S Timmons and J Tanner

International Journal of Nursing Practice 2005; 11: 8591

RESEARCH PAPER

Operating theatre nurses: Emotional labour and the hostess role

Stephen Timmons MA(Soc&PolSci) MA(SociolCult) MSc PhD PGCAP
Lecturer, School of Nursing, University of Nottingham, United Kingdom

Judith Tanner BN MPhil PhD PGCE

Lead for Nursing Research, Derbyshire Hospitals Foundation NHS Trust, United Kingdom

Accepted for publication September 2004 Timmons S, Tanner J. International Journal of Nursing Practice 2005; 11: 8591 Operating theatre nurses: Emotional labour and the hostess role Emotional labour has been established as a signicant factor in nursing work, although no studies have been done looking at emotional labour specically in an operating theatre nursing context. Theatre staff (17 nurses and three Operating Department Practitioners (technicians) were observed in practice over a period of nine months by one of the authors. Each of the staff was subsequently interviewed. The transcriptions of the observation eldwork notes and the semistructured interviews were analysed for themes and content. The (predominantly female) nurses perceived that one of their responsibilities was looking after the surgeons.We have described this as the hostess role. This role consisted of two major areas of activity: keeping the surgeons happy and not upsetting the surgeons. Examples are given of how this was accomplished through talk and actions. The (predominantly male) operating department practitioners did not see this as part of their work. This hostess role is a kind of emotional labour, but performed with coworkers rather than patients. Like other forms of emotional labour, it is strongly gendered. The emotional labour performed by the theatre nurses was necessary to maintain what has been called elsewhere the sentimental order. Key words: emotional labour, nursephysician relations, operating room nursing.

INTRODUCTION Emotional labour

Emotional labour was rst described by Hochschild.1 She studied a group of airline stewardesses and found that their work was characterized by the manipulation of emotion according to the rules (both written and unwritten) of the airline. The stewardesses were expected to smile and be nice to passengers, even when they felt angry, not least because of the passengers behaviour. Hochschild

Correspondence: Stephen Timmons, Lecturer, School of Nursing, University of Nottingham, Queens Medical Centre, Nottingham NG7 2UH, United Kingdom. Email: stephen.timmons@nottingham.ac.uk

shows how this emotion work (like other forms of labour) is commodied by the airline and is part of the product being sold. Emotional labour can be described as the work that workers have to do with their feelings in order to comply with the role(s) that the organization requires them to play. She denes emotional labour as the management of feeling to create a publicly observable facial and bodily display.1 The concept of emotional labour has now been applied in a variety of studies, covering a wide range of workers and workplaces, including strippers,2 teachers,3 beauty therapists,4 care managers5 and image consultants.6 In addition, Hochschilds analysis has become wellknown in studies of nursing and nursing work, principally

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through James7,8 and Smith.9 Smith studied student nurses in the United Kingdom (UK). Her initial interest was in how well students coped with the stresses of practice, and what inuence this had on whether they stayed in the course. What became apparent from her interviews with students was how much of their work (and the most stressful part of it) could be characterized using Hochschilds concept of emotional labour. The students reported both the existence of rules which governed the expression of feelings and the necessity to act in a way that was at odds with the way in which they were feeling. James used the concept of emotional labour to explain both the division of labour and the labour process10 in a hospice.7,8 James concluded that the invisibility of emotional labour and its associations with family care mean it has ambivalent status.8 As both Smith9 and James7,8 show, this is because emotional labour is usually undervalued in health services. They argue that emotional labour is strongly gendered: it is seen as something that women can (and ought) to do naturally and it is, therefore, not worth rewarding or making part of formal programmes of training. The idea that emotional labour is always a negative phenomenon for the worker has been questioned by, inter alia, Wharton,11 Tolich12 and Wouters,13 who claim that working in a highly charged emotional setting can be rewarding as well as stressful. Miller14 has criticized many of the workplace studies of emotional labour for emphasizing the inauthentic emotion expressed, as opposed to the times when genuine emotion is expressed. In addition, workers for whom emotional labour is not a central part of their work, but who might nonetheless end up doing it (like doctors or lecturers) have been neglected in this literature. A further critique is offered by Zorn, who says the work on emotional labour has largely focused on selfpresentation in the service of customers or clients, not on the work of emotion management in co-worker interaction.15 Most of the research done on emotional labour in nursing does not take account of work done with colleagues rather than patients. Following on from Zorn in this paper, we will not analyse the emotional labour that nurses perform with patients, but that which they do with colleagues; in this case, doctors. Specically, we will look at operating theatre nurses and surgeons. Contrary to the prejudices of some parts of the nursing profession, theatre nurses do undertake emotional labour with patients: in the anaesthetic room, recovery and when patients are awake for

certain procedures. However, patients are anaesthetized for much of the time in the theatre, which means that the emotional labour that theatre nurses do takes a different form, as we will show.

Doctornurse relations
The working relationship between doctors and nurses has been extensively studied since the publication of Steins classic paper on this subject.16 Steins picture of submissive nurses who can only seek to inuence doctors has been superseded by a much more sophisticated picture of this relationship.1721 Svensson claims that doctors and nurses now operate as equals, their relationship being characterized by negotiation rather than domination.22 We would not go so far as this, rather agreeing with Mackay that The power relationship between nurses and doctors is not completely one-sided,23 but also that The deference accorded to the medical profession and the acceptance of doctors power and status centrally inform the way in which nurses relate to doctors.23 Allen shows how the professional boundary between doctors and nurses is, in a variety of different ways, blurred24,25 and not, in the context of her study, negotiated in the way Svensson analyses.22 We were unable to nd any studies that specically consider emotional labour within an operating theatre context. Fox has written about life and work in the operating theatre from a sociological standpoint, though he does not focus on working relationships.26,27 Tanner and Timmons discuss some aspects of the working relationship between operating theatre nurses and surgeons,28 but they use Goffmans space analysis29 rather than emotional labour to explain it.

METHODS
This paper is based on a study to identify the skills and knowledge of operating theatre nurses and the appropriateness of methods of professional training and education.30 The eld work was conducted in ve UK National Health Service (NHS) hospitals and drew on an ethnographic methodology. The ve hospitals involved were selected largely for reasons of geographical convenience; however, they were not untypical of UK NHS District General Hospitals. As is normal practice with qualitative research, this was a purposive sample. Statistical representativeness was not sought with this sample; however, the staff who took part were broadly representative of NHS theatre nurses in terms of age, grade, gender and level of education. Managers of the theatre departments

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involved were invited to nominate staff, who were then approached in writing to see if they would take part. A total of 20 theatre staff were observed in practice over a period of nine months by one of the authors. A second observer was also used on two occasions. The participants were aware that they were being observed as ethical permission would not have been granted for a covert study. Seventeen of the staff were theatre nurses and three were Operating Department Practitioners (ODPs) (technicians). The grades of the nurses studied were NHS D and E grades (12 operating room nurses, four anaesthetic staff and four recovery staff). These are staff grades and not management grades. The main reason for choosing this number was purely practical. This study was carried out at the same time as working full-time and the methodology had to be realistic and achievable. The limitation of this is acknowledged. In addition, although 20 staff were observed directly, these observations included their interactions with the whole theatre team and this would have the effect of increasing the observed behaviours to represent more than the identied twenty staff. The eld work for the study involved observing each of the 20 staff for a day. (The follow-up interviews were carried out in addition to this). Each observation lasted for the whole shift from 08:00 hours to 17:30 hours, or until the operating list nished. It was felt to be important to be present at the beginning and end of the shifts, or operating lists, even though the activities appeared to be mundane tasks, such as tying up rubbish bags or cleaning trolleys. This represented 200 h of observational eld work, which was carried out over a period of six months. Although the staff were aware that they were being observed, this does not appear to have affected the data unduly. Evidence for this is the poor practice that was observed, rather than, as might have been expected if the Hawthorne effect was in operation, a tendency for staff to do things by the book. Data from observations were recorded in eldwork notes taken contemporaneously and then written up on a computer afterwards. The transcriptions of the eldwork observations were shown to a theatre nurse expert to ascertain if they portrayed a meaningful account of theatre nursing practice. Each of the staff were interviewed after observation for 45 min. Interviews were tape-recorded, and subsequently transcribed verbatim. The interview schedule, derived from a review of the literature and the authors own experience, is listed in Appendix I.

These data, along with the transcribed observation eldwork notes, were analysed with the support of QSR NUD*IST software (QSR International, Melbourne, Australia). Although the analysis of large amounts of qualitative data can be carried out manually (e.g. by using cutting and pasting), using a computer software package can provide an efcient and organized alternative. It must be noted that the software programme merely takes over the ling of the data and the actual analysis, identifying themes, links and storylines, is undertaken by the researcher. The data were rst read, and then split into short sections of between one to 10 sentences. Each of these sections was assigned a code. These codes were phrases or words which best described the content, or meaning, of the section. All of the data were assigned codes and some sections were assigned to more than one code. For example, the following codes people management, time management, nurse cajoles staff, list starting times, lists run by E grade and short staff were grouped together under the umbrella heading of management. Through this process of renement, themes and an overarching framework became apparent. The codes were grouped into 33 umbrella headings. These headings were then grouped into the following three themes: (i) the theatre nurse; (ii) interprofessional relationships; and (iii) the theatre environment. All data grouped under specic codes and umbrella headings were then retrieved to allow the researcher to draw out similarities and differences. Ethical approval for the study was granted by the relevant NHS local research ethics committee. Written consent was obtained from participants for both observation and interview, including tape-recording.

FINDINGS
Of the staff involved in the study, 15 of the theatre nurses were female and two were male. The ODPs studied were all male. This pattern broadly reects the gender balance of staff in NHS operating theatres. They ranged in age from 3045 and typically had been qualied for 10 years. All had a rst-level (registered nurse) qualication in nursing and a range of educational qualications, including some at diploma and degree levels. As this was a qualitative study, the calculation of a participation rate is neither appropriate nor necessary. Statistical representativeness and, hence, generalizability were not being sought from this sample; instead, this group was assembled purposively, with a view to obtaining

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rich, complex data of the type reported here. However, they are not untypical of theatre nurses and ODPs in the UK NHS. One of the themes which emerged during the analysis was the hostess role. This described the nurses perception that it was their responsibility to look after the surgeons rather like an air hostess or a party hostess: The surgeons are excellent, I have a great rapport with them. I like to think its because I look after them very well. I feel I know them so I know what they need, what their peculiarities are. (Nurse) [The surgeons] are good most of the time, although some of them have tantrums.You give them what they want and you look after them. (Nurse) There were two aspects to the hostess role: keeping surgeons happy and not upsetting surgeons. Analysis of both these aspects identies examples of emotional labour. Keeping surgeons happy describes positive actions carried out by nurses with the intention of keeping surgeons happy.The examples of these activities are similar to those undertaken by a hostess, such as providing food and drink, music and light conversation. For example: . . . [the nurses] are making social chit chat to maintain ambient atmosphere . . . (Second observer) The theatre sister goes to the coffee room mid-morning. The canteen delivers a number of sandwiches each morning for surgeons who might be scrubbed all day and unable to get out of theatres for lunch. These sandwiches are available on a rstcome, rst-served basis. The theatre sister goes to the coffee room mid-morning and selects the consultants favourite sandwich. She comes back into theatre and interrupts his operation to tell him she has got his favourite egg sandwich and has put it in a cupboard in the prep room. (Second observer) There is a tape recorder in the theatre.The staff have been listening to current chart music while they prepare the theatre for the operating list. Nurse E gets out a box of tapes. She takes one out and says the consultant likes this one. She puts it in the machine ready for when the consultant comes in. (Second observer) During the procedure, Nurse A asks the consultant about his recent trip to Italy. They maintain this pleasant conversation throughout most of the operation. (Second observer)

Yes, some staff hide surgeons favourite instruments so that they can appear to nd them and look good in front of the surgeon. (Nurse) Not upsetting surgeons describes actions which nurses refrained from undertaking to prevent antagonizing surgeons. In order to provide some context to not upsetting surgeons, it is important to appreciate that surgeons can be particularly volatile. For example, the nurses frequently referred to surgeons bad tempers, shouting and tantrums: From my point of view, I want to keep them all happy because it makes life easier for me, it makes life easier for them and it makes for a much happier working environment.Why antagonize people when you know that it is going to get their backs up and they are going to start complaining and whingeing? (Nurse) Many of the examples of not upsetting surgeons relate to instances where nurses did not inform surgeons of their poor practice. Nurses might have tolerated poor practice rather than antagonize surgeons even though the poor practice was to the detriment of unconscious patients: The surgeon walks into the theatre. He is carrying his coffee mug and eating a roll.This contravenes theatre infection control policies. None of the nurses say anything to him. (Nurse) Surgeon comes in to theatre, he is not wearing a hat.This contravenes the theatre dress code and presents a risk of infection. The nurses, including Nurse W, dont say anything. Another surgeon comes in, looks at the surgeon with no hat and says What, no hat, is this a new rule?. (Second observer) In the following example, the interviewer asked a nurse why she poured ether over some swabs for a surgeon? (Ether, a hazardous substance, is banned from theatre departments): He likes using [ether].We have to get pharmacy to supply it especially for him.Yes, I know we shouldnt be using it. (Nurse) The nurses would accommodate surgeons demands even if they did not agree with them: The instruments had been set up and we had to wait about 30 min for the patient.When the patient came in and they were about to start operating, the surgeon asked the Sister if

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these were the same instruments? She said Yes, but they are all right. The surgeon said I want fresh instruments. The nurse got new instrument trays out. Later, the nurse said to me I didnt need to change them but I wasnt going to argue with him. (Second observer)

DISCUSSION Theatre nursing as a hostess role

James shows how emotional labour is commodied, that is, it is part of the paid work that nurses undertake and it is, therefore, both required and expected of them.7 The theatre nurses had a similar expectation of emotional labour, but in their case it was performed for the benet of the surgeons as opposed to patients. The emotional labour performed by theatre nurses can be understood as being their hostess role. One of the traditional duties of the party hostess is to keep the conversation going and the atmosphere pleasant. As is shown in several of the examples above, this is part of what the nurses were doing and were expected to do.

sentimental order.31 They dene this as the intangible but very real patterning of mood that characteristically exists on each ward.31 Likewise, the theatre nurses studied were striving to maintain a particular mood in the operating theatre, which was light-hearted and convivial, with a minimum of disturbances for the surgeons. Strauss et al. found that the sentimental order of the ward was capable of being disturbed by certain events and that the nurses they studied had to work in order to restore the sentimental order.32 They delineate seven categories of sentimental work and, of these seven, the theatre nurses in our study certainly engaged in interactional work to gain the surgeons cooperation and rectication work, which might be termed soothing rufed feathers when the sentimental order has been disrupted. It was noticeable that the nurses worked hard to not upset the sentimental order, whereas the surgeons were able to do so, presumably because they knew that the nurses would pick up the pieces. In addition, Hochschild points out that one of the implicit duties of the air hostesses she studied was the maintenance of a convivial atmosphere.1

Emotional labour and gender

Although the nurses undertook emotional labour to perform the hostess role, this contrasts with the ODPs. The ODPs were aware of the different relationship held between themselves and surgical staff compared with the nurses and surgical staff and refused to emulate it. This is illustrated by one of the ODPs who said: We [the ODPs] are not treated like them [the theatre nurses] by the surgeons, and we would not tolerate it if we were. This also suggests that gender plays a part in the expectation that emotional labour will be performed. The majority of the theatre nurses interviewed and observed were female (15 out of 17). This reects the gender distribution among the wider theatre nurse population, whereas all three of the ODPs studied were male (likewise representative of their group). Both James7,8 and Smith9 point out the importance of gender in understanding who performs emotional labour and why. Though men can (and do) perform emotional labour, it is seen as being something that women can do naturally and, furthermore, that they should do.

The costs of emotional labour

One of the reasons why these ndings are signicant is that emotional labour (like labour of any sort) is not without its cost to the labourer. Freund, drawing on the work of Goffman29 and Hochschild,1 shows how the performance of emotional labour takes its toll, in both physical and psychological terms.33 Again, this view must be tempered by consideration of those who, like Wharton,11 Tolich,12 and Wouters,13 point out the rewards of this kind of work. Though the theatre nurses found their work for the surgeons stressful and frustrating, some of them spoke about what they did with considerable pride.

CONCLUSION
Although emotional labour has become a well-understood and accepted way of analysing nursing work, surprisingly little has been written about the emotional labour undertaken by operating theatre nurses. Perhaps this is because of some of the prejudices of the wider nursing profession, that operating theatre practice is in some way not real nursing, or perhaps because the operating theatre is a closed world to which it is difcult to gain access. We found that, along with nurses in other areas, theatre nurses are performing emotional labour, though due to the circumstances, it takes a slightly different form from that found in wards. This hostess role might go some way

Why perform emotional labour?

The emotional labour performed by the theatre nurses was necessary to maintain what Glaser and Strauss call the

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in explaining why operating theatre nursing is so stressful, which presumably plays a part in the continued (though long-standing) difculties that operating theatres have in recruiting and retaining nursing staff. When health services across the world are attempting to move to a more multidisciplinary, egalitarian model of professional relations, it might be that the kinds of practices that we have analysed could be an obstacle to these new ways of working, not least the expectation that the surgeons held that emotional labour would be performed on their behalf. Referring specically to relationships between theatre nurses and surgeons, Espin and Lingard state that the nursing profession has revised its handmaiden image for that of an autonomous, expert health care profession.34 We would dispute this. Although the nurses we studied had shed the handmaiden role, it seems that they exchanged it for that of a hostess. Anecdotal evidence suggests that this role might be found in other areas of nursing. For instance, something that is said about a successful ward sister is that she is good at keeping the consultants happy. We would suggest that the emotional labour that ward nurses perform on behalf of doctors, or of other coworkers, might form a fruitful area for further study. Perhaps the best description of this hostess role is found in an unlikely source: PG Wodehouse. In the following excerpt, Wodehouses hero, Bertie Wooster, describes hosting a party: You know how it is when youre a host . . . you have all sorts of things to divert your attention, keeping an eye on the waiters, trying to make the conversation general, heading Catsmeat Potter-Pirbright off from giving his imitation of Beatrice Lillie, a hundred little duties.35

ACKNOWLEDGEMENT
Thank you to Professor Nicky James for her comments.

REFERENCES
1 Hochschild A. The Managed Heart: The Commercialization of Human Feeling. Berkeley: The University of California Press, 1983. 2 Pasko L. Naked power: The practice of stripping as a condence game. Sexualities 2002; 1: 4966. 3 Price J. Emotional labour in the classroom: A psychoanalytic perspective. Journal of Social Work Practice 2001; 15: 161180. 4 Sharma U, Black P. Look good, feel better: Beauty therapy as emotional labour. Sociology 2001; 35: 913931.

5 Gorman H. Winning hearts and minds?Emotional labour and learning for care management work. Journal of Social Work Practice 2000; 14: 149158. 6 Wellington C, Bryson J. At face value? Image consultancy, emotional labour and professional work. Sociology 2001; 35: 933946. 7 James N. Emotional labour: Skill and work in the regulation of feelings. Sociological Review 1989; 37: 1833. 8 James N. Care = organisation + physical labour + emotional labour. Sociology of Health and Illness 1992; 14: 489509. 9 Smith P. The Emotional Labour of Nursing. London: Macmillan, 1992. 10 Braverman H. Labour and Monopoly Capital. New York: Monthly Review Press, 1974. 11 Wharton A. The affective consequences of service work: Managing emotions on the job. Work and Occupations 1993; 20: 205232. 12 Tolich M. Alienating and liberating emotions at work. Journal of Contemporary Ethnography 1993; 22: 361381. 13 Wouters C. Response to Hochschilds reply. Theory, Culture and Society 1989; 6: 447450. 14 Miller K. The experience of emotion in the workplace: Professing in the midst of tragedy. Management Communication Quarterly 2002; 154: 571600. 15 Zorn T. Politics, emotion, and the discourse of ICT adoption and implementation. In: Power M (ed.). Annual Meeting of the AustraliaNew Zealand Communication Association; 1012 July 2002, Gold Coast, Queensland, Australia. Gold Coast, Qld, Australia: Bond University. Available at URL: http://www.mngt.waikato.ac.nz/Depts /MCOM/ict/symposium/ANZCAversion.pdf. Accessed 6 January 2005. 16 Stein L. The doctornurse game. Archives of General Psychiatry 1967; 16: 699703. 17 Hughes D. When nurse knows best: Some aspects of nurse/doctor interaction in a casualty department. Sociology of Health and Illness 1988; 10: 121. 18 Porter S. A participant observation study of power relations between doctors and nurses in a general hospital. Journal of Advanced Nursing 1991; 16: 728735. 19 Porter S. Nursings Relationship with Medicine: A Critical Realist Ethnography. Aldershot: Avebury Press, 1995. 20 Wicks D. Nurses and Doctors at Work: Rethinking Professional Boundaries. Milton Keynes: Open University Press, 1998. 21 Harvey J. Upskilling and the intensication of work: The extended role in intensive care nursing and midwifery. Sociological Review 1995; 43: 765781. 22 Svensson R. The interplay between doctors and nurses: A negotiated order perspective. Sociology of Health and Illness 1996; 18: 379398. 23 Mackay L. Conicts in Care: Medicine and Nursing. London: Chapman & Hall, 1993. 24 Allen D. The nursingmedical boundary: A negotiated order? Sociology of Health and Illness 1997; 19: 498520.

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25 Allen D. The Changing Shape of Nursing Practice: The Role of Nurses in the Hospital Division of Labour. London: Routledge, 2001. 26 Fox N. The Social Meaning of Surgery. Buckingham: Open University Press, 1992. 27 Fox N. Discourse, organisation and the surgical ward round. Sociology of Health and Illness 1993; 15: 1642. 28 Tanner J, Timmons S. Backstage in the theatre. Journal of Advanced Nursing 2000; 32: 975980. 29 Goffman E. The Presentation of Self in Everyday Life. London: Allen Lane, 1969. 30 Tanner J. The appropriateness of problem based learning as a method for post-registration theatre nurse education. PhD thesis. Chelmsford, UK: Anglia Polytechnic University, 2003. 31 Glaser B, Strauss A. Time for Dying. Chicago: Aldine, 1968. 32 Strauss A, Fagerhough S, Suczek B, Wiener C. Social Organization of Medical Work. Chicago: University of Chicago Press, 1985. 33 Freund P. Social performances and their discontents: The biopsychosocial aspects of dramaturgical stress. In: Bendelow G, Williams S (eds). Emotions in Social Life: Critical Themes and Contemporary Issues. London: Routledge, 1998; 268294. 34 Espin S, Linguard L. Time as a catalyst for tension in nurse surgeon communication. AORN Journal 2001; 74: 672682. 35 Wodehouse P. The Code of the Woosters. London: Herbert Jenkins, 1938.

APPENDIX I Interview schedule

1. 2. 3. 4. How long have you been qualied? How long have you worked in theatres? Do you have any postqualifying specialist courses? What did you learn from these postqualifying courses?

5. Do you help out on the anaesthetic/scrub side? 6. Would you like to be more involved in working on the anaesthetics/scrub side? 7. Do you think scrub nurses need to know about anaesthetics? 8. Do you think anaesthetic nurses need to know about scrubbing? 9. How would you describe your relationship with the surgeons in your theatre? 10. How would you describe your relationship with the anaesthetists in your theatre? 11. Do you ever see the surgeons/anaesthetists outside of the theatre environment? 12. Have you ever heard of the role of the rst assistant? 13. Can you describe the role of the rst assistant? 14. Do you know anything about the insurance or the legal cover for rst assistants? 15. Do you think you need nurses in theatre? 16. Do you think nurses have different skills from ODPs? 17. What do you think advocacy means? 18. Can you think of any examples of when you have acted as a patients advocate? 19. On a scale of 15, 5 being the best, how would you rate your decision-making skills? 20. How have you developed your decision-making skills? 21. On a scale of 15, 5 being the best, how would you rate your problem-solving skills? 22. How have you developed your problem-solving skills? 23. Can you give me an example of any learning you have experienced recently?