Sociology Discussion 4

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After reading chapters 4-6 and the articles “Strategies of Emotion Management” and “Integrating Dark Humor and Compassion…” how do intensive care nurses and hospice workers use emotion management/front stage/back stage behavior to protect their own psychological and emotional wellbeing? Why is it important to be able to maintain appropriate front stage and back stage behaviors in the medical field or in your chosen profession? What are some of the consequences if these performances are not maintained?


book reference:

Title Sociology
Author David M. Newman


Nursing Inquiry 2014; 21(2): 162–170 Feature Strategies of emotion management: not just on, but off the job Clare Hammonds and Wendy Cadge Brandeis University, Waltham, MA, USA Accepted for publication 29 April 2013 DOI: 10.1111/nin.12035 HAMMONDS C and CADGE W. Nursing Inquiry 2014; 21: 162–170 Strategies of emotion management: not just on, but off the job Intensive care nurses, like professionals in other intense occupations characterized by high degrees of uncertainty, manage the emotions that result from their work both on and off the job. We focus on the job strategies – calling-in, sharing their experiences with others and engaging in a range of activities oriented to emotional recovery – that 37 intensive care nurses use to manage their emotions off the job. These strategies show how the social organization and division of labor in intensive care units influences nurses’ emotional management outside of them and how organizational troubles for hospitals becomes personal ones for staff. They further support theoretical approaches that view emotions as dynamic elements belonging to individuals rather than aspects of people that can be fully appropriated by organizations. Key words: critical care, emotion management, emotional labor, emotions, intensive care unit, nurses, nursing practice. Intensive care nurses, like members of other emotionally intense professions characterized by a high degree of uncertainty, negotiate their emotions as standard parts of their job. In medical workplaces characterized by norms of detached concern, staff learn to express sensitivity to patients they keep at emotional distances (Fox 1957; Cadge and Hammonds 2012). From their experiences with cadaver dissection to their first interactions with patients, healthcare professionals learn to have short memories, use humor and focus on the technical aspects of work as ways to manage their emotions (Coombs and Goldman 1973; Lawler 1993; Feldstein and Gemma 1995; Lewis 2005). Much of the research that considers how healthcare providers manage their emotions developed from Arlie Hochschild’s The Managed Heart (1983 [2003]). Hochschild’s study of airline stewardesses, and the scholarship that follows from it, utilizes a social constructionist approach to argue that people’s emotional experiences in workplaces and their strategies of emotion management reflect status hierarchies Correspondence: Clare Hammonds, Department of Sociology, Brandeis University, MS 071, 415 South Street, Waltham, MA 02454, USA. E-mail: in the organization best understood in terms of structural, organizational and economic factors (Smith 1992; Martin 1999; Pierce 1999; Bolton 2000). We agree with much in this line of research and aim to further it here in two ways by applying it to the case of intensive care unit (ICU) nurses. First, scholars tend to describe people’s emotional experiences at work as static rather than embodied experiences they carry between life domains. As a result, studies tend to focus on how people manage emotions at work rather than work-related emotions outside workplaces. In so doing, scholars often fail to recognize the breadth and depth of workers’ emotional experiences and the different management strategies they employ on and off the job. Second, by relying on Hochschild’s distinction between public emotional labor made in service of employers and private emotion work carried out away from job sites, some studies conceal how the social organization of workplaces structures and how workers manage their emotions away from the job. This question inverts the classic relationship between personal troubles and public issues by asking how organizational troubles or issues – in this case for hospitals and intensive care units – become personal ones for staff. © 2013 John Wiley & Sons Ltd Strategies of emotion management We investigate here the emotional strategies used by 37 nurses working in a neonatal and a medical intensive care unit at one large academic hospital in the United States. Understanding the approach to emotion management employed by nurses is particularly important given that emotional competence is often considered essential to successful nursing practice (Bellack 1999). We briefly describe how the nurses approach emotion management at work generally and on the job more specifically. We then focus primarily on the strategies they employ to manage work-related emotions off the job. While intensive care nurses rarely bring work home in briefcases or on laptops, the social organization and division of labor in these two intensive care units leads them to bring emotional experiences home and negotiate them there. Many of the nurses interviewed describe dreaming, thinking and behaving toward their patients when they are not at work. Off the job, they engage in practices that include calling-in to check on patients, sharing their work experiences with people who help them cope and participating in a range of activities oriented to emotional recovery. Intensive care nurses, like other professionals, are ‘multiskilled emotion managers’ in the words of Sharon Bolton (2001) utilizing different emotional strategies on and off the job. We show that their emotion management strategies are best explored as they experience them in multiple life domains. As they attempt to limit the impact of workplace emotions outside of work, these nurses show that their emotional experiences are fluid and what happens on the job is intimately linked to their experiences and management strategies off. Such emotional linkages are likely not only limited to nurses but also shared by others including police and emergency medical technicians who work in intense environments with high degrees of uncertainty. EMOTIONS IN HEALTH-CARE Attention to how workers manage their emotions came to the forefront with the publication of Arlie Hochschild’s nowfamous 1983 book, The Managed Heart. Hochschild’s insights about the content and process of emotion management informed many studies about how employees manage their emotions and the emotions of others in workplaces. This scholarship emphasizes how the structure and organization of occupations and workplaces influences the emotional content of work and the specific emotions workers manage on the job (Wharton 2009). In this social constructionist framework, emotion management occurring off the job is seen as distinct from processes that occur at work where emotions are appropriated by organizations. Much of the © 2013 John Wiley & Sons Ltd research building on this framework views workplaces as having emotionally distinct and bounded cultures that lead people to have emotional experiences that are separate from other life domains (Lively and Powell 2006). Hospitals – and intensive care units more specifically – are one site of emotionally intense, often uncertain, work that includes contradictory norms about emotion management. This is particularly the case for nurses who are trained to embody cultural imperatives of empathetic care and professional mandates of detached concern (Reverby 1987; Lawler 1993; Halpern 2001; Lewis 2005). The existing studies of how nurses – in intensive care units and more generally – manage their emotions tend to emphasize cognitive strategies through which they suppress them (Menzies 1960; Froggatt 1998; Maunder 2008). Nurses are encouraged to deal with the uncertainty and emotionality of their work while maintaining neutrality and orienting to organizational imperatives of efficiency (Smith 1992; Wilkinson 1995). In a study of hospice nurses, for example, Froggatt found them employing distancing strategies – switching emotions on and off, ‘hardening’ so that the emotions of others would have no effect on them and ‘stepping back’ or mentally distancing themselves from the work – to create a barrier between themselves and ongoing losses in the work (1998). Other studies illustrate how nurses create emotional barriers by emphasizing tasks rather than individual patients (Menzies 1960; Maunder 2008). Institutional context matters as some hospice volunteers have recently been encouraged by volunteer coordinators to push against medical norms of detached concern to ‘notice how they feel’ (Fox 2006). Few studies of healthcare professionals explore the extent and ways individuals take their emotions home from work and manage them there. Most studies, instead, focus exclusively on emotions in workplaces where scholars view them as organizationally constructed (Mann 1999). Most scholars do not see emotions in workplaces as embodied in individuals or traveling between life domains but as aspects of people appropriated by organizations (James 1992; Phillips 1996). This approach conceals the depth of workers’ emotional experiences and the specific strategies they engage in to manage their emotions off the job. Scholars writing about the sociology of emotions more generally consider how emotions operate for people in multiple domains (Wharton and Erickson 1993; Lively and Powell 2006; Turner 2009). We adopt this theoretical approach to emotions here. At home, where intensive care nurses lack both the norms of their workplaces and the supports for emotion management present in them, they develop other ways to manage the work-related emotions they experience. 163 C Hammonds and W Cadge Before outlining these strategies, we first describe how nurses working in two intensive care units at one large hospital experience the norms of emotion management on the job. We briefly consider how they manage their emotions at work and then devote most of our attention to the strategies they employ for managing work-related emotions off the job – while at home, with their families and in other spheres. Many of the nurses interviewed describe dreaming, thinking and acting around their patients when they are not at work. This approach to understanding how nurses manage work-related emotions are off-the-job models and encourages other scholars to overcome the split between public and private emotional work evident in much current literature. RESEARCH METHODS The data we analyzed were gathered in interviews the second author conducted between October 2005 and June 2006 with 37 intensive care nurses who work at City Hospital, a large academic hospital. Our use of interview data in this study heeded Savage’s (2004) call for more coherence between the theoretical approach to emotions and the methodological approach used to study them. In this case, our perspective that emotions are primarily social experiences necessitated an approach that would provide us with specific information about how the nurses themselves describe their emotions. City Hospital, where the interviews were conducted, is located in a major northeastern metropolitan area in the United States and is regularly ranked as one of the country’s best hospitals. The nurses work in the neonatal intensive care unit (NICU) (N = 20) or medical intensive care unit (MICU) (N = 17) at City Hospital, each with beds for eighteen patients. Work on each unit is fast paced, intense and unpredictable. Staff members see medically and ethically complex cases daily, often requiring them to work with families to make difficult decisions. Death is common. Each unit practices primary nursing through which nurses are assigned to specific patients they stay with throughout their time in intensive care (Manthey 1992). Unlike in hospitals where nurses are granted little autonomy, the nurses in both of these units were empowered educationally and by their nurse managers and leaders to work directly with physicians. We focus on nurses rather than other staff in the intensive care unit because they are numerically dominant and spend the most time with patients and families. When this research was conducted, the neonatal intensive care unit employed a total of 60 nurses and the medical 164 intensive care unit 65. All of the staff nurses were invited, by e-mail and signs posted in the unit, to participate in this research project about ‘personal beliefs and work.’ They were offered two free movie tickets or $10 gift certificates to the hospital coffee shop in exchange for a thirty-minute interview. Individual nurses suggested others, and reminder e-mails were sent until no further nurses came forward to be interviewed. We obtained approval from the Institutional Review Board at the second author’s university before beginning this research. The interviews included questions about each respondent’s personal background, experience in the intensive care, memorable patients, self-care and personal beliefs. Most of the interviews took place in a private conference room in the intensive care either during or immediately before or after a shift. The data analyzed here were primarily shared in response to questions about whether individuals think about their patients when they are not at the hospital, how they make sense of the difficult parts of their work and how they take care of themselves while doing this work. All interviews were recorded and transcribed. Using a grounded theory approach, the interviews were systematically coded for related themes. This analytic approach was well suited to our research question as there is little prior research on how intensive care nurses or other professionals establish emotional boundaries off the job (Strauss and Corbin 1990). Demographically, all but three of the nurses interviewed were women, almost exclusively white women, reflecting the demographics of nurses in these units. All were licensed registered nurses and had either a B.A. or B.S. in nursing. About one-fifth also had or were working on masters degrees. All had experience in nursing before starting in the intensive care, sometimes after completing intense hospital-based training programs. Some nurses had worked in other units at City Hospital before starting to work in the intensive care unit. Each nurse worked 8- or 12-hour shift, often alternating between days and nights, for 40 hours per week on average. Nurses ranged in age from their early 20s to their mid-60s with the medical ICU nurses in their mid-30s and the neonatal ICU nurses in their mid40s on average. Likely as a result of their ages, the nurses in the neonatal ICU had been nurses, had worked at City Hospital and had worked in the neonatal ICU for longer than the nurses in the medical ICU. Nurses in the neonatal ICU had almost twice as many years of experience in intensive care (13.8 years) as did those in the medical ICU (7.5 years). Pseudonyms are used to present our findings to protect the confidentiality and anonymity of the research participants. © 2013 John Wiley & Sons Ltd Strategies of emotion management FINDINGS Negotiating emotional boundaries generally Intensive care units are emotionally intense environments in which the threat and presence of death is constant. In such contexts, the nurses interviewed spoke about the challenges of maintaining the emotional distance needed to buffer the stress associated with their work. Judy describing this dilemma explained: I think it’s definitely like emotionally tiresome sometimes. I go home and it’s like nothing seems that important sometimes and it’s like…you had a traumatic death or something…you go home and you’re like, ‘All right.’ Everyone else is having normal day at the office, but I had to witness the most horrible thing, but you know. Hannah, a nurse in the NICU, echoed similar sentiments about the difficulties of leaving work emotions behind at the end of a shift: So sometimes I come home…and I’m still like pumped up, you know, like adrenalin-wise. And sometimes I even hear like the monitors beeping in my head. I know that sounds crazy, but I’ve expressed that to other peers, other co-workers, and they say the same thing. Almost all of the nurses interviewed described – at least sometimes – thinking about their patients outside of work hours. As they think about patients, they continue to negotiate emotional boundaries between work and home. A few think about patients’ medical conditions while most think about how they and their families are doing following the emphasis the units and hospital more generally puts on holistic care for families. ‘I think about them a lot when I’m home,’ said Karen. Marilyn thinks about them while she is ‘doing the dishes.’ Nurses think especially about their primary patients when they have been working with them for a long time or when the patients are not doing well. The close bonds nurses often develop with primary patients develop directly from the hospital’s emphasis on primary nursing care. Some nurses think about patients and families ‘all the time…wherever I am’ while others are triggered by certain things. When Kimberly, a neonatal nurse, was out shopping, she saw and purchased small slippers for one of her primary patients because something about them reminded her of the patient. ‘She [the patient] can’t wear clothes right now so I thought she should wear some slippers.’ Dottie tries to build up an emotional wall at work to help her get through the day. It is outside of work, she explained, that: Certain things will trigger like you might be in a grocery store or in Mass or something like that and there’s © 2013 John Wiley & Sons Ltd something that kind of clicks in and you start thinking about something that happened and it just brings back…it sets off a cascade [of emotion]. Other nurses have photographs of their primary patients in their homes that are themselves triggers. Peggy shows her children photographs of her primary patients saying they become ‘characters just like your co-workers,’ and Jamie has hung photographs of a long-term primary patient on her refrigerator. She explains: Sometimes I just take it home with me….my whole family knows him [a long term primary patient]…His picture is still hanging on my refrigerator, and my kids still ask about him…Two of my girls [daughters] actually met him when they came in…one day when he was here. In addition to consciously thinking about patients and families, a number of nurses dream about them. ‘I dream about them constantly,’ said Judy. When she is working many days in a row, she says, ‘I feel like I never leave work, ‘cause I go home and I dream about them and I come back [laugh].’ Penny similarly dreams about patients ‘all the time….I wake up at night, thinking, I have to check the blood sugar on the…you know.’ Her dreams are not simply about taking care of her patients but about being connected to them. In another dream, ‘I woke up one morning at like 6 am saying, “I don’t see Jonathan [a patient]…” I thought I took him home with me. I had a dream that I took him home with me. Yeah, crazy.’ Marilyn explains, ‘I’m always dreaming about them at night, you know. I wake up in the morning and go, “Wow that was really a good dream. I hope she [a patient] is still okay [laugh]”.’ The kind of easy laughter that accompanies nurses’ stories about these dreams suggests that they are common enough to have become part of the job. As much as nurses think about patients and families when they are awake but not work at work, patients and families enter their unconscious worlds through their dreams. While most of the nurses interviewed negotiated emotional boundaries between work and home that had varying degrees of permeability, a few nurses negotiated this balance by seeking to create strict emotional boundaries around work experiences. Peggy has worked in the neonatal ICU at City Hospital for more than 20 years. She feels strongly about not being in touch with patients once they leave the intensive care unit. In her words, ‘I don’t make contact with my patients outside’. She thinks this emotional distance is necessary so she can move on and care for other patients, and so patients and families can better connect with future healthcare providers. ‘I think when they leave me, they need to form a bond with their pediatrician…..I don’t want to set up a struggle between coming back and asking me if it’s the 165 C Hammonds and W Cadge right thing or not.’ She also feels like this distance is in part mandated by her profession as a nurse, ‘I try not to become like an intimate friend. I want to be the nurse, but I’m not their best friend.’ Parents sometimes e-mail Peggy photographs of former patients as they grow up, which she is always happy to see, but feels strongly that this communication be kept to a minimum and not initiated by her. Rob in the medical ICU aims to create similar space between himself and his patients once they leave the unit, for professional reasons and reasons of emotional self-protection. He, in his words, ‘tries not to be in touch with or hear from former patients’ aiming to ‘leave work at work.’ He is not sure how exactly he learned to do this but said he had to in order to continue working on this unit so that ‘now it’s pretty much ok.’ In the words of Hannah, this kind of separation and distance from patients once they leave the unit is essential, ‘in order to be able to function and not get overly involved….you have to know that cut off point,’ a point she thinks comes with ‘time and maturity.’ Strategies of emotion management on the job The nurses put their ideas about emotion management into practice in several ways at work drawing on resources available in the workplace. In so doing, they aim to protect their own psychological and emotional well-being. They draw on the support of colleagues, talk with patients’ families and adopt several cognitive strategies including those aimed at changing their perception of a situation. The most common way nurses described negotiating emotions on the job was by ‘venting’ to colleagues. Martha remarked, ‘I think we cope a lot…with each other, and that makes it a lot easier because everyone kind of feels the same way and understands how the other person feels.’ She explained, ‘Usually I vent…to my coworkers, or, you know….we have a really good rapport with each other.’ NICU nurse Christina similarly stated: It always makes you feel better when you sit down with other people that day and kind of go over the whole thing right then and there – rather than go home and kind of hash it out in your own head…to kind of generate conversation about it is better than not. While relying on colleagues to help manage emotions on the job was certainly a dominant strategy, other nurses spoke about how patients’ families helped them cope with difficult situations. Nancy captured the importance of these relationships when she remarked, ‘Well, you talk with each other. You talk with the staff and…I guess some days you just cry with the family and you know…it’s sad, there’s sadness when people – some people die at 21.’ Tamara also spoke of how family connections helped her manage emotions on the job. The death of a baby on the unit shortly after the birth of her own child had prompted feelings of great sadness. In response, Tamara explained, ‘I sat over in that bed space over there…and I bawled my eyes out with that father’. In addition to relying on other colleagues to manage emotions, some nurses rely on cognitive approaches. One approach was to emphasize the work that the nurse had done to help the patient. NICU nurse Kosta for example, explained that: And you know, a young person dying – it hits you very hard. How do I deal with that? I just do. It’s sad. You do the best you can, and again that’s a gratification knowing that you’re just doing everything you know how to do, and you are just working 110%. Similarly MICU nurse, Dottie remarked, ‘Of course, like taking care of the dying patient…can sometimes be emotionally wrenching, but also can give you a great sense of pride in where you work and helping out in that respect.’ Both Kosta and Dottie managed difficult emotions on the job by reframing the death of a patient. No longer was the focus on the difficult experience of the patients’ death, but rather on the work the nurse did to help that patient. Another way nurses described managing emotions at work was by reconstructing the situation as a positive. This was particularly true in instances where a patient had passed away. Often, nurses would reframe the loss in terms of relief because the suffering was over. Angela expressing this strategy saying: And you feel bad for the family and the people that are left behind, but you know that they really eventually move on, and you know, sort of get over it, and like part of them is maybe relieved of their suffering is over, and their long, drawn-out hospital stay or something. The use of collegial relationships to process difficult emotional states was a theme that came up frequently and is very much in line with Lewis’ conclusion that: Strategies of emotion management off the job …the very difficult emotional situations that the nurses regularly face, allied to the fact that it is expected that they deal with their own emotions professionally (i.e. suppress them), mean that they are likely to turn to each other to cope when pain and distress is experienced (2005, 525). While some of the nurses sought to manage their emotions by creating impermeable boundaries around their work emotions and experiences, most aim to negotiate a balance, trying to create some, but not too much, emotional space 166 © 2013 John Wiley & Sons Ltd Strategies of emotion management from patients and families not just at work but also in other life domains. As they individually and collectively sort through their work-related thoughts and dreams off the job, the nurses interviewed developed three sets of off the job strategies for managing their emotions. They rely on coworkers as they called-in to obtain information about patients, share experiences with people who help them cope and engage in activities oriented to emotional recovery. They utilize these strategies at homes, in restaurants, in gyms and in other venues. Some use the commute or physical transition away from work as one way to manage their emotions. Some spoke about using the commute to ‘decompress’ by thinking through things that just happened or sometimes just crying. Kosta lives a distance from the hospital and explains: My rule is that when I finish a shift I have until my garage door goes up to process whatever it is that has happened on that shift. And when the garage door goes up, my family is not to bear the brunt of a bad shift. Tamara has learned over time to ‘detach’ herself until she finishes work when difficult things happen, like a patient dies, which then leads her to, ‘bawl my eyes out all the way home.’ Laura also explains the importance of this transition period in her process of emotion management stating, ‘Well, taking the train home, or driving home, sometimes I’m able to just kind of think through my day.’ CALLING-IN Nurses we interviewed call-in to work from home to check on patients or visit patients on days off as one strategy of managing their emotions. Most of the nurses reported calling-in from home, at least occasionally, to check on the status of a particular patient. In the words of Lillian: You know, I just had a patient who…it was someone that I took care of for a long time and I went on vacation for a week. But I was wondering what happened with Koo. I kind of called to check in and see. And he had passed away, which I kind of expected…. As Barbara stated, ‘We’ve all at one point called off-shift to see how so and so’s doing.’ In talking about calling-in, many nurses are aware of the frequency of their calls and even set guidelines for themselves about how often they allow themselves to call, with less being better than more. Marie explains: I have called back many times…I have woken up in the middle of the night – not every day – and called in and said ‘how’s this one doing? I do call back but I try not to make a big habit of it. © 2013 John Wiley & Sons Ltd For Martha, ‘There are times when you get very involved and I will actually call like once or twice a week and ask how the person’s doing. But rarely. I really try not to.’ Others talk about limiting their calls to once a day as a way of managing their thoughts about a certain patient. Tamara explains: Occasionally there’ll be a baby in the back of my mind that I’ll really be worried about, and I will allow myself to call once a day to check on the baby, if that’s something that I feel like I absolutely have to do. Rather than stewing about it, I will call and ask. The examples of Martha and Tamara illustrate how nurses call-in as a way to address the emotions that result from not having information about a patients’ health status. The goal of calling-in here seems to be to gain enough information to allow the nurses to comfortably limit the extent to which they are thinking about particular patients off the job. In doing so, calling-in is a strategy for helping nurses construct emotional boundaries between home and work. In addition to calling-in as a personal strategy of emotion management off the job, several nurses spoke about callingin as a collective strategy. Nurses at home rely on nurses currently working to call them at home if something upsetting happened to one of their patients. This suggests that phone calls are not just an individual strategy used to manage their own thoughts and emotions off the job but a strategy they use collectively to warn and help colleagues be emotionally prepared to return to the unit. Marilyn said she often thinks about her patients at home. Describing a certain patient who had surgery a few weeks earlier, she says she asked herself, ‘Should I call, should I find out…but then…you try to separate yourself but it’s not easy.’ Then she thought ‘If something really bad had happened to her [the patient], they [other nurses] would have called me because they know to call the primary nurse.’ She concluded, ‘So I’m like, “She must be fine, ‘cause nobody called me”.’ Following a similar logic, Susan would sometimes call to check-in on a patient while also being aware that ‘people [nurses] would call if something was going wrong. Because there were a few times when we didn’t think he [a patient] was going to make it. They called me at home.’ In addition to calling-in, some nurses stated that they actually went to visit particular patients on their days off. Angela explained ‘There’ve been a few that I’ve called on my days off, and my…cystic fibrosis patient I even went in to visit him a few times on my day off.’ While this was certainly not an approach adopted by most of the nurses interviewed, this does highlight another way in which nurses try to manage work- related tensions off the job, by creating bridges back to the workplace to gain information about patients. 167 C Hammonds and W Cadge SOCIAL SUPPORT In addition to calling-in, many nurses described how they managed emotions off the job by talking through their work experiences with friends and family who helped them cope. Penny, explaining how she dealt with work emotions off the job said: My fiance…I’ll just call him and say, “I had a rough day.” And we’ll go out and get something to eat and you know, he’ll ask me about it and you talk about it, and that’s sort of when you get to relieve the tension that you didn’t get to relieve in front of the parents… A lot of talking though. Jennifer similarly explains, ‘Sometimes just talking about your own feelings…even talking about it with sometimes like family members that have no idea what you’re really talking about. Just to like get it out and voice those words and get it out of your system.’ While Penny and Jennifer spoke about talking to their family members in general, other nurses were more specific, explaining that friends and family who were not healthcare providers were less useful social supports than those who were apt to understand the demands and emotions of the job. Jean remarked, ‘My husband doesn’t get it, so I don’t even bother to talk to him about it.’ Joanne on the other hand explained, ‘Yeah, I think – well, my spouse is a nurse, too, so it helps that, you know we both kind of – we know where each other’s coming from.’ Similar to this, Kosta also expressed that it was people with experience in this type of work that were able to provide the social support necessary for emotional recovery. She says: I don’t really talk to my friends about it. People who aren’t in nursing or don’t do this kind of thing – I know from a fact they don’t want to hear about it. It’s too hard, it’s too painful. I know my sister doesn’t like to hear about it. She doesn’t even like to hear when I’ve got a really sick kid going. My mom will listen to anything. Like I said, she’s a nurse. Penny also described drawing on the support of family members who worked in health- care. ‘My mother’s also a nurse,’ she said, ‘so if we’ve had a particularly difficult day’ we talk about it and maybe ‘sit down with a glass of Bailey’s….what are you going to do?’ Among nurses who described having other healthcare providers in their immediate networks, these people became central to nurses’ efforts to manage emotions off the job. ACTIVITIES AS AN EMOTIONAL DISTRACTION In addition to strategies nurses used to directly sort through their emotions off the job, some also described engaging in 168 practices primarily aimed at creating a distraction from their work emotions. They spoke about exercising, watching TV, listening to music, crying and/or praying as other personal strategies that give them some distance from work. In the words of Christina, ‘There are times where I just need to watch TV or listen to music and forget about the day…’ Dottie echoed this point claiming, ‘You try to distract yourself.’ While the specific activities nurses engaged in varied, they were all aimed at pulling their attention away from the emotional strains of their work and allowing them to create and maintain emotional boundaries. For some nurses, these activities were more social. Lillian explained: Yeah, you know, like it’s nice if you can meet up with friends and go to watch a baseball game and have a beer, or I’m a big gym person and going running and stuff like that. So just getting out and not just going straight home and sitting there before coming back the next day. For other nurses like Joanne, the activities were more solitary ones. ‘I try to stay pretty balanced outside of work with exercising and just doing stuff for me,’ she said. Similarly, Abby described the emotional relief and renewal she experienced off the job by spending time alone outdoors. She says: I’m a big nature person. And I have a home near a lake that is an unbelievably renewal for me. It’s…on an island. It’s extremely quiet. We have tons of wildlife. Beautiful mountains, beautiful lake and that – just every moment that I’m there enriches me. That is my home. Despite the differences in the type of activity, using distractions was an important way that nurses managed their emotions off the job. DISCUSSION On the job, intensive care nurses manage their emotions and those of the patients and families with whom they work. The intensive nature of ICU work, with its low patient–nurse ratios and regular family contact, leads nurses to continue to manage work-related emotions when their shifts end as they think and dream about patients. The division of labor in the hospital encourages this emotional investment by assigning nurses primary patients and encouraging them to care for family members. It is at home, where nurses lack colleagues and other work structures, that they develop their own strategies. As they call-in, share their experiences with others and engage in a range of activities, nurses continually negotiate their emotional boundaries trying to obtain the right amount of distance from patients and families. Both on and off the job, social support is a central way nurses manage emotions. At work, they draw on colleagues © 2013 John Wiley & Sons Ltd Strategies of emotion management in a process sociologist Peggy Thoits (1986, 417) would describe as ‘emotion-focused coping’. Off the job, they rely on coworkers in a different way as they call-in to check on patients. Rather than participating in ‘emotion-focused’ strategies these strategies are ‘problem focused’ as they help nurses manage emotions resulting from a lack of information. Some nurses also rely on families and friends. On the job, it was the patients’ families who often shared a nurse’s grief or sadness. In their absence, some nurses looked to their own families. This confirms Thoit’s finding that, ‘… others who share similar perceptions of and emotional reactions to an individual’s circumstances (or can do so vicariously due to previous experience) are the most likely sources of efficacious coping assistance’ (1986, 421). Some nurses also relied on cognitive emotional management strategies. On the job, they reframed difficult situations to emphasize their work or to see loss in more positive terms. Away from work, they often aimed to distract themselves through exercising, watching TV or praying to create space for emotional recovery. The nurses we interviewed combined these strategies in ways not clearly related to demographic factors, the length of time they had been on the unit or the specific ICU in which they worked. The strategies nurses use to manage their emotions off the job illustrate the importance of expanding the examination of nurses’ emotion management to specifically consider approaches to ‘self-directed’ emotion management and how these practices are in turn impacted by the domain and place in which they occur. Certainly, existing studies of emotion among critical care nurses have emphasized the important therapeutic value of ‘other-directed’ emotion management (O’Connell 2008). Beyond this however, there has been considerably less attention paid to how nurses manage their own emotions outside of the patient–provider relationship. Our findings have implications for the future study of emotion in nursing practice, suggesting that there is significant emotion work that continues to go on among nurses when they leave the worksite. This is particularly important to consider given a growing recognition of the impact emotional distress has on the psychological health of the provider. ICU nurses in particular are at an increased risk of developing problems like post-traumatic stress disorder (Mealer, Jones, and Moss 2012). On the basis of the findings of our interviews, we suggest that nurses and nursing education programs should focus on developing an understanding of the kind of coping strategies that are employed by nurses when they leave the work site, and institutions should consider how they might provide support resources to nurses when they are off the job. © 2013 John Wiley & Sons Ltd In addition to the implications our findings have for the study of nursing practice, our analysis may also support the development of a more integrated theoretical framework to study emotions more generally. These findings support theoretical approaches that view emotions as dynamic elements belonging to individuals rather than aspects of people that can be fully appropriated by organizations. We encourage future researchers to develop frameworks that do not rely on distinctions between public and private – between emotions managed in work contexts and those managed at home – when both sets of emotions results from organizational aspects of work. Studies in this vain might move analysis away from particular worksites or occupations, to instead focus on individual workers. Such an approach can also provide insight into factors that account for individual variation in emotion management strategies off the job, such as years of employment or home situation, coupled with general features and standards of the job, the organization and the industry. This case study suggests that self-focused emotional labor will be most ongoing among professionals working in industries and/or workplaces, like ICU nursing, characterized by high degrees of uncertainty and the continued presence of death. If this is the case, we would expect to see evidence of the off the job strategies of emotion management evident among intensive care nurses also among firefighters, police officers, ambulance drivers, members of the military and others who have worked in similarly characterized environments. To the degree that similar strategies are evident in professions dominated by men, future studies can also consider the gendered dimension of emotional labor off the job that we could not address here in a profession dominated by women. ACKNOWLEDGEMENTS This research was supported by grants and fellowships from the Robert Wood Johnson Foundation Scholars in Health Policy Research Program at Harvard University, the Louisville Institute, the Radcliffe Institute for Advanced Study at Harvard University and the Jane and Theodore Norman Fund at Brandeis University. We are grateful for feedback on earlier drafts from Peter Cahn, David Cunningham, Elaine Howard Ecklund, Marla Frederick, Sara Shostak, Neville Strump and several anonymous reviewers. REFERENCES Bellack J. 1999. Emotional intelligence: A missing ingredient? Journal of Nursing Education 38: 3–4. 169 C Hammonds and W Cadge Bolton SC. 2000. Who cares? Offering emotion work as a “gift” in the nursing labor process. Journal of Advanced Nursing 32: 580–6. Bolton SC. 2001. Changing faces: Nurses as emotional jugglers. Sociology of Health & Illness 23: 85–100. Cadge W and C Hammonds. 2012. Reconsidering detached concern: The case of intensive care unit nurses. Perspectives in Biology and Medicine 55: 266–82. Coombs RH and LJ Goldman. 1973. Maintenance and discontinuity of coping mechanisms in an intensive care unit. Social Problems 20: 342–55. Feldstein RJ and PB Gemma. 1995. Oncology nurses and chronic compounded grief. Cancer Nursing 18: 228–36. Fox RC. 1957. 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Thoits PA. 1986. Social support as coping assistance. Journal of Consulting and Clinical Psychology 54: 416–23. Turner JH. 2009. The sociology of emotions: Basic theoretical agreements. Emotion Review 1: 340–54. Wharton AS. 2009. The sociology of emotional labor. Annual Review of Sociology 35: 147–65. Wharton AS and RJ Erickson. 1993. Managing emotions on the job and at home: Understanding the consequences of multiple emotional roles. The Academy of Management Review 18: 457–86. Wilkinson M. 1995. Love is not a marketable commodity: New public management in the British national health service. Journal of Advanced Nursing 21: 980–7. © 2013 John Wiley & Sons Ltd Copyright of Nursing Inquiry is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
458122 2Journal of Contemporary EthnographyCain © The Author(s) 2011 JCEXXX10.1177/089124161245812 Reprints and permission: http://www. sagepub.com/journalsPermissions.nav Integrating Dark Humor and Compassion: Identities and Presentations of Self in the Front and Back Regions of Hospice Journal of Contemporary Ethnography 41(6) 668­–694 © The Author(s) 2012 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/0891241612458122 http://jce.sagepub.com Cindy L. Cain1 Abstract In The Presentation of Self in Everyday Life, Goffman drew attention to the various ways that individuals present themselves across settings. One aspect of his discussion was the division of space into front and back regions. In this article, I use data from two years participant observation and forty-one interviews with hospice workers to examine the ways that workers identify as well as how they use those identities to account for discrepancies between front and back region behaviors. Front stage behaviors emphasize compassion, while backstage behaviors include dark humor, strategizing, and detachment. This article argues that workers create a hospice identity that emphasizes authentic emotional expression and enlightenment about death as a way to explain away discrepancies in behavior. This work challenges assumptions that fronts are only performances and that back regions are more authentic by showing how workers integrate the two into a professional sense of self. Keywords hospice, care work, identity, presentation of self, emotions 1 University of Arizona, Tucson, AZ, USA Corresponding Author: Cindy L. Cain, University of Arizona, 1145 E. South Campus Dr., Tucson, AZ 85721 Email: ccain@email.arizona.edu 669 Cain We cuss in the conference room and cry with the family. —Nickie, Director of Hospice Services Workers across various occupations and organizations are expected to manage public perceptions of their companies, professions, and work-related selves. In doing so, they engage in an array of impression management strategies, including displaying appropriate emotions for the setting (Hochschild 1983), learning and disseminating organizational meanings (Grant, Morales, and Sallaz 2009), acting like a “good soldier” (Bolino 1999), and partitioning different aspects of their work into defined areas or times (Goffman 1959; Manning 2008). Care workers feel especially pressured to use these strategies because, if they fail to convince others that they are warm as well as competent, they face the prospect of losing their jobs (Abel and Nelson 1990; England 2005; Findlay, Jeanette Findlay, and Stewar 2009). In this article, I focus on how hospice workers partition time and space as a strategy for managing perceptions of hospice as a type of work and hospice workers as compassionate, caring professionals. My analysis draws upon Goffman’s (1959) classic writings on the front and back regions of social life. The front region (or front stage) refers to any time or location in which workers exhibit the official meaning of the setting, conforming to the expectations of their identity in this setting. The back region (or backstage) refers to any time or location in which workers are not dramaturgically “on” and, consequently, may express unofficial or even counterofficial selves or interpretations. The two regions have a symbiotic relationship in that activities in the backstage allow workers to maintain appropriate behaviors during the front stage, while front stage activities provide fodder for discussions and activities in the back region. I use participant observation and interviews with staff members from a midsized hospice in the southwestern United States to assess the front and back region behaviors of hospice workers. Hospice is an end-of-life care option that emphasizes quality of life over quantity of life, the need for acceptance of death as a natural part of life, assistance to the family as well as the patient, and comfort at the end stages of life (NHPCO 2012). I combine ethnographic and interview methods to get a sense of how workers explain behaviors that often diverge from one another. My findings reveal that hospice workers present themselves in front regions as caring, compassionate, and serious professionals. Meanwhile, in their back regions they engage in morbid humor, strategize about how to change the conduct of patients and caregivers, and display detachment from death. Although these front- and backstage actions seem to oppose one another, hospice workers report that both sets of 670 Journal of Contemporary Ethnography 41(6) behaviors are authentic expressions of self and important to their professional work. I argue that workers integrate these differing presentations of self through the creation of a hospice identity that emphasizes emotional authenticity and enlightenment about death. The findings of my study confirm Goffman’s (1959) initial theorizing about the importance of the backstage for keeping the front stage in order. My findings also challenge the assumption that front stage activities are all performances while backstage behaviors are more authentic expressions of self. Drawing on ethnographic observations and interviews, I show that both sets of behaviors are staged, but felt to be authentic by workers. Moreover, I highlight how hospice workers’ use their hospice identities to construct front- and backstage behaviors as essential to continuing hospice work. Finally, by demonstrating how hospice workers use backstage areas to better prepare for front region performances, this article argues that different performances of self are important components of managing the stress of emotional labor. The Work and Identities of Care Workers To better understand the experiences of hospice care workers, this project draws on two interrelated sets of concerns. First, because care workers must closely monitor their presentations of self when interacting with patients and caregivers, we can gain a more comprehensive understanding of their workrelated identities by documenting both their front- and backstage behaviors. Goffman’s (1959) concept of behavioral regions provides a useful theoretical orientation in this regard. Second, to make sense of how workers account for these differing presentations of self, I draw on sociological research and theory related to the creation and maintenance of social identities, with an empirical focus on the identities of care workers. Front- and Backstages According to Goffman (1959), front regions are defined by the maintenance of proper appearances and adherence to rules of decorum. The front contains the setting (décor, physical layout, props) as well as the characteristics (rank, age, gender, ethnicity) of the individuals who serve as participants. The front exists separately from the individuals who fill the roles within in it, so much so that Goffman (1959, 27) notes that each participant enters an already established front and, simply by conforming to expectations of the social situation, helps reproduce the “collective representation” of reality. The front is highly Cain 671 scripted and often does not allow participants to express their personal thoughts, feelings, or desires. In the workplace, front regions hold the official interpretations of the job at hand, the requirements for completing the job, and ideas about the worth of the job and other participants. Workers and those whom they serve do not always agree on the interpretation of the situation (Mangold and Babakus 1991), which may be especially problematic for workers who must keep up the appearance of caring (Abel and Nelson 1990). To keep the interaction on track, even as participants do not always accept the performances, these encounters often include staged behaviors for both staff members and consumers of that service (Grove and Fisk 1992). In addition, workers perform emotional labor and sometimes even exaggerate emotions for the audience in efforts to evoke a particular feeling in others (Hochschild 1983; Smith 2008). Workplaces also typically have backstage regions that are out of view to the publics they serve. In these back regions, workers can express beliefs that are not permitted in the front stage (Hughey 2011), openly denigrate members of groups they do not like (Sallaz 2010), laugh at customers or the work situation (Tracy, Myers and Scott 2006), learn about and practice their responses to stigma related to work (O’Brien 2011), and perform tasks that would be inappropriate in sight of others (Turner 1976). According to Goffman (1959, 111), these back region behaviors must exist in order to make the front stage behaviors possible. They allow workers time and space to prepare for their roles, practice appropriate ways of being, blow off steam, and take a break from emotionally burdensome roles. Goffman (1959) also noted that workers form teams, strategize about how to approach the work situation, and teach or critique one another on their performances in the back region. Smith (2008) notes how backstage activities with trusting coparticipants are essential for the production of effective front stage performances of emotions. Teamwork requires the establishment of consensus over rules of interaction (Futrell 1999; Manning 2008; Misztal 2001), so team practice especially helps in contexts where norms and rules of interaction are not constant, such as crisis-based situations. With enough practice, teamwork seems effortless, happening without the audience perceiving team communication or direction (Hindmarsh and Pilnick 2002). Although workers frequently become skilled at hiding back region activities, the line between front and back regions is not always clear. Tanner and Timmons (2000) studied operating rooms and concluded that front stage regions included areas with patients, but as the patients underwent anesthesia the space transformed into a backstage area. Tardy (2000) found that the 672 Journal of Contemporary Ethnography 41(6) same play area could be front stage if children with unfamiliar parents were around, but transitioned into a backstage when children were not paying attention and parents trusted one another. These variations have led some scholars to argue that we should think of regions as having a front/back continuum, rather than as distinct geographic spaces or times (MacCannell 1973). This perspective seems especially applicable to caring work because staff members turn any and all settings into front stage areas when necessary, but they can also slip into back region behaviors if they think they are not under surveillance by clients or family members. According to Tseelon (1992), impression management research following Goffman assumed that actors strategically manipulate their public displays to hide their true selves (see Bolino et al. 2008; Durr and Wingfield 2011; Kumra and Vinnicombe 2010 for recent examples). By extension, this scholarship often concludes that the backstage is more “authentic” than the front stage (Chriss 1995). This conclusion contradicts Goffman’s original theorizing, which emphasized that all social interactions include dramaturgy and performances. And while Tseelon’s (1992) critique was published twenty years ago, studies of impression management have either (1) focused exclusively on front region presentations of self, emphasizing how particular performances work to advantage some actors while sidestepping the issue of back region behaviors (Collett 2005; Greener 2007), or (2) implied that workers exhibit their true selves in the backstage and that their front stage activities include only performance (Huppatz 2010; Kumra and Vinnicombe 2010). Hospice workers challenge these assumptions. I found that hospice workers see both front stage and backstage behaviors as important parts of their professional identities. This conclusion is consistent with Goffman’s original observations. In fact, he noted (1959, 111) that all social situations include performances: “when one’s activity occurs in the presence of other persons, some aspects of the activity are expressively accentuated and other aspects, which might discredit the fostered impression, are suppressed.” According to Goffman, all social interactions include some aspects of impression management, but what people conceal (and highlight) shifts depending on their audience and setting. By analyzing these different modes of dramaturgical concealment and display, I document the extent to which hospice workers describe their behaviors as both authentic and staged. Although my analysis makes no judgment about the actual “authenticity” of the hospice workers’ presentations of self, it does focus on how workers construct and enact authentic selves, drawing on elements from the front stage as well as the backstage. Cain 673 Identities of Care Workers Our conceptions of self emerge through our interactions with others (Cooley 1902). We form ideas about ourselves based on our interpretations of how others appraise us. However, given a particular view of ourselves, we must also constantly monitor and maintain a preferred identity (Stets and Burke 2003). In addition, we may have multiple identities at once, but characteristics of the situation help us to decide which identities matter most and how these identities will shape our actions (Ashforth, Harrison, and Corley 2008; Burke 2004). Identities shape social action in the workplace by providing a “definition of the situation” and offering potential lines of action (Burke 2004). For instance, if a nurse provides care for someone in an official capacity, she might interact with the patient differently than she would if the person was also her mother. Ashforth, Harrison, and Corley (2008) argue that identities tie workers to organizations, making the study of identity at work especially important to understanding workers’ experiences. Identities also shift one’s orientation toward unpleasant or difficult tasks, such as dissecting a human cadaver on the way to becoming a physician (Madill and Latchford 2005) or learning how to communicate more like a physician than a student (Lingard et al. 2003). Many studies of workers’ identities have focused on what happens when one’s identity is challenged or when a discrepancy arises between their actions and identity (Alvesson, Ashcraft and Thomas 2008; Pratt, Rockmann, and Kaufman 2006). For example, Brennan (2009) argues that discrepancies between how nurses see themselves and how they are expected to act lowers job satisfaction. In addition, Burke (2004) points out that we have numerous studies of the enactment of identity, but we need to pay more attention to the goals of identity, such as gaining legitimacy, providing meaning, or extracting more labor from others. In this article, I examine how workers negotiate identities and how they use those identities to account for discrepancies in behaviors. While few scholars have explored the identities of hospice workers (see MacDonald 1991 for an exception), a number of researchers have documented the identities of other types of health care workers, especially nurses and physicians. After analyzing the content of introductory nursing textbooks, Goodrick and Reay (2010) concluded that nurses have shifted from serving as assistants to physicians to having identities grounded in a distinct sense of professional expertise and autonomy. Nurses in some settings defined themselves against the physicians and attendants by emphasizing 674 Journal of Contemporary Ethnography 41(6) their attention to holistic care (Chambliss 1996) as well as their ability to make independent decisions (Allen 2000). To establish a distinct medical identity, nurses sometimes manage information during interactions with physicians (Riley and Manias 2009). In settings where teamwork is emphasized, such as hospice, medical support staff tend to form an identity around working well with others (Lewin and Reeves 2011). Certified nursing assistants (CNAs) often form an identity around providing high-quality care to those most in need, sometimes accepting deplorable wages and work conditions because their identity as a caring person gives the work meaning (Stacey 2011). In addition, providing medical care often involves “dirty work” (Ashforth and Kreiner 1999), pushing some care providers to form an identity that is professional and compassionate as a way to ameliorate the disgrace of performing work that involves the management of disgust (Sanders 2010). Nurses and nursing aides provide the bulk of medical care to hospice patients, but because the hospice philosophy emphasizes caring for all aspects of patient needs at the end of life, social support workers also play a prominent role. The latter group includes not only social workers but also counselors, chaplains, and volunteers. MacDonald (1991) found that hospice social workers did not have a clear set of tasks with which to define themselves, and consequently did not have a distinct professional identity within hospice. Other social support personnel form an occupational identity that includes a sense of calling (Christopherson 1994; Dreher, Holloway, and Schoenfelder 2007) or an emphasis on performing saintly work (Solari 2006). Methods and Setting I engaged in participant observation, informal interviews, and semistructured interviews to gather data about the identities and interactions of hospice workers. Because these methods are especially attuned to the processes by which behaviors and identities are constructed, they are ideal for assessing Goffman’s writings on the interaction order (Hillyard 2010). In fact, in a recent review of literature related to identity, Owens, Robinson, and Smith-Lovin (2010, 495) commented that “we may need new studies of naturally occurring situations to fully exploit the linkages between internalized structure and situated action.” In a related vein, Barley and Kunda (2001) argued that we need more studies of the process of work, especially ethnographic accounts like this one, to continue to build knowledge about work and workers. Hospice serves as an ideal venue for examining workers’ presentations of self. Hospice organizations are shaped by the hospice philosophy, which seeks to provide a “good death” to patients. A “good death” is thought of as Cain 675 death with dignity, peace, acceptance, and the control of pain (Hart, Sainsbury, and Short 1998). It also encourages communication and cooperation as well as interdependence between professional positions, and the use of interdisciplinary teams to conduct care. Interdisciplinary teams consist of physicians, nurses, CNAs, social workers, chaplains, counselors, and volunteers working together to meet the complex medical, social, spiritual, and psychological needs of patients and their families. The nature of hospice work makes it especially important that hospice workers carefully manage impressions of self. The setting for this study is a midsized hospice organization in the southwestern United States, here called Rose Hospice. This location typically has approximately one hundred patients enrolled at any point in time and employs forty-five to sixty-five staff members. I use pseudonyms to refer to all staff members and organizations to ensure their anonymity. Although there is great variation in the size of hospices throughout the United States, the patient enrollment and staff size of Rose Hospice is average for this region. I entered the site as a hospice volunteer so my research includes full participation in patient services, observation of staff behavior, and partial participation in administrative responsibilities, such as paperwork and communicating with other team members. All aspects of this research were approved by my University Human Subjects Protection Program. Much of the work of hospice takes place in the homes of patients or adult care facilities; however, this particular organization also runs an inpatient unit for those with care needs that exceed the abilities or resources of home caregivers. The inpatient unit is a short-term facility and most patients in the unit are either expected to die within days of entering the facility or come to the unit to give caregivers a break from daily care. The inpatient unit has ten rooms available at a time and is furnished to look like a comfortable hotel. Each room has a hospital bed, a few chairs or a small couch, a sink, refrigerator, and space to store belongings. Observation of staff–patient interactions took place primarily in the inpatient unit, but also included some visits to patients’ homes and adult care facilities. During patient visits, I did not take notes out of respect for the patients’ families and the wishes of the hospice workers, but after each meeting I recorded my experiences in audio and written format. My observation at the inpatient unit included attending meetings in the conference room; visiting patients with nurses; visiting family members with social workers, counselors, and chaplains; and spending time in the nurses’ station. The social workers and chaplains were initially more open with me about their jobs and lives outside of work than the nurses and CNAs. The nurses and CNAs were first tolerant, and then accepting, of my presence in their space. Overall, I spent 676 Journal of Contemporary Ethnography 41(6) about four hours per week in the inpatient unit over the course of eight weeks from March to May of 2010. I also conducted participant observation at weekly Interdisciplinary Team Meetings, referred to as IDG by the staff. Team members include a physician that served as the medical director, nurses, social workers, counselors, and chaplains or spiritual directors. In total, nine to twelve staff attended each meeting. I observed weekly meetings for approximately nine months from January to September of 2010, with each meeting lasting between two and four hours. I describe the content of the meetings below. Throughout 2009 and 2010, I also volunteered at the main office, performing administrative tasks, interacting with the staff, and collecting preliminary ethnographic data on the operations of hospice. I spent slightly more than two years making weekly visits to the main office, IDG meetings, the inpatient unit, and the homes of patients. I supplemented data gathered through observations of the inpatient unit and weekly IDG meetings with semistructured interviews of thirty-four staff members as well as informal interviews of seven staff members. Participants included eight nurses, eight CNAs, five chaplains, four social workers, three volunteers, four counselors, six administrators, and three physicians. These interviewees represent the diverse experiences of workers within hospice, while still focusing attention on the staff members who perform the most patient care (i.e., nurses, nursing assistants, social workers, and chaplains). In these interviews I asked workers questions about how they did their work, how they came to hospice, how this job compares to others they have had, how they feel about the company and their coworkers, and how they fit work with their family life. The interviews ranged from 38 to 87 minutes long, with most interviews lasting at least one hour. Interestingly, I did not ask workers about their professional identities, but this theme consistently came up in my inductive coding of the ethnographic field notes and interviews, indicating that workers have a strong sense of professional identity and that it shapes both how they act and how they feel about the work they do. Also, by not explicitly asking about worker identities, I was able to get a more comprehensive view of how workers’ sense of self fit within their work activities (Sveningsson and Alvesson 2003). Getting Access and Building Trust Even though volunteers are technically part of the hospice team, I found that the hospice workers initially treated me like an outsider and did not integrate me into their backstage behaviors. However, entering the setting through the volunteer program meant that I used a “side-in” (Chambliss 1996), instead Cain 677 of top–down, approach to observation. I came in as a volunteer and built up access over time, simultaneously gaining trust and information about hospice. This approach allowed me to avoid many of the access problems that typically plague research on medical institutions. For several weeks, the hospice workers did not discuss sensitive topics in my range of hearing or used vague references to keep some aspects of the work hidden. Sensitive topics included problems with other workers, elder abuse of patients, and complaints about the organization. As my research unfolded, however, workers became more open and even explained common situations to me as they happened. I conducted all research overtly and I made an effort to integrate fully with the workers to build trust (Miller 2004). Gaining trust was especially important in that I sought to observe workers’ behaviors behind the scenes and to ask them questions about sensitive topics, including feelings and behaviors that might be damaging to their professional careers. In turn, I had to monitor power dynamics between myself and the participants carefully (Hoffmann 2007; Kleinman and Copp 1993). To ensure that we had trusting relationships, I took the role of student and confidant. I also performed my own emotional labor in the following ways: I ensured participants that I did not judge them for their comments, I hid my frustration when they dodged tough questions, and I buried my delight when I was finally able to get some of the respondents to open up. I also ended the interview with an invitation to ask me anything they wanted or suggest other types of questions I should be asking. This invitation usually resulted in a few short questions about why I was interested in hospice and suggestions for additional questions or persons to interview. Strategies of Data Analysis I analyzed the written and voice data through an iterative process that included my observations as they happened, an exploration of themes that emerged on typing and compiling notes, and rereading and coding the written notes. I transcribed all audio recorded notes, and all of the interviews were transcribed by a professional service funded by the National Science Foundation. After reading the transcribed notes and interviews, I used Atlas.ti to construct a coding scheme and a set of theoretically interesting themes. Some themes, like the identity of care workers, emerged through this process, while I derived others, especially related to emotional labor, from the literature. In both cases I carefully noted unexpected, surprising, and contradictory findings. Guided largely by Charmaz’s (2006) version of grounded theory, I performed analysis of themes and concepts as I collected ethnographic and interview data. I used memo writing to work through emerging ideas and to orient 678 Journal of Contemporary Ethnography 41(6) future data collection through theoretical sampling. I evaluated and modified my conceptual approach as I collected data, which proved to be immensely helpful in sorting out how workers made sense of their contradictory behaviors. I then used memos, voice notes to myself, field notes, and interview transcripts to pull together conceptual links that were not always observable to participants in the setting. The Front Stage of Hospice Front stage behaviors performed by hospice workers most often occurred during interactions with patients and family members. During these interactions, workers typically projected absolute professionalism, expertise, and caring. During one visit, Vonda, a social worker, allowed me to observe her conversation with the two daughters of an ailing woman. Although she had been quite busy throughout this day, Vonda took me aside to show me the case file, go over the list of topics to discuss, and come up with a strategy for discussing difficult topics. She told me that she felt “frazzled,” and then warned that she needed to talk to the family members about their funeral plans and “they might get a little teary.” When we entered the patient’s room, I was struck by how Vonda’s presentation of self changed. I recorded the following in my field notes: She really put all of the distractions aside and was just “there with the patient.” She sat in the room, and we talked with the patient’s family again. She asked the daughters about their funeral plans for their mother and the youngest started to cry quietly. Vonda touched the shoulder of the youngest daughter twice to console her, and each time she said, “I’m sorry, I know this is really hard.” Then the daughter wiped her eyes and started asking questions about funeral preparations. Other interactions followed the same pattern—that is, workers brought up difficult topics, family members and patients responded emotionally, and then the hospice worker assessed the needs of family members and offered support. Throughout the entire process, the staff member remained calm and compassionate. The counselor, Michelle, frequently met with family members as their loved ones began to decline. I accompanied Michelle on a visit with a daughter of a longtime patient in her home. Michelle, the daughter, and I sat on the porch and no one said anything for the first few minutes. We sat in silence. Eventually the daughter said that she was upset that her mother was declining, Cain 679 but felt relief that they had help during this difficult time. Michelle nodded and held the daughter’s hand, still not saying much, but clearly offering support. After a few moments, Michelle reiterated that hospice was there to help and asked if the family needed anything. After we left, Michelle said “I like to come out here. I feel good helping her [the daughter] because they are a nice family.” Even as we transitioned to a backstage area she kept the calm, supportive face that she used during the interaction with the daughter. In another situation, I witnessed Rita, the inpatient unit nurse, greet an incoming patient. Although the patient did not seem to be responsive, Rita quietly introduced herself and welcomed the patient. Later in the afternoon this same patient started to call out, asking where she was, and if someone could help her. Rita entered the room and said, “You’re in a safe place. We’re going to take good care of you.” She patted the patient’s hand and continued to reassure her until she calmed. Rita then told me that the patient was not cognizant enough to talk about where she was or how she got there, but it helped to tell her calmly that she was safe. Rita was known throughout Rose Hospice for always treating patients in dignified and respectful ways, while also remaining calm herself. All of these examples demonstrate the ways that hospice workers prioritize providing sensitive, compassionate, and flexible care for patients and their families. They took the time to say nothing, hold hands, and reassure patients who were not responsive. Workers took pride in meeting the needs of those who are suffering, while also accepting that their ultimate goal is not to “save” the person. The philosophy of hospice—to provide comfort, not a cure—was espoused and embodied in the front stage behaviors of staff at all levels. Nurses especially highlighted that this kind of work was a form of true nursing, and Cheryl, a hospice nurse for fifteen years commented, “Hospice is the only kind of nursing that I like.” These front stage presentations of self were consistent with the workers’ commitment to the hospice philosophy, and although workers admitted that they sometimes had to project feelings they did not have in these encounters, they also emphasized that their caring self-presentations felt real. As Vonda, a social worker, commented, “I don’t think that we’re faking it, or acting. . . . But, I suppose we do sometimes. I guess I just don’t notice.” However, to keep up this level of care and perform required forms of emotional labor, they needed to engage in backstage activities with their coworkers. The Backstage of Hospice The backstage presentation of self of hospice workers differed markedly from the front stage. While workers consistently viewed and presented themselves 680 Journal of Contemporary Ethnography 41(6) as caring, compassionate, and professional, they often deemphasized those characteristics when they were in a group of other hospice professionals, especially when interacting in IDG meetings. IDG meetings began at 8 o’clock in the morning. I often arrived a few minutes early to say hello to the volunteer coordinator, Robin, who served as a key informant throughout this research. Other team members were frequently in their offices gathering paperwork, getting coffee from the communal kitchen, or sitting in the common space, discussing unresolved issues of care and compliance. The nurses entered the meeting one at a time to discuss their patients, with the official meeting beginning when the first nurse entered with the patient records. Each nurse typically supervised the care of eight to fifteen patients, and three or four nurses presented during each meeting, so the meetings often lasted two to three hours. Although all members of the interdisciplinary team were required to attend these meetings, most of the conversation took place between the nurse and the medical director. Periodically other team members would also interject to give additional details on the state of a patient, question assumptions of the medical workers, and suggest other issues that might be unknown to these workers. The social workers were the most active of the nonmedical workers, but even they often expressed boredom and frustration with the time taken out of their workday. During interviews, social workers frequently mentioned that they were committed to high-quality care but they saw IDG meetings as being more about compliance than care, and they preferred to spend their time in the field rather than in the office. Nonmedical workers passed the time in the meeting by writing and passing notes to one another, quietly whispering about work and nonwork topics, and making lists of tasks. Joking and “messing around” were common activities at this end of the table. Medical workers usually ignored the misbehavior of the nonmedical workers, but sometimes participated in the joking. Dark Humor and Morbid Conversations Meetings were used not only to check in about patient care but also to address difficult aspects of the work. Hospice workers often did this with humor, teasing, and conversations that outsiders might regard as morbid. During one meeting a long-time nurse, Bonnie, reported that her patient had died unexpectedly. The medical director, Dr. Brown, asked Bonnie what the patient died from, and from the other side of the table, Ramon, a social worker replied, “She [the nurse] killed him.” In another situation, a social worker noted that a patient drank approximately three to six ounces of hard alcohol each afternoon. Cain 681 Dr. Brown laughed, and said, “I probably would too if I was in his situation.” Several others agreed and then revealed what kinds of substances they would prefer if they faced a similarly painful dying process. These jokes were not meant to be offensive, but they often presented otherwise serious issues in a casual manner, demonstrating the extent to which the hospice workers had routinized issues surrounding death. Workers also frequently talked about their own deaths. Proximity to death broke down social norms about the inappropriateness of these kinds of conversations, permitting workers to have morbid conversations. Before one meeting, the dietician expressed her concern that all of her children are boys and that unless she has a girl, she fears that no one will take care of her as she ages and approaches death. In another situation, Keith, a long-time hospice chaplain, explained that hospice fit with his life “because basically to me it’s practice for my own dying. So that’s kind of how I approach each day.” He then elaborated this explanation by saying that working with people at the end of life forces him to firm up his own beliefs about death and the afterlife. On at least two other occasions, workers confronted suicides of former colleagues. Although the hospice philosophy generally holds that with appropriate support systems and pain management, suicide would be less attractive to those facing the end of life, workers’ conversations showed ambivalence about the morality of suicide. During both of these situations, workers commented on the modes of suicide used and assessed their own perception of these tactics. When one former colleague hanged himself at work, the workers at Rose Hospice expressed sadness at his death, but also commented that “I could never do that in my workplace—how horrible for his coworkers” (Robin, Administrator). In general, the workers avoided judgmental language, but they did not hide their own preferences, should they ever take their own lives. This was a somber conversation, but one that workers did not avoid. On another occasion, Barry, a chaplain in his 70s, said, “I don’t believe in suicide, but with dementia I might consider it.” Suicide was frequently a serious conversation among the workers, but even more frequent was conversation about preferences for disposing of their bodies after death. One conversation about cremation became humorous to the workers as they discussed a situation in which a former patient’s loved one tried to pour out his cremains, only to find big bone segments in the urn. Cremains is a term created by the funeral home industry, but accepted and used by staff at Rose Hospice. Robin, the key informant for this study, explained that after cremation the bones of the deceased are ground up and are the consistency of sand, not ash, so funeral directors are careful to use the word “cremains” instead. 682 Journal of Contemporary Ethnography 41(6) She explained that “‘ashes’ could be misleading to loved ones.” I recorded the staff’s discussion of cremation preferences in my field notes: [The staff] agreed that bone segments would be a horrible sight to confront while mourning, but they laughed as they discussed their own cremation preferences. Meanwhile, the meeting had ended and workers were leaving the meeting room while still discussing cremation and laughing. The volunteer coordinator turned to me and mentioned that they should keep their voices down because this conversation could be offensive to families dealing with the impending death of a loved one. Within seconds, all of the workers were quietly discussing other, more appropriate topics. The monitoring of this conversation as the workers left the conference room signaled the move from a backstage of the staff meeting to the front stage of the public halls of the inpatient unit. Workers negotiated spaces like this throughout their workdays. In fact, one of the most common themes recorded in my field notes are moments when laughing in the nurse’s station became too loud and one of the other staffers (e.g., another nurse or the social worker) would chastise the group, reminding them to respect the visiting families. The following excerpt from my field notes illustrates this dynamic: A patient with dementia had been trying to get out of her wheelchair all day, so the nurse brought her down to the nurses’ station to keep an eye on her. At one point the patient grabbed a bowl of sugar packets off the counter and threw it across the room. At first Rita [Nurse] seemed annoyed, but then the patient grabbed the bowl of creamers and threw it across the room as well. Belinda [CNA] then laughed and quickly moved the other items over so that the patient couldn’t reach them. Belinda, Rita, and I all looked at each other and started laughing. Yolanda [Social Worker] immediately walked in and said, “Shush, the family is visiting in 106.” Yolanda did not think the laughter was inappropriate, but she emphasized that the family might not appreciate it. Laughing was almost universally seen as an inappropriate to front stage behavior within the inpatient unit. As Goffman (1959, 2) highlighted, managing these moments represents an attempt to keep what is “given off” in interactions consistent with intentional presentations of self. Cain 683 Strategizing to Change Behavior During IDG meetings, workers also had frequent conversations about how to “educate” family members who were resistant to common hospice practices. Periodically, family members would not want their loved ones on pain medications because they feared the patient would not be aware of their surroundings, but the patient felt high levels of discomfort during bathing, transfer from wheelchair to bed, or any other kind of movement. During IDG the workers often reiterated that level of pain medication was to be decided by the medical power of attorney, but that they must make sure the family is fully aware of the level of pain. Implicit to this group discussion was an emphasis on strategies for changing the behaviors of caregivers and family members in the (presumed) interests of the patient, as demonstrated by the following interaction in IDG: Nurse: She [Patient’s Daughter] doesn’t want any pain meds. Medical Director: But she’s [Patient] in pain. Nurse: I know. We need to have more discussion about her options. Medical Director: Has she [Daughter] been there when you transfer her [Patient]? Nurse: No, and that’s when it’s worst. Medical Director: Next week just wait until the daughter gets there and then try to move her. That’ll get her to rethink the pain meds! In this case the workers brought back region behaviors into a front region interaction in an attempt to persuade others. The team discussion of this strategy allowed the front stage encounters to go smoothly, even as workers tried to change the behaviors of caregivers. Another situation where hospice workers strategized about changing the behavior of caregivers was related to hydration. Many patients at the end of life reach a point in which they can no longer swallow. Hospice, unlike hospital care, sees this as a natural process and advises caregivers not to try to give the patient food or water once they reach this stage. If the patient cannot swallow, but is given food or water, they could choke, thus hastening and making death more painful than it would be if they died from dehydration. Hospice workers frequently talked about how to educate family members about choking and how to persuade them to stop trying to feed their loved ones. During a training session for social workers, a group of ten hospice social workers discussed how to approach a son feeling guilt over not feeding his mother: 684 Journal of Contemporary Ethnography 41(6) We just have to have compassion for him, but also let him know that it is natural to want to feed her and it’s hard to know when she’s passed that point of being able to swallow. . . . We also need to educate his siblings so that they don’t blame him. (Janie, Social Worker) These educational efforts frequently did not succeed, prompting staff to have regular backstage conversations about how to get through to family members who thought they were doing more harm by withholding food and water. Detachment toward Death Even during backstage activities, hospice workers found it important to maintain professional, and often unemotional, presentations of self. During IDG, staff regularly discussed the death of a patient, often saying things like “they went home—the big home” or expressing relief that the patient’s suffering had ended. But unless a particular staff member had grown very close to this patient, they rarely spent more than a few moments discussing him or her. During interviews, several staff said that outsiders often do not understand that hospice is not sad because they become accustomed to death and accept it as inevitable. Stephanie, a certified nursing assistant, said “It’s all in how you attach yourself. You have to know when to detach, and you can’t get too attached.” Others expressed more ambivalent perspectives, claiming that they try to remain detached, but sometimes still need help to maintain appropriate boundaries between themselves and their patients. In the front regions, the workers emphasized their caring self, even crying about loss if it felt appropriate, but during backstage activities they often kept their sadness quiet. These findings contradict the assumption that backstage behaviors are a more authentic expression of self than behaviors in the front region. Both sets of behaviors include elements that workers describe as genuine to their sense of self, and both sets also include behaviors that are intentionally staged. While it is often taken for granted that the front stage includes managing one’s presentation of self, one CNA explicates how the backstage also includes staging: “It’s hard sometimes. I don’t always feel like being friendly or making jokes, but we all have to get along, so I try” (Darlene, CNA). As the opening quote, “We cuss in the conference room and cry with the family” (Nickie, Director), demonstrates, hospice workers recognized the discrepancy between their front- and backstage behaviors. They made sense of these contradictions by saying “This is part of hospice” (Nickie, Director) and “If we didn’t laugh, Cain 685 all we would do is cry” (Robin, Administrator). I argue, in fact, that workers used their hospice identities to account for their divergent behaviors to one another and outsiders. Workers’ Identities During interviews, most hospice workers described their job with hospice as very different from any other type of work they have done. Some described it as “finding your place” (Michelle, Counselor), “fitting in with family” (Robin, Administrator), or “feeling at home” (Ramon, Social Worker). They came to see themselves not as nurses or social workers or chaplains, but as hospice nurses, hospice social workers, and hospice chaplains. As Anna, a new hospice social worker, said, “I’ve always wanted to work in hospice.” She explained that as soon as she learned about hospice, she knew it was the place for her. This strong dedication to hospice was integrated into a hospice identity that included authentic emotional experiences and enlightenment about death. Authentic Emotional Experiences Workers’ main explanation for feeling such affinity for hospice was the ability to feel authentic emotions while going about their work. In fact, several staff members told me that they like hospice because the hospice philosophy encourages them to make real connections with their patients and their family members. Keith, a chaplain, said that he liked hospice because “This is where the juice [of life] is!” and Kate, a social worker, said, “You’re with people when . . . the bullshit is over with and there is honesty.” However, like abortion clinic workers (Wolkomir and Powers 2007), hospice workers do not form emotionally intensive relationships with all patients. In fact, they find ways to balance the needs of the job and their own self-care needs by making connections with some patients and situations, while detaching from others. When I asked which patients really touched them, most workers told stories of patients they related to because of their age, family situations, or personalities. They described their relationships with these patients as being close “like a friend or family member” (Deanna, CNA), signaling that workers bonded with patients who permitted authentic emotional connections. Even within close relationships with patients, however, staff members were careful to distinguish between their own emotional states and those of their patients. Ramon, a social worker, explained this separation: “sometimes I will express that [sadness] clearly aloud, okay, because usually my judgment would be is that it’s noticeable by the client or family,” but he added that 686 Journal of Contemporary Ethnography 41(6) he must appropriately moderate his emotional expressions. Ramon explained that he always reassures the family that he is not suffering and that their needs come first. Another social worker, Vonda, said that she often has tears when dealing with families who are emotional, but she tries not to sob or draw attention to her emotions. One nurse, Bethany, admitted that she did not cry when with family members, but noted that she felt confident that her job would not be in jeopardy if she did. In fact, Lisa, a CNA, mentioned in an informal interview that she sometimes feels like she is expected to feel sadder than she actually does. This ability to feel authentic emotions but not detract from the pain of the families is an important component of workers’ identities. Like the physicians in Coombs and Powers’ (1975) study, the hospice workers came to believe that the worker who “loses coolness and presence of mind . . . also loses the confidence of patients and staff” (251). Being able to feel emotions while also keeping them within “appropriate limits” was an important element of being a hospice worker. Enlightenment about Death Joking about death has the potential to be offensive and insensitive to those suffering loss, but hospice workers described their backstage humor as “understanding that death is inevitable” (Dr. Smith, Physician) and sometimes even funny. For instance, Michelle, a counselor, was known for keeping a running list of ways that she would not like to die, which included while sitting on the toilet and while caregivers were intoxicated. These preferences came from real-life situations of patients, and hospice workers sometimes laughed at the horror of the situation, while also discussing how to meet the needs of others who might be in a similar predicament. While many medical ethnographies have focused on gallows humor as a form of distancing (Becker 1976; Wear et al. 2006) and stress release, Chambliss (1996) argues that the routinization of death and tragedy first leads to distancing, and then that distance allows participants to see humor in death and tragedy. In Rose Hospice, staff used humor not only for distancing but also to align themselves with patients, especially against poorquality adult care homes, inadequate home caregivers, or primary care physicians who did not seem to have the patient’s best interests in mind. For instance, physicians were often seen as a barrier to hospice. As Bethany, a nurse, observed: Many physicians will not want anything to do [with patients] once they go on hospice. I’ve called physicians to get a medication ordered, and Cain 687 they’ll say, “I don’t want to be any part of her death,” just because they really don’t understand, or maybe they don’t want to understand. Discussions of difficult physicians sometimes resulted in jokes at the expense of physicians: when one physician wanted to stop a patient’s medications for seizures, Dr. Brown, the hospice medical director muttered, “Sure, we’ll do what he thinks will help, but she’s just as likely to end up in the psych ward as feel better.” Several other staff members laughed at this comment while Dr. Brown signed the orders. Having a sense of humor in such situations enabled workers to deal with emotionally difficult times and uncooperative others while also allowing them to demonstrate their acceptance of death. Hospice workers saw themselves as more enlightened about the inevitability of death than the average person. They emphasized the need to celebrate the ending of life in similar ways to the beginning of life. They also described time spent with the dying as a gift and reminded others that it is an honor to be present in the final moments of life. Hospice workers typically had significant experiences with death before entering hospice, as illustrated by the fact that several staff members described losses that led them to hospice and characterized the ideal hospice worker as one who had previous encounters with death and dying. However, these experiences did not necessarily make hospice workers adept at dealing with their own psychological issues. As Keith (chaplain) observed: “You’d think we’d be good at it, but most people just push it down and never really deal with their feelings.” Hospice workers formed an identity around being enlightened about death and privileging real emotional encounters over superficial forms of medical care that focus too much on the body and not enough on the person. This identity allowed them to reconcile their front stage commitment to care and compassion with their backstage expressions of morbid humor, strategizing to change others’ behaviors and display detachment toward death. It did this by defining each set of behaviors as just “part of hospice” and essential to being able to continue to provide care. In fact, workers often characterized former staff who could not make it in hospice as “taking themselves too seriously” (Robin, Administrator). Discussion and Conclusion Although hospice workers sometimes convey callousness in their backstage comments about death and dying, they pride themselves in offering the highest level of care and compassion to their patients and patient family members. How do we make sense of these divergent behaviors? Front stage behaviors 688 Journal of Contemporary Ethnography 41(6) require distancing from others’ emotions and stress while still appearing caring and compassionate, developing coping skills to deal with one’s own emotions and stress, and honing the ability to communicate well with those in crisis. Meeting these complex demands is an important component of emotional labor (Hochschild 1983), but it also provokes stress, emotional burnout, and dissatisfaction with work (Wharton 1999). In this setting, workers mitigated negative consequences of emotional labor through their interactions with one another in the back regions. Backstage activities enable them to sustain their front stage performances. Through joking, strategizing about how to change others’ behavior, and detaching themselves from death, hospice workers use coping techniques that allow them to continue meeting the demands of care work in front regions. In addition, workers used scenarios and stories from their front stage interactions to share poignant, humorous, or disturbing experiences with one another while they were backstage. Through their conversations about these experiences, hospice workers not only developed strategies for dealing with difficult situations, but also built meanings that enabled them to sustain their work and identities as hospice care providers. In addition to highlighting one factor that protects against the negative consequences of emotional labor, this study helps to extend the dramaturgical perspective. When workers conceal their backstage joking and strategizing, they are not hiding their “true” selves. Instead, they are subordinating one part of their hospice identity in order to maintain the caring and compassionate part. However, they see both parts as essential to being a hospice worker. Unlike much research that assumes that the front stage consists of contrived performances and the backstage reveals more authentic behaviors, my findings confirm Goffman’s (1959) assertion that all social interactions, including front and back regions, are characterized by performances. Although workers were reluctant to admit that they ever “acted” at work, it was clear that even in backstage areas they were engaged in the process of deemphasizing some aspects of self (e.g., strong feelings of loss over particular patients) while emphasizing others (e.g., their sense of humor and acceptance of death). While workers regarded these backstage behaviors as key components of their hospice identities, it is important to recognize that their backstage presentations of self were just as performative as their front stage presentations. And hospice workers viewed both types of conduct as authentic expressions of their professional identity and their ability to handle death. Hospice care has several qualities that may make it especially useful for exploring work-related identity formation. First, hospice work is poorly understood (Zimmermann 2004), stigmatized (Hejoaka 2009), and only used Cain 689 during times of crisis. Given these qualities, workers have a strong incentive to protect the image of hospice care and themselves as moral workers (Chambliss 1996). End-of-life care may also encourage staff to form hospice identities because the fronts workers try to display may be prone to audience disbelief. Patients and patients’ family members are often not accustomed to noncurative models of care, and as such may be suspicious of the displays of hospice workers. Finally, within hospice the division between front and back region presentations is not complete. Spaces used for backstage activities become front stage as patients and their family members approach the conference room or the nurse’s station; the homes of patients seem to be backstage but become the center of front stage activity as workers come in to provide care and, throughout the workday, hospice workers interact with a variety of others, moving quickly from clearly defined backstage areas to front regions. These qualities combine to produce work situations with many opportunities for hospice workers to “mess up,” or fail to keep expressive control, during end-of-life care interactions. Given the challenges of controlling the definition of the situation, hospice workers are aware of how their actions will be received by patients and patients’ family members. Their discussions among themselves construct both front stage expressions of caring and backstage displays of morbid humor as simply parts of being a hospice worker, signaling that their hospice identities allow them to combine the divergent behaviors as authentic and as essential aspects of their work performance. By doing so, they can account for their behavior in situations where the expressive cues they “give off” contradict those they intentionally display. Workers’ awareness of these discrepancies pushed them to think about how to account (to themselves and others) for divergent behaviors, thus providing the conditions for the formation of a hospice identity. Understanding how hospice workers’ behaviors fit within their professional identities highlights several important considerations. First, research on work settings would benefit from a full analysis of both front- and backstage behaviors. This research is especially needed to understand medical and caring occupations. Interactions with patients are important, but they are made possible by interactions outside the view of patients. Ethnographic data collection techniques are particularly useful for capturing the complexities of divergent behaviors. Second, both sets of behaviors (care and compassion in the front stage and morbid joking, strategizing, and treating death with detachment in the backstage) are better understood by contextualizing them within workers’ interactions and identities. Workers’ identities can help to explain behaviors that seem to diverge from one another. Finally, in this case the hospice identity allowed workers to better cope with the emotional stresses of 690 Journal of Contemporary Ethnography 41(6) caring for those at the end-of-life. Because hospice workers integrated both sets of behavior into their work life and sense of self, they felt able to continue to perform their work, even during times of stress. The caring aspects of the hospice identity enabled them to display continued commitment to the compassionate goals of their work, while the backstage activities helped workers to express private or troublesome feelings and bond with one another. In combination, these aspects of the hospice identity mitigated the difficulties involved in providing emotional labor within end-of-life care. Declaration of Conflicting Interests The author declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. Funding The author disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research was supported by the National Science Foundation, Doctoral Dissertation Improvement Award (1129541). 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Running head: SOCIOLOGY DISCUSSION

Sociology Discussion
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SOCIOLOGY DISCUSSION

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Sociology Discussion

Intensive care nurses and hospice workers use several emotional management
strategies to protect their psychological and emotional well-being. Intensive nurses use
several off the job routines such as calling their patients, sharing their work experiences with
other individuals who help them to cope with the harsh work conditions...

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