1. art and entertainment
2. books and literature

Emplacing Anger: Emotion Management in West African Pediatric Wards
Ryann Manning
PhD Student
Organizational Behavior and Sociology
Harvard University
rmanning@hbs,edu
April 21, 2015
DRAFT – PLEASE DO NOT CITE OR CIRCULATE WITHOUT PERMISSION
ABSTRACT: A wide range of workers are regularly tasked with managing their
own and others’ negative emotions. Existing literature points to several strategies
for doing so, but is based largely on organizational settings characterized by clear
and consistent feeling rules and by readily available backstage space. Using
observational and interview data from high-mortality pediatric hospital wards in
West Africa, I find that nurses in highly visible settings characterized by complex
and contradictory emotional cultures often struggle to adhere to the dominant
feeling rules in their organizations and profession. In particular, during urgent, lifethreatening situations, nurses frequently and publicly express anger and frustration
toward the parents of their patients, in direct contravention of the feeling rules that
the nurses adamantly assert. When nurses are able to construct or discover small
opportunities for protected backstage space, albeit partial and temporary, they are
better able to adhere to feeling rules and deliver professional, compassionate care.
These spatial strategies for emotion management are therefore an important
resource for workers in this setting. My findings advance theory on emotion
management and on the sociology of space and place, and contribute to a growing
literature on the abuse and neglect of patients by health workers.
Emotions infuse our working lives. From hospitals to restaurants, airplane cabins to police
interrogation rooms, a wide range of workers are tasked with managing their own or others’
emotions. Though emotional labor can impose a burden on workers (Bono and Vey 2005; Boyle
2005; Hochschild 1983; Kahn 1993) it can also help them protect and sustain their own well-being
or derive pleasure or meaning from work (Bolton 2000; Korczynski 2003; Stenross and Kleinman
1989; Wharton 1999). The skilled management of negative emotions, in particular, can be essential
for advancing organizational goals and meeting the needs of both internal and external actors
(Geddes and Callister 2007; Lewis 2005; Martin 1999; Pierce 1995).
Existing literature on workplace emotion management rests on a strong but often implicit
assumption: that each organizational setting is governed by clear and internally-consistent feeling
rules, norms for what emotions are appropriate and acceptable for workers to feel and to express.
However, many organizations have complex and multifaceted emotional cultures—encompassing
not only norms but also vocabularies and beliefs related to emotion (Peterson 2006)—with
potentially contradictory prescriptions for employees’ emotion management. Although some
scholars of emotion have acknowledged this complexity (see, e.g., Hochschild 1979; Peterson 2006;
Thoits 1990), they do not fully explore the implications. As a result, we know little about how
workers manage difficult emotions when the feeling rules dominant in their organization are
inconsistent or incompatible with other aspects of its emotional culture.
In this article, I draw from extensive observational and interview data from three hospital
wards treating critically ill children in a West African country, and show that nurses working in
these settings face complex emotional cultures and often struggle to adhere to their organizations’
and profession’s dominant feeling rules. In particular, during urgent, life-threatening situations,
nurses frequently and publicly express anger and frustration toward the parents of their patients, in
DRAFT – DO NOT CIRCULATE OR CITE WITHOUT PERMISSION
2
direct contravention of the professional expectations that nurses themselves adamantly assert.
However, when nurses are able to construct or discover small opportunities for protected, private
space—in a setting in which such backstage space is extremely limited—they are better able to deal
with the complex and contradictory emotional culture, to adhere to the dominant feeling rules, and
to deliver professional, compassionate care.
This article makes several contributions. First, I build on the literature on emotion
management by exploring how workers manage difficult emotions in complex and even
contradictory emotional cultures. Specifically, I theorize a new set of strategies for emotion
management—spatial strategies—that can be combined with those identified by existing literature;
with these techniques, workers are able to construct temporary and partial backstage spaces to help
them better manage difficult emotions. Second, I contribute to the growing literature on abuse and
neglect of patients by health workers, which has not previously considered abuse as resulting from a
failure of emotion management, nor addressed the role of space in facilitating or discouraging
abusive behaviors. Third, I contribute to the sociology of space and place, by showing that even in
workplaces characterized by near-constant visibility and low levels of backstage space, workers can
still find temporary protected spaces in which to engage in emotion management.
EMOTION MANAGEMENT AND CONTRADICTORY EMOTIONAL CULTURES
A rich tradition of scholarship on the sociology of emotions and on emotion in organizations
has examined how workers manage their own emotions in order to express the emotions considered
acceptable and appropriate by their employers or occupations. Studies have highlighted two distinct
but interrelated sets of strategies for managing negative or potentially disruptive emotions: workers
DRAFT – DO NOT CIRCULATE OR CITE WITHOUT PERMISSION
3
may use distancing or detachment to protect themselves emotionally, or they may engage in
emotional labor to align their felt or expressed emotions with applicable norms.
The first strategy emerges from literature on workers who regularly confront the darker
aspects of life and death. The emotional burden for these workers can be substantial; they may
experience direct and vicarious trauma (Kahn 2003), begin to doubt their capabilities or
professional identity (Stayt 2009), or become fixated on death or overwhelmed by a sense of futility
(Good et al. 1999). To cope, such workers often cultivate distance or detachment from their clients
or patients (Lewis 2005; Maben, Latter, and Clark 2006; Menzies 1960; Sorensen and Iedema 2009;
Stayt 2009; Sutton 1991). Individuals employ “distancing tactics” (Stayt 2009:1272) to protect
themselves, and organizations embed these defense mechanisms in their structure, culture, and
routines (Menzies 1960). Although some workers find emotional engagement unavoidable (Field
1984) or desirable (Margolis et al. 2008), many are taught that too much involvement with clients
can exact a psychological toll (Sorensen and Iedema 2009; Sutton 1991); instead they must walk a
“tightrope… between closeness and distance” (Meerabeau and Page 1998:297).
The second strategy, commonly called emotional labor when performed as part of paid
employment and emotion work when performed in private life (Hochschild 1983), involves actively
managing one’s emotions in order to align them with the applicable feeling rules: normative
expectations for what emotions should be experienced and expressed in a given situation
(Hochschild 1979; Wharton 2009). When workers experience dissonance between the emotions
they actually feel and those they perceive are required (Rubin et al. 2005), they may engage in
“surface acting,” feigning emotions they do not feel; or “deep acting,” changing their inner feelings
to match what is expected (Hochschild 1983). In the case of negative emotions, workers are often
DRAFT – DO NOT CIRCULATE OR CITE WITHOUT PERMISSION
4
expected to suppress or avoid them (Geddes and Callister 2007), but may also be required to
generate or express them in certain situations (Martin 1999; Pierce 1995; Sutton 1991).
Scholars have studied emotional labor in a diverse array of occupations, ranging from flight
attendants and bill collectors (Hochschild 1983; Sutton 1991) to call center workers (Korczynski
2003; McCance et al. 2013) and nurses (Bolton 2001; Diefendorff et al. 2011). Many have focused
on the deleterious effects of emotional labor (Bono and Vey 2005; Boyle 2005; Meerabeau and
Page 1998; Stayt 2009) but others have argued that workers selectively deploy different emotion
management techniques, some of which may be enjoyable or rewarding (Bolton and Boyd 2003;
Bolton 2000; Lopez 2006; Stenross and Kleinman 1989). Emotional labor involving reciprocal
emotion management (Lively 2000) or collective processing of emotions (Lewis 2005, 2008;
McCance et al. 2013)—by, for instance, developing “communities of coping” (Korczynski 2003) or
using shared laughter and storytelling to defuse and displace difficult emotions (Martin 1999;
Sutton 1991)—may be particularly satisfying.
This literature has greatly enhanced our understanding of how workers’ emotional
experiences are shaped and constrained by social factors, including the emotional culture: the
vocabularies, beliefs, and norms (e.g., feeling rules) related to emotion (Peterson 2006) of an
organization or group (see also Barsade and O’Neill 2014; Gordon 1989). However, most of these
studies rest on a strong implicit assumption: that workers face a clear and internally-consistent set of
feeling rules. Scholars conceptualize these norms as stemming from both “employers’ specific
requirements for emotional display and… societal and cultural beliefs about emotional expression”
(Wharton 2009:156), but tend to assume that the result is relatively clear to both workers and
clients. For instance, one study of convenience store clerks found “instant, tacit agreement between
clerks and customers about which norms of emotional expression should guide their behavior”
DRAFT – DO NOT CIRCULATE OR CITE WITHOUT PERMISSION
5
(Sutton and Rafaeli 1988:474). These differed when the store was busy from when it was slow, but
in each case the norms were clear to all participants. Similarly, a study of waiters found distinct but
internally coherent small group cultures governing emotion management during the day and night
shifts (Hallett 2003).
In practice, feeling rules and other aspects of emotional culture are often dynamic,
multifaceted, or contradictory. Scholars of emotion have acknowledged this complexity. As early as
1979, Hochschild (1979:567–568) observed that there may be “conflicts and contradictions between
contending sets of rules” during times of social change, while another early study acknowledged
that “when it comes to deciding what rules are to govern action, thought, and feeling, organizational
ones will not always suffice or win out” (Van Maanen and Kunda 1989:58). Echoing this, a more
recent study found that strong professional norms requiring nurses to suppress emotions and
maintain a “professional” distance were in tension with more personal norms of involvement with
patients (Lewis 2005). Existing literature on workplace emotion management does not fully explore
the consequences of this complexity, except to suggest that it might increase the likelihood of
emotional deviance (Thoits 1990), cause workers to “eschew… professional feeling rules” in favor
of alternate sets of norms (Lewis 2005:573), or “contribute to an inability to effectively manage our
emotions” (Peterson 2006:126). We therefore know little about how workers manage their emotions
when the feeling rules defined by their employers or occupations are unclear, inconsistent, or
contradicted by other aspects of the emotional culture. Are the strategies for emotion management
described by existing literature still relevant in such circumstances? Are there additional strategies
required for successful emotion management in the face of a complex emotional culture?
In this article, I seek to explain how nurses in three West African pediatric hospital wards, in
which the dominant feeling rules are directly contradicted by other cultural influences, are
DRAFT – DO NOT CIRCULATE OR CITE WITHOUT PERMISSION
6
sometimes able to successfully adhere to those feeling rules, and at other times express anger and
frustration that violate organizational prohibitions. To do so, I draw on literature that links the
expression and management of emotion to the structure and use of space.
EMPLACING EMOTION MANAGEMENT
In recent decades, a few scholars have called for a rediscovery by sociology of space and
place (Baldry 1999; Gieryn 2000; Kornberger and Clegg 2004). Space and place, like time, are
ever-present but often invisible (Markus 2006), a “medium through which social life happens”
(Gieryn 2000:467) that structures and is structured by human interaction (Bourdieu 1989; Lefebvre
1991). Places, which range in size from a nation or city to one corner of a room, are not only vessels
for social interaction but also reflect and constitute systems of power and meaning (Chanlat 2006;
Muetzelfeldt 2006). Scholars define space and place in diverse and sometimes contradictory ways
(see, e.g., Gieryn 2000; Goonewardena et al. 2008; Taylor and Spicer 2007). In this article, I
conceptualize space as encompassing material form, symbolic meaning, and the practices of social
actors. By this conception, a given space is neither limited to nor completely divorced from its
physical features, such as distance and material structure, but is also enacted by the social actors
who inhabit it, and who endow it with meaning through their actions and perceptions.
We know from existing literature that space matters to workers’ experience and expression
of emotion. In particular, numerous studies have shown that workers manage emotions differently
across three spatial regions: front stage, where the performances that constitute social life take
place; backstage, where social actors are protected from the audience and thus free to step out of
character; and a residual offstage space (Goffman 1959). Backstage space can make it easier for
workers to manage difficult emotions, enabling them to express or process prohibited emotions in
private (Freund 1998; Jeffery 1979; Korczynski 2003; Meerabeau and Page 1998; Sutton 1991)
DRAFT – DO NOT CIRCULATE OR CITE WITHOUT PERMISSION
7
while displaying employer-sanctioned emotions during front stage interactions. Frequently, workers
use private backstage areas for collective coping and mutual support (Lewis 2005; Martin 1999),
though they may also cope individually or with the support of family members (Boyle 2005). In the
healthcare setting, workers often sequester to the backstage emotion-laden activities and events,
including those related to death and dying (Oliver, Porock, and Oliver 2006; Sudnow 1967) and
discussing or expressing judgments of patients or family members (Heimer and Staffen 1995;
Jeffery 1979).
Protected backstage space is therefore important not only for morale and group cohesion
(Tanner and Timmons 2000) and productive risk-taking (Ross 2007), but also for facilitating
emotion management. The availability of such space, however, varies dramatically across settings.
Front and backstage may be delineated through the physical structuring of space or through
interactions and meaning-making. To create backstage spaces, individuals may use physical (Lewin
and Reeves 2011) or temporal (Lewis 2008) boundaries, “concealment rituals” (Costello 2006), or
devices that obscure their identities (Ross 2007; Tanner and Timmons 2000). The presence,
composition, or level of (in)attention of various audiences may also distinguish front from
backstage (Goffman 1959). In some settings, however, workers have limited privacy and are
restricted in their ability to exclude certain audiences or otherwise create backstage space. For
example, the flight attendants in Hochschild’s classic study were usually front stage throughout a
flight, and were discouraged by management from using the limited backstage available to them
(the galleys) for venting emotions (Hochschild 1983). Many other workplace settings, ranging from
open-plan offices to closely-monitored airport security lines, also limit workers’ access to backstage
areas to a greater or lesser degree. Despite this frequency, we know little about how these limits on
backstage space affect workplace emotion management.
DRAFT – DO NOT CIRCULATE OR CITE WITHOUT PERMISSION
8
In this article, I cross these two literatures, and combine the notion of a complex and
contradictory emotional culture with the importance of backstage space. I draw from observational
and interview data on hospital wards in West Africa in which backstage space is elusive and nurses
are highly visible. In these intensely public and culturally complex spaces, I find that nurses strive
to discover or construct protected spaces in which to process, vent, and otherwise manage their
difficult emotions. Although the spaces they construct are temporary and partial, their spatial
strategies for emotion management prove to be a valuable resource during emotionally-fraught lifethreatening incidents, and enable nurses to better adhere to the expectations of their organizations
and profession.
THE STUDY: BACKGROUND, METHODS, DATA
This article is based on inductive, qualitative fieldwork with nurses treating pediatric
patients in public hospital wards in West Africa.1 The hospitals, which I will call Capital and
Provincial Hospitals, were selected to be representative of how under-resourced healthcare systems
care for severely ill patients. I focus on nurses and pediatric patients because of their importance to
public health scholars and practitioners. Nurses comprise nearly 75% of the clinical healthcare
workforce in the country where this research took place, and outnumber doctors 20 to 1. Nurses are
also perhaps the prototypical emotion managers (Theodosius 2008). The busy hospital wards that I
study have high rates of severe illness and inpatient mortality, and therefore provide an excellent
opportunity for observing how nurses manage life-or-death situations.
Context and Research Sites
1
To protect the confidentiality of my research participants, I will not identify the specific country or hospitals involved.
All names are pseudonyms.
DRAFT – DO NOT CIRCULATE OR CITE WITHOUT PERMISSION
9
My research sites are government hospitals located in one of the poorest countries in the
world, where more than half of the population lives in severe poverty, and nearly twenty percent of
children die before the age of five. Still rebuilding from a civil conflict in the 1990s, the country’s
governance structures, public services, and infrastructure are extremely weak. Despite considerable
public investment in recent years, health facilities remain under-resourced, skilled medical staff are
sorely lacking, and there are significant performance problems among health workers.
Both hospitals are publicly funded referral and teaching hospitals staffed by civil servants.
Capital Hospital, which treats more than 11,000 pediatric inpatients per year, is within walking
distance of approximately one million impoverished city dwellers. Provincial Hospital is located in
one of the country’s largest district capitals, and treats around 8,000 pediatric inpatients per year.2 I
conducted preliminary interviews and observations in all inpatient wards of Capital Hospital, but
later focused data collection on three wards (details in Table 1) chosen to reflect a typical nurse’s
experience: the pediatric inpatient ward in Provincial Hospital, and a general pediatric ward and
step-down unit for more severely ill children at Capital Hospital.
INSERT TABLE 1 ABOUT HERE
Death is a constant presence at these facilities. The vast majority of patients are under the
age of five and suffering from preventable and treatable—but frequently fatal—conditions such as
malaria, pneumonia, malnutrition, and diarrheal diseases. In 2012, Capital Hospital admitted more
lost nearly 13% of inpatients, or more than 120 infants and young children each month, not
including those who are dead on arrival or immediately thereafter and are never officially admitted.
Comparative data for Provincial Hospital are not available, but the mortality rate is likely similar.
Each nurse will be aware of a high proportion of these deaths.
2
Numbers for Capital Hospital come from hospital reports. Similar data were not available for Provincial Hospital, so I
estimated this based on daily admissions during my stay, adjusted for seasonal variation and under-reporting.
DRAFT – DO NOT CIRCULATE OR CITE WITHOUT PERMISSION
10
The wards differ substantially from facilities in wealthier countries. They are often dirty and
chaotic, with no electronic monitors or high-tech equipment except for a few oxygen concentrators
in Capital’s step-down ward and in the “IV room” (IVR) in Provincial Hospital.3 Wards are
crowded with non-staff adults, because each child is accompanied at all times by a caregiver,
usually a mother, grandmother, or sister. Nurses delegate responsibility to these caregivers for the
children’s feeding, bathing, and most other daily care, as well as for monitoring their condition and
alerting nurses if they show signs of deterioration, such as worsening diarrhea or fever, difficulty
breathing, or convulsions. Caregivers sleep in the hospital, usually in the child’s bed, which is
sometimes also shared with other patients. For the most part, time moves very slowly; staff and
patients sit idly for hours in the tropical heat, waiting for something to happen. Nurses spend much
of the day at the nurses’ station, chatting with one another or, occasionally, with patients, and
catching up on record-keeping. These periods of suspended animation alternate with sudden bursts
of activity: medication rounds, doctor’s rounds, waves of new admissions, and emergencies
heralded by a caregiver’s cry and attended by a flurry of activity.
Methods and Data
I collected the core data for this article during two phases of field research in 2012, and I
also incorporate historical data from 2008-2011, during which time I lived in the country and
worked in Capital Hospital as part of a technical assistance and capacity-building team.4 My work
at that time involved analyzing why the hospital was failing to provide an adequate standard of care,
and how that might be improved. Thus, while not formally conducting research, I engaged in active
observation and analysis, and wrote personal notes and memos, public reflections, and reports and
proposals for my colleagues. These writings document, among other issues, problems of poor
3
Used in the place of compressed oxygen cylinders, these machines make ambient air more oxygen-rich.
At the time I was an advisor and manager, but I had prior training in research methods and had recently completed a
large qualitative study in the same country.
4
DRAFT – DO NOT CIRCULATE OR CITE WITHOUT PERMISSION
11
performance by hospital staff and instances of conflict between staff and patients. They provide
important background to help me interpret data from the later study. My earlier observations and
experiences helped motivate and inform the design of this project, which strives for a balance of
distance and involvement (Anteby 2012).
When I re-entered Capital Hospital in 2012, I did so with this background, but in a very
different role. Due to high turnover, only a small number of the nurses knew me from before, but I
took care with all nurses to distinguish this project from my earlier role. I had no prior experience
with Provincial Hospital and the nurses there knew me only as a researcher.5
As summarized in Table 2, I use four types of data: interview, observational, archival, and
historical. First, I conducted 23 relatively formal, semi-structured interviews with 29 nurses or
trainee nurses, plus dozens of informal ad hoc interviews and conversations with many more.
Nurses were selected to reflect a diversity of backgrounds, levels of experience, and observed
behavior. Informal conversations took place as and when the nurses’ workload allowed. I created a
spreadsheet with basic demographic and professional information about all the nurses I had met or
observed, updated this each night from my field notes, and used it to select future interviewees. I
also approached nurses whose interactions with patients and families had been particularly positive,
puzzling, or problematic. Interviewees were not compensated, but on my last days in the field, I
bought candy or soft drinks for all the nurses as a token of gratitude.
INSERT TABLE 2 ABOUT HERE
My interview protocol covered a range of topics related to the nurses’ training, experience,
motivations, and professional identity, including how they thought other people viewed the nursing
profession. Most relevant for this article, I asked nurses at length about their perceptions of and
5
I explained that I was conducting academic research, and provided no technical or managerial support while in the
field. The similarity of findings between the two hospitals suggests that my prior role at Capital Hospital did not alter
the nurses’ behavior or other aspects of my data.
DRAFT – DO NOT CIRCULATE OR CITE WITHOUT PERMISSION
12
experiences with patients and their families, and how they managed difficult emotions and
challenging situations with families. Specifically, I asked them what they did when they got
frustrated, angry, or upset about something that happened at work, and what they felt and did when
patients died. With few exceptions, all interviews were conducted in the local creole language,
which I speak fluently. Nearly all formal interviews were digitally recorded, and the others were
transcribed immediately based on detailed notes. For ad hoc interviews, I took notes in a small
notebook either during the conversation or immediately thereafter.
The second type of data come from 164 hours of direct, first-hand observation of nurses at
work, and include extensive field notes and tables tracking nurses’ activities over space and time.
More than 80% of my observation was focused on the three focal wards, where I spent
approximately 4-6 hours per day and five days per week during the second phase of research.
Various practical and ethical considerations prevented me from taking part in the nurses’ tasks, and
thus my participation was limited primarily to spending time with the nurses, chatting and
establishing trust and rapport, while also observing their behavior, particularly their interactions
with one another and with patients, family members, and other visitors. The nurses spent large parts
of their day sitting at the nurse’s station (up to 50 percent of their time according to data from six
representative days), so it was straightforward for me to observe and talk with them.
In total, I have data on approximately 150 nurses from my observations and interviews,
reflecting the demographic and professional diversity of nurses in both hospitals, including all tiers
of trained, trainee, and untrained nurses. All but a handful of nurses were female, with a wide range
of ages, ethnicities, birthplaces, and training schools.
The third and fourth types of data are archival (photos, artifacts, and hospital data on patient
numbers and staffing levels) and historical (from minutes, reports, and other written materials from
DRAFT – DO NOT CIRCULATE OR CITE WITHOUT PERMISSION
13
2008-2011). These primarily serve to inform my analysis of the interview and observational data,
and as an additional source of data on the emotional cultures on these wards.
Data Analysis
In preparation for analysis, I transcribed and translated my interview recordings from the
local creole language into English, while taking note of any terms that were particularly evocative
or difficult to translate. I coded my handwritten field notes manually at first, and then subsequently
transcribed relevant sections of my field notes, including those relating to emotional culture,
expression, and management. As described later, I also transcribed and translated all aspects of field
notes that related to patient deaths and urgent incidents. Coding of these qualitative data followed
an abductive process (Timmermans and Tavory 2012), in which iterative rounds of coding allowed
me to identify surprising findings and approach them from various theoretical perspectives, seeking
ways to better understand my data and build theory. Four analytic categories emerged from this
process and formed my final coding scheme: feeling rules and emotional culture; emotion
management techniques; expressions of emotion; and the structuring and use of space.
The first category of codes relate to the emotional culture on these wards, particularly the
feeling rules that prescribe the direction, intensity, and duration of emotions that workers should
experience and express in a given situation (Peterson 2006; Wharton 2009). To decipher the feeling
rules governing nurses in Capital and Provincial Hospitals, I used data from interviews in which
nurses discussed what emotional experiences and expressions were considered appropriate on the
wards; field notes in which I observed nurses discussing their colleagues’ emotional displays;
observational data from incidents in which nurses enforced particular feeling rules; and artifacts that
reinforced or symbolized feeling rules, such as the poster in Figure 1. In addition, while iterating
DRAFT – DO NOT CIRCULATE OR CITE WITHOUT PERMISSION
14
between my data and literature, I discovered and coded evidence of alternate, sometimes conflicting
elements of the emotional culture of these hospital wards.
The second category of codes capture emotion management: actions the nurses took to align
their own emotions with the relevant feeling rules. I follow previous scholars (for a review, see
Wharton 2009) in using both observational and interview methods to capture nurses’ emotion
management. I coded my interviews for nurses’ own accounts of how they managed emotions, and I
coded behaviors that I observed and which reflected specific emotion management techniques.
Specifically, I coded for two types of emotion management drawn from prior theory and research:
protective distancing and emotional labor.
The third category of codes relate to expressions of emotion by nurses. In this paper, I focus
primarily on expressions of emotion during 30 emergency incidents, including 13 cases in which the
child died and 17 urgent cases in which, as far as I know, the child survived. I include as urgent
cases all children whom I saw convulsing (13) plus four who were not convulsing but who nurses or
doctors made clear were facing a life-threatening situation. I also incorporate more limited data
from two cases in which I saw the body after death, and six recently-occurred deaths that I heard
nurses or doctors discussing. Data on these incidents come predominantly from first-hand
observation, with some comments from nurses during interviews and discussions following the
incidents. After transcribing and translating my field notes into a narrative account of each incident,
I created a table of the 30 incidents, with columns specifying details about each case including the
interactions (if any) between nurses and patients’ family members and whether nurses expressed
any emotion—usually sympathy, sadness, anger, or blame—to me or to one another. I also recorded
features of the ward and of individuals, including demographic and socioeconomic data on the
DRAFT – DO NOT CIRCULATE OR CITE WITHOUT PERMISSION
15
nurses, patient, and family; information about the busyness and overall mood of the ward at the time
of the incident; and any other deaths or urgent cases earlier in the shift.
The final category of codes represents a theme that emerged from my observational data: the
spatial dynamics of the hospital, and the ways in which nurses strive to create and use protected
backstage spaces. As discussed earlier, existing literature shows that workers often process their
emotions in private, backstage areas or at home or otherwise off stage. In analyzing my data, I
began to wonder if the lack of backstage space at Capital and Provincial hospitals may be
constraining how nurses manage negative emotions. To test this emerging theory, I moved down a
level of analysis and divided the 30 emergency incidents into171 composite actions or interactions,
155 of which involved nurses. (The others involved only doctors, patients’ family members, or
others on the ward). I separated actions according to the parties involved in the action or interaction,
with a new action created each time the configuration of individual(s) changed. For instance, if two
nurses were speaking to one another and another nurse joined them, I created two actions, the first
involving two nurses and the second involving three. If one of the nurses subsequently left the
conversation and went to speak to a patient, this became a third action. One example of an incident
broken down into component actions and coded in this way is included in Table 3.
INSERT TABLE 3 ABOUT HERE
Finally, I coded each component action for any emotions expressed and for the level of
backstage space, which was coded on a scale from 1 (virtually no backstage) to 5 (almost fully
backstage).6 I found that the availability of backstage space was very low overall, but ebbed and
6
Coding criteria for the availability of backstage space are as follows. 1: Virtually no backstage. Active attention from a
crowd of other patients and other staff. 2: Low/Medium backstage. Numerous parents and/or non-staff observers nearby
and observing the actions and interactions of nurses, but their attention is divided / not focused on nurses. 3: Medium
backstage. Fewer people around and/or attention is divided. Includes actions that are less likely to attract attention (e.g.,
giving injection, wrapping body after death) but are observable and observed by at least some bystanders. Also include
relatively private conversations between nurses and just one patient or family member. 4: High/Medium backstage.
DRAFT – DO NOT CIRCULATE OR CITE WITHOUT PERMISSION
16
flowed across the component actions of a given incident. To analyze the interplay of space and
emotional expression across incidents, I used truth tables (Becker 1998) to systematically count the
occurrence of different configurations, and created a series of graphs to help visualize the rhythm of
interactions. In addition, I analyzed the actions of each nurse within and across incidents to explore
the co-occurrence and sequencing of backstage availability and emotional expression.
PROFESSIONAL FEELING RULES AND COMPETING EMOTIONAL CULTURES
Interviews, artifacts, and observations at Capital and Provincial Hospital reveal a strong set
of feeling rules that emphasize professionalism and compassionate care. Nurses view these rules as
the most dominant aspect of their workplace’s emotional culture, but I find that they coexist with
two other, largely contradictory systems of meaning: the culture of colonial-era nursing, which
continues to influence nurses today; and the expressive emotional culture of the broader society, in
which nurses are embedded outside of work and which also enters the wards through porous
boundaries and via patients, families, and visitors. I will describe each of these influences in turn.
Dominant Feeling Rules: Modern, Professionalized Nursing Culture
During formal and informal interviews and in conversations among themselves, the nurses at
Capital and Provincial hospitals articulate clear and consistent prescriptions that they should
provide professional and compassionate care. They say they are expected to cultivate feelings of
empathy for patients and their families, while displaying a neutral affect and offering comfort and
reassurance. As one nurse explained, “I don’t want [the patients’ families] to see me cry… I need to
encourage them.” This expectation is also evident in the language used in the nightly report book on
Semi-private conversations among nurses or between nurses and me, or nurses and doctors, but can be overheard by
patients or others not involved in conversation. 5: Almost fully backstage: private conversations among nurses or
between nurses and me.
DRAFT – DO NOT CIRCULATE OR CITE WITHOUT PERMISSION
17
Capital Hospital’s step down ward, which the night shift uses to document any deaths, emergencies,
or significant changes in patients’ conditions. During one period, every single entry ended with the
phrase, “Nursing care duly rendered and relatives reassured,” a clear signal of how the author
understood the organization’s feeling rules.
Nurses also emphatically asserted that they should not shout, argue, or express anger with
patients or family members. As one senior nurse at Provincial Hospital put it, “You have to comport
yourself… Because if [a patient or family member] confronts you, and you get in an argument with
him, the job won’t go on well.” A more recently trained nurse chimed in, “It’s not ethical.” In
another interview, I asked a supervising nurse if it was ever acceptable for nurses to speak harshly
to patients’ families—for instance, when families failed to obey nurses’ instructions. “It is not
necessary and it is not appropriate,” she asserted emphatically and without exception. Other nurses
independently agreed. “If you holler, it means you don’t know your job,” said one, while another,
when asked for her least favorite aspects of the job, said one was seeing her colleagues shout at
patients. Nurses not only denounced shouting when speaking with me, but also in conversations
among themselves. For instance, two nurses were awaiting the next shift’s arrival one night and
gossiping, within my earshot, about their colleagues. One recounted with disapproval a nurse who
yelled at a woman whose child had died. She must have never lost a close family member, the two
surmised, shaking their heads, or she would have shown more empathy.
This language that nurses use to describe these dominant display rules invokes a modern
professionalized nursing culture. This is further reinforced by symbolic resources, such as signs
posted prominently around the hospital by nurse supervisors. For example, a “Notice to all
Colleagues” posted in several places around Capital Hospital, and shown in Figure 1, draws on the
modern conceptualization of patients as clients and healthcare as a service relationship, and calls on
DRAFT – DO NOT CIRCULATE OR CITE WITHOUT PERMISSION
18
nurses to “maintain a client friendly environment at all times.” It also explicitly invokes the
“professionalism” of nurses, and emphasizes their role in providing compassionate care. Another
posted notice quotes a nursing pledge, borrowed from a South African school of nursing, which
includes modern notions of confidentiality and non-discrimination, such as “I will hold in
confidence all personal matters coming to my knowledge” and “I will not permit considerations of
religion, nationality, race or social standing to intervene between my duty and my patient.” These
norms are shared and reinforced by members of the public, who frequently complain (though not
directly to nurses) of rudeness or harsh treatment by health workers. They, like the nurses I
interviewed, saw nurses shouting at patients as having crossed a “threshold of impropriety” (Geddes
and Callister 2007).
INSERT FIGURE 1 ABOUT HERE
Thus, the dominant feeling rules reflected both in cultural artifacts on these hospital wards
and in how nurses talk about their role are consistent with a modern, professionalized nursing
culture. However, I also found evidence that these norms coexisted on the wards with two other,
largely contradictory systems of meaning.
Alternative Feeling Rules: Historical Residue and the Culture of British Colonial Medicine
Nursing was a core element of the British colonial project in Africa, crucial to the control of
native populations and the expansion of empire (Comaroff and Comaroff 1992; Howell et al. 2013;
Nestel 1998). As essential foot soldiers in a “civilizing” mission, nurses and other health workers
sought to confront what they saw as rampant disease and disorder in African societies (Vaughan
1991), and to correct what seemed primitive and backward (Allman 1994). Such efforts were often
steeped with condescension, an attitude that persists in many spheres of modern African life
(Englund 2006). As they travelled to Africa, British colonial nurses carried with them the
DRAFT – DO NOT CIRCULATE OR CITE WITHOUT PERMISSION
19
professional and organizational cultures of their day, which were imparted to (and reinterpreted by)
indigenous medical personnel (Van Tol 2007). The remnants of those cultures persist today.
One sign of this historical residue is the rigid system of nursing uniforms used in my field
sites, as in much of Anglophone Africa. In stark contrast to typically vivid and elaborate West
African attire, nurses are required to wear old-fashioned British nursing uniforms—understated
cotton dresses, often with pinstripes, cinched waists, and scalloped piping—in colors and styles
determined by their level of training and position in the hospital. The rules are the most strict, and
strictly enforced, during socialization: trainees wear white aprons, linen caps, and watch fobs
straight from a 1950s British hospital. (Trainees are also required to use English rather than local
languages, another residue of colonialism.) These uniforms stem from the militarized origins of
British nursing and echo the nineteenth and early twentieth century Nightingale nursing ethos,
which dictated that nurses be “exemplars of middle-class morality and deportment, paragons of
cleanliness and order” (Nestel 1998:262). Uniforms are also symbols that help distinguish trained
nurses from the uneducated masses (Nestel 1998) and set nurses apart from the private, familial
sphere: in uniform, they are no longer mothers and sisters from the same neighborhoods as their
patients, but professionals occupying a sterilized and Westernized public realm.
The cultural residue of colonial nursing is also evident in the minority viewpoint expressed
by a few nurses that shouting at parents can sometimes help educate them and correct their
behaviors. For instance, one highly skilled and dedicated nurse manager at Capital Hospital told me
that shouting at mothers was occasionally necessary to prevent dangerous behaviors. After telling
me how angry she felt toward parents who leave against medical advice, she recounted one case in
which a mother later returned, her child much sicker. The nurse shouted at her, telling her she been
“careless with [her] child.”
DRAFT – DO NOT CIRCULATE OR CITE WITHOUT PERMISSION
20
Q:
So after you yell [vex] at a patient like that, do you feel better?
A:
I feel better, because I’m just trying to make her understand… So the next
time, when they put her child on treatment, she’ll say, ‘Oh, let me take [the
pills]… When I [didn’t], the nurse got angry at me.’ She’ll have it in the back
of her mind. If she wants to be careless, when she remembers ‘that nurse got
angry at me,’ that will motivate her.
From this perspective, shouting can help protect children by educating their parents, or
sometimes other parents on the ward. As one nurse said, “I tell [some parents], ‘If this child dies,
you’re responsible. It’s your carelessness that made the child die’… Then I call the other patients
and say, this one is an example to you, that when you have your child at home, the moment when
your child [starts behaving differently or complaining of pain]… you come” to the hospital. One
night I observed this kind of group warning in action:
Suddenly, a woman rushed to the nurse’s station with a toddler in her arms.
A crowd formed: staff, visitors, and the mothers of other patients. Before I knew what
was happening, one nurse was holding the girl upside down by her ankles and
slapping her on her back. “Was she feeding her?” someone asked, and I realized she
must be choking. With each slap from the nurse’s open palm, the toddler’s body
whiplashed, her head snapping through the air.
Meanwhile, another nurse began yelling at the assembled crowd. “This is
why you should not hand feed your children,” she shouted, “and why you should
holler if they begin to choke!” Gesturing wildly, she recounted another case, when a
grandmother refused to follow the nurse’s advice on how to feed her grandchild, and
DRAFT – DO NOT CIRCULATE OR CITE WITHOUT PERMISSION
21
as a result, the child died. That death was the grandmother’s fault, the nurse said,
just as this young girl’s mother was to blame for the fact that her daughter’s life was
slipping away. Listening silently, the crowd gazed from the angry nurse to the child,
still hanging upside down from the first nurse’s right hand. A moment later, the
nurses declared the child dead and laid her on a table.
I never saw the child’s mother, though she was almost certainly nearby, but the nurse’s angry
speech had made her cautionary tale for the other mothers on the ward.
Broader Influences: The Expressive Emotional Culture of West African Societies
In addition to these two conflicting sets of occupational norms—drawn, respectively, from
the cultures of modern and colonial-era nursing—is a third influence on how nurses in Capital and
Provincial hospitals manage and express their emotions: the expressive emotional culture that
prevails in the surrounding society. 7 People in this country, as in much of the region, often express
emotions vocally and forthrightly, sometimes shifting abruptly from calm, polite conversation to an
outright shouting match, and then returning to amiable interaction. A level of verbal conflict that
might elsewhere damage the parties’ relationship is here often temporary, and later brushed off with
surprising ease. In the local creole language, to allow this flash of negative emotions is to “blow” or
“blast”, and many people find it helpful and appropriate to “blow” for a moment when they are
angry or frustrated, so they can then move on.
Grief is also expressed in highly vocal and visible ways. A mother’s response to the death of
her child is usually to shriek or wail loudly, tear off her head wrap or other clothing, and collapse to
7
The emotional culture outside the hospital is of course even more complex than which governs nurses’ actions within,
and other scholars have found that some cultural groups in this region disapprove of “overt displays of emotion”
(Fanthorpe 2007:17). My own observations during this field work and for many years prior, however, along with
informal interviews with many people native to this country, are consistent with the norms described in this section.
DRAFT – DO NOT CIRCULATE OR CITE WITHOUT PERMISSION
22
the floor. This may continue for hours, and friends and relatives (or even acquaintances) may join
the mother in her vocal expression of grief. Attitudes toward this vocal expression are mixed: nurses
express admiration for those rare cases in which mothers are subdued at the loss of their children,
and ethnographers have documented a similar preference for stoicism among some ethnic groups in
West Africa (see, e.g., Jackson 2011), and yet such control is by far the exception to the norm.
Nurses are themselves embedded in this wider culture, and inevitably carry it with them onto
hospital wards. In addition, the porous boundaries of these hospitals make it easy for the outside
world to infuse the wards. This is hardly unique to Capital and Provincial hospitals—all
organizations are embedded in and influenced by larger cultural systems—but these wards represent
an extreme case. They are constantly open to the surrounding environment, which includes blaring
horns and blasting music from dense urban traffic at Capital Hospital, and chickens who jump onto
hospital beds and wander the corridors of Provincial Hospital. At both hospitals, a near-constant
flow of people wander in and out of the wards at will, including staff, patients, visitors, and vendors
selling food, diapers, or household goods. Nurses lack authority over which patients to treat—these
are public hospitals open to all, and doctors are responsible for admission and discharge decisions—
and nurses struggle to effectively police the borders of their wards.
Nurses’ frustration at the intrusion of an external emotional culture into the purportedly staid
and professional spaces of the hospital wards is exemplified by the stories they tell patients or
visitors who fight with one another, or who insult or accost healthcare staff. “Patient, visitor, they
don’t have any respect, any regard” for us, one told me. Another recounted a time when she was
working in a different provincial hospital, and the deputy mayor’s wife was brought to the hospital
due to an accident. Large crowds of visitors arrived, far too many to be accommodated in the tiny
ward. “They almost wanted to beat me” when I told them to leave, the nurse said, “Ehhh! Fight
DRAFT – DO NOT CIRCULATE OR CITE WITHOUT PERMISSION
23
fight fight.” While expressing empathy for the visitors’ behavior—that if it were her mother, she
would also want to rush in—the nurse said she was “vexed” and had to “cool her heart” before
attending to the patient, and only after the visitors had finally been convinced to leave.
In summary, nurses in Capital and Provincial hospitals must grapple with competing
prescriptions, practices, and taken-for-granted assumptions regarding the appropriate expression of
emotion at work. Although the vast majority of nurses firmly and emphatically articulate feeling
rules requiring professional dispassion and compassion, they are also influenced by colonial-era
nursing practices and by the expressive emotional culture of the broader society. Given this
complexity, how do they manage their own negative and potentially disruptive emotions? Do they
simply revert to free expressions of emotion, “blowing” and “blasting,” as they might in their
private lives? Do they enact the role of colonial “maternal imperialists” (Allman 1994), scolding
and correcting mothers’ behavior? Or do they successfully adhere to the professional norms they
adamantly assert—and if so, how? The next section will consider these questions in the context of
emotionally fraught, life-threatening incidents.
EMOTION MANAGEMENT AND EXPRESSION DURING CRITICAL INCIDENTS
In this section, I focus on nurses’ emotion management during 30 urgent cases, and find that
in these critical, life-threatening moments, nurses often struggled to adhere to feeling rules. Instead,
they frequently and publicly expressed anger and frustration toward the parents of patients. In 10 of
30 urgent incidents, 5 of them fatal, I saw nurses shout at or publicly scold parents. As shown in
Table 4, shouting or public scolding was twice as likely to occur than any effort to comfort or
reassure parents. In one case, a nurse used physical violence and public humiliation to berate a
mother who failed to call the doctor when her baby started convulsing. As I wrote in a field memo:
DRAFT – DO NOT CIRCULATE OR CITE WITHOUT PERMISSION
24
I looked over to find the nurse slapping a woman, likely the child’s mother,
on the back and arm. The woman was very young, her hair loose and frazzled (a
sign of extreme distress) and she wore the standard attire of the city’s poor: a
second-hand shirt, cotton sarong, and plastic flip-flops. Clearly confused and
ashamed, she kept looking around the ward to see who was watching. Indeed, she
was in full view of two wards’ worth of doctors and nurses, several dozen mothers
or caregivers, and her own child – all witnesses to her shame.
Shouting and gesturing rapidly, the nurse made the woman use her tank top
to clean the exam table and her child. The nurse then wiped her own hands on the
tank top, which the woman was still wearing. Only after this striking public
humiliation did the nurse explain to the mother what she meant by a convulsion; I
could see her pantomime tight fists and vibrating arms. Before that, the mother
likely had no idea what the nurse was talking about, let alone how serious a
symptom this was.
Though unique in its use of physical violence, this case otherwise mirrored other incidents in which
nurses shouted at or publicly blamed parents.
INSERT TABLE 4 ABOUT HERE
There are many reasons that nurses at Capital and Provincial Hospitals might be angry or
frustrated at work, including challenging working conditions, low pay, and limited control over
their postings. The nurses’ anger and frustration toward parents can be explained, in part, by the fact
that parents in this setting often do share the blame for the severity of their child’s illness. In one
extreme case, I saw a baby die from sepsis that the staff believed was caused by her being left too
DRAFT – DO NOT CIRCULATE OR CITE WITHOUT PERMISSION
25
long at home in a dirty diaper. More generally, data show that parents frequently wait for days or
longer to seek care for their children, or seek care first from a pharmacy, drug peddler, or traditional
healer, and arrive at the hospital too late for the children to be saved.8 Staff at Capital and Provincial
Hospitals express frustration about these delays, saying that parents “sit down and wait” and then
arrive expecting a miracle, sometimes even lying about how long their children have been sick.
They also express frustration with parents who remove their children from the hospital prematurely,
known colloquially and in official records as “absconding.” 9 This infuriates health workers because
the children, whose lives they have worked hard to save, will likely deteriorate again when their
parents bring them home too soon. This “work loss” (Glaser and Strauss 1964) also means parents
may return expecting that nurses will save their child again. As one nurse told me, “You’re treating
a patient, they start to get better, and then they leave. And when the child gets worse and comes
back and passes off (dies)” they blame the hospital.
Sometimes, nurses’ anger toward parents may serve to displace or cope with other
uncomfortable and potentially threatening emotions, such as grief, guilt, anxiety, or shame (Katz
1999; Meerabeau and Page 1998). Nurses often experience the death of a patient as a threat to their
own skill and competence; as one senior nurse manager said, “[When a patient dies, it suggests that]
maybe you don’t know anything.” Patients who come too late to save can make the nurses’ work
seem futile; “your efforts go in vain,” one explained. Nurses also feel that some parents hold them
accountable for failing to save their children, and although these accusations trigger no legal or
professional sanctions, they do carry an emotional and social weight and corroborate negative
8
The many reasons for delay include some parents’ poor understanding of illness and medicine; perceived or real
financial barriers; transportation constraints; work or family obligations; and lack of trust in hospital-based care. Studies
show that poor families around the world often delay seeking care or go first to alternative providers, and turn to
Western health facilities as a last resort (Mota et al. 2009; Nyamongo 2002; Ryan 1998; Scott et al. 2013; Spry 2012)
9
Parents may abscond for many of the same reasons that they delay seeking care, or they may be frightened by things
they observe on the ward, tired of the hospital’s unpleasant conditions, unhappy with the treatment they have received,
or confident their child is getting better and can safely go home.
DRAFT – DO NOT CIRCULATE OR CITE WITHOUT PERMISSION
26
stereotypes of nurses as incompetent, corrupt, or cruel. Deciding that parents are to blame may help
the nurses deflect blame from themselves, and may shield them from some of the taint and stigma
that stem from their association with death (Ashforth and Kreiner 1999). Expressing this blame
publicly and in a way that parents consider inappropriate, however, is likely to backfire: reinforcing
negative public perceptions of nurses and giving parents yet another reason to delay care-seeking or
abscond from the hospital (Bowser and Hill 2010; Martineau 2012; Moyer et al. 2014).
Not only does shouting at parents likely exacerbate the problems that anger nurses in the
first place, but it also violates the nurses’ own beliefs regarding appropriate emotional expression.
As described above, some influences on the emotional culture of these wards make allowances for
open expressions of negative emotions, and a few nurses articulated the view that shouting at
parents might sometimes be beneficial or educative. However, the vast majority of nurses
specifically and emphatically asserted that nurses should never shout, argue, or express anger with
patients or family members and should instead “reassure” and “encourage” them. This is not lip
service; nurses exert to adhere to the prohibition on shouting, and to assist their colleagues to do the
same. I observed nurses engaging in various emotion management techniques, including (as I will
describe later) collective processing and other techniques to “cool their hearts” and maintain the
emotional expressions required of professional nursing care. Nurses also engaged in emotional
detachment, taking steps to distance themselves from patients and their caregivers. For instance,
they rarely physically touched the children or engaged in conversation with their parents. In many
(if not most) cases, neither the nurses nor the parents ever learned one another’s names.
Nurses are clearly striving to manage their emotions in line with the feeling rules that they
ardently articulate, but their efforts are only sometimes successful. What factors might explain this
variation? To understand when nurses succeed or fail at emotion management, I first ruled out a
DRAFT – DO NOT CIRCULATE OR CITE WITHOUT PERMISSION
27
number of factors that seemed likely, but proved not to matter. The variation was not a function of
individual difference; some of the nurses I observed being unusually committed and compassionate
one moment behaved with callousness or aggression in the next, while nurses I had seen harshly
shame patients’ families on one day were comforting on another. I found no difference in the
likelihood of nurses to shout at or publicly scold parents who were of a particular ethnic, religious,
or socioeconomic status, either in absolute terms or relative to their own. The age of the patient also
did not matter, nor did the nurse-patient ratio.
Eventually, after rounds of iterating between my data and existing theory, a theme emerged
that helped me understand the variation in nurses’ expressed emotions during urgent situations, and
thus their success (or failure) at emotion management. To explain, I turn to characteristics of the
hospital wards as spaces with material form and symbolic meaning.
The Structure of Space: An Elusive Backstage
Overall, nurses in Capital and Provincial Hospitals lack the backstage space that workers
elsewhere often use to express or otherwise process negative emotions. These wards are intensely
public spaces. Only waist-high walls divide the large, open wards in Capital Hospital, while in
Provincial Hospital, shown in Figure 2, five extremely crowded rooms hold dozens of beds,
overflow patients lie on beds in the corridor, and the sickest children occupy the tiny IVR, a lowtech intensive care unit crammed with staff, children, and their anxious parents. There are no
curtains or private patient rooms in either hospital, and patients and staff share the same spaces.
Beds and exam tables, some holding two or three children, are often just inches apart. There are
very few designated spaces—whether physical, temporal, or virtual—for nurses to speak privately
among themselves. The nurses’ stations are within eyesight and earshot of many members of the
public, and lack the physical barriers that help create privacy for nurses in other hospitals. The
DRAFT – DO NOT CIRCULATE OR CITE WITHOUT PERMISSION
28
Capital and Provincial nurses sometimes tried to create a barrier by sitting with their backs to the
ward, but this was only possible in rare moments when there were no patients nearby. Nurses also
occasionally sought privacy in the nurse changing room on each ward, but they were discouraged
from doing so during their shifts. More often they simply disappeared, to wander the grounds, talk
with friends on other wards, or otherwise escape.
INSERT FIGURE 2 ABOUT HERE
Privacy is especially lacking during emergencies. Every urgent incident and patient death
that I observed occurred before an audience of multiple nurses, sometimes doctors, and other
patients and families. In the absence of electronic monitoring equipment, a child’s decline is nearly
always announced by a terrified mother’s wrenching cries, or her collapsing to the floor in fear and
shock. Everyone knows what those cries herald, and other parents and visitors turn to watch or
gather nearby. The nurses have no way to conceal what transpires: beds lack curtains and also often
hold multiple patients lying side by side. In the IVR at Provincial Hospital—the location of the
sickest children and most emergency cases—beds are crammed together, as shown in Figure 2, with
barely enough space to move between them. Deaths are particularly public (Manning 2008).
Because of this, the Capital and Provincial nurses have few spaces at work to express their
emotions privately, or to engage in the kind of collective coping that has proven valuable for
workers in other settings. In addition, nurses are constrained by professional norms from using
“offstage” areas—their homes, churches, or other places outside the hospital—for this purpose.
When asked how they managed anger or frustration (“vexation” in the local language), several said
they would step away from the ward, leave the hospital, or stay home in order to “cool their heart.”
However, when I asked whether they sought support from friends, family members, or members of
their church or mosque, the nurses looked at me quizzically. One admitted she sometimes spoke
DRAFT – DO NOT CIRCULATE OR CITE WITHOUT PERMISSION
29
with her sisters and asked them to help her pray for specific cases, and a few said they spoke to
God, but most asserted emphatically that would never discuss their patients with anyone outside the
hospital, citing training on medical ethics. Even when I probed further, saying that surely they could
talk about their own feelings without revealing patients’ names or other details, they did not budge.
Despite these constraints, I found that nurses did occasionally construct or discover a small
measure of bounded, private space, even during urgent situations. In the next section, I will describe
these efforts, which I call spatial emotion management techniques.
Finding Space for Emotion Management
During the 30 urgent incidents, I observed nurses taking various actions to construct or take
advantage of partial and temporary backstage spaces. They created backstage with their bodies, by
turning their backs to the parents or encircling an exam table to shield it from view; by lowering
their voices; or by moving to a different part of the ward or another area of the hospital. For
instance, on several occasions, including the incident in Table 3, nurses on the step-down unit
crossed to the adjacent emergency room in the midst of dealing with an urgent situation, thereby
entering a kind of backstage away from their own patients even as they remained front stage on the
other ward. Sometimes, the nurses were able to create a virtual backstage merely by using technical
or clinical language that parents were unlikely to understand. In total, just 17 out of 171 component
actions were coded as having “High/medium backstage” or being “Almost fully backstage.”
These temporary backstage areas were used for multiple purposes, including (in one case)
discussing the patient’s condition and treatment options, but most frequently for emotion
management. I saw multiple instances of collective processing and other types of emotional labor
taking place in these backstage spaces. For example, the nurses involved in the incident in Table 3
left the front stage of their own ward to chat and laugh with their colleagues in the emergency room,
DRAFT – DO NOT CIRCULATE OR CITE WITHOUT PERMISSION
30
a common way to defuse negative emotions. Another time, while I was conducting a relatively
private informal interview with a nurse on the step-down ward, a child on the adjacent emergency
room died and her mother began to wail. Unprompted, the step-down nurse began to speak to me,
quietly but with obvious emotion, about how those deaths made her feel. “It’s not easy. When I first
came, I cried every day,” she said, taking advantage of the unusually private moment to express and
process her grief. Indeed, the most common backstage activities I observed among nurses at Capital
and Provincial hospitals, during 11 of 17 actions with high backstage, were collective or individual
efforts to make sense of patient deaths and critical incidents. In three cases, nurses expressed sorrow
or regret at a child’s death. In another eight cases, they discussed the causes or circumstances
leading to the child’s critical conditions.
Moreover, when backstage space was available, nurses did not publicly express anger or
frustration at the parents of their patients. I found zero instances in which a nurse who had access to
backstage space earlier in the critical incident subsequently shouted. Three nurses were involved in
incidents where there was both a relatively high level of backstage and instances of shouting, but in
all cases the shouting came first and the nurses used the backstage to gain control of their emotions
and better align their emotional expressions with the dominant feeling rules. An example is the case
of the baby in Capital Hospital who was found to be suffering from severe sepsis, supposedly from
being left in dirty diapers for too long before coming to the hospital. Several nurses and a doctor
furiously and very publicly blamed the girl’s mother for not showing the child’s rash to the doctor
sooner, while the mother argued that she had. After a brief series of vocal and angry counteraccusations, the health workers withdrew to the nurse’s station, turning their backs and creating a
partial backstage far from that mother and from a nearby group of other mothers. With this time and
space, the staff members gained control of their anger and, in the local parlance, “cooled their
DRAFT – DO NOT CIRCULATE OR CITE WITHOUT PERMISSION
31
hearts.” When the child later died, they betrayed no reaction, and quickly returned to other tasks
while chatting casually with one another as though nothing had happened.
In summary, protected backstage space—an important resource for emotion management—
is extremely limited on these wards, likely contributing to the high frequency of shouting at parents.
Within these constraints, however, nurses work to construct or discover partial and temporary
backstage opportunities. When they do so, they are able to overcome the tensions created by the
complexities and contradictions of the emotional cultures they face, and to successfully adhere to
the feeling rules promoted by their profession and organizations.
DISCUSSION AND CONCLUSION
Existing scholarship has highlighted several emotion management techniques that workers
can use to manage negative or potentially disruptive emotions, but this literature rests on a strong
assumption: that organizations are governed by clear and internally-consistent feeling rules. In this
article, I consider a very different organizational setting, pediatric hospital wards in a West African
country that are infused by complex and often contradictory emotional cultures. I show that nurses
in these wards often struggle to adhere to the dominant feeling rules in their organizations and
profession, and instead respond to emotionally fraught life-threatening situations by publicly
expressing anger and frustration toward the parents of their critically ill patients. These failures of
emotion management are likely more frequent due to the highly visible nature of the hospital wards,
in which backstage space is extremely limited. When nurses in these wards are able to construct or
discover small opportunities for protected, private space, they are better able to adhere to feeling
rules and deliver the professional, compassionate care that they aspire to provide. These spatial
DRAFT – DO NOT CIRCULATE OR CITE WITHOUT PERMISSION
32
techniques for emotion management represent an important contribution to our understanding of
workplace emotion management.
This article contributes to three streams of literature: on emotion and emotion management;
abuse and neglect of patients by health workers; and the sociology of space and place. First,
building on the sociological and organizational literature on emotion, this article answers a call for
“contextually rich, ‘real time’ emotion studies of organizational life” (Fineman 2000:14) and
provides an important, if troubling, counterpoint to recent scholarship on compassion in
organizations (Rynes et al. 2012). It extends our understanding of workplace emotion management,
based primarily on Western service organizations, to a new social, cultural, and organizational
environment, one characterized by a complex and contradictory emotional culture. By exploring
emotion management in this setting, I shed light on the struggles of individuals at the nexus of
cultural and institutional contradictions (Creed, DeJordy, and Lok 2010) and provide a rare glimpse
into what happens when emotion management efforts fail—and what might help them succeed.
Specifically, I build on the emotion management strategies identified by existing theory, and show
that workers can combine these with spatial strategies for emotion management in order to
successfully adhere to feeling rules.
Second, my findings contribute to the growing literature on abuse and neglect of patients by
health workers (Bowser and Hill 2010; D’Ambruoso, Abbey, and Hussein 2005; Freedman 2013).
This literature has suggested that maltreatment of patients by nurses, midwives, and other health
professionals may be partially explained by client and provider characteristics (Matthias and
Benjamin 2003), socio-economic and power differentials (Moyer et al. 2014), and efforts to exert
authority and control over patients (D’Oliveira, Diniz, and Schraiber 2002; Jewkes, Abrahams, and
Mvo 1998), among other factors (Bowser and Hill 2010). Prior studies have not previously
DRAFT – DO NOT CIRCULATE OR CITE WITHOUT PERMISSION
33
conceptualized abuse as a failure of emotion management, nor addressed the role of space in
facilitating or discouraging abusive behaviors. My findings identify additional drivers of these
behaviors, and point to the potential of using spatial interventions and support for emotion
management to reduce their prevalence.
Third, this study offers important insights for literature on the influence of space and place
on social life (Bazerman and Gino 2012; Hurdley 2010; Lebaron and Urgen 1997; Zhao 1998). The
value of temporary backstage areas for workers who are trying to gain control of negative and
disruptive emotions adds to a growing literature on the sometimes surprising benefits of safe and
private settings within organizations (Bernstein 2012; Kellogg 2009). These findings also contribute
to studies by social geographers, who see a dynamic, recursive relationship between space and
emotions, such that “emotions are understandable—‘sensible’—only in the context of particular
places” (Davidson and Milligan 2004:524). Scholars in this tradition have explored emotional
dimensions of the geography of health and illness (Parr and Butler 1999) including how the spatial
location of caregiving affects practices and the caregivers themselves (Milligan 2005; Parr and
Philo 2003; Twigg 2000). My study offers a different but complementary perspective on the
spatiality of emotion.
Finally, this study underscores the importance of place for the sociological study of emotion,
and argues for diversifying our empirical settings in order to enrich and extend theories of emotion
management. As one scholar notes, “to study emotions sociologically is to study them in context”
(Hallett 2003:712). Without diverse contexts, our understanding will necessarily be limited.
An important boundary condition to these findings relates to the nature of control on these
hospital wards. While visibility and surveillance are generally understood to be mechanisms of
control (Bernstein 2012; Foucault 1977:201; McKinlay and Starkey 1998; Salzinger 2003; Sewell
DRAFT – DO NOT CIRCULATE OR CITE WITHOUT PERMISSION
34
and Barker 2006), at Capital and Provincial Hospitals, I find visibility without control. Nurses are
constantly observed by their colleagues and by patients and their families, but the accompanying
organizational control strategies are absent or nonfunctioning. Supervisors are few in number and
frequently absent from the hospital wards; they are bound by an inflexible and largely dysfunctional
civil service, and lack the power to suspend, fire, or otherwise punish workers; and the country’s
weak institutional environment means that there are very few legal or occupational restrictions on
workers’ behavior. The organizations’ clients (patients and their families) are disempowered by
poverty, lack of education, and limited alternatives for care, and thus do not speak up against the
nurses’ behavior or express their dissatisfaction by choosing another health facility. As a result,
nurses largely have free rein to interact with parents as they choose. In other settings characterized
by cultural complexity and limited backstage space, but with stronger organizational control, we
might expect rewards and punishments to bring workers’ emotional expressions more in line with
the relevant feeling rules, but failures of emotion management will likely still occur. In that sense,
the behavior of nurses in Capital and Provincial hospitals is likely to represent an extreme case, but
not qualitatively different from what we might see in other settings.
Similar struggles to adhere to employer expectations for emotion management are likely in
other organizations characterized by inconsistent or contradictory emotional cultures. This might
include organizations undergoing rapid change, or those that span national, regional, or social
boundaries, and are embedded in multiple cultural contexts. These struggles—and occasional
failures—are likely less visible in settings that involve more organizational control or have less
emotionally-charged interactions, but the factors and mechanisms that determine success or failure
may be quite similar to those I observed. In particular, spatial strategies for emotion management
are likely to be an important resource for many workers who grapple with difficult emotions and
DRAFT – DO NOT CIRCULATE OR CITE WITHOUT PERMISSION
35
conflicting prescriptions for emotional expression, and who lack ready access to private, backstage
spaces in which to vent, process, or otherwise manage those emotions. Whether knowledge workers
tackling high pressure jobs in open plan offices, case workers providing social services in clients’
homes, or airport security personnel who work under the dual gaze of supervisors and members of
the public, many modern workers would benefit from opportunities to discover or construct
protected backstage space in which to manage their own or others’ difficult emotions.
DRAFT – DO NOT CIRCULATE OR CITE WITHOUT PERMISSION
36
REFERENCES
Allman, Jean. 1994. “Making Mothers: Missionaries, Medical Officers and Women’s Work in
Colonial Asante, 1924-1945.” History Workshop Journal (38):23.
Anteby, Michel. 2012. “Relaxing the Taboo on Telling Our Own Stories: Upholding Professional
Distance.” Organization Science 1–29.
Ashforth, Blake E., and Glen E. Kreiner. 1999. “‘How Can You Do It?’: Dirty Work and the
Challenge of Constructing a Positive Identity.” Academy of Management Review 24(3):413–
34.
Baldry, C. 1999. “Space - The Final Frontier.” Sociology 33(3):535–53.
Barsade, Sigal G., and Olivia. A. O’Neill. 2014. “What’s Love Got to Do with It? A Longitudinal
Study of the Culture of Companionate Love and Employee and Client Outcomes in a LongTerm Care Setting.” Administrative Science Quarterly.
Bazerman, Max H., and Francesca Gino. 2012. “Behavioral Ethics: Toward a Deeper
Understanding of Moral Judgment and Dishonesty.” Annual Review of Law and Social Science
8(617):1–44.
Becker, Howard S. 1998. Tricks of the Trade: How to Think About Your Research While You’re
Doing It. Chicago: The University of Chicago Press.
Bernstein, Ethan S. 2012. “The Transparency Paradox : A Role for Privacy in Organizational
Learning and Operational Control.” Administrative Science Quarterly 57(2):181–216.
Bolton, Sharon C. 2000. “Who Cares? Offering Emotion Work as a ‘Gift’ in the Nursing Labour
Process.” Journal of Advanced Nursing (JAN) 32(3):580–86.
Bolton, Sharon C. 2001. “Changing Faces: Nurses as Emotional Jugglers.” Sociology of Health &
Illness 23(1):85–100.
Bolton, Sharon C., and Carol Boyd. 2003. “Trolley Dolly or Skilled Emotion Manager? Moving on
from Hochschild’s Managed Heart.” Work, Employment & Society 17(2):289–308.
Bono, Joyce, and Meredith A. Vey. 2005. “Toward Understanding Emotional Management at
Work: A Quantitative Review of Emotional Labor Research.” Pp. 213–34 in Emotions in
Organizational Behavior, edited by Charmine E. J. Hartel, Wilfred J. Zerbe, and Neal M.
Ashkanasy. Mahwah, NJ: Lawrence Erlbaum Associates, Inc.
Bourdieu, Pierre. 1989. “Social Space and Symbolic Power.” Sociological Theory 7(1):14–25.
DRAFT – DO NOT CIRCULATE OR CITE WITHOUT PERMISSION
37
Bowser, Diana, and Kathleen Hill. 2010. Exploring Evidence for Disrespect and Abuse in FacilityBased Childbirth Report of a Landscape Analysis.
Boyle, Maree V. 2005. “‘You Wait Until You Get Home’: Emotional Regions, Emotional Process
Work, and the Role of Onstage and Offstage Support.” Pp. 45–65 in Emotions in
Organizational Behavior, edited by Charmine Hartel, Neal M. Ashkanasy, and Wilfred Zerbe.
Mahwah, NJ: Lawrence Erlbaum Associates, Inc.
Chanlat, Jean-Francois. 2006. “Space, Organisation and Management Thinking: A Socio-Historical
Perspective.” Pp. 17–43 in Space, Organizations and Management Theory, edited by Stewart
R. Clegg and Martin Kornberger. Liber & Copenhagen Business School Press.
Comaroff, John, and Jean Comaroff. 1992. “Medicine, Colonialism, and the Black Body.” Pp. 215–
34 in Ethnography and the Historical Imagination. Boulder: Westview Press.
Costello, John. 2006. “Dying Well : Nurses ’ Experiences of ‘ Good and Bad ’ Deaths in Hospital.”
Issues and Innovations in Nursing Practice 594–601.
Creed, W. E. Douglas, R. DeJordy, and J. Lok. 2010. “Being the Change: Resolving Institutional
Contradiction through Identity Work.” Academy of Management Journal 53(6):1336–64.
D’Ambruoso, Lucia, Mercy Abbey, and Julia Hussein. 2005. “Please Understand When I Cry out in
Pain: Women’s Accounts of Maternity Services during Labour and Delivery in Ghana.” BMC
Public Health 5:140.
D’Oliveira, Ana Flavia Pires Lucas, Simone Grilo Diniz, and Lilia Blima Schraiber. 2002.
“Violence against Women in Health-Care Institutions : An Emerging Problem.” The Lancet
359:1681–85.
Davidson, Joyce, and Christine Milligan. 2004. “Embodying Emotion Sensing Space: Introducing
Emotional Geographies.” Social & Cultural Geography 5(4):523–32.
Diefendorff, James M., Rebecca J. Erickson, Alicia A. Grandey, and Jason J. Dahling. 2011.
“Emotional Display Rules as Work Unit Norms: A Multilevel Analysis of Emotional Labor
among Nurses.” Journal of Occupational Health Psychology 16(2):170–86.
Englund, Harri. 2006. Prisoners of Freedom: Human Rights and the African Poor. Berkeley, CA:
University of California Press.
Fanthorpe, Richard. 2007. Sierra Leone: The Influence of the Secret Societies, with Special
Reference to Femal Genital Mutilation.
Field, D. 1984. “‘We Didn’t Want Him to Die on His Own’--Nurses' Accounts of Nursing Dying
Patients.” Journal of Advanced Nursing (JAN) 9(1):59–70.
DRAFT – DO NOT CIRCULATE OR CITE WITHOUT PERMISSION
38
Fineman, Stephen. 2000. “Emotional Arenas Revisited.” Pp. 1–24 in Emotion in Organizations,
edited by Stephen Fineman. London: SAGE Publications.
Foucault, Michel. 1977. Discipline and Punish. Random House of Canada.
Freedman, Lynn P. 2013. “Disrespect & Abuse in Childbirth: Learning at the Intersection of Public
Health and Human Rights.”
Freund, Peter E. S. 1998. “Social Performances and Their Discontents: The Biopsychosocial
Aspects of Dramaturgical Stress.” Pp. 268–94 in Emotions in Social Life: Critical themes and
contemporary issues, edited by Gillian Bendelow and Simon J. Williams. London: Routledge.
Geddes, Deanna, and Ronda Roberts Callister. 2007. “Crossing the Line(s): A Dual Threshold
Model of Anger in Organizations.” Academy of Management Review 32(3):721–46.
Gieryn, Thomas F. 2000. “A Space for Place in Sociology.” Annual Review of Sociology 26:463–
96.
Glaser, Barney G., and Anselm L. Strauss. 1964. “The Social Loss of Dying Patients.” American
Journal of Nursing 64(6):119–21.
Goffman, Erving. 1959. The Presentation of Self in Everday Life. New York: Random House.
Good, Mary-jo Delvecchio, Esther Mwaikambo, Erastus Amayo, and James M. Imunya. 1999.
“Clinical Realities and Moral Dilemmas: Contrasting Perspectives from Academic Medicine in
Kenya, Tanzania, and America.” Daedalus 128(4):167–96.
Goonewardena, Kanishka, Stefan Kipfer, Richard Milgrom, and Christian Schmid, eds. 2008.
Space, Difference, Everyday Life: Reading Henri Lefebvre. New York and London: Routledge:
Taylor & Francis Group.
Gordon, Steven L. 1989. “The Socialization of Children’s Emotions: Emotional Culture,
Competence, and Exposure.” Pp. 319–49 in Children’s understanding of emotion, edited by
Carolyn Saami and Paul L. Harris. Cambridge: Cambridge University Press.
Hallett, Tim. 2003. “Emotional Feedback and Amplification in Social Interaction.” The Sociological
Quarterly 44(4):705–26.
Heimer, Carol A., and Lisa R. Staffen. 1995. “Interdependence and Reintegrative Social Control:
Labeling and Reforming ‘Inappropriate’ Parents in Neonatal Intensive Care Units.” American
Sociological Review 60(October):635–54.
Hochschild, Arlie Russell. 1979. “Emotion Work, Feeling Rules, and Social Structure.” American
Journal of Sociology 85(3):551–75.
DRAFT – DO NOT CIRCULATE OR CITE WITHOUT PERMISSION
39
Hochschild, Arlie Russell. 1983. The Managed Heart: Commercialization of Human Feeling.
Berkeley and Los Angeles, CA: University of California Press.
Howell, J., A. M. Rafferty, R. Wall, and A. Snaith. 2013. “Nursing the Tropics: Nurses as Agents of
Imperial Hygiene.” Journal of Public Health 35(2):338–41.
Hurdley, Rachel. 2010. “The Power of Corridors: Connecting Doors, Mobilising Materials, Plotting
Openness.” The Sociological Review 58(1):45–64.
Jackson, Michael. 2011. Life Within Limits. Durham and London: Duke University Press.
Jeffery, Roger. 1979. “Normal Rubbish: Deviant Patients in Casualty Departments.” Sociology of
Health and Illness 1(1):90–107.
Jewkes, Rachel, Naeemah Abrahams, and Zodumo Mvo. 1998. “Why Do Nurses Abuse Patients?
Reflections from South African Obstetric Services.” Social Science & Medicine 47(11):1781–
95.
Kahn, William a. 1993. “Caring for the Caregivers: Patterns of Organizational Caregiving.”
Administrative Science Quarterly 38(4):539.
Kahn, William a. 2003. “The Revelation of Organizational Trauma.” Journal of Applied Behavioral
Science 39(4):364–80.
Katz, Jack. 1999. How Emotions Work. Chicago: University of Chicago Press.
Kellogg, Katherine C. 2009. “Operating Room: Relational Spaces and Microinstitutional Change in
Surgery.” American Journal of Sociology 115(3):657–711.
Korczynski, M. 2003. “Communities of Coping: Collective Emotional Labour in Service Work.”
Organization 10(1):55–79.
Kornberger, M., and Stewart R. Clegg. 2004. “Bringing Space Back in: Organizing the Generative
Building.” Organization Studies 25(7):1095–1114.
Lebaron, Curtis D., and J. Urgen. 1997. “Built Space and the Interactional Framing of Experience
During a Murder Interrogation.” Human Studies 20:1–25.
Lefebvre, Henri. 1991. The Production of Space. Oxford: Blackwell Publishers.
Lewin, Simon, and Scott Reeves. 2011. “Enacting ‘team’ and ‘teamwork’: Using Goffman ’ S
Theory of Impression Management to Illuminate Interprofessional Practice on Hospital
Wards.” Social Science & Medicine 72(10):1595–1602.
Lewis, Patricia. 2005. “Suppression or Expression: An Exploration of Emotion Management in a
Special Care Baby Unit.” Work, Employment & Society 19(3):565–81.
DRAFT – DO NOT CIRCULATE OR CITE WITHOUT PERMISSION
40
Lewis, Patricia. 2008. “Emotion Work and Emotion Space: Using a Spatial Perspective to Explore
the Challenging of Masculine Emotion Management Practices.” British Journal of
Management 19(s1):S130–40.
Lively, Kathryn J. 2000. “Reciprocal Emotion Management: Working Together to Maintain
Stratification in Private Law Firms.” Work and Occupations 27(1):32–63.
Lopez, Steven H. 2006. “Emotional Labor and Organized Emotional Care: Conceptualizing Nursing
Home Care Work.” Work and Occupations 33(2):133–60.
Van Maanen, John, and Gideon Kunda. 1989. “‘Real Feelings’: Emotional Expression and
Organizational Culture.” Research in Organizational Behavior 11:43–103.
Maben, Jill, Sue Latter, and Jill Macleod Clark. 2006. “The Theory-Practice Gap: Impact of
Professional-Bureaucratic Work Conflict on Newly-Qualified Nurses.” Journal of Advanced
Nursing (JAN) 55(4):465–77.
Manning, Ryann. 2008. “A Blue Bundle.” Dispatches from Sierra Leone, May 16.
Margolis, Joshua D., George Benson, Cecily Cooper, and John Galvin. 2008. “Navigating the Bind
of Necessary Evils: Psychological Engagement and the Production of Interpersonally Sensitive
Behavior.” Academy of Management Journal 51(5):847–72.
Markus, Thomas A. 2006. “Built Space and Power.” Pp. 129–42 in Space, Organizations and
Management Theory, edited by Stewart Clegg and Martin Kornberger. Liber & Copenhagen
Business School Press.
Martin, Susan Erlich. 1999. “Police Force or Police Service? Gender and Emotional Labor.” Annals
of the American Academy of Political and Social Science 561:111–26.
Martineau, Fred. 2012. “What Influences Treatment-Seeking Behaviour: A Qualitative Study of
Primary Caregivers of Children under Five Years of Age in Freetown, Sierra Leone.” London
School of Hygiene and Tropical Medicine.
Matthias, Ruth E., and A. E. Benjamin. 2003. “Abuse and Neglect of Clients in Agency-Based and
Consumer-Directed Home Care.” Health and Social Work 28(3):174–84.
McCance, A. Silke., Christopher D. Nye, Lu Wang, Kisha S. Jones, and Chi-yue Chiu. 2013.
“Alleviating the Burden of Emotional Labor: The Role of Social Sharing.” Journal of
Management 39(2):392–415.
McKinlay, Alan, and Ken Starkey. 1998. “Managing Foucault: Foucault, Management and
Organization Theory.” Pp. 1–12 in Foucault, Management and Organization Theory: From
Panopticon to Technologies of Self, edited by Alan McKinlay and Ken Starkey. London:
SAGE Publications.
DRAFT – DO NOT CIRCULATE OR CITE WITHOUT PERMISSION
41
Meerabeau, Liz, and Susie Page. 1998. “‘Getting the Job Done’: Emotion Management and
Cardiopulmonary Resuscitation in Nursing.” Pp. 295–312 in Emotions in Social Life: Critical
themes and contemporary issues, edited by Gillian Bendelow and Simon J. Williams. London:
Routledge.
Menzies, I. E. P. 1960. “A Case-Study in the Functioning of Social Systems as a Defence against
Anxiety: A Report on a Study of the Nursing Service of a General Hospital.” Human Relations
13(2):95–121.
Milligan, Christine. 2005. “From Home to ‘home’: Situating Emotions within the Caregiving
Experience.” Environment and Planning A 37(12):2105–20.
Mota, Ruben E. Mujica, Antonieta Medina Lara, Esthery D. Kunkwenzu, and David G. Lalloo.
2009. “Health Seeking Behavior after Fever Onset in a Malaria-Endemic Area of Malawi.”
American Journal of Tropical Medicine and Hygiene 81(6):935–43.
Moyer, Cheryl A., Philip B. Adongo, Raymond A. Aborigo, Abraham Hodgson, and Cyril M.
Engmann. 2014. “‘They Treat You like You Are Not a Human Being’: Maltreatment during
Labour and Delivery in Rural Northern Ghana.” Midwifery 30(2):262–68.
Muetzelfeldt, Michael. 2006. “Organizational Space, Place and Civility.” Pp. 113–28 in Space,
Organizations and Management Theory, edited by Stewart Clegg and Martin Kornberger.
Liber & Copenhagen Business School Press.
Nestel, S. 1998. “(Ad)ministering Angels: Colonial Nursing and the Extension of Empire in
Africa.” Journal of Medical Humanities 19(4):257–77.
Nyamongo, I. K. 2002. “Health Care Switching Behaviour of Malaria Patients in a Kenyan Rural
Community.” Social Science & Medicine 54(3):377–86.
Oliver, Debra Parker, Davina Porock, and David B. Oliver. 2006. “Managing the Secrets of Dying
Backstage: The Voices of Nursing Home Staff.” OMEGA: The Journal of Death and Dying
53(3):193–207.
Parr, Hester, and Ruth Butler. 1999. “New Geographies of Illness, Impairment and Disability.” Pp.
1–24 in Mind and Body Spaces: Geographies of illness, impairment and disability, edited by
Ruth Butler and Hester Parr. London: Routledge.
Parr, Hester, and Chris Philo. 2003. “Rural Mental Health and Social Geographies of Caring.”
Social & Cultural Geography 4(4):471–88.
Peterson, Gretchen. 2006. “Cultural Theory and Emotions.” Pp. 114–34 in Handbook of the
Sociology of Emotions, edited by Jan E. Stets and Jonathan H. Turner. New York, NY:
Springer.
DRAFT – DO NOT CIRCULATE OR CITE WITHOUT PERMISSION
42
Pierce, Jennifer L. 1995. Gender Trials: Emotional Lives in Contemporary Law Firms. University
of California Press.
Ross, D. a. R. 2007. “Backstage with the Knowledge Boys and Girls: Goffman and Distributed
Agency in an Organic Online Community.” Organization Studies 28(3):307–25.
Rubin, Robert S., Vicki M. Staebler Tardino, Catherine S. Daus, and David C. Munz. 2005. “A
Reconceptualization of the Emotional Labor Construct: On the Development of an Integrated
Theory of Perceived Emotional Dissonance and Emotional Labor.” Pp. 189–212 in Emotions
in Organizational Behavior, edited by Charminie E. J. Hartel, Wilfred J. Zerbe, and Neil M.
Ashkanasy. Mahwah, NJ: Lawrence Erlbaum Associates, Inc.
Ryan, G. W. 1998. “What Do Sequential Behavioral Patterns Suggest about the Medical DecisionMaking Process?: Modeling Home Case Management of Acute Illnesses in a Rural
Cameroonian Village.” Social Science & Medicine 46(2):209–25.
Rynes, Sara L., Jean M. Bartunek, Jane E. Dutton, and Joshua D. Margolis. 2012. “Care and
Compassion through an Organizational Lens: Opening UP New Possibilities.” Academy of
Management Review 37(4):503–23.
Salzinger, Leslie. 2003. Genders in Production: Making Workers in Mexico’s Global Factories.
Berkeley and Los Angeles, CA: University of California Press.
Scott, Kerry, Shannon McMahon, Fatu Yumkella, Theresa Diaz, and Asha George. 2013.
“Navigating Multiple Options and Social Relationships in Plural Health Systems: A
Qualitative Study Exploring Healthcare Seeking for Sick Children in Sierra Leone.” Health
policy and planning.
Sewell, Graham, and James R. Barker. 2006. “Coercion versus Care: Using Irony to Make Sense of
Organizational Surveillance.” Academy of Management Review 31(4):934–61.
Sorensen, Roslyn, and Rick Iedema. 2009. “Emotional Labour: Clinicians’ Attitudes to Death and
Dying.” Journal of Health Organization and Management 23(1):5–22.
Spry, Emily. 2012. “Treatment-Seeking Behaviour of Caregivers of Children under 5 Years Old
with Fever in Freetown: A Cross-Sectional Survey.”
Stayt, Louise Caroline. 2009. “Death, Empathy and Self Preservation: The Emotional Labour of
Caring for Families of the Critically Ill in Adult Intensive Care.” Journal of Clinical Nursing
18(9):1267–75.
Stenross, Barbara, and Sherryl Kleinman. 1989. “The Highs and Lows of Emotional Labor:
Detectives’ Encounters with Criminals and Victims.” Journal of Contemporary Ethnography
17(4):435–52.
DRAFT – DO NOT CIRCULATE OR CITE WITHOUT PERMISSION
43
Sudnow, David. 1967. Passing On: The Social Organization of Dying. Englewood Cliffs, NJ:
Prentice-Hall, Inc.
Sutton, Robert I. 1991. “Maintaining Norms about Expressed Emotions: The Case of Bill
Collectors.” Administrative Science Quarterly 36:245–68.
Sutton, Robert I., and Anat Rafaeli. 1988. “Untangling the Relationship Between Displayed
Emotions and Organizational Sales: The Case of Convenience Stores.” Academy of
Management Journal 31(3):461–87.
Tanner, J., and S. Timmons. 2000. “Backstage in the Theatre.” Journal of Advanced Nursing (JAN)
32(4):975–80.
Taylor, Scott, and André Spicer. 2007. “Time for Space: A Narrative Review of Research on
Organizational Spaces.” International Journal of Management Reviews 9(4):325–46.
Theodosius, Catherine. 2008. Emotional Labour in Health Care: The Unmanaged Heart of Nursing.
Oxon, UK: Routledge.
Thoits, Peggy A. 1990. “Emotional Deviance: Research Agendas.” Pp. 180–203 in Research
Agendas in the Sociology of Emotions, edited by Theodore D. Kemper. Albany, NY: State
University of New York Press.
Timmermans, S., and I. Tavory. 2012. “Theory Construction in Qualitative Research: From
Grounded Theory to Abductive Analysis.” Sociological Theory 30(3):167–86.
Van Tol, Deanne. 2007. “Mothers, Babies, and the Colonial State: The Introduction of Maternal and
Infant Welfare Services in Nigeria, 1925-1945.” Spontaneous Generations 1(1):110–31.
Twigg, Julia. 2000. Bathing - the Body and Community Care. London: Routledge.
Vaughan, Megan. 1991. Curing Their Ills: Colonial Power and African Illness. Stanford, CA:
Stanford University Press.
Wharton, Amy S. 1999. “The Psychosocial Consequences of Emotional Labor.” Annals of the
American Academy of Political and Social Science 561:158–76.
Wharton, Amy S. 2009. “The Sociology of Emotional Labor.” Annual Review of Sociology
35(1):147–65.
Zhao, Dingxin. 1998. “Ecologies of Social Movements Student Mobilization during the 1989
Prodemocracy Movement in Beijing.” American Journal of Sociology 103(6):1493–1529.
DRAFT – DO NOT CIRCULATE OR CITE WITHOUT PERMISSION
44
TABLES AND FIGURES
Table 1: Research Sites1
General Pediatric Medical
Ward (Capital Hospital)
35 beds.
Sometimes 2 children / bed.
Pediatric Step-Down Ward
(Capital Hospital)
~ 8 beds.
Often 2-3 children / bed.
Severity
of patient
illness
Patients should be relatively
stable, but may deteriorate
without being transferred.
Patients sicker than in the
general ward, but less than in
the adjacent ER or ICU.
Patientnurse
ratio2
Average 7.4 patients / nurses
(Range 4.1-9.2)
Average 4.1 patients / nurses
(Range 1.9-8.0)
Beds and
patient
load
Pediatric Inpatient Ward
(Provincial Hospital)
~ 36 beds in general wards,
some 2 children / bed.
~ 6 beds in IVR, usually 2-3
children / bed.
Patients divided: more stable
in 3 general wards, critical
cases in the “IV room”
(IVR), a low-tech ICU.
Average 7.2 patients / nurses
(Range 1.3-10.0)
Notes:
1
The three sites are not meant to be comparative cases, but to test for similar findings across different settings.
2
The patient-nurse ratios were calculated each day based on my notes on the numbers of patients and nurses
actually present on the ward for a given shift. I varied whether this was the afternoon or morning shift.
DRAFT – DO NOT CIRCULATE OR CITE WITHOUT PERMISSION
45
Table 2: Data and Methods
Overall
Two phases of research in 2012
Data on ~150 nurses, reflecting diversity of nurses in both hospitals.
Professional diversity: State Registered Nurses (SRNs), State Enrolled
Community Health Nurses (SECHNs), Untrained nursing aides, and Trainee
nurses
Demographic diversity: Mostly female but also a handful of male nurses; wide
range of ages, ethnicities, birthplaces, and nursing schools
Interviews
23 semi-structured interviews with 29 nurses or trainee nurses
Dozens of informal, conversational interviews
Observations
164 hours of direct, first-hand observation; ~ 4-6 hours of ward observations per
day & ~ 5 days per week in June-July 2012
Additional observations in January 2012
Observed nurse behavior and interactions with one another and with patients,
parents, visitors
Narratives and discourse: how the nurses spoke about their jobs, patients and
families, and workplaces
Archival
Photos, artifacts, hospital data
Used primarily to inform analysis of the interview and observational data
Historical
Minutes, reports, personal and public writings from 2008-2011
Used primarily to inform analysis of the interview and observational data
DRAFT – DO NOT CIRCULATE OR CITE WITHOUT PERMISSION
46
Table 3: Single Emergency Incident Broken Down into Component Actions
Each row is a separate action or interaction, arranged chronologically to recount the whole incident.
Action #
Details of actions / interactions
1
Convulsing child, dad calls N12. She comes over, feels the child's body, tells the dad to pull
all the child's clothes…
2
Then N12 takes a side trip to the ER front desk, to laugh with Ns there. Then returns to
step-down…
3
Dad says to N12, politely but scared “nurse…” N12 says “I'm coming”, putting on gloves,
then actually jogs across the ward to get something and comes with glucometer &
thermometer
4
N10 and N21 talking about results of the child's tests and what to do. N12: temperature is
100.7. N10: Did you give paracetemol? N12: [inaudible]. N10: [inaudible, something about
blood sugar]. Then N10 gives the chart to N12 and says to go show the Dr.
5
N10 to N11 (at the child's bed) – “is he still convulsing?” …
6
N12 at front desk with N10, discuss patient. N12: “His body is warm.” N10: “His mother
wrapped him” [in too many layers of clothes]
7
N12 went to bed to check child. Touched, then…
8
N12 called to N11 (who was across the room) “what’s his blood sugar?”
9
Dad calls to Ns again. N11 and N12 go with [medication] and the convulsions finally stop.
Table 4: Nurse Interactions with Parents
Behavior
Examples
# Incidents
involving
behavior
# Fatal incidents
involving
behavior
Reassuring
One nurse from the step-down ward walked across
to the neighboring ER to comfort a mother who was
wailing loudly at the loss of her child. “You have to
bear it,” she said gently. “Don’t make yourself sick”
5 out of 30
total
incidents
4 out of 13 fatal
incidents
10 out of
30 total
incidents
5 out of 13 fatal
incidents
When a grieving mother returned to the ward to
collect her belongings, the nurses were very
sympathetic. “Mama, bear it,” they said.
After shouting at a mother whose daughter was dead
on arrival to the hospital, a group of nurses told her
to “hold your heart until you reach” home and “don't
cry out.”
Rebuking
A nurse and the community health officer shouted at
a mom who hesitated when told to go to the lab to
get tests. The mom was obviously overwhelmed and
afraid to leave her child's side.
A young mother stood next to the exam table on
which her baby lay, convulsing. Nurses sitting at
their station called out questions to her, and scolded
her loudly for not completing her baby’s
vaccinations and for having the wrong information
on her chart. Later, another nurse stopped by and
started yelling at the woman, who was by then
sobbing. "Why are you crying?” he asked. “Don't
cry... This is an emergency ward, you need to steel
your heart…You waited so long to come when your
kid was sick, you waited until he was convulsing.
Now you expect he'll suddenly get better? They
gave him medicine, now you need to wait until he’s
better.” The mother replied, “I swear, it was [just]
today [that he got sick], and we went to get
treatment.” When asked where they went, she said
the pharmacy. At that, the nurse grew furious and
began shouting again: “Don't go to the pharmacy,
you should come here! You don't pay for care here!”
48
Figure 1: Signs of Emotional Culture at Capital Hospital
49
Figure 2: Pediatric Ward in Provincial Hospital
50