change our outer appearance in order to
make our inner feelings correspond to how we appear. Deep acting requires us to change
our inner feelings by a variety of methods so that they become our authentic feelings
which we freely present to the outside world. In surface acting we may experience
feelings of dissonance but this is not the case with deep acting because of the degree of
authenticity achieved. A critical issue concerns the extent to which professionals should
be trained to manage negative feelings in ways that lead to good quality of care while at
the same time preserving the authenticity of their experience.
Since the publication of Hochschild’s classic work, researchers in this field have
tended to focus on the three main aspects highlighted above:
230 P. Smith and H. Cowie

i the requirement of employees to have contact with people through face-to-face or

voice-to-voice interaction
ii the organisation’s requirement that employees produce an emotional state in another
person while at the same time managing their own feelings (for example, flight
attendants ensuring that passengers feel cared for or debt-collectors inducing fear in
those who owe the company money).
iii the organisation’s pressure on employees to conform to its culture.
In response to this growing body of research, Bolton (2000, 2003), Bolton and Boyd
(2003) challenged Hochschild’s original conceptualisation and expanded it by shifting
the emphasis from work environment to operating states within the work environment.
They proposed that there are four different kinds of emotional labour in the workplace
(Bolton and Boyd, 2003, p.19): presentational (where emotions are managed according
to social rules); philanthropic (where emotion management is offered as a gift);
prescriptive (where emotions are managed in line with organisational or professional
codes of conduct); pecuniary (where emotions are managed for commercial gain).
The presentational and philanthropic states tended to lead to positive views of emotional
labour, while the pecuniary state led to a negative view of emotional labour.
The prescriptive state, arising from professional or organisational feeling rules, created
both positive and negative outcomes. Within this framework, Bolton and Boyd (2003)
propose that there are multi-situated systems of activity involved in the performance of
emotional labour, including the degree of effort made by individuals in conforming to
organisational emotion rules as well as individuals’ resistance to demands for emotion
management. In other words, the context influences the range of feeling rules that exist in
the workplace and it may not always be the organisation that defines the emotional
agenda. This idea represents a substantial departure from Hochschild’s original theory.
With specific regard to healthcare settings, Bolton (2000, p.501) argues that
“the introduction of a market rationality into the management of the British
NHS has led to the term ‘emotional labour’ being used as part of a ‘business
model’ of healthcare where a nurse’s caring skills are utilised as a resource,”
indicating the “commodification of emotional labour” (Hochschild, 1983). However,
Bolton extends Hochschild’s (1983) concept of ‘gift exchange’ to show how the
actors – in this case gynaecology nurses – engage in varying degrees of emotion work
and therefore can choose what, when, where, how much and to whom they offer the gift
of emotion. The nurses described how the therapeutic use of humour gave patients the
opportunity to have a laugh in an ‘emotionful place’ that was a ‘woman’s world’. A ward
sister confirmed: “The essential basis of nursing is caring. You cannot be a nurse if you
don’t care” (Bolton, 2000, p.583). This study demonstrates the interaction between
different levels of emotion management: as individuals the nurses were prepared to give
patients extra time if they required it but at the same time worked hard to enact
professional feeling rules to present the image of a professional carer.
Theodosius (2006, 2008), from a different theoretical perspective, claims that the
concept of emotion management, although innovative in its time, ignored the
unconscious processes taking place during patient-nurse interaction. She argues that
working with emotions is integral to the way in which nurses construct their personal
identity and proposes that unconscious processes may underlie their decision to become
nurses in the first place (Theodosius, 2006, p.899). Theodosius’s (2006) methodology
 Perspectives on emotional labour and bullying 231

attempted to recover these unconscious emotions from patients, nurses and other health
care professionals by using diaries, interviews and participant observation. Theodosius
was concerned that the early emotional labour research of nursing (James, 1992;
Smith, 1992), rather than exposing emotion work and making it visible, had marginalised
it and driven it underground.
Theodosius (2008) extended the analysis of emotional labour to examine the nature of
emotions that nurses feel and how they form a part of their social identity which goes
beyond the presentational symbolic forms expressed through the emotion management
framework first inspired by Hochschild (1983). She also suggests ways that nurses can be
supported to learn to incorporate and manage complex, messy emotions as part of who
they are in terms of both their personal and professional self through reflexive
‘inner dialogue’ to develop these theoretical perspectives. Theodosius demonstrates her
approach through a series of powerful vignettes from which she concludes that
‘therapeutic’ emotional labour (which she distinguishes from ‘instrumental’ emotional
labour) “is still an important component to nursing care, that is still central to the nursing
identity and that society in the form of those nurses care for – still needs and believes
in it” (Theodosius, 2008, p.172). In the vignettes Theodosius describes complex and
challenging situations where nurses are working at the extremes: from loving care
to complaints; from trust and reciprocity with patients to feeling as if working at
‘half measures’ and being bullied by colleagues. Theodosius’s in depth analysis can best
be appreciated in reading it in its entirety but in summing up she highlights the essential
nature of two way relationships between nurses, patients and their carers which
contribute to the emotional labour process.

4 Organisational perspectives

However important it is to consider the interpersonal nature of the relationships in such

healthcare contexts, no analysis would be complete without considering the organisation
as a whole. Hochschild (1983) referred to this as ‘collective emotional labour’.
With regard to the management of emotions in the organisation, some emotional display
rules are explicitly taught to employees through induction, training and supervision.
Others, however, are implicitly learned through a process of observation of organisational
rituals and processes. Where the situation is ambiguous, employees make their own
judgements of what is allowed with the result that some rules are adopted while others
are ignored. Korczynski (2003) develops Hochschild’s concept of ‘collective emotional
labour’ by investigating the phenomenon of informal communities of coping that workers
form themselves in order to deal with the daily emotional pressures or even abuse that
they experience from their customers or service users. Here Korczynski moves away
from Hochschild’s focus on the harm of emotional labour on workers in order to
demonstrate how the communities of coping not only offer peer support but can also
act as forms of resistance. The call centre workers in Korczynski’s study dealt with
abusive interactions from customers by turning to colleagues rather than supervisors
for emotional support. In some instances, the communities of coping developed into
informal systems for employees to share extremely negative emotions about the
customers whom they served. In this way the informal communities of coping ran counter
to management policy since the organisation preferred workers not to vent their anger
with peers but instead only to share positive feelings about customers with colleagues.
232 P. Smith and H. Cowie

Additionally, the communities of coping could facilitate collective resistance to

some company proposals; for example, the introduction of performance-related pay.
Trade unions, understandably, were likely to view such communal ways of coping with
the pain of emotional labour as a potentially political basis for addressing the service
user/manager/employee relationships.
Glaso et al. (2006, p.257) take these ideas further by using the concept of emotional
labour to study leader-subordinate relationships in organisations, proposing that the
purpose of emotional labour is to influence other people’s perceptions, emotions,
attitudes and behaviour, and that displayed emotions are a tool for creating a mood,
emotional reaction or experience in others. This can be used in both positive and negative
ways depending on the intended outcome. For example, angry emotions can be directed
towards an individual or a group by management or by the peer group (Bowie, 2000).
Again, the use of emotional labour will be different if the commodification of labour
takes place in an unequal relationship between employee and customer or service-user
(Korczynski, 2002). Additionally, the climate of the organisation can have a strong
influence on the ways in which emotions are expressed (Cowie et al., 2002).
From a similar perspective, Townsend (2008) argues that we need to take account of
three sets of pressures on employees: management expectations, peers and the workers
themselves. Managers and supervisors attempt to induce their subordinates to conform to
the organisational culture and to follow certain rules. At the same time, co-workers who
fit the organisational culture will also put pressure on employees to behave in particular
ways and will engage in emotional labour to achieve this. Finally, employees will put
pressure on themselves to behave in ways that management deems to be appropriate in
order not to be perceived as outsiders. Each of these three sets of pressure involves
emotional labour on a daily basis, with costs and benefits in varying degrees. Many
employees, particularly those who have embraced the organisation values and culture,
find benefit in their emotional labour. Those who do not fit for whatever reason,
however, will experience costs, as we showed at the beginning of this paper where we
explored the consequences of inappropriate emotional expression in healthcare contexts,
such as in the care of older people.
Braverman (2002) suggests that organisations should manage specific incidents by
training their staff to find solutions that respect the emotions of the recipients of care.
Gazoni et al. (2008), for example, demonstrate the need for systems to support staff
in particularly stressful specialties such as anaesthesiology where the physician
(and by inference nurse specialists) have to deal with the emotional impact of
catastrophic events resulting in patient death. These authors identified evidence-based
strategies, including training programmes and open communication among colleagues,
patients and their families, to address profound emotions such as grief and guilt.
The capacity of leaders to listen and learn facilitates the recognition and effective
management of emotions and is germane to the development of a caring culture.
In a study of patient safety, Smith et al. (2009) described how patients and service users
require complex levels of care. In a similar way, Taylor (2006) argues that the emotional
toil of caring for people in sickness and as they die is rarely referred to in policy, even
though stress is inevitable when working with seriously ill patients and their relatives.
At a wider policy level, therefore, the organisation must consider appropriate
systemic interventions to take consistent account of the power of emotionally sensitive
individuals to use their own and others’ emotional states to prevent problems and find
solutions to bullying and abuse. Such policies should emphasise the importance of
 Perspectives on emotional labour and bullying 233

interpersonal skills, teamwork and leadership in promoting an open culture that

counteracts the tendency to scapegoat and blame individuals (for example, the older
person with a continence problem) rather than adopt a systemic analysis.
The concept of emotional intelligence, first described at length by Goleman (1995),
is worthy of consideration in this respect. Huy (1999) has connected emotional labour
and emotional intelligence theoretically and suggests that particularly at times of change
the process of change can be facilitated by judicious attention to emotions (Huy, 1999).
He concludes that emotions are an integral part of adaptation and change and emotionally
intelligent individuals are able to recognise and use their own and others’ emotional
states to solve problems.
Sakiyama (2009), following Fineman (2006), argues that emotional intelligence
involves judging people’s ability to deal with others and proposes that individuals
can achieve a positive attitude towards others by changing their cognitions rather than
focussing on their emotions. Such intelligence is beneficial to organisations in order to
deal with difficult interpersonal situations.

5 Discussion

The wealth of empirical studies inspired by Hochschild’s ground breaking study have
shown that there is a variation in how different types of emotional labour are valued and
recognised within the healthcare workplace. For example, the emotional labour of cancer
care is dependent upon whether the person with cancer is being actively treated or
has reached the palliative care stage (James, 1992; Kelly et al., 2000). It is perhaps
because of the heightening awareness of the need for nurses and others to be able to be
given emotional spaces to think and feel about their practice that there have been
some criticisms of Hochschild’s work which have described emotional labour as a
‘technical fix’, perpetuating the body-mind dichotomy and potentially separating out
emotions from the technical and physical aspects of care. It could be argued that at the
time when the topic was first being researched and written about, the language of
emotions revealed the hidden world of nursing and learning to be a nurse. Subsequently,
emotional labour has since become ‘normalised’ and incorporated into the everyday
language of nursing and care work and the current discourse of dignity and compassion
(Smith, 2008).
Benner and Wrubel (1989) propose a philosophical approach to the concept of care,
which transcends the body-mind split and enables connection and concern between nurse
and patient. Emotions are seen as the key to this connection because
“they allow the person to be engaged or involved in the situation .... The
alienated, detached view of emotions, as unruly bodily responses that must be
controlled actually cuts the person off from being involved in the situation in a
complete way.” (Benner and Wrubel, 1989)
Views such as these represent a trend over the past decade amongst nurses in the USA
and Europe to move to a more holistic approach to care and away from the over-reliance
on high tech medicine. This trend has continued over the intervening decades with
increasing attention to the role of emotions in nursing and caring. Three characteristics
of this trend can be noted. The first characteristic, illustrated by Theodosius’ work,
focuses on the role of the unconscious through a psychoanalytic and psychodynamic
234 P. Smith and H. Cowie

approach to the study of emotions. The second characteristic involves phenomenology

and embodiment as characterised by Benner’s (1984) work which continues to be
acknowledged as important for nursing. Finally, the symbolic interactionist and Marxist
stance of the cognitive approach to emotions, characterised by Hochschild’s work,
has attracted increasing theoretical critiques, in particular the risk that emotions
become marginalised and normalised, and so detract from what might otherwise be given
‘freely’ as part of who one is rather than simply what one is paid to do (McClure and
Murphy, 2007).
Hochschild’s (2003) description of four models of care offers useful insights into the
division of labour within the health service and the potentially gendered nature of care.
She proposes a cultural continuum of ‘traditional’, ‘post modern’, ‘cold modern’ and
‘warm modern’ in health care. The traditional model encourages nurses, in particular
women, to give over and above what they are supported to do both personally and
professionally. Such an approach reverses the changes that have taken place in women’s
entry into the workforce and tends to absolve men from the responsibility to care.
The post modern model demands the removal of the central image of the caring mother
figure, placing men and women as equals in the workforce and promoting the need for all
sectors of society to learn to live without care. The cold modern solution institutionalises
all forms of human care while the warm modern model values care at the individual,
family and public level supported by systems and processes in which nurses and other
professionals operate (Hochschild, 2003).

6 Conclusion

Hochschild’s (1983) research inspired a wealth of studies which took her original
analysis further to demonstrate the variation in how different types of emotional labour
are valued and recognised within healthcare and other workplace settings. There are also
a number of theoretically linked studies which demonstrate the relevance of workplace
bullying to staff and service users’ levels of emotional well being. Additionally,
phenomenological and psychoanalytic research considers the role of personal choice in
promoting relationships between healthcare staff and patients, and the role of effective
leadership, team working and the management of change in creating an ‘emotionful’
workplace.
A number of conceptual questions remain about the nature of care, each of which
is fraught with contrasts and contradictions (Smith and Cowie, 2009). If care is seen
as a right can it be professionalised? Is it morally right to control or manage emotions,
and who decides what is appropriate and what is permissible? Indeed, some emotional
intelligence research would seem to suggest that emotions are controlled by the needs
of the organisation. The bullying literature is useful here for providing insights as to the
ways in which workers can both resist control and yet be controlling. The essential
message seems to be about keeping the balance between rationality and emotion.
To this end, the provision of leadership that creates a culture grounded in care,
respect and compassion for the healthcare professionals at the front line should,
in turn, enable them to respond with appropriate emotions to the patients in their care
(Allan et al., 2008).
 Perspectives on emotional labour and bullying 235

Acknowledgements

Financial support was provided by the DAIWA Anglo-Japanese Foundation and by

Hiroshima University and the University of Surrey. This gave the authors time to present
their ideas, discuss them with colleagues in health and education from UK and Japan,
and prepare the manuscript for submission to IJWOE. Helen Cowie and Pam Smith
contributed equally in the writing of this paper.

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