Abstract
This article draws upon the emotion at work literature to explore how workers manage their feelings in dealing with death as a routine part of their working lives. It focuses on a specific group of workers, healthcare assistants (HCAs) in a hospital setting, who in delivering direct patient care have a particularly intimate relationship with dying and death. Based upon interview data from HCAs in four English acute hospital trusts, the article argues that the emotional outcomes of patient deaths can be explained by the nature of death as an event – its structure, context and actor circumstances – and by how HCAs appraise that event through the use of cognitive change and attentional deployment.
Introduction
The first time I ever saw a lady who’d passed on . . . they were washing her and everything, and I’ll always remember, the one thing that got to me, was the fact that a nurse auxiliary opened the window and she went ‘go on’ and then she shut the window. It still sends shivers down my spine just thinking about it. (Healthcare assistant)
Scholars of work have paid limited attention to the activities associated with death undertaken by employees as a routine part of their working lives. Given the burgeoning literature on emotion at work over recent years (Coupland et al., 2008; Lopez, 2010) it is a surprising lacuna. Workplace involvement with death is likely to constitute a rich ‘affective zone’ (Fineman, 1993) with an array of emotions typically stimulated. Indeed, a number of occupations can be identified as engaging with death on a regular basis. Many of these occupations will be found within the healthcare workforce, although death-related roles in a variety of other employment settings can readily be highlighted: for example, funeral directors, coroners, bereavement counsellors, scenes of crimes officers, cemetery workers, fire fighters, police officers, ambulance staff, various religious figures, and select groups working in the media.
With a few important exceptions (Glaser and Strauss, 1968; James, 1992, 1993; Katz and Johnson, 2006; O’Donohoe and Turley, 2006), work activities dealing with death have rarely been the focus of detailed research within mainstream organizational studies. In other fields of study this neglect is even more striking. For instance, in thanatology, dedicated to the study of death, there have been relatively few published studies focusing on death in the workplace (Black, 2007; Hyland and Morse, 1995).
This article seeks to address the absence of research on death-related work, with a particular focus on healthcare employees, the most sizeable group of workers dealing with death on a routine basis. More specifically, it considers the emotional experience of healthcare assistants (HCAs), a non-professional group in closer, more regular contact with the patient than perhaps any other work group in a hospital setting. The article explores how and why HCAs emotionally respond to death at work, seeking to relate such responses to death as an appraised event.
In exploring death as an appraised event among HCAs, the article engages with a number of literatures. It seeks to broaden debates on emotion at work by exploring the emotional consequences of managing death in the workplace, a not uncommon, but often overlooked, occurrence. It suggests that the treatment of this issue by the dirty work literature has not been sensitive enough to the affective components of this activity, while the care literature has obscured the event-driven nature of emotions. Arguing that an appreciation of emotional responses to death among HCAs needs to reclaim death as an event, an analytical framework is designed that relates affective outcomes to the nature of an event and the techniques used to appraise it.
The article comprises five parts: considering the literature that contributes to an understanding of worker engagement with death; presenting an analytical model designed to explore the relationship between death as an event and emotional responses to it, and developing a series of research questions; outlining the research approach adopted to address these questions; setting out the results; and finally discussing them.
Working with death
Employee engagement in death-related work has often been weakly conceptualized in organizational studies and other literature, with few explicit attempts to differentiate forms of such work and their consequences. This weakness is illustrated in the characterization of those employees dealing with death in the workplace as ‘dirty workers’. Drawing upon Hughes’s (1958: 122) original definition of dirty work as ‘physically, socially or morally tainted’, Ashforth and Kreiner (1999: 415) describe physical taint as occurring where ‘an occupation is . . . directly associated with garbage, death, effluent and so on’. Certainly, these authors distinguish occupational roles by the depth and breadth of the dirty work undertaken, implicitly acknowledging the different ways in which work groups might engage with death. However, the emphasis on ‘taint’ and the juxtaposition of death with effluent and garbage, places severe constraints on how death-related work might be studied.
The notion of ‘taint’ has negative social and ethical connotations, particularly acute in the case of those undertaking physically tainted work (Jervis, 2001). The presentation of dirty work as tainted has encouraged a focus on stigma, and a concentration on the cognitive and behavioural means by which workers seek to justify and ‘normalize’ their work activities (Benjamin et al., 2011; Kreiner et al., 2006). Yet to view death-related work as physically tainted is to oversimplify the varied forms of such work and their consequences. To juxtapose activities that relate to ‘death, garbage and effluent’ understates what are likely to be qualitatively different employee work experiences, and in the case of death-related work precludes a research agenda beyond employee responses to stigma.
There are many striking differences between work roles that relate to death, effluent and garbage. As the healthcare assistant quoted at the outset highlights, dealing with death is distinctive in generating profound spiritual and existential issues for the worker. Equally noteworthy are the affective and relational components of death-related work roles. There are few death-related workplace situations that fail to be affective – generating or engaging feelings – or relational – involving worker interaction with a range of actors (e.g. the deceased and their families). At the same time, for the worker the nature of these components will vary according to the work role in question. Worker engagement with death can be categorized by the timing and the enacted context, suggesting three types of work role: involvement only in the deferred aftermath of death (e.g. the funeral director); engagement exclusively at the point of death, such as employees in emergency care; and provision of ongoing care and, therefore, participation before, at, and in the immediate aftermath of death, the case with many healthcare workers.
This latter work role, dealing with death as part of an ongoing care process, is likely to be a particularly intense emotional experience. It is within the care process that workers will develop a relationship with the patient or client, deepening feelings at the point of and in the aftermath of death. Indeed, a strong affective dimension has been stressed in much of the research on care work, including studies exploring care of the dying (England, 2005).
The affective features of care work have been articulated in different ways. Strauss et al.’s study (1982: 254) of the management of dying in a hospital context, stressed the centrality of sentimental work, seen as emerging ‘where the object being worked on is alive, sentient, reacting – an ingredient either because deemed necessary to get the work done effectively or because of humanistic considerations’. Kanov et al. (2003: 811–812) articulate this affective component as compassion at work, defined as noticing another’s suffering, empathically feeling the other’s pain and acting to ease it. They draw attention to the perceived importance of compassion in the relationship between medical staff and patients, especially in the context of holistic healthcare provision, although these researchers mainly concentrate on compassion between co-workers.
More generally, an affective dimension has often been presented as a defining or intrinsic feature of care work. James (1992), for example, characterizes care work as comprising ‘organization + physical labour + emotional labour’. Similarly Cancian (2000: 137) views caring as ‘a combination of feelings of affection and responsibility, with action that provides for an individual’s personal needs or well being in a face to face interaction’. Indeed, Kahn (1993: 539) notes that ‘ideally (caregivers) are accessible emotionally as well as physically and intellectually, in creating meaningful relations with care seekers’.
This stress on emotional engagement highlights the distinctive nature of care work, but it raises analytical difficulties. First, there is a risk of conflating emotion as a feature of care work, with emotion as a consequence of such work. Second, there is a danger of overlooking the influence of meaning: that is how employee perceptions moderate emotional responses to their care activities. The former difficulty encourages closer attention to the causes and circumstances of emotional engagement in care work, while the latter suggests the need for a sharper focus on worker interpretations as an influence on emotional outcomes. The next section develops a framework displaying sensitivity to both of these factors as a means of deepening our understanding of worker responses to death in the workplace.
Understanding emotional responses: Death as an appraised event
Death as an event
While emotional intensity might well be an essential feature of care work, a deeper appreciation of worker feelings must acknowledge the uneven character of the worker’s experience in providing care to any given individual over time and given shifting circumstances. Care is unlikely to be a linear process: it will respond to changes in the patient’s condition, with likely implications for the nature and intensity of worker emotions. Indeed, tightly defined, emotion is more typically seen as a response to a causal stimulus, rather than as an enduring quality characterizing a situation or process. As Lord and Kanfer (2002: 6) note, ‘[e]motions are generally of short duration and are associated with a specific stimulus’. Death might be viewed as a discrete and significant event within the care process, likely to prompt an emotional response from those workers involved. It follows that any consideration of emotional responses requires a closer consideration of the form assumed by death as an event.
In general, an event comprises three features: a structure, an organizational context and a set of actor circumstances. Death as an event within the care process might be differentiated according to these features, with consequences for emotional outcomes.
Structure derives from how the episodes comprising an event unfold, with various authors suggesting a relationship between this unfolding and the emotional outcomes (Briner, 1999). Hallett (2003: 708), notes that events have ‘after-shocks’ creating a cumulative emotional effect: ‘As interactions (associated with an event) continue, they become an added stimulus, feeding back into emotions aroused earlier, and amplifying them.’ The structure of an event might vary in temporal and integrative terms. Temporal variation reflects episodes unfolding over a more or less extended period of time. Integrative variation sees the constituent episodes flowing more or less seamlessly from one another: similar to a ‘domino effect’, the episodes might closely connect and follow-on from one another, or be much more loosely associated, fragmented and detached. These variations may have emotional consequences, so death as an event comprising disconnected episodes spread over a considerable period of time might well have a different emotional impact to a death made up of intimately related episodes unfolding over a short timescale.
An event will also be characterized by the organizational context, the corporate routines and work systems that influence proximity to and involvement in it. Organizational context might be associated with the job: Morris and Feldman (1996) theorize a link between work tasks, responsibilities, control and the nature and consequences of emotional labour. The precise nature of the task(s) performed will impact on the nature and intensity of the emotional labour required.
Finally, an event will be characterized by the circumstances of a set of engaged actors: in the case of death, the actors involved are typically the patient, the patient’s family, and the workers involved in the provision of care. However, the circumstances confronting these actors are likely to vary, with potential consequences for worker feelings. For example: the personal profile of patients will differ; family members will be unevenly involved in the care process; and the workers themselves will be variously equipped, in terms of capability, to deal with the situation.
Appraisal and emotions
While the nature of death as an event – its structure, organizational context and actor circumstances – is likely to be a significant influence on emotional responses, various literatures suggest that an appreciation of worker feelings cannot rely solely on the character of the stimulus.
These literatures point to moderating influences on the relationship between an event and its emotional outcomes; however, views vary on the nature and power of these moderating influences. One stream of literature contests the capacity of moderating influences to constrain the emergence of genuine employee feelings (Ashford and Humphrey, 1993). Certainly, there is anthropological evidence to suggest that emotions are socially constructed, the ritual and management of death being sensitive to cultural context (Palgi and Abramovitch, 1984). However, this same evidence points to ‘Real’, universal and unmediated emotional responses to death, which cut through and often provide a shared rationale for culturally diverse routines, attitudes and behaviours. This approach might be linked with the view that emotional responses are instinctive (Lord and Kanfer, 2002) or unconscious (Craib, 1995), with employees having little scope to reflect on and consider their emotional reaction to a stimulus.
The second stream explores the scripted nature of the employee’s emotional response to an event. This approach was famously articulated by Hochschild (1983) in her work on emotional labour, the scripting being rooted in management-sponsored feeling or display rules. These rules encouraged surface or deep acting by the employee, with alienating and other negative psychological consequences for the Self. Others have broadened the basis for this scripting; Bolton (2005), for example, stressing that emotional labour might additionally be regulated by rules that derive from the workers’ pecuniary interests, from their altruism or from professional standards. Indeed, this view has been developed by Coupland et al. (2008) who have related the construction of workplace emotions to the rules associated with professional roles.
A final stream claims that the employee has an opportunity to give meaning to a stimulus, which then affects the emotional responses to it (Erickson and Wharton, 1997). This stream connects to a body of literature that highlights the importance of employee cognition as moderating the influence of various external and internal workplace pressures on employee well-being and stress (Daniels and Guppy, 1994). More specifically, it is reflected in the development of appraisal theories (Scherer, 1999), which as Hwang (2006: 6) notes, ‘contend that individuals elicit different emotional responses to the same event due to different evaluations and interpretations of the event’.
Appraisal theories interface with instinctive and scripted approaches in various ways, but generate a number of particular issues on the dynamics of emotional responses to death. An appraisal might still be instinctive or unconscious (Power and Dalgleish, 1997). Indeed, while a considered employee interpretation of an event might well be designed to stimulate manageable emotions, a more instinctive appraisal might equally prompt negative, less easily managed feelings (Daniels et al., 2004, 2006; Power and Dalgleish, 1997).
Appraisal theories sit less easily with scripted approaches to emotion management. Korczynski (2002), for example, notes Hochschild’s tendency to overlook meaning in her emphasis on the alienating consequence of enacted emotional labour. Thus, Hochschild suggests that emotional labour, whether in the form of deep or surface acting, invariably produces debilitating psychological outcomes – guilt or stress – discounting the possibility that workers might lend a positive interpretation to their emotion work with less adverse outcomes. Certainly, an appraisal approach raises questions about how and why events are appraised in particular ways, various scripts possibly being used as interpretative schema with implications for emotional outcomes.
Appraisal theories, therefore, encourage a concentration on employee interpretations of death as an event, while permitting an ongoing interest in the uncontrolled and scripted nature of emotional responses. Gross’s (1998) emotion regulation process model has proved particularly influential in exploring employee-customer emotions in interactive service organizations (Grandey, 2000). This model emphasizes the scope for individuals to regulate their emotions by appraising an event or stimulus at various points and in different ways. Gross (1998) presents the initial opportunity for the individual to appraise an event as antecedent-focused, and suggests that this form of appraisal might emerge as:
Cognitive change, where the situation is re-interpreted as a means of generating different, perhaps more manageable, outcomes; or
Attentional deployment, where the subject shifts focus, connecting to memories, past experiences or an ‘appropriate’ set of values and norms as the basis for the emotional responses.
The distinction between attentional deployment and cognitive change provides an opportunity to map the interpretation given by employees to death as an event, as well as to consider how these techniques might be related to different emotional responses.
In summary, reclaiming death as an event within the care process encourages a focus on the nature of that event – its structure, context and actor circumstances – and on how that event is appraised to regulate emotion by cognitive change and attentional employment, as a means of deepening our understanding of how workers emotionally respond to it. Figure 1 sets out the features of this model, generating a number of research questions:
Structure, management and emotional outcome of a death experience.
How does the structure of death as an event – its temporal and integrative qualities – influence the workers’ emotional response to it?
How do organizational context and actor circumstances shape death as an event and in what ways do these factors affect the employees’ emotional reactions?
Drawing upon the distinction between attentional deployment and cognitive change, what substantive form do workers’ attempts to regulate emotion in these terms take, and how do these interpretative schemas moderate the influence of death as an event on emotional outcomes?
These questions are addressed in research focusing on a particular group of workers, healthcare assistants (HCAs).
Research approach
The social organization of death in a hospital setting (Sudnow, 1967) suggests that for the nurse and the HCA death is likely to be an extended and intimate event. The registered nurse and the HCA provide the routine care of the dying patient, with occasional interjections from the doctor, who withdraws from the patient on death, leaving others to deal with the management of the body. In the immediate aftermath of death, it is the nurse and HCAs who undertake ‘Last Offices’ – the cleaning and laying-out of the body.
This pattern of work has encouraged a research focus on emotion at work among registered nurses (Smith, 1992; Theodosius, 2008); however, the emotional experiences of HCAs have largely been overlooked. This is a striking omission given that HCAs are perhaps more intimately involved with death and its immediate aftermath than nurses and certainly other healthcare workers. This intimacy, in part, derives from established characteristics of the role and those who fill it. The HCA is a long established part of the National Health Service (NHS) workforce in Britain, comprising almost one-third of the nursing workforce in secondary healthcare (NHS Information for Health and Social Care, 2009). The role is unregulated with low barriers to entry, attracting a different type of person to that usually performing as a registered nurse. Both nurses and HCAs are overwhelmingly women, but they often come from different socio-economic backgrounds, the latter also having more diverse work and life experience than the former (Kessler et al., 2010).
The importance of these differences as an influence on affective engagement with death is highlighted by James (1992: 503) in her study of caring work in a hospice. She notes that there is ‘almost an inverse of status and skill in emotional labour . . . young staff-nurses relied on the four older [HCAs] who were described as being the backbone of the unit’. James implies that this reliance is derived from the distinctive background of the HCAs as well as the structure and nature of their roles. Thus, HCAs were seen to bring a much richer set of tacit skills developed beyond the workplace, often in a domestic context, to the care process than nurses, and, partly as a consequence, to engage more closely with patients.
The HCAs’ greater intimacy with death and the dying patient can also be associated with recent changes in the structure of the nursing workforce in Britain. The reform of nurse training from the late 1980s, with a shift away from on-the-job training toward in-the-class learning, left HCAs, rather than student nurses, as the main hands-on support for nurses on the ward (Stoke and Warden, 2004). This support has increasingly taken the form of HCAs providing much of the direct patient care as registered nurses are drawn to alternative administrative and technical tasks and responsibilities.
Data collection
As part of a broader project on the nature and consequences of the HCA role in a hospital setting, emotional engagement with death was seen as a means of exploring the impact of the role on those who performed it. Between 2007 and 2009 HCAs in four, variously sized and located, English NHS hospital trusts were interviewed and observed. This article draws upon the interview data, which provided the richest material on responses to death. The HCAs worked on general surgical and medical wards. A ward team would typically comprise 6–10 HCAs, with two to three working on any given shift. At least two HCAs were interviewed on each ward, selected by the ward manager, but encouraged by the research team to choose different levels of experience in the role. Of the 82 HCAs interviewed in total, 53, some two-thirds meaningfully spoke about their experiences with death. The remaining 29 had not encountered death, found it difficult to talk about this issue, or provided extremely generalized responses.
The 53 HCAs were fairly evenly distributed between the four hospital trusts, and shared a number of features: almost all were women (90%), and most had a partner (69%) and children (73%). In other respects there was some diversity: the average length of service in the hospital trust was close to seven years, but the range extended from one month to 28 years; the average age was around 40 years, although those included in the sample ranged from 20 to 60 years old. To provide some context for the views expressed in the findings section, each HCA quote is attributed by hospital location, HCA ID number, gender (female [F] or male [M]), age and length of service in years, for example: Midland_7: F/34/19.
Interviewees were asked to recount their first experience of death on the ward and how they had coped with it. This was linked to a more general discussion about how they dealt with their emotions at work. HCAs were asked whether they had ever become attached to a patient and how they had managed this situation, often encouraging mention of a patient who had died. Finally, HCAs were questioned about what they most ‘liked’ and ‘disliked’ about their job, prompting some references to death on the ward. All interviews were taped and transcribed, with those parts of the interview dealing with dying and death extracted for further analysis.
The interviews resulted in narratives about death that varied markedly in detail and length, ranging from just 16 seconds to 11 minutes. However, in total, our HCAs spoke for around two and half hours on specific death-related issues. A small number of HCAs recounted complete stories about a dying patient: these came from 11 HCAs, who each spoke for more than four minutes on these subjects. In such cases we were able to explore the nature of death as an event and its influence on emotional outcomes. Most of the HCAs provided more fragmented information. This limited our ability to assess the link between event structure – how death as a discrete event unfolded – and emotional outcomes, but still allowed us to explore event-context and actor circumstances and their association with HCA emotions.
Our analytical approach to exploring these narratives was inductive and iterative (Glaser and Strauss, 1967). The HCA narratives were coded according to the contextual factors that influenced emotional responses. It then became apparent that similar contextual circumstances, such as performing Last Offices, were often perceived in different ways, with emotional consequences. This encouraged us to return to the literature to develop an analytical framework that captured this interpretative dimension used to regulate emotions. Gross’ (1998) distinction between attentional deployment and cognitive change as a means of emotion regulation provided the most useful analytical insights in this respect. The narratives were further coded by the regulatory technique adopted by the HCA.
Before presenting the findings, it is worth drawing upon our observational and other material to provide a brief backdrop to HCA engagement with death on the ward. First, death was an ever present possibility on our wards but a relatively rare event. There was typically a number of patients at any given time who were dying; however, on only two of 39 observed shifts did a patient die, and on another observed shift a patient had a cardiac arrest. Second, formal hospital rules on the management of emotions among nursing and other staff were noticeable by their absence. There were procedural rules for the handling of related activities, such as dealing with Last Offices, but the communication of even these rules to HCAs was at best uneven.
The next section presents the findings, addressing, in turn, the research questions posed.
Findings
Emotional responses and event structure
Two of the complete HCA narratives highlight how differences in the nature of an event – its structure, context and actors – elicited contrasting emotional reactions. The first culminates in the HCA becoming distressed and upset.
Story 1: What happened was [nurse’s name] had said to me ‘oh this lady’s really unwell’ and . . . she asked me if I minded sitting with her; because she didn’t have any family with her, and she said that she could possibly die and how do I feel, if I feel uncomfortable about doing it then don’t do it, but she thought it would be a good learning opportunity. So I went and sat with her because I didn’t mind . . . and as I was stroking her hand she did die and it was like it weren’t real really. I helped clean her and then when they wrapped her up . . . in the sheet, the thing that got to me most was actually covering her face, wrapping her head up . . . I kept looking because I kept thinking I could see her breathing . . . Anyway I finished that shift and . . . I had an appointment to try on wedding dresses and my mum was meeting me in the shop. I went in and I was fine, I didn’t feel upset or anything, but then when I started talking about it and I told my mum, I just burst into tears. I just explained to her that it was when I wrapped the lady’s head up, that’s what really got me really. I don’t know why. [North_9: F/36/5)]
The second narrative generated an emotionally ambiguous response, reflected in a degree of confusion and anger on the part of the HCA:
Story 2: It was a proper, a full [cardiac] arrest. That was obviously my first one and it wasn’t a very pleasant experience because she was bleeding internally and it was really messy and I wasn’t prepared for that one. And then we managed to get her back, I was doing the blood pressure and somebody had managed to get her back and she died the next morning, and I couldn’t understand what was the point, was I doing it right? I’d two matrons and two sisters in with me and they wouldn’t have let me do it if I wasn’t doing it right. But the question stayed with me for a long time . . . We sort of had a good talk about it and they said, ‘No, you was doing everything correct’. I said, ‘and what was the point in going through all that for her to just still [die]’, but then I thought well it gave her a chance, the only way I could . . . accept the fact, was the fact that her family could have been with, was with her in the end, whereas the other way they wouldn’t have been. [London_2: F/52/6]
In considering the structure of these two recounted events, it is clear that they were underpinned by a shared framework. As Table 1 indicates, they unfolded in four main episodes: prelude, point of death, immediate and extended aftermath. It is equally apparent that the integrative and temporal components of structure varied, contributing to the different emotional responses. Story 1 is characterized by a compressed timeline and tightly integrated episodes. There is a momentum to the unfolding episodes that builds to an emotional response in the form of distress and tears. In quick succession, the HCA sits with the patient, holds her hand at the point of death, performs Last Offices and moves straight on to meet her mother. Story 2 develops over a longer period, with the episodes more loosely linked to one another: the HCA is present when the patient ‘arrests’, but absent at the point of death, and not intensively involved in the aftermath of death. This pattern provides more space and greater opportunity for the HCA to reflect, eliciting a shifting and volatile emotional response: the HCA moves from anger to confusion to acceptance.
Structure and context of the death experience
There are also striking differences in the respective organizational contexts of these deaths – the tasks the organization called upon the HCA to perform – and in the actors’ circumstances – the patient’s condition; how the HCA’s own personal situation framed their engagement with the death; and whether and how the patient’s family is involved. In Story 2, direct involvement in a ‘messy’ patient death led to HCA anger, confusion, self-doubt and guilt. In Story 1, the performance of Last Offices, in particular the covering of the face, combining with personal circumstances and the extended aftermath – the opportunity for the HCA to recount her experiences to her mother in a setting with strong personal connotations, a wedding dress shop – resulted in a more overt and sharper emotional outburst in terms of tears.
Drawing on the interview data from our broader sample of HCAs provides an opportunity to identify a range of actor circumstances and features associated with the organizational context that influenced emotional responses to death.
Actor circumstances: The patient
Emotional responses were sensitive to the age of the patient: the younger the patient the deeper the emotional reaction:
[We had] a young gentleman not long after we moved here and he was in his thirties, and that one sticks in my mind. That was quite heart-rending because he was so young and he was actually quite fit, but it was actually a brain tumour and it was so awful to see him deteriorate like he did. [London_3: F/50/8]
HCA feelings were also connected to the intensity of patient suffering. In the following case it is this suffering that lends poignancy to the death, although again age plays its part:
If it’s a younger person and if they’ve had a really bad bleed or they’ve haemorrhaged . . . and then you have to clean them and lay them out, that I think about afterwards, because it’s not the fact that they’ve died, it’s the fact that they’ve had to suffer and you go home and you think that is an awful way to die. [North_10: F/31/1]
HCAs’ emotions were associated with how long the patient had been on the ward and to the closeness of the relationship with the HCA: even an older patient who had been on the ward for some time could prompt an intense emotional response on death:
If they’ve been with you a long time and pass away or something, it can be quite sad . . . sometimes you can’t help your feelings. [Midland_7: F/34/19] It depends on how much you’ve looked after that patient and how well you’ve got to know that patient and how well you get on with them, because obviously you get on with people in different ways. Some days you do get very upset. [South_12: F/42/9]
The suddenness of the death had emotional consequences. Immediate contact with the patient before death and surprise at the timing of the death could prompt a sharp emotional response, often sadness or shock:
I was chatting to her [the patient], she was fine . . . I just finished giving my last dinner out and the crash alarm went off . . . She was in the chair and she’s just slumped and they tried to resuscitate her a couple of times. I mean she was a good age, she was 94. I felt awful because I sat there and thought I’d just been speaking to her literally just over an hour ago and she was fine . . . that was the last time that I properly had a cry. [Midland_10: F/23/2] We had this little man that was on the ward; he must have been on the ward for months and months and he used to be a bit of a wanderer . . . Two weeks ago I was feeding him with his supper, and we put him back to bed and he just died, and it was so quick and I just felt like a lump in my throat. I went home and I just couldn’t stop thinking about it. [South_24: F/54/1]
Actor circumstances: The patient’s family
The presence of relatives, particularly their distress, could influence the HCAs’ emotional response:
If anything like that [a death] happens and I’ve got close to the family, it’s the families that make me cry and things like that because how emotional they are, and they’re trying to talk to you and they can’t hold it back, and it’s like now I’m filling up. But yes, that’s the only bit that gets me; I sometimes feel that I have to walk away. [North_4: F/31/1]
The level of personal comfort and support provided by family to the patient also impacted on HCA emotions. For example, a patient dying alone often prompted an acute HCA emotional response:
I don’t like to see a patient die on their own . . . I should be hardened to this after 13 years, but it really cuts me up if I think you know ‘oh he’s died on his own’. [Midland_1: F/56/13] A few years ago we had a 12 year old who hung himself . . . This little one actually had his life support turned off, and even the mother went home before he died . . . I actually stayed to the early hours of the morning with him because I didn’t want to leave him in there on his own. [London_7: F/52/12]
Actor circumstances: The worker
The HCA’s background circumstances could affect their capacity to deal with their emotions. This was illustrated by an HCA, who recounted the difficulties faced in managing a mix of emotions (hers and those of others involved) in the wake of a patient death:
It can be very hard, I mean there was one time . . . when we had . . . quite a horrible death actually and we had to do all that and then come out, and another man was celebrating his 60th birthday and wanted us to put balloons up and that. I found that was very hard to come from that situation straight in to put[ting] balloons up for him and making it special; and it was sort of coming out from a really horrible situation into a bubbly situation. At times like that you sort of take five minutes on your own and just get your bearings back. Because you’ve got to be professional still, other patients are relying on you. [London_2: F/52/6]
The measured coping response mentioned at the end of this quote might be related to the tacit skills brought by this HCA to the role. Certainly this link is not explicitly made and therefore needs to be treated with care, but a review of the HCA’s personal background indicates that it might well have fostered the tacit skills needed to deal with such a complex configuration of emotions. London_2 was a middle aged woman (52 years old) with an average length of service in the hospital (six years) who left school at 15 with no qualifications and had not subsequently acquired any formal qualifications. However, she had brought up two children, worked in a diverse range of work roles – in shops and schools – and crucially had cared for her mother recovering from a stroke.
Organizational context: Tasks
Certain organizational tasks were viewed as more harrowing to the HCA than others. For some, although not all (see Cognitive change: Extended care) the performance of Last Offices was disturbing for the HCA. One HCA expresses these strong negative feelings, implicitly linking them to the de-personalized administrative routines associated with Last Offices:
With the Last Offices, after the family have gone we wash the patient down and you put on a shroud: it’s a vile thing, it’s horrible. Cards have to be written out with the patient’s name, their age, the consultant, the ward that they’ve come off, their date of birth, their hospital number. You get three cards, so you have to stick one on the chest which, it makes it vile. [Midland_10: F/23/2]
Organizational context: Support
The support provided to the HCA in dealing with death, by members of the ward team, was also a crucial influence on emotional responses: the stronger the support, the more likely negative emotional reactions were to be mitigated. For example, team member sensitivity to the HCA’s first performance of Last Offices impacted on whether HCA fears were effectively dealt with:
I’d never seen a dead body before, but [the nurse] was like pushing me in to doing it, thinking because I’m a healthcare I know what to do, and get on with it. I went in there and I said, ‘I haven’t seen a dead body’; and then she said ‘oh just touch it!’ . . . but I felt pushed then in to wrapping up the body and I didn’t want to, I wasn’t ready. [South_22: M/50/7] [The patient] passed away and [the Sister] in charge said ‘have you ever done one’ [Last Offices before] I said ‘no’. She says ‘come on, you can come with me’ . . . She did take me under her wing, she was very good. And I cried all the way through it. That’s really bad isn’t it? But I got over that and the second time wasn’t so bad. [Midland_1: F/56/13]
This team support was further reflected in the availability of opportunities to deal with the emotional fallout of a death: the chance to confide in HCA and nurse colleagues; or the organizational provision of time and a private space to cope:
I just found myself a quiet, little corner to have a bit of a weep and tried to get it straightened out. There’s no point bottling it up, if you can find a quiet, harmless sort of outlet that doesn’t bother anybody else, I don’t see the harm in it. [South_21: F/27/3]
Event appraisal: Cognitive change and attentional deployment
While the emotional consequences highlighted in Stories 1 and 2 were associated with the nature of death as an event – its structure, the organizational context and actor circumstances – they were also influenced by the meaning given to it by the HCAs. In the case of Story 2, the HCA resolved the mixed emotions stimulated by the revival and, soon after, the death of a suffering patient, through interpreting the unfolding episodes as providing time for the family to be present. The HCA in Story 1 was unable to find such a consoling interpretation. Indeed, this HCA gave the event a nightmare-like meaning, suggesting that it was ‘unreal’ and imagining a breathing corpse.
Confronted with the profound and deeply moving nature of death, HCAs’ emotions were sometimes revealed as immediate and unmediated: the ‘Real’ could often assert itself unbidden and in an unmediated way:
Nothing really can prepare you for the death and nothing can really prepare you for the way, you know, the relatives don’t want to go home, the way they need to be talking and sometimes they just need to go over it and over it, whether that be the death or just the fact that they’ve been given certain news and you just need to be there. [South_14: F/31/6]
However, the range of stories recounted by HCAs uncovered a number of shared meanings given to death, classified as cognitive change and attentional deployment, which influenced the emotional response.
Cognitive change: A full life
A number of cognitive changes were highlighted by HCAs in their engagement with death. HCAs interpreted death in the context of a ‘full life, well lived’, common in dealing with elderly patients. This interpretation was underpinned by the perception of death as ‘inevitable and natural’, allied to a view that the patient was often resigned to going:
They’re old: a lot of them they want to go anyway; they find that ‘I’ve had enough, leave me alone, don’t feed me’ and ‘I’ve had enough, I want to go’ . . . and I have to accept their wish. [South_23: F/49/6] You have to bear in mind that on this ward most of the people that die are elderly, so it’s really sad but there is a kind of naturalness too. [South_2: F/35/5]
Cognitive change: Extended care
HCAs often viewed care as continuing after death. This interpretation was deployed in performing Last Offices, converting an apparently distressing task into one that could evoke positive emotions:
I enjoy doing it, that’s an awful thing, isn’t it, but . . . if I’ve looked after a patient for X amount of weeks or X amount of months, then I think laying the person sort of to rest is the last thing that you can do for them. [Midland_6: F/48/10] I really enjoy doing Last Offices . . . It’s the last thing you do for the patient, the last bit, if you do it right, it’s dignified. [Midland_2: F/42/3]
Cognitive change: A transfer of care
HCAs sometimes interpreted Last Offices as a form of care not only for the deceased patient, but also for the remaining relatives. For example, dealing with and presenting the body in a sensitive and considerate way was seen as a means of addressing the suffering of those close to the deceased:
It’s awful but it’s quite nice to know that I made them [look clean], at such a horrible time for their family to come and see them, because a lot of families do want to come and see them after they’ve passed away . . . and like there was one family that came in and I sat with them and I had a cup of tea and they were OK then. [North_13: F/21/1]
It is an approach illustrated by the HCA keen to signal to the family the care given to the deceased patient:
I put like talcum powder [on the body] so the family can see it, so they think, ‘oh he’s had a wash’. [Midland_4: M/38/8]
Cognitive change: The living dead
HCAs often pretended that the deceased was asleep or still alive, reflected in the tendency to talk to the patient, particularly during Last Offices, helping to soothe the emotional rawness of the situation:
I know it sounds daft but I still talk to them as though them still alive; it’s how I deal with it. I just sit there and ‘oh well they’re asleep, I’ll just carry on’. I know it sounds daft but it’s the only way that I can properly get my head round it. [Midland_10: F/23/2] I talk to them as if they’re still with us . . . You just say your goodbye and even when the porters come to get them, they’re quite fussy – be gentle with them, don’t bang their head, we’re there to help all the time. [London_3: F/50/8]
Attentional deployment: Personal connection
Attentional deployment emerged in two forms: as a link between a patient’s death and a personal memory or experience and as an attempt by the HCA to distance themselves from death by focusing on abstracted institutional or personal norms, values and practices. There were cases where the interpretation of a patient’s death by linking it to a personal experience, enabled the HCA to cope better with the situation:
I can’t say I was shocked [by a patient death] because, because I’d seen my mum die and my dad die. [London_2: F/52/6]
It was more common for this link to prompt negative feelings – sadness and distress – implicitly intruding on, rather than supporting, the provision of care:
The first time [a patient died], I was so nervous, because just before I started working here I lost my mum, especially with what she died of, she died of cancer . . . and I remember this lady died of cancer as well. I would just imagine like my mum . . . they [team members] actually saw that I’d got tears on my eyes. [London_20: F/40/4] My dad died four years ago and I came back to work after a couple of days and then I was sent in to do Last Offices. I thought that was quite heartless really because I found that very hard. [London_4: F/52/15]
Attentional deployment: Distancing
HCA attempts to shift attention by distancing emerged in part by presenting death as a cumulative experience that might be guarded against:
I’ve seen so many people pass away and you’ve just got to be compassionate . . . It’s not something you get used to but . . . I find I can cope with it. [London_16: F/45/4] You don’t get hardened to it you just protect yourself from it a little bit . . . I mean there’s been a couple of times when I’ve had to run off the ward and cried a bit and then come back . . . It’s hard; it took a while to get used to. [Midland_10: F/23/2]
Distancing was also achieved by drawing upon the notion of ‘professionalism’. Defined in a fairly loose way, professionalism was implicitly presented by HCAs as requiring personal emotions to be set aside to ensure efficient and effective performance:
On a professional basis you try to control them [your emotions] although occasionally you can’t, and then you might go home and have a good cry, you know, a glass of wine and then start again. [South_12: F/42/9] Sometimes you can get a bit too involved and I don’t think that’s professional . . . I think sometimes the girls do get a bit, you know, like they kiss and cuddle them and I sort of, it’s just me I suppose . . . I don’t think you should do that. [London_16: F/45/4]
While reliance on ‘the routine’ and ‘the professional’ allowed the HCAs to distance themselves from the death as a means of regulating their emotions, it was still a ‘hard-won’ response, with feelings never far below the surface:
The family were so nice, they were really lovely . . . and when the mother died it just hit me. I was crying my eyes out, I thought ‘oh no’ . . . I’ll try and be a bit tougher, I felt that I’ve got to keep going, so I’ve got to keep doing my job, I’ve got to be there for somebody else. [South_10: M/53/1] You will get involved and let them know you care but you have to make that step back sometimes, because then it can get very complicated. It can be hard not to get involved, but I think you’ve got to draw that line from it being a caring role and being too involved because it’s not healthy for the patient or yourself at the end of the day. [London_2: F/52/6]
In summary, and returning to the three research questions initially posed, it is clear that these findings establish and elaborate on the relationship between the nature of death as an event, its appraisal by HCAs and their emotional responses to it. The first question suggested that event structure influenced emotional outcomes: the HCA stories revealed differences in the unfolding of death over different time frames and through a series of unevenly integrated episodes, with consequences for HCA feelings. The second question claimed that death as an event might vary according to actor circumstances, and organizational context: the findings have revealed HCA sensitivity to the patient’s condition and the involvement of patient families, as well as to the tasks performed and the availability of organizational support. The third question proposed that events might be appraised by HCAs, with cognitive changes and attentional deployment influencing emotions. The findings highlighted the various forms assumed by these different appraisal techniques. Cognitive change was presented as: a life well lived, extended care, and a still living patient; while attentional deployment emerged as: personal connections and distancing.
Discussion and conclusions
This article sought to address an aspect of work neglected within the organizational studies literature but an essential part of many occupational roles, dealing with death and dying. This neglect was particularly striking in the case of employees in healthcare, those most likely to deal with death as a routine part of their work lives and encouraged a focus on healthcare assistants, a group of workers increasingly involved in the care of the dying in a hospital setting
It was argued that previous attempts to conceptualize and research worker engagement with death had shown limited sensitivity to the affective aspects of employee engagement with death. The dirty work literature, in particular, had presented employee engagement with death as physically tainted, equating it with activities related to dealing with ‘garbage and effluent’ (Ashforth and Kreiner, 1999). Given the HCA experiences of death as presented in this article, it would be difficult now to view death-related work as adequately categorized with these forms of dirty work, or to see a research agenda solely limited to the management of stigma or normalization as appropriate. HCA engagement with death generated profound and genuine negative and positive emotions, and brought to the fore a caring dimension of work unlikely to be found as core to employees dealing with ‘garbage’.
The research literature on caring was viewed as much more sensitive to the affective dimension of work with death and dying. However, its treatment of worker emotions created an alternative set of analytical difficulties. It presented the engagement of worker emotions as intrinsic to care work (James, 1992), so conflating emotional engagement as a feature and a consequence of care work. This risked obscuring the causes of emotional engagement within the care process, and departed from a tight definition of emotion as a response to a specific stimulus. We have sought to reclaim death as an event within the care process likely to stimulate worker emotions, and in so doing built upon, sharpened and applied those features of an event – its structure, organizational context, and actor circumstances – likely to influence worker feelings.
In addition, the article has taken the discussion beyond the features of an event to suggest that responses to death might be moderated by the employee’s appraisal of death as an event. Noting alternative views on moderating influences within the emotion at work literature, stressing the scripted or the more instinctive nature of emotional responses to a stimulus, the article adopted an alternative, appraisal approach. This approach was predicated on the assumption that employees had a brief space to interpret an event with implications for their emotional response to it.
In drawing upon Gross’ (1998) appraisal model to explore how HCAs regulated their emotional responses to death, a number of points has emerged. The distinction between cognitive change and attentional deployment has proved useful in characterizing, mapping and explaining emotional responses to death as an event; more specifically our research has allowed us to elaborate on the various forms assumed by appraisal, and how they have related to the emotional outcomes. In adopting an appraisal approach we have also been able to make links to the instinctive and scripted perspectives. It was striking, for example, that, while the employee might have space to interpret an event, this could still lead to negative, and less easily managed, emotions, particularly apparent where death as an event was linked to unhappy personal memories or experiences. Moreover, given the absence in a hospital setting of well-developed management-sponsored feeling rules (Hochschild, 1983), the attentional deployment used by HCAs to manage their emotions in dealing with death, revealed the importance of other influential scripts.
For our HCAs, one such script distancing, based on ‘professionalism’, emerged as an important means of regulating emotions. While this connects to a broad literature that suggests the significance of a professional rhetoric in constructing emotional responses (Coupland et al., 2008), the use of a ‘professional rhetoric’ by HCAs suggests its power as a disciplinary device (Fournier, 1999). HCAs consistently resorted to ‘professional standards’ as a means of rationalizing the regulation of their emotions in the face of death. This was not only a testament to the pervasiveness of such rhetoric throughout the nursing workforce, but more significantly to its capacity to impose an attitudinal and behavioural response on a low status, relatively poorly paid work group, far removed from any ideal conception of a profession (Freidson, 2001).
Equally, there was evidence to suggest that appraisal techniques were scripted by the kind of altruistic values highlighted by Bolton (2005): thus, instances of cognitive change, presenting Last Offices as an extension of care, independent of professional values, might well be viewed as the HCA providing positive emotions to patient and families as a ‘gift’. The basis for this altruism is still open to debate. At the outset, we suggested that HCA approaches to emotion regulation might be drawn from beyond the workplace and linked to broader life experiences (James, 1993). We have sought to make these links by relating the personal backgrounds of HCAs to their emotional engagement in different death-related situations. However, given the structure of the study and the nature of data collected, it proved difficult to fully establish such a connection, a difficulty that points to the article’s limitations.
Our open, unstructured approach to HCA engagement with death has generated rich material on emotional responses, and allowed the various meanings associated with death-related work to emerge. It has, however, provided limited opportunity to pursue more direct and ordered comparisons between the views and backgrounds of the different HCAs. Moreover, in concentrating on a single occupational group, we were unable to make strong assertions about the distinctiveness of the HCA engagement with, and responses to, death. It was suggested that as a non-professional group of healthcare workers, HCAs might regulate their emotions in the workplace differently to a professional group and, some crude links were made between HCA backgrounds and emotional engagement. However, in the absence of comparator groups in our study, HCA distinctiveness in this respect must remain speculative.
Given these shortcomings, future research on emotional engagement with death in the workplace might draw upon the occupational group as a useful unit of analysis. While we have focused on a work group dealing with death as part of the care process, emotional response are likely to vary for work groups where death as an event assumes a very different form, clearly the case where groups are exclusively dealing with those at the point of death, or with the deferred aftermath of death. Moreover, a comparison of emotional engagement with death between the diverse occupational groups within the healthcare process might provide scope to explore how variation in the structure and regulation of occupational roles shapes interpretations of death as an event in the same work context. Occupations are organized in different ways, underpinned by different values and attracting those with very different work and life experiences: such factors might well lead to contrasting interpretations of death as an event, with implications for emotional outcomes.
Footnotes
Acknowledgements
The authors would like to express their thanks to the article’s reviewers, who provided supportive and constructive comments. They are also grateful to Howard Gospel and Stephen Bach for commenting on an early draft.
This article presents independent research commissioned by the National Institute for Health Research (NIHR) Service Delivery and Organisation (SDO) programme (08/1619/155). The views expressed in this article are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health. The NIHR SDO programme is funded by the Department of Health.