There’s no emotional labour in Florence Nightingale’s nursing

A lot of nurses pass through this course.

They usually take a keen interest in the notion of emotional labour, which is examined in Unit 3 ‘Selling Emotions: Emotional Labour’.

‘Emotional labour’ refers to a kind of work in which employees have to induce feelings they don’t feel and/or suppress feelings they do feel, the purpose of which is to create a certain emotional state in others, usually customers.

Nurses are expected to be compassionate and kind towards patients. They are supposed to care. They are care givers. Nurses are expected to make patients feel cared for. And this regardless of the characteristics and behaviour of patients, who are as capable as the rest of us of being boorish, awkward and heavy (there’s a lot of heaving lifting in nursing). People don’t become angels just because they get sick.

‘Emotional labour’ usually helps nurses make more sense of their work. They realize that they are suppressing  real feelings about what they do and trying real hard to have the feelings expected of them. Hiding what they feel and faking what they don’t is exhausting. It lies behind the tremendous level of burnout and sickness among nurses. They are often forced to choose between their own health and that of their patients.

But that’s not all. Increasingly, the emotional labour of nursing takes place in branded health organizations. A brand is a good or service wrapped in an emotional persona. An emotional narrative connects health care professionals and their ‘clients’. Like Disney ‘cast members’ they must follow a script and always be in character. This kind of caring isn’t felt, it’s quantified and measured as nursing ‘outcomes’.

The corollary of emotional branding is the commodification of that which is branded, in this case health care. When health care is branded the nature of the therapeutic relationship is transformed. Whereas ‘patients’ are people to be cared for and treated, customers or clients are people we sell things to—drugs, technological interventions and ‘care’ itself.

Here one thinks of Magnet Hospitals. See also:

http://smithandjones.com/journals/hospital-marketing-newsletter/

http://trilliumhealthpartners.ca/Pages/default.aspx

http://www.saintelizabeth.com

Mayo clinic

Where did this nurse-as-care-giver come from?

It is surely related to a belief that there is a moral component to illness. All that pain and suffering must mean something. Getting better is a moral process too. That’s why nurses must empathize.

There is also a connection to the Magdalene strand of Christian theology. Nurses must empathize, feel the suffering of patients. And who better to empathize than someone who knows suffering first hand. This is the nurse-as-Mary-Magdalene, a fallen woman who redeemed herself through a lifetime of penance. This air of redemption through penance lies behind the much admired nurse-as-nun. By this account, nurses are supposed to suffer.

Another influence is the invention of the nurse-as-heroine by romantic novelists. A disappointment in love transports our heroine to war hospitals in distant lands. The wounded and the dying become surrogates for  lost love. The English Patient: Hana, just 18 when she leaves to become a nurse in the war. Her English patient with ‘hip bones like Christ’, a noble warrior who suffers for his actions. An abandoned monastery …

The model for this imagined nurse is the popular image of Florence Nightingale, tending the Crimean wounded by candlelight, the lady with the lamp.

Florence Nightingale is the lady-with-the-lamp

Florence Nightingale as the lady-with-the-lamp

The actual Nightingale is a very different proposition. Nightingale is acknowledged as the founder of modern nursing. But hold on. There’s a lot of emotional labour in ‘modern’ nursing, but there’s none whatsoever in Nightingales Notes on Nursing: What it is and what it is not (1859). Reading this book today, one suspects that her critique of emotional labour would be withering. Let’s consider why.

Her approach to nursing is based on her understanding of disease, as a natural reparative process. Diseases are not separate entities ‘out there’ but reactions to conditions in which we have placed ourselves (p. 19). They are not ‘caught’ by infection but ‘begun’ from want of cleanliness, ventilation and light (Nightingale 1859, p. 19). Put another way, diseases are an organism’s capacity to act, but they require specific conditions for that capacity to be exercised.

The belief that small-pox, for example, ‘was a thing of which there was once a first specimen in the world, which went on propagating itself, in a perpetual chain of descent, just as much as that there was a first dog, (or a first pair of dogs), and that small pox would not begin itself any more than a new dog would begin without without there having been a parent dog’.

‘Since then I have seen with my eyes and smelt with my nose small-pox growing up in first specimens, either in close rooms or in overcrowded wards, where it could not by any possibility have been “caught”, but must have begun’. (Nightingale 1859, p. 23)

‘I have seen diseases begin, grow up, and pass into one another …. I have seen, for instance, with a little overcrowding, continued fever grow up; and with a little more, typhoid fever; and with a little more, typhus, and all in the same ward or hut’ (p. 23).

‘It is well known that the same names may be seen constantly recurring on workhouse books for generations. That is, the persons were born and brought up, and will be born and brought up, generation after generation, in the conditions which make paupers. Death and disease are like the workhouse, they take from the same family, the same house, or in other words the same conditions. Why will we not observe what they are?’ (Nightingale 1859, p. 70, my emphasis).

From this understanding of disease flows Nightingale’s nursing practice. Conditions make paupers. Conditions make death and disease. Nursing, then, should focus on conditions.

For Nightingale, disease is ‘not necessarily accompanied by suffering’ (Nightingale 1859, p. 5). Rather, suffering is caused by practical matters which hinder’s nature’s reparative process, such as the want of fresh air, natural light, warmth, quiet, cleanliness, or a sensible diet.

The first canon of nursing? ‘To have the air within as pure as the air without’ (p. 9). (‘Windows are made to open, doors are made to be shut’ (Nightingale 1859, p. 12).)

‘Second only to their need of fresh air is their need of light’ (Nightingale 1859, p. 51). (‘A dark house is always an unhealthy house, always an ill-aired house, always a dirty house. Want of light stops growth, and promotes scrofula, rickets, etc., among the children’ (Nightingale 1859, p. 16).)

The most cruel absence of care which can be inflicted either on the sick or well’? Unnecessary noise (Nightingale 1859, p. 27).

She talks of walls hung with cares, ghosts of troubles haunting beds, of ‘the cruelty of letting [patients] stare at a dead wall’ (Nightingale 1859, p. 38, my emphasis), for ‘the craving for variety in the starving eye, is just as desperate as that for food in the starving stomach’ (Nightingale 1859, p. 35).

‘To any but an old nurse, or an old patient, the degree would be quite inconceivable to which the nerves of the sick suffer from seeing the same walls, the same ceiling, the same surroundings during a long confinement to one or two rooms’ (Nightingale 1859, p. 37, my emphasis).

Here’s something for the digital age: ‘I have never known persons who exposed themselves for years to constant interruption who did not muddle away their intellects by it at last’ (Nightingale 1859, p. 33).

Where does all this take us?

‘Caring’ for Nightingale does not entail a responsibility for patients’ emotions. It means caring for nature’s reparative process by creating the conditions for it to do its work. ‘Care’ means care-ful attention to patients and their practical conditions. It is nature herself which is kindly, compassionate (or, one supposes, not). In the book, ‘care’ is most often associated with ‘common sense’.

This sounds to me like good advice.

The voice in Notes on Nursing and the very way Nightingale lived her life tells us loud and clear that we are each responsible for our own emotions.

In this light, consider the kerfuffle caused by the recent research* of Dr. Anna Smajdor who contends that nurses (and doctors) do not have to treat patients with compassion.

‘Compassion is not a necessary component of healthcare, since the crucial tasks associated with healthcare can be carried out in the absence of compassion.

‘One can remove an appendix without caring about the person it is taken from, empty a bedpan without caring about the patient who has filled it, or provide food without caring about the person who will eat it.’

‘Unless we regard healthcare professionals as saints, we cannot demand that they guarantee an unlimited flow of compassion for each patient. Indeed, it is not only unfair, but dangerous to do so.’ (Source)

Nightingale, I believe, would agree.

* Smajdor’s research appears in the current issue of Clinical Ethics and is not yet publicly available. When it is, I will return to this issue.

Nightingale’s Notes on Nursing: What is is and what it is not (1859) is freely available on the internet. I downloaded it from the internet archive here. It reads well on an iPad.

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