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'You Wait Until You Get Home": Emotional Regions, Emotional Process Work, and the Role of Onstage and Offstage Support
services organization specializing in prehospital emergency care. The organiza
tion in question, the Department of Paramedical Services (known hereafter as
the DPS), could best be described as an emotion-laden organization, where
emotionality is central to the raison d'etre of the organization.
The linkage between emotional regions within organizations and emotional
process work is illustrated through a closer examination of the offstage (or
nonwork) region within the DPS. Thoits's (1984, 1 985, 1991) work on emo
tional process work and Goffman's ( 1959) work on regions will also help illus
trate how, in this instance, emotional process work can be "privatized" and
thus removed from the realm of organizational responsibility.
This chapter is divided into the following sections. First, I provide an over
view of the research site and design. Second, I discuss the concepts of emotional
regions, emotional labor, and emotional process work, and how these relate to
the study discussed here. Third, I provide a detailed and richly narrative style ac
count of the nature of emotional labor and how it is performed within the DPS.
Within this section I also highlight the different approaches to the performance
of emotional labor in front-stage regions, which includes illustrations of surface
and deep acting, and the process of emotional "switching." Fourth, I illustrate
the nature of offstage support within the DPS, and discuss how the overreliance
on this kind of support may leave an organization such as the DPS vulnerable to
the negative financial consequences of occupational stress.
EMOTIONAL CULTURES, REGIONS,
Emotional culture within organizations consists of three components: emo
tional vocabularies (Gerth & Mills, 1 953; Gordon, 1981), emotional norms
(Gordon, 1 989; Hochschild, 1979, 1 983; Scheff, 1 979, 1990) , and meanings of
power and status (Kemper, 1978) . Gordon (1990) also differentiated between
institutional and impulsive orientations within emotional cultures. Institu
tional meanings of emotions are those given by organizational members when
they are in full control of their emotions. Members effect achievement and
maintenance of institutional norms, and in doing so continue to uphold and re
produce emotional culture (Gordon, 1989).
In formal organizations such as the DPS, the application of impulsive
modes of emotional expression is considered either deviance or indicative of
faulty socialization (Gordon, 198 1 ; Thoits, 1989) . However, permission to ex
press impulsive emotion is granted to those with power and status, typically
middle- and upper-class men of Anglo-Celtic origin (Hochschild, 1983;
Pierce, 1 999) . These "status shields" also apply to relationships between cli
ents and organizational members. Those with greater professional status are
less likely to witness impulsive orientations to emotion than those with lower
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status (Hochschild, 1983 ) . For example, patients are less likely to exhibit dis
plays of extreme emotion in the presence of medical consultants than they are
in front of clinical staff that are considered of lower status.
The concept of emotional region is derived from Goffman's (1959) drama
turgical perspective. Performance, which is a central component of an organi
zation, is defined as "all the activity of a participant on a given occasion that
serves to influence any of the other participants" (Goffman, 1959, p. 26) . Per
formances are only successful when individuals can show that their actions are
genuine, while sustaining simultaneously a "front" that is considered authen
tic (Goffman, 1 959, p. 28) .
Successful performance is also staged by teams "who share both the risk and
discreditable information in a manner comparable to a secret society" (Goff
man, 1959, p. 1 08, as cited in Manning, 1992). Teams are organized by "direc
tors" who manage disputes and delegate responsibility. Teams also act in "front
regions," which are defined as spaces within which they perform for their public
(Goffman, 1959, pp. 102-1 14). Teams "rehearse, relax, and retreat" to "back re
gions," spaces hidden from publics' view when front region performances are
"knowingly contradicted as a matter of course" (Goffman, 1959, pp. 1 10-1 14) .
Goffman's (1959) conceptualization of front and back regions i s used here heu
ristically to develop further Fineman's (1993b) notion of the "emotional archi
tecture" of organizational culture, in which he suggests within organizations
physical spaces exist in which different feeling rules apply.
The concept of emotional culture builds on Gordon's ( 1981) original con
ceptualization, joining both Goffman's (1959) description of regional behavior
and audience segregation and the differentiation perspective of organizational
culture (Martin, 1 992), which recognizes the importance of subcultures.
Therefore, emotional culture can be observed within three "regions"-front
or onstage, backstage, and offstage. The front-stage sector is where emotional
labor is performed, whereas the backstage sector is where interaction with or
ganizational members happens and where emotional process work is likely to
occur. In comparison, offstage regions are located outside the physical realm
of the organization itself. As Hosking and Fineman (1990) asserted, differenti
ation between front-stage and backstage organizational emotionality helps us
understand the nature and consequence of emotional labor, particularly within
the context of emotional culture.
EMOTIONAL LABOR AND EMOTIONAL
Recent research on the links between the performance of emotional labor and
emotional dissonance indicates that a complex array of factors has both posi
tive and negative effects on the individual's emotional well-being in the work-
place (Hartel, Hsu, & Boyle, 2002). These factors include the quality of the im
mediate workplace emotional climate in which the service encounter occurs
(Ashforth & Humphrey, 1995), the influence of gendered cultural norms
(Wharton, 1 993), the degree of job control and routinization (Leidner, 1993;
Van Maanen, 1991 ), and the quality of organizational responses to stress in
duced by emotional labor (Kunda & Van Maanen, 1999) .
Early work on the conceptualization and operationalization of emotional la
bor created a clear distinction between emotion work and emotional labor
(Hochschild, 1979, 1 983) . Expanding on Hochschild's (1983) definition of
emotional labor previously discussed, Hochschild (1983) also argued that
emotive dissonance was an inevitable consequence of emotional labor because
it resulted in a transmutation of the private emotional region into the public
commercial region. However, emotion as a process involves the appraisal of a
series of affect-related events, which may involve the experience of discrete or
private emotions such as sadness or envy. Although the context in which the
appraisal and subsequent emotional regulation take place may change from a
public to private one, the process of appraisal, attribution, and regulation of
emotion is essentially the same (Weiss & Cropanzano, 1996).
Therefore, I propose that emotional process work is an integral part of emo
tional labor, and is an extension of the service provider-client interaction. In
addition, I also propose that organizational response to this aspect of an em
ployee's work influences significantly both the quality of the service outcome
and the levels of individual employee stress fitness and emotional health.
Emotional Process Work
Emotional process work occurs before, during, and after a service encounter,
and involves a number of strategies that enable the employee to maintain a
normative emotional state. Thoits (1984, 1985) explained that when emotional
management techniques fail and individuals are unable to deal satisfactorily
with "deviant" or "outlaw" emotions such as disgust, extreme anger, or hatred,
they then have to process this failure as a violation of feeling or expression
norms. Thoits (1985) cited two conditions that she viewed as central to the
prediction of emotion work failure: the persistence of deviant or outlaw emo
tions, and the absence of social support. Thoits (1985) explained that when in
dividuals are committed to competent identity enhancement and are aware of a
discrepancy between situational feelings and emotional norms, attempts at
emotional process work follow, and self-attributions of deviance occur as a re
sult of persistent failure to create an individual normative state. For example, if
a paramedic felt extreme anger after attending a case such as child abuse, this
would be considered the emotional norm for this particular situation. How
ever, if the same officer felt nonchalant or disinterested about the same case,
he might attempt to move his feelings closer to the emotional norm for this sit-
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uation. If he were unable to do this, then he would be more likely to label his
own emotions as deviant.
Therefore, Thoits's (1984, 1 985, 199 1 ) work has implications for how emer
gency service organizations confront the reality of work stress and the mainte
nance of appropriate emotional climates within the organization. Within an
emergency service context, emotional process work occurs after a case has been
completed and involves a variety of strategies that are designed to assist the offi
cer to return to a normative emotional state. The parameters of a normative
state are determined by both societal and organizational cultural norms, and are
influenced by gender, national culture, and generational emotional norms.
Emotional process work may be as simple as one officer acknowledging to an
other officer that the previous patient was rude or obnoxious, or it may involve
many weeks of coping with a major traumatic event such as a plane crash. All of
ficers "do" emotional process work, and the degree to which they accomplish
successfully emotional normality varies according to level of experience, degree
of social support, and ability to cope with the demands of emotional norms and
feeling rules that the organization places on them.
RESEARCH SITE AND DESIGN
The DPS provides prehospital emergency care to subscribers to its service. It
is a public-sector organization that has developed a culture emergent from a
combination of both militaristic and not-for-profit influences. The DPS is a
male-dominated organization, with over 90% of the on-road staff being men.
As part of their duties as "caring" paramedics, the DPS on-road staff are ex
pected to perform as emotionally complex individuals while simultaneously
adhering to a strict hegemonically masculinist code of conduct. Officers are
expected to display the "softer" emotions of compassion, empathy, and cheer
fulness in public, while refraining from the expression of grief, remorse, or
sadness in the company other officers. Although this expectation is not harsh
in itself, it becomes untenable when the DPS relies heavily on the "privatizing"
of emotional process work.
Using Thoits's (1991 ) work on social support as a basis, emotional process
work is defined as the emotion work in which officers engage after emotional
labor has been performed. Although this practice incorporates what Hochs
child (1983) referred to as emotional management, in this particular context it
is used to differentiate between the processes used while emotional labor is
being performed, and those utilized to make sense of the interaction to which
emotional labor is central.
In keeping with Hochschild's ( 1 983) original definition, emotional labor is
defined here as the appropriate level of display, feeling, and exchange that oc
curs between the service provider and the service recipient. Therefore, the
practice of emotional labor includes both individual emotion work and emo
tion management of others' feelings. In the DPS context, emotional labor is
specifically defined as the management of the emotional interface between
paramedic and patient, and/or persons located within the vicinity of the inter
action with whom the officer needs to communicate with in order to success
fully accomplish the task at hand.
This ethnographic style qualitative study of the emotional labor practices
within ambulance work utilizes a triangulated approach that involves extensive
observation of work routines and practices. Given that self-reports of intangi
ble and unobservable feelings and inner emotion work may be difficult to vali
date through formal interviews only, I chose this observational methodological
approach because I considered it the most appropriate way of accessing this
kind of data (James, 1993). Document analysis of training and human resource
materials, recruitment practices, and organizational mission statements was
My approach to ethnographic research is influenced by the classic anthro
pological approach, which requires the researcher to adopt the role of "profes
sional stranger" (Agar, 1 996). According to Van Maanen (1988), this kind of
ethnographic study can be categorized as more of a "critical" than "realist" ac
count of the culture of the DPS. Therefore, it does not focus exclusively on my
personal experience as a fully immersed participant, but rather is a critical ac
count of organizational emotionality within the workplace. Although I was
physically and emotionally involved in particular cases, I did not wear a uni
form, was not permitted to comfort or reassure patients, and was not fully ac
countable to the DPS as an employee or volunteer. My own experiences in the
field did not involve "doing emotion" in the same way that ambulance officers
did. This psychic distance from the actual work in which officers engaged is
indicative of the well-documented dilemma field-workers face when they are
restricted in their ability to gain unlimited and pure access to informants in the
field (Hubbard, Backett-Milburn, & Kemmer, 200 1 ) .
Fieldwork was conducted within the DPS over an 18-month period. During
that time I conducted 500 hours of observation, and attended and partially ob
served 1 10 cases. I observed cases with SO on-road officers, 9 of whom were
women. In addition to these observations, I conducted 30 in-depth interviews
with officers across the 7 DPS geographical regions. I also attended training
sessions, spent time within communication call centers, and held informal
discussions with senior managers and counselors about DPS policies regard
ing posttraumatic stress disorder and stress debriefing.
An ethnography is a written representation of either a whole or parts of a cul
ture, and carries serious intellectual and ethical responsibilities (Van Maanen,
1988). Therefore, every effort has been made to protect the identities of the
paramedics who agreed to be interviewed for this study. The names of these in
terviewees have been changed to maintain anonymity. Care has been taken to
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choose names that do not correspond with those officers who were observed or
interviewed. At no time during fieldwork were patients' names recorded.
ON-STAGE AND BACKSTAGE REGIONS: THE DPS
AND THE PERFORMANCE OF EMOTIONAL LABOR
Emotional labor is an integral part of a paramedical officer's work day. Several
aspects of paramedic work impinge on how and why emotional labor is per
formed. They include the management of patients' emotions through surface
and deep acting; the management of one's own emotions through emotional
switching; generational and geographical differences between officers; and
training to perform emotional labor. Hochschild ( 1 983) differentiated between
surface and deep acting, in that surface acting involves a superficial expression
of the appropriate emotion. Deep acting involves the combination of the actual
exhortation along with the expression of the emotion. Emotional switching is
an emergent category from the data, and it involves the ability to change one's
emotional demeanor quickly. In paramedic work this occurs frequently, partic
ularly in the move from a highly emotionally charged job to one that is less tax
ing and emotionally demanding.
There are four emotional labor practices that are specific to paramedical
work: the ability to manage the patients' and one's own anxiety; managing peo
ple who are out of their usual environment; being able to cope with a constant
state of uncertainty; and the ability to simultaneously "care for" and "care
about" others (James, 1 993). This section focuses on emotions through sur
face and deep acting, as they are a critical component of a paramedical officer's
Most paramedical officers admit that they do a significant amount of surface
acting. This involves smiling, teasing, and light humor, all of which should be
taken at face value only. During the study's observations, there were several oc
casions when officers were friendly toward the patient but then complained
bitterly about the patient's attitude or expectations after the patient had been
transported. In these cases, patients complained about the length of time
spent for the ambulance to arrive, which irritated the officers, because lengthy
delays were often out of their control.
Although officers generally displayed a friendly demeanor in front of most
older patients, several officers either ignored dementia patients, or treated
quiet or depressed patients in a condescending manner. A more somber de
meanor was observed on several night shifts, when officers treated many intox
icated, indigenous, or adolescent patients.
During observations, officers reported that they used surface acting tech
niques with almost every patient. Whether it be sharing a joke with a shy or
fearful patient, smiling in the face of a belligerent one, or developing a "neu
tral" expression when having to coax an intoxicated person into the back of the
ambulance, officers view acting as part of their work. However, they also distin
guish between surface acting, that is, expressing positive or negative emotions
even if they are not authentic, and deep acting, when officers are required to
actually feel the emotion they are projecting. Officers define surface acting ei
ther as the act of expressing positive feelings, especially in circumstances
where the situation does not lend itself to positive emotionality, or as the sup
pression of negative emotions, such as sadness or disgust. In both circum
stances, the performance requires officers to give something that is either
themselves, or denies parts of themselves.
There are many techniques officers use to perform surface acting success
fully. Humor was cited as the major strategy used, and during observations it
was the most common way of engaging with patient: As one senior officer
If you can make someone laugh or smile you've got the battle half won. Treat
them like an equal. Get their mind off their worries. Have a joke with them or
whatever. If you get their mind off what's hurting them you're well on your way.
According to Francis (1994), humor as emotion management involves a so
phisticated cultural performance, which strengthens and often restores nor
mal feelings. Francis (1994) also stated that humor is used as an integrative
device that effectively reduces (or redefines) an external threat. This bonding
process often occurs at the expense of the excluded person or persons.
A good example of how humor is used to alleviate patients' and relatives'
anxiety was when a man in his eighties was transported home from a hospital
after a hip replacement operation. Officers needed to be able to gauge how
much humor they can perform, and in this case, they used the opportunity to
make light of a delicate situation. When the patient arrived home, the officers
sensed that the relatives needed much reassurance, as they seemed particu
larly anxious about the difficulty the patient would experience walking up the
front stairs. The officers were extremely jovial, and joked with both the patient
and his relatives. One of the younger officers even took the crutches and ran up
and down the sidewalk outside the house with them. The relatives were not of
fended by this, and even seemed to appreciate the mild joke at the patient's ex
pense. This is an example where the officers j udged correctly how much hu
mor was acceptable, and even used the permission given by the relatives to
engage in "horseplay. "
However, there are occasions when humor either fails or is unappreciated.
When a form of surface acting has failed, officers have the option of reverting
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to silence or changing the topic of conversation to strictly medical issues
(Palmer, 1983) . In the case of long trips from rural areas to metropolitan hos
pitals and vice versa, humor is one of many strategies officers used to quell irri
table patients. As this officer of 6 years indicated, there is often a difference be
tween the type of surface acting performed on a longer and shorter trips:
I think a lot of DPS officers joke a lot of things off and they've got standard lines
that they can use to laugh it away and maybe try to get this person around through
humor. But there's a bit of a difference there between city and country too be
cause where I am I'll probably have a patient on board a maximum of twenty min
utes. So for me, it's quite easy. I can put up with them and be nice to them for
that period of time and then I can just refer them on. But with a country person
having to put up with a whinger from the back of the bush to the city on a long
trip would be extremely difficult. There are two in the car, and if by the end of the
day you're starting to become weary you can swap over. . . . All you can do is what
is within your power at the time. All you can do is try to be friendly, try to under
stand where they're coming from.
During the course of an average day shift, officers transport many nonurgent
cases. These cases usually involve a low level of technical skill, although they
often involve a considerable amount of surface acting. Many nonurgent pa
tients are older frail women, sometimes suffering from dementia, and some
officers expressed a significant amount of ambivalence toward these patients.
Although all officers I observed transporting these patients expressed either
positive emotions or affective neutrality, in many cases officers expressed dis
like or discomfort about these cases to other officers after these patients had
been transported. For example, one younger officer referred to nonurgent
cases as "granny-busting." Others referred to these cases as "humpers" or
"geries," which refer to older patients who have difficulty walking or commu
nicating. As one officer of 20 years explains, this kind of emotional distancing
is a vital part of the job for officers who are barely out of adolescence:
DPS officers dissociate very well. I mean, how can you not? The DPS is now
made up of officers in their late teens to early thirties who have all got families
and they pull kids out of pools and go to motor accidents. In a lot of cases they're
treating elderly people around the same age as their parents with the same sort of
complaints. If they don't dissociate themselves with that patient emotionally they
get caught up in the web of themselves. And occasionally you do.
As one officer explained, emergency service workers are exposed to more
emotionally distressing situations in the course of one shift than many people
would experience in a year. This unsanitized experience of the social world is
one that most officers come to accept as "part of the job." Officers also justify
their tendency to distance themselves emotionally as part of the process of de-
veloping a veneer. The following quote is from an officer with 8 years of experi
ence who explained that developing such a shield is important part of acting
out the professional role of the paramedical officer:
A lot of people may be upset but you just harden because you do see so much of
death and dying . . . it's just a part of life. We're not isolated from it the way the
general public is. Years ago everyone saw death and dying. There was a lot more
blood around, we killed our own animals. It's not that we're necessarily special,
it's just that we keep seeing what most people saw forty or fifty years ago. We also
get to see a lot more inappropriate behavior and people trying to cope with things.
If you don't have that veneer, if you don't have some hardness, you're not going to
Therefore, surface acting is not only a strategy for managing patients' emo
tions; it is also considered an important method in managing one's own emo
tions and emotional conflicts. Many officers admit that developing an extreme
focus at the scene of major trauma, what they describe as tunnel vision, is the
most common method of suppressing or denying individual emotional re
sponses. This form of affective neutrality is also considered necessary for both
managing the anxiety of the patient, and appearing professional:
You become more job orientated. You see the patient as a job. You don't see
them as a person. Once you get them settled down you might give them some re
assurance. It's a professional thing. You have to close it out. It's very hard to ex
Thus, officers' perception of professionalism involves successful accom
plishment of an affectively neutral performance. In this respect, ambulance of
ficers are not unique. What distinguishes DPS officers is the degree to which
they find themselves in situations that call on them to engage in deep acting.
In the context of the DPS, deep acting involves the management of all aspects
of an affective state, including the ability to change how one is feeling about an
event or person. The most common deep acting technique officers referred to
was when a patient was objectified. This was achieved through officers devel
oping the image of the patient as a thing or object, and in doing so, temporarily
suspending any emotional attachment they may have to the patient as a human
being. Although most officers admit that this strategy should not be used fre
quently, many explained that high levels of stress and emotional exhaustion
encourage the overuse of this strategy. One officer justified the use of this
technique by highlighting that deep acting strategies are no different from
those used by other health professionals:
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The analogy of a piece o f meat was given to me early on i n my DPS career and it's
right. I mean, it's a terrible term. But the analogy I was given was that a surgeon
treats a patient as a piece of meat and does his best possible job on it. Carves it
like Michelangelo carved David and then puts it back. And that's the way DPS
paramedics do their job. If they get emotionally tied to it then they can't effec
tively do the job.
Smith and Kleinman (1989) explained this tendency toward objectification
by drawing comparisons between the socialization processes of military re
cruits and medical students. Both undergo a process of desensitization where
emotions are blunted by sleep deprivation and changes in the way students
perceive human bodies.
Although some officers overuse surface and deep acting strategies needed
to achieve emotional distancing, others are prone to emotional attachment
with patients, particularly those who remind an officer of a relative, child, or
loved one. Many officers I spoke to explained that all officers are prone, at
some time during their careers, to communicate inappropriate emotional
messages to the relatives of the dying patient, because officers find it difficult
to reconcile their lifesaving role with the very real possibility of losing the pa
Most of the officers who had worked in the DPS for many years described
circumstances where they had given false hope to a patient or relative because
they were unsure or unable to perform the kind of emotional labor specific to
that context. A common example was giving false hope to the relatives of burn
victims based on the percentage and degree of burns to the body. Officers
stated that they were most likely to fail in their efforts to engage in deep acting
at the end of a series of night shifts, after a series of urgent cases in one shift,
or when they failed to dissociate successfully.
Cases involving critically ill children were cited as the most risky in this in
stance. This is similar for the majority of emergency service personnel, most of
whom cited cases involving the death of, or serious injury to, children as the
most emotionally challenging (Palmer, 1983) . The cases I observed involving
children always evoked a different response from officers in that they appeared
to work at a faster pace. One officer explained that apart from the fact that
many officers had young children themselves, they also felt added pressure to
always save the child, regardless of the severity of the case. This demands of
officers a dramaturgical performance that is quite distinct from adult cases.
The following quote from an officer with 8 years of experience illustrates the
extreme emotional and physical pressure officers finds themselves under dur
ing the course of attempting to save a child's life:
When you walk into a scene where there's a child who is ill, if it's a SIDS or some
thing, there are so many expectations. The parents, especially with SIDS, know
the child's dead. You know the child's dead. But if the child's still warm you have
to give them every opportunity. . . . You see, there's so much expectation on us
when we go into a situation we can't turn around and go to pieces because then
we're not doing our job.
The death of a child is probably one of the few instances where a strong
emotional reaction to a case is legitimized. Although several younger officers
expressed angst about this, most officers believed that that an increase in the
acceptance of public displays of grief, if only for children, is a positive change
within the emotional culture of the DPS.
In summary, the majority of officers interviewed and observed cited emo
tional labor as an important "tool" in the DPS officers' repertoire of skills.
During the course of observation, the officers described a number of surface
and deep acting techniques utilized in the performance of emotional labor.
These included managing the emotions of patients through extortion and sup
pression of emotion. The specific techniques also included use of humor to
manage anxiety, the avoidance of false hope, emotional distancing through de
veloping tunnel vision, disparaging stereotypes, and the categorization of pa
tients into deserving and undeserving cases. Officers also spoke of the process
of hardening through developing an emotional veneer of affective neutrality
One of the most enjoyable and frustrating aspects of paramedical work is
the unpredictability of each shift. An officer may be kept busy with many
nonurgent cases in the morning, only to find that the afternoon is quiet. Then,
just before the end of the shift, the officer may be called to several urgent
cases. As such, the paramedic cannot predict exactly what he or she will be do
ing on any one shift.
Nonurgent cases make up the bulk of an ambulance officer's work, particu
larly on day shifts and during the early part of night shifts. Although an urgent
case involves less technically skilled work than nonurgent cases, it does involve
a considerable amount of emotional labor. However, there is no compulsion to
perform emotional labor during nonurgent cases, and many officers express
ambivalence regarding how much "skill" is involved in these cases. For exam
ple, some officers are very frank about their assessment of nonurgent cases as
boring, dead end, and no better than "driving a taxi." Although it is highly
likely that officers would attend an urgent case during every shift in urban re
gions, in provincial and rural areas officers may have to settle for weeks of
However, although some officers may complain about too little stress, oth
ers experience shifts that are almost dangerously frantic. The effects of too
much or too little stress in emergency services have been documented by
Mitchell (1984). A busy night shift may consist of up to 10 urgent cases, and
each of these may be legitimate. The constant pressure to be emotionally "up"
for the duration of a shift often takes its toll, and many officers argue that it