The Emotional Labour of Care

A response to Medicine Unboxed Voice 2013

I was 17 years old, working as a health care assistant on an elderly care ward at Winchester hospital in 1988. I remember a morning shift when I was responsible for helping six patients get washed and dressed. No matter how demented or unaware of their surroundings, we wanted every patient to be properly dressed and “sat out”. Maureen was 81 years old, suffering from Alzheimer’s disease, her confusion compounded by a recent stroke and a urine infection. She was lying in bed, calling out, “Na! Na! Na! Na! Na! Na! Na! Naaaaaa!” I pushed my trolley with a bowl of warm soapy water, wipes, fresh clothes and clean linen up to her bed and pulled the curtains around. I squeezed her hand and said, “Good morning Maureen, I’ve come to help you get ready for the day”. She looked at me and continued saying, “Na!” I pulled back the sheet and saw that she had managed to pull off her padded incontinence knickers, faeces were all over the sheets, down her legs, up her back all the way to the nape of her neck and in her hair. She seemed completely unaware. I had been working on the ward for a month and was used to bodily fluids, but the smell still made me retch. I quickly stepped outside the curtains as my mouth filled with saliva and my stomach tightened. I concentrated on my breathing for a minute and went back inside to see Maureen holding her faeces-covered hands in front of her face. I grabbed a cloth and without having time to put on gloves or an apron, wrapped it around her hands. Instinctively she snatched them away – she shocked me with her strength and left my bare-hands covered in brown slime.

Eventually, she was sitting in the chair beside her bed, washed and dressed; it was 8.30am. I had another 5 patients to go. As I pulled back the curtains, I heard an unmistakeable squelching sound and its accompanying smell. Perhaps, I hoped, I was mistaken. Other patients were lying in soiled sheets and incontinence pads, calling out for help, or too confused or weak to call. Briefly I looked at Maureen, my bag full of soiled cloths, the bowl of tepid dirty, soapy water and the clock on the breakfast trolley, slowly cooling porridge congealing. Should I pull the curtains around again, start all over again? Keep the other patients waiting? I didn’t know, I really didn’t. I closed my eyes, gritted my teeth and I moved on to my next patient.

Eight years later I was 25 years old, working as a casualty doctor in Greenwich. It was about 2.30am, there were perhaps 12 patients waiting to be seen and the time between arrival and my assessment was about 3 hours: about average for that time of the night. The call came out on the PA to say that a serious trauma call was coming in by ambulance. I made my apologies to the tearful young woman who was having a miscarriage and ran to the desk. It was only my fifth day as a junior casualty doctor and it was my first trauma call. The nurse in charge took me aside. She explained that the three young women coming in were already dead, killed in a car crash. It was my job to certify them. All I had to do was go into the ambulance and check their vital signs. I remember standing outside in the icy february night. My heart was pounding in the back of my throat when the ambulance pulled up, blue lights on, siren off. The doors opened and one of the paramedics held the door open. I climbed in. It was the first time I had ever been in an ambulance. I can only remember one of the faces, or perhaps so long after the event what I can remember is an amalgamation of all three. She was the same age as me. Her face was grotesquely twisted, like her unbroken face might have looked like an hour ago, reflected in a broken mirror. Micropore tape held her jaw and temples roughly straight. Her eyes were wide open, each staring, frightened, in different directions. Certification of death meant shining a light into her eyes and listening to her heart and lungs. Kneeling down, praying or sobbing all seemed more appropriate. I performed my duty, solemnly, terrified, utterly unprepared. I walked back into the department, straight into an angry relative, demanding, drunkenly, when – the fuck – I was going to see his wife.

This week aged 42, I finished my morning GP duty session at 1.30pm after taking 53 calls from anxious patients, seeing 10 patients face-to-face and doing one home visit. I sent one woman to hospital with an infected knee, spent 30 minutes with a man who since his teenage daughter was diagnosed with schizophrenia has lost his job, been arrested for drunk driving and bought rat-poison with the intention of suicide, and stopped half the regular prescriptions for an elderly woman who told me she wanted to stop postponing death. I was just about to slip out to get some lunch when the practice manager called to ask if she could speak to me urgently, one of my patients had complained about me and had written to the local newspaper, the MP and the parliamentary health ombudsman. I opened my door to find one of our trainees waiting outside – “Please can you help me?” she asked. My next session was due to start at 2pm, there were 15 patients booked in, I had 43 blood results to check, a boxful of hospital letters, and a message from a social worker about a patient that was expected to die. I hadn’t had anything to eat or drink, or even time to pee since I left home at 7.15.

Work like this constitutes a normal working day for health professionals, but at the same time it is completely abnormal. To do this, and to engage seriously, compassionately and with full attention and moral seriousness demands what Iona Heath has described with eloquent passion as a “Labour of Love”. It is emotional labour. If we expect healthcare professionals to treat care as a vocation and patients with empathy and compassion, we need to appreciate the enormous burden of patient-centred care. We must treat carers with the kindness and respect we expect them to treat their patients. We must make time to help them give the personal care their patients need and time to listen to them. We must listen to their concerns, their doubts, fears and distress.

Not a day goes by without someone in health policy or politics claiming that the NHS has put professionals before patients for too long, or that public service propagates professional complacency or that the threat of competition or prison is needed to improve care or compassion. These claims are profoundly depressing and so far removed from my experiences of 25 years of personal care, so insulting to all the dedicated, caring professionals I’ve worked with, and so, so wrong for patients.

Why Managing Emotion is Such a Crucial Task

Menzies Lyth, the emotional labour of care and social defences, blog by Richard Smith

Thinking about the emotional labour of nursing –
supporting nurses to care Sawbridge Y, Hewison A 2013

How do you care? Wonderful blog by a nurse about how she cares for elderly paitents.

Threats cannot make healthcare workers more compassionate

The last thing the NHS needs is a compassion pill 

Do Doctors Need to be Kind?

Iona Heath Love’s Labours Lost: Why Society is Straitjacketing its Professionals and How We Might Release Them

A very similar experience described by a newly qualified nurse

A child’s tragic story ended my nursing career. Guardian Feb 2016

28 responses to “The Emotional Labour of Care

  1. Jonathon

    My heart is sore. For you, for your younger selves and for every healthcare professional (in attitude, not letters after your name) working on the edge of overwhelm. You deserve better.
    I’ve been staring at this for 10 minutes, wanting to write more, yet unable to find the words. I’ll simply say that you have reminded me, again, why I choose to work around the NHS.

    Tilla

  2. Thank you, Dr. Tomlinson this is really good, it captures really well the reality of what I can expect, when I start working.

  3. You remind me of some of my psychologically disturbing experiences as a medical student and then as a junior hospital doctor. Now in retirement, I think of those times when that crystallisation of vocation took place.
    The healthcare needs of the community today are no different, but I fear that too many of our newly qualified doctors, having emerged from the current educational sausage machine, may not have had either that experience or the motivation to excel in anything other than ticking the boxes handed down by the politicians. Those same politicians whose fingers are not on the pulse but the purse. Those political cynics who encourage the population to demand what they want, not what they need, knowing that those massaged wants will be used to bankrupt the NHS and offer the profiteers the opportunity to take over.
    Am I depressed? No. Good will out!

  4. This is a must read blog! Thanks for this perspective

  5. julia.andrsen72@yahoo.co.uk

    I am a 41 year old GP and these experiences echo my own. I do still love my job and daily try my best but the emotional and physical burden of simply having too much to do in too short a time can be, at times, overwhelming. I believe I am permanently on the cusp of doing harm because of lack of time to consider increasingly complex needs. This was beautifully written and should be read by all.

    • Thanks Julia, I know how common it is and I’m glad it resonates. I’ve been studying doctors’ narratives of their experiences as patients and have used it to give lectures to medical students and trainee GPs recently. I intend to put it online when it’s a finished piece. As I was cycling from Cheltenham to Gloucester last night I thought of this blog and thought I should write it down while it was fresh in my mind. I hope to come up with some ideas about how we can better care for ourselves and each-other in the next few weeks/ months, and will of course share them,
      Kind regards,
      Jonathon

      • Jonathon-thanks again for your thoughtful thoughts.I look forward to hearing some ideas about how to care for each other-we do not seem to prioritise this, and time, of course, is the hardest thing to find when we are all under pressure.To do our jobs well, it needs to hurt emotionally sometimes I think-but we also need to find ways to repair that hurt and look out for it in others.
        Regards,
        Richard.

      • Thanks Richard,
        I was reminded by Iona Heath at Medicine Unboxed at the weekend, that emotional labour is where we find the greatest satisfaction in our work, as well as the greatest suffering. Menzies Lyth’s insight was that we develop social defences, either as individuals or institutions to prevent emotional engagement in order to protect ourselves from suffering. The risk she identified was that emotional labour isn’t simply a danger that leads inevitably to burnout, but is a source of great therapeutic value and necessary for job satisfaction. The key is to find ways in which we can give ourselves and eachother the capacity for emotional labour without burning out.
        The problem, is that where productivity and efficiency are drivers of care, the time for reflection and listening is squeezed out. We all need to figure out some solutions for this,
        warm regards,
        Jonathon

  6. Who cares for the carers ? I wish some of the politicians and writers for The Daily Mail would shadow gps, nurses, drs , and carers to see what working in health and social care really is like .Employers need to be person centred in their approach to their staff .I believe the majority of people who work in healthcare want to care but systems do not encourage or allow or support them to do so .

    • Linda….Wondering if you are a carer?. It would be useful if the authentic voice of ‘carers’ was heard more rather than through people who have not had their hands on experience …..not just for a short period of time but often as a life time job where there is no choice/no career structure/no extra specialist training at taxpayers/employers expense/ no opportunities to attend or speak at conferences,international and national events etc , no titles/accolades/medals or other signs of status .just ‘quietly getting on with it.’..until fairly recently the opportunities for speaking out for themselves have improved via social media… still too often though others are not making enough effort step aside and let those with the knowledge experience ,maybe but not always love of the kind Iona claims..lead the show themselves.

  7. This really resonates with me as a working GP and now a GP tutor to first and second year medical students… you’ve put into words something that I often struggle to articulate; the sheer overwhelming nature of the work we do as health care professionals. Lately I’ve found poetry seems to help me express some of these things. Voice, such an important thing for all.

  8. Thankyou again for another beautiful read. You’re helping motivate me to finish my phd thesis 😉
    You might enjoy Karen Hitchcock’s writings – an Aust medico and writer –
    http://www.themonthly.com.au/karen-hitchcock

  9. Myself and my brother are nurses, my mother was a nurse. Her regular battle cry is no one in this family should be in the caring profession because we are not emotionally equipped for such work.
    I read your wonderful blogs and they really resonate with me. I have been in the situation you describe in your first paragraph countless times, and each time it upsets me afresh. I will never get used to breaking bad news and will always have a catch in my voice when supporting the family of terminally ill patients.
    I want patients and relatives to know I care but I understand that caring the way I do isn’t healthy for me sometimes. I am saddened that many more people will read the Daily Mail’s take on health professionals than these excellent blogs.
    As I work in Scotland we are sheltered from some of the recent healthcare policy decisions. I will continue to deliver the type of care that I would like if I were a patient, aware of the damage of caring too much whilst thinking it is better than not caring at all.

  10. You have eloquently hit the spot. We need to care for the carer, the professional carer and the patient.

  11. Reblogged this on jorowsite and commented:
    How can we support the healthcare worker more to care for patients better?

  12. This is all very real. Beautifully expressed.

  13. Reblogged this on learn4kicks.

  14. Whew what can I say except thank you

  15. The blog shold be essential reading for everyone who doesn’t work in a caring role and thinks they could do it better. Not all days are like the ones described. Some are less pressured and sometimes you just can’t put your whole self in. In the short run I have always found the more I put in the more I get out but I wonder about the long term price. My friend, GP just killed himself after a long and respected career. Nobody knows why he did it but surely the years of emotional labour must have contributed. Two of the three consultants in my service were on antidepressants. Sure, medicine and nursing and the undervalued “healthcare assisting” have always been hard emotional work but think what it might be like to have been taught and to have learned learned how to do it in times when there was a certain ammount of time and equipment and then to be reqired to do the job to the same high technical and emotional standard with diminishing resorces. The sense that we are not doing the job properly, or even well enough, that we have anyway, is reinforced whenever we open a newspaper. We kid ourselves that if only we could work harder, longer and more empathically we could at least stop things from slipping backwards. Does it helps, at all to recognise that as well as the inevitable horrors of sickness and dying we are facing a planned reduction of what we are allowed and paid to do?

  16. thend@freenetname.co.uk

    Thank you for this.

    Best wishes

    Terence Henders

  17. “Not a day goes by without someone in health policy or politics claiming that the NHS has put professionals before patients for too long”

    Is it possible that the UK can afford fewer doctors per capita to provide empathic, patient-centred care because British doctors make salary demands that are among the highest in the world (1.)?

    In Cuba – a poor country with limited resources – there are three times as many doctors per 1000 patients to provide healthcare. This is achievable because Cuban doctors are paid just above the national average wage for their country.

    Inequalities of wealth have an impact on social inequality (the richer you are the less likely you are to be empathic, compassionate and selfless towards those less fortunate than yourself (2.).

    Social inequality is also a major factor in determining the health inequities and disease burden that necessitate provision of greater levels of care.

    A healthcare system that provides low numbers of very well-paid yet burnt-out doctors is not a system that is designed with patients’ needs in mind.

    If (as happens in Cuba) you only had one third of your current list of patients, would it not be better for both your mental and physical health and that of your patients?

    And if GPs really valued emotional labour as opposed to paying lip service to the idea, wouldn’t they be sharing their profits equitably with their HCAs and nurses?

    1. Torsen, I. (2013) UK GPs are best paid in the industrialised world http://www.onmedica.com/NewsArticle.aspx?id=de86bae2-2e60-4a86-a64c-506a4dd08074

    2. Grewal, D. (2012) How Wealth Reduces Compassion
    http://www.scientificamerican.com/article.cfm?id=how-wealth-reduces-compassion

    • First consider the costs involved in medical undergraduate and post-graduate education, indemnity costs, continued education costs, BMA/GMC/RCGP fees … etc. and subtracted this from the average HCA/nurse/ wage …
      Secondly I don’t know of any healthcare professional who thinks that more money would counteract the emotional demands of their job even though the suggestion that making doctors and nurses poorer would make them more compassionate seems counter-intuitive.
      Finally, structural inequalities are a reflection of society, Cuban doctors are a reflection of Cuban society so we cannot successfully import Cuban medical culture without converting to Cuban social culture, however much we dreamy Utopians may wish.

  18. |I know many low paid healthcare workers would definitely think more money would would help to counteract the emotional demands of the job……more opportunity to work shorter hours /, to recharge batteries in ways the higher paid are able /to repair the damage to bodies/ etc. The the inequalities in pay highlights the way those who do the hands on work are treated.. they do often resent the the way those who control their work have lost touch with what the reality is actually like. It is actually valuable hear others’ experience of different structures and their analysis of how the NHS is perceived. The days when the NHS was regarded as the gold standard are fading – it can and must learn to adopt new structures and daresay learn a different morality in some ways from what works in other societies

  19. And surely also it is loose headlines proclaiming 13,000 needless deaths which provoke the public and generate unsustainable pressures. It can’t be right to allow a statistical estimate to whip up such hysteria.

    Even at Mid Staffs where many deaths resulting from poor care were likely, it can’t be right to imply that hundreds died avoidably until case note and other evidence has confirmed this cause as the most likely contributing factor.

    Although Dr Laker was dubious that his review process could ever have identified avoidable deaths with certainty, his conclusion that he was only able to confirm “perhaps” one from among those drawn to his attention by relatives, must raise doubts regarding the suggested figures of 400-1200.

    If the police also then investigated 300 of the suspected cases but find “insufficient evidence” to proceed further, either massive deliberate loss, spoiling or destruction of case note evidence occurred (presumably feasible) or the actual scale of deaths attributable to poor care must surely have been exaggerated.

    Francis makes plain the severity and extent of poor care but, until evidence of hundreds of deaths attributable to it is confirmed, stating as fact that “1200 died” avoidably (for example, as Dr Phil Hammond did in Private Eye), rather than just “many are likely to have died”, must raise a question as to whether these headline figures are meant purely for publicity, purely to encourage hysteria.

    If the medical fraternity feel such headlines and consequent public frenzy to be damaging and perhaps skews future policy, even if thought useful in the short term to expose poor care, how can NHS statistics be used and released responsibly and fairly while nevertheless preventing cover-ups, obfuscation and denial?

  20. Oh dear! Jackson! Is there an appropriate repost to those who think that a generous salary makes a doctor less caring?
    I suppose it was inevitable that someone might drag out the spectre of the pompous Hospital Consultant, with his big house, flash car and posh wife – a caricature of a minority of today’s medics and the consequence of NHS Consultants being able to indulge themselves in private practice. This has created obvious conflicts of interest which the public have not been slow to appreciate.
    Those who would defend this aberration claim that private practice helps to shorten NHS Hospital waiting lists. True, but it also persuades the needy, who may have put aside savings for an emergency, to part with their money.
    Doctors in general are very well paid, but how many of us had the protected time to spend with our families that the even better paid lawyers and accountants could enjoy?
    I may be in a minority of one, but I believe that if Hospital Doctors devoted all their time to the NHS, then waiting lists would be wholly dependent on the number of doctors employed and the supply of NHS facilities.
    Today it is the Executives and Managers of the NHS whose fingers have slipped from the pulse to the purse. The Chief Executive in Colchester, whose annual salary exceeds £150,000 before any allowances are made for expenses, currently presides over a target fudging culture and a heavy handed approach to dissent. It is parasites like this that should be pilloried.

  21. Reblogged this on #healthystaff4healthypatients and commented:
    This resonates so much with my own experiences of caring and the experiences of others who have come to tell their story. Re-blogging in support of a subject close to my heart. Working on the solution.

  22. This resonates so much with my own experiences of caring and the experiences of others who have come to tell their story. Re-blogging in support of a subject close to my heart. Working on the solution.

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