Emotional labour/body work: The caring labours of migrants in the UKs

National Health Service

S. Dyer
*
, L. McDowell, A. Batnitzky
School of Geography, Oxford University Centre for the Environment, South Parks Road, Oxford OX1 3QY, United Kingdom
a r t i c l e i n f o
Article history:
Received 1 November 2007
Received in revised form 21 July 2008
Keywords:
Service sector employment
Care
Migration
Emotional labour
Body work
Greater London
a b s t r a c t
The provision of care is an increasingly pressing issue in the Global North. With an ageing population and
policies encouraging women into the labour market, there is a growing need for workers to undertake
paid caring. This poses important and urgent questions about the social organisation of labour markets.
Care work typically is low paid and undertaken in precarious, informal, or temporary situations. Many
posts are lled by economic migrants, raising concerns about a care decit in sending countries. In this
paper we examine the caring work undertaken by migrant workers in a West London Hospital. We
employ a twofold characterisation of caring work. Like other bottom-end service sector work, this work
is characterised by the face-to-face emotional labour. However, it also requires body work: close and
often intimate physical contact between carers and those they care for. We argue that both of these
aspects are important in understanding how caring work is constructed as poorly regarded and low paid.
We show how these features play out in particular ways for migrant workers employed in such caring
work.
2008 Elsevier Ltd. All rights reserved.
1. Introduction
Care is a fundamental requirement of the human condition. At
different points in our lives we require varying amounts of support
from others. When we are young or ill and often when we are old
we need the care of others more urgently and more completely
than usual (Kittay et al., 2005, p. 433). Despite its universal and
essential nature, care has often been theoretically neglected and
socially undervalued. Human dependency has been described as
the elephant in the room, the aspect of life actively ignored in most
political, economic, and moral models of life (Gilligan, 1997; Folbre
and Nelson, 2000; Kittay et al., 2005; Lawson, 2007). However, in
recent years an ageing population and more women entering the
labour market have brought the provision of care onto the political
agenda (Anderson, 2000; McDowell et al., 2005; Freud, 2007). Cur-
rent government thinking reinforces contemporary trends for care,
and other social reproductive functions, to be increasingly pro-
vided by the market. Where once the home was the realm of famil-
ial caring duties undertaken for love, increasingly care is bought
and sold as a commodied product. This shift poses important
and pressing questions about the social organisation of care mar-
kets, the implications for workers employed in this work, and for
those whom they care for.
Employment in caring work, by which we mean paid work that
involves the care of others, is routinely poorly paid and is often
undertaken on a temporary or informal basis (England, 2005). Such
conditions and the resultant concentration of those with little
autonomy in the labour market are symptomatic of bottom-end
service work (Leidner, 1991; Gray, 2004; McDowell et al., 2007).
Gendered assumptions about the emotional labour required by
face-to-face work play an important role in the devaluing and fem-
inising of this work (Hochschild, 1983; Kerfoot and Korczynski,
2005) However, in caring work these constructions are exacer-
bated by wider symbolic associations and hierarchies that come
into play when jobs involve work on the bodies of others (Wolko-
witz, 2002, 2006). Describing the mechanisms through which this
work is devalued serves to demonstrate that such outcomes are
neither natural nor inevitable.
The care labour market now operates at a global scale, with a
great deal of care work being undertaken by migrant workers (Mis-
ra, 2003). While the traditional image of a migrant worker is a
young single man, the increasing demand in the Global North for
people to undertake caring work has led to a rising feminisation
of economic migration (Kofman et al., 2005; Vertovec, 2006). Many
migrant women are employed in advanced industrial economies as
domestic workers caring for homes and families (England and Sti-
ell, 1997; Yeoh et al., 1999; Anderson, 2000). Many others are em-
ployed in more professionalised caring occupations as nurses and
nannies (Pratt, 1999; Hochschild, 2000; Yeates, 2004; Brush and
Vasupuram, 2006). The concentration of migrant women in low
0016-7185/$ - see front matter 2008 Elsevier Ltd. All rights reserved.
doi:10.1016/j.geoforum.2008.08.005
* Corresponding author.
E-mail address: sarah.dyer@ouce.ox.ac.uk (S. Dyer).
Geoforum 39 (2008) 20302038
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paid caring work signals the double jeopardy faced in the labour
market by workers who are both female and migrants (at times
compounded by also being of black and minority ethnicity
(BME)) (Adib and Guerrier, 2003; Browne and Misra, 2003). How-
ever, this segmentation also poses challenges for men who either
nd themselves effectively excluded from this area of work or stig-
matised by undertaking such womens work (McGregor, 2007;
Batnitzky et al., in press).
In this paper we explore the provision of paid care through the
lens of migrant workers experiences in the UKs National Health
Service (NHS). We argue that through multiple mechanisms this
work, and indeed these workers, is devalued. While we do not
want to re-inscribe already entrenched dualisms of mind/body or
mind/emotion, we discuss, in turn, the aspects of this work as
emotional labour and body work. We begin by unpacking the no-
tion of caring as a particular type of labour, the gendered nature of
which persists in the transition from familial duty to the commod-
ied realm.
2. Caring work: the commodication of care
Whether or not it is undertaken as a commodied exchange,
care is marked by its associations with the familial and the femi-
nine. Paid caring work is constructed as womens work (Novarra,
1980) and is often symbolically organised as if it were in the un-
paid domestic sphere (Glenn, 1992; James, 1992). These associa-
tions construct care as symbolically outside the economic.
Feminist economists have argued that a signicant factor in the
inadequate recognition of this work is an assumed dichotomy be-
tween love and money (England and Folbre, 1999; Folbre, 2002).
The social good produced by good care is not captured and turned
to prots and thus societies free ride on the care provided by oth-
ers. Workers are seen as having a special vocation involving in-
nate skills and (quasi-religious) devotion, thus contributing to
the low status and poor pay of this work. Economists, therefore ar-
gue that one cause of the pay penalty in caring work is the intrinsic
value of performing caring work. The soft rewards of caring act as
partial compensation for low pay (England, 2005). It is argued
those involved in caring work are less likely to engage in certain
types of industrial action, such as strikes, because of feelings of
duty for their charges: the prisoner of love dilemma (Folbre and
Nelson, 2000).
Empirical research shows that carers themselves adopt a frame-
work that mirrors the lovemoney dichotomy. Workers have been
shown to emphasise a distinction between work and non-work,
with care classed as non-work. Describing gynaecology nurses
commitment to the femaleness of their work, Bolton (2005, p.
173) explains how the nurses she interviewed sought to conrm
the underlying expectation that nursing is a vocation, involving
altruism and an overwhelming drive to care for people, rather
than offering a career involving choice and skills. Bolton shows
how these constructions are double-edged, for while they provide
a strong professional identify and self-esteem in the face of others
perceptions of gynaecological nursing as dirty work, they contrib-
ute to the devaluing of this work and attribution of this as un-
skilled and naturally female. In research examining nursing in
hospices James (1992) identies a distinction made by nurses be-
tween physical tasks, such as administering medication, and care.
She argues that . . .the framework of physical labour also became
the justication and explanation of paid work. Having been sitting
talking to a patient a nurse would say I must go and do some work
now, meaning physical tasks (James, 1992, p. 497). This framing
was used, in part, to construct boundaries by staff. No nurses,
she says, would feel comfortable complaining that they were re-
quired to care too much whereas they did feel able to complain
about being given too many tasks to carry out. However, these con-
structions by workers reproduce the assumptions which devalue
their labour.
Understanding the mechanisms structuring caring labour mar-
kets requires an analysis of care itself. Although part of our every-
day lives, care is analytically difcult to dene. A complex notion, it
refers both to activities, such as feeding and bathing, and to feel-
ings, such as empathy, sympathy, and love as well as those of sor-
row, grief, and anxiety (Folbre and Nelson, 2000). In recent years
scholars have tended to characterise caring work as relational work
that involves the nurture of others (England and Folbre, 1999).
However, Duffy (2005) argues that doing so reproduces class and
racial hierarchies by excluding those undertaking lower paid and
lower-status work primarily women of colour. She argues instead
for a denition of caring work as reproductive work or the work
that is necessary to ensure the daily maintenance and ongoing
reproduction of the labour force (Duffy, 2005, p. 70). This deni-
tion includes non-relational and non-nurturant work such as food
preparation and cleaning. While she is able to show with analysis
of the 2000 US census how BME women are excluded by narrower
denitions, her thesis poses an important question about the ex-
tent to which cleaners, for example, can be described as caring
workers. This is an argument that qualitative research can usefully
contribute to. While our analysis of caring work includes consider-
ation of the emotional and the relational, in our research we
adopted an open sampling frame any migrant worker in the hos-
pital in order to prevent prejudging which workers are caring
workers and to prevent re-inscribing gendered and racialised hier-
archies of care.
In the context of a hospice James (1992) describes caring work
as being dened by care = organisation + physical labour + emo-
tional labour. While she is right in identifying these elements of
care, we argue that her denition is insufcient. Care also involves
skills, rational labour, and body work and takes place within so-
cial and political contexts, which as much as organisational ones,
shape its structure and meaning (Conradson, 2003). Thus we begin
our characterisation of caring work with an analysis of the emo-
tional labour it requires but go on to assess the role of body work
it involves.
2.1. Caring as emotional labour
In common with work in other areas of the service sector,
employment relations in the NHS are structured by a three-way
relationship between employees, managers, and the customer
(Wolkowitz, 2002, p. 502). This structure has been termed a cus-
tomer-orientated bureaucracy to capture the ways in which work-
ers are governed through the standardising disciplining of a
bureaucratic organisation and also by the demands of a present
customer (Korczynski, 2001; Kerfoot and Korczynski, 2005). The
embodied attributes and gendered performances of workers are
particularly important in customer-orientated bureaucracies as
workers become responsible for resolving the intrinsic tensions
of how their work is organised (Forseth, 2005). The toil and skills
involved in undertaking such emotional labour go unrecognised
(c.f. Payne, 2006) and this work is naturalised as an effortless
expression of femininity (Hochschild, 1983; Krumal and Geddes,
2000; Hampson and Junor, 2005). In the healthcare sector this
plays out as women choose (and are chosen for) caring work over
other jobs and co-construct gender and work identities (Halford,
2003; Bolton, 2005), whilst patients and their families engage with
healthcare workers in the context of gendered understandings of
care.
The neo-liberalisation of much welfare provision is an impor-
tant context shaping the costs of emotional labour for many caring
workers. As Wolkowitz (2002) observes both pulls of the
S. Dyer et al. / Geoforum 39 (2008) 20302038 2031
customer-orientated bureaucracy dynamic have been heightened
in British and North American healthcare work due to reorganisa-
tion and increasing privatisation (England and Ward, 2007). Work-
ers might experience more demanding customers who are less
deferential than patients were (Rogers et al., 1999) and they do
so within an environment of rationalised managerialism (Mohan,
1995; Clarke and Newman, 1997; Twigg, 2000a). Clarke (1999, p.
49) argues that welfare provision is increasingly structured
around an internal calculus of efciencies (inputs and outputs)
and an external calculus of competitive positioning within a eld
of market relations. In this context the provision of care has been
rationalised to a series of tasks which fails to account for the rela-
tional and context specic nature of caring. The rationalisation of
care further hides the emotional labour workers perform by not
including it within these tasks. This exacerbates the devaluing of
emotional labour, as witnessed in the wider service sector, but also
means that workers undertake tasks and form relationships out-
side what they are remunerated for. As prisoners of love, or at
least of professional identity or human decency, workers continue
to perform emotional labour and care beyond the rationalised
schedules of bureaucracies that employ them.
2.2. Caring as body work dirty work
A further important factor in the organisation of the caring la-
bour market is its association with the human body. The human
body, particularly when ill, old, or diseased, unsettles the modern
Western emphasis on rational autonomy and thus needs to be fun-
damental to our conceptions of justice (Young, 1990). Although
there are some exceptions, such as psychoanalysis and counselling,
most caring work takes the customers body as its immediate site
of labour (Wolkowitz, 2002). Moreover, this work performed on
the bodies of others is often undertaken using the workers own
body as a primary vehicle (Jervis, 2001, p. 94). In a culture which
esteems the cerebral over the physical, the autonomous above
the dependent, and the disciplined over the uncontrolled/able;
body work (Gubrium, 1975; Wolkowitz, 2002, 2006) is marked
by the intimate, messy contact (Wolkowitz, 2002, p. 497) it in-
volves. Wolkowitz (2002, p. 501) argues in order to understand
the structuring of body work labour markets we must move be-
yond distinctions of manual and mental labour. The structures of
gender, class, and race segmentation in these labour markets, she
argues, are organised by attitudes to the body, to different parts
of the body, and to different states of the body. As caring work in
the British economy is increasingly being undertaken by migrant
workers, we must also add migration status segmentation to the
structures at play in these labour markets. Following Wolkowitz
(2002, p. 499) we believe scholars need to be explicit in recogniz-
ing, and therefore attempting to deal with, the centrality of body
work to post industrial national and global economies.
Higher status occupations dematerialise their work on the
body through distancing techniques. These encompass the use of
instruments and frameworks of scientic or professional knowl-
edge. These higher status and better paid occupations deal with
the bounded body leaving lower-status ones to deal with what
is rejected, left over, spills out and pollutes (Wolkowitz 2002, p.
501). Moreover, lower-status body work often involves caring for
old or diseased bodies that cause so much dis-ease in contempo-
rary Western societies; loathsome or feared bodies (Young, 1990;
Jervis, 2001) or ones which are simply ignored (Twigg, 2000b).
Work on the unbounded body is written as of hierarchically lowly
and symbolically dirty (Hughes, 1951; Brody, 2006). However,
body work has also been described as ambivalent work (Twigg,
2000b, p. 391). Certainly, for many undertaking such work it is.
In nursing, for example, there is a tension between an emphasis
on the value of embodied nursing skills which draw on the profes-
sions heritage and contemporary theoretical re-consideration of
the (phenomenological) body (Lupton, 1994; Bolton, 2005), and
an increasing (medical) professionalisation of nursing which stres-
ses distancing techniques (Philpin, 1999).
Undertaking dirty work represents a challenge to workers be-
yond low pay, for the symbolic associations that contribute to the
structuring of body work as being of low worth attach themselves
to the workers (Hughes, 1951). In a sense, those involved in dirty
work become constructed as dirty workers. Ashforth and Kreiner
(1999) identify three axes of dirty work: the social, physical, and
moral. Much caring body work is best characterised as socially
stigmatised, although some is also physically dirty work involving
the unbounded body. Research has shown that people experience
dirty work as posing a challenge to their identity and self worth
(McGregor, 2007). Workers undertake a number of strategies to at-
tempt to mitigate the issue, including the use of humour, forming
strong collective identities, and emphasising the dignity of earning
a wage (Bolton, 2005; Stacey, 2005; Kreiner et al., 2006).
The ability to construct migrants as other plays an important
role in the construction of their work. The writing of anthropologist
Mary Douglas (1966) has shown how notions of dirt rest on cate-
gories of matter out of place. What is out of place is potentially
polluting. As a common construction of migrants is people out of
place it is hardly surprising that a position of low autonomy in
the labour market intersects with low socio-symbolic status to re-
sult in an over-representation of migrants in these positions (Adib
and Guerrier, 2003; Misra, 2003). These workers handle distasteful
tasks which are necessary for the functioning of society (Ashforth
and Kreiner, 1999, p. 416). Rather than being rewarded for under-
taking such essential work, they are stigmatised by it. Notions of
pollution here play an important role in enforcing inequality in
the labour market (Jervis, 2001, p. 89). As Wolkowitz (2002, p.
501) argues, the worker is employed as much to carry dirts stig-
ma as to labour.
2.3. Caring as work for migrants
Historically care has been seen as womens work. However, it is
constructed as such where gender intersects with race and class
(amongst other categories) to construct a hierarchy of carers. An
intersectional understanding of gender resists essentialist formula-
tions and allows the complex lived realities of gender relations to
be explored (Adib and Guerrier, 2003; Browne and Misra, 2003;
Valentine, 2007). Caring work and productive labour are relational.
The entry of white middle class women into the labour market de-
pends on other women undertaking the caring they themselves
once provided within their homes (Glenn, 1992; Browne and Mis-
ra, 2003). This includes, most obviously, childcare but also care for
the old and ill. In healthcare a gendered and racialised hierarchy
exists, with male doctors ranked above white female nurses who
in turn are superior to BME women working as nurses aides (US)
or health care assistants (HCAs) (UK) (Glenn, 1992). Different
nationalities are naturalised in different roles, for example the g-
ure of the Filipina nurse (Brush and Vasupuram, 2006). Migrant
men describe being feminised through undertaking womens
work (McIlwaine et al., 2006; McGregor, 2007). A US ethnographer
who attended nurse aides training described the emphasis placed
on deference to those in authority, on not asking questions, and
doing what one is told. He quotes a woman from Jamaica observing
I cant gure out whether theyre trying to teach us to be a nurses
aides or black women (Diamond, 1988, discussed in Glenn, 1992,
p. 23).
Power relations are further entrenched by the willingness of the
Global North (and countries such as Saudi Arabia and UEA) to ac-
tively recruit caring workers from poorer parts of the world (Agu-
stin, 2003). In what has been termed a care drain (Kittay et al.,
2032 S. Dyer et al. / Geoforum 39 (2008) 20302038
2005, p. 405), the North staffs its hospitals and care homes with
doctors, nurses, and carers from abroad creating a care decit in
the sending countries as parents leave children with friends and
family in order to migrate and societies (often devastated by pov-
erty and disease) are left without doctors, nurses, and other work-
ers. Scholars have highlighted the post-colonial implications of
these relationships. Brush and Vasupuram (2006) have argued that
nurses, among other workers, are produced as an export product
by some nations in the same way that crops such as sugar and tea
were previously. Similarly, Hochschild (2003) has argued that the
Global North is extracting love from the South in much the way
that colonial powers used to extract raw materials. Certainly,
receiving states are implicated in the working conditions of these
workers, creating the conditions for exploitation by, for example,
allowing some workers in to the country on visas that tie them
to particular employers (Huang and Yeoh, 1996; Anderson, 2000;
Ruhs and Anderson, 2006). We turn now to a case study in order
to demonstrate the connections between emotional labour and
body work in the organisation and devaluing of the caring work
carried out by migrant workers in a Greater London hospital.
3. Research methods
This paper draws on the experiences of migrant workers en-
gaged in caring work in a West London NHS hospital. We call the
hospital West Central Hospital (WCH) for the sake of condential-
ity. These workers represent a subset of caring workers and their
experiences are shaped by, amongst other factors, the organisation
they are employed by. Hospitals are large organisations, in com-
parison with most care homes for example. Their role is primarily
to provide medical care to patients who are generally resident for
only a few days, if at all. Thus these workers experiences will be
different from those working in other settings and we would wel-
come the development of the analytic framework used here to ac-
count for those. In our analysis we identied themes emerging
from the data (in the light of the literature reviewed above). Quo-
tations in the texts are illustrative of these themes.
As we have argued, care is a complex notion and caring work is
organised by entrenched hierarchies. Our aim in interviewing
workers across the occupational spectrum is to cut across the hier-
archies of care and capture the ways gendered assumptions and
symbolic associations organise caring work within the hospital
(James, 1992; Twigg, 2000b). We interviewed 60 non-British-born
workers employed at the hospital. These workers were recruited
through an advert in the staff newsletter, posters in staff areas,
and snowballing techniques. We told potential interviewees that
we were interested in talking to them about their experiences of
being a migrant worker in the hospital and provided them with
an information sheet approved by the hospitals research ethics
committee. Recruitment through snowballing combined with mi-
grant workers over-representation in particular jobs (for example,
as discussed below, geriatric nursing) means our sample is not sta-
tistically representative of the hospital workforce. The interviews
followed a semi-structured format through which we explored
decisions to migrate, experiences of migration, work biography,
and everyday working lives. Our interviewees originated from 30
countries and had a range of migration experiences, from very re-
cent migrants to those with British citizenship who had lived in the
UK for decades. Some workers had trained as healthcare profes-
sionals in their country of birth as a ticket abroad while others
had migrated and taken jobs in the NHS out of utility. Fourteen
of our informants were men, reecting womens over-representa-
tion in the NHSs workforce. Informants are identied by pseud-
onyms, their job, gender, and country of birth. Our aim in this
paper is not to unpack migration per se, but following Conradson,
(2003, pp. 451452), we are interested in the spaces, practices
and experiences that emerge through and within relations of care.
4. Caring work undertaken by migrants in a West London
hospital
We now turn to the caring work undertaken by migrant work-
ers in WCH. Having shown how bottom-end service sector work is
devalued and feminised through constructions of emotional la-
bour, we begin by considering migrants experiences of undertak-
ing emotional work.
4.1. Emotional labour
In this section we describe three aspects of emotional labour.
First, we describe the specic contexts in which migrant workers
nd themselves performing emotional labour in, what we termcul-
tures of emotional labour. Secondly, we describe the caring work
that is hidden by rationalised healthcare regimes, before turning
to the intense nature of the emotional labour of caring bodywork.
4.1.1. Cultures of emotional labour
Turner and Stets (2006) have suggested that undertaking emo-
tional labour can be particularly stressful for migrant workers. Much
communication of emotion rests on culturally bounded subtleties
which people must relearn when they migrate. Workers who are re-
quired to undertake emotional labour must contend with subtle but
importantly different norms and expectations. Given the numbers
of migrant workers employed in bottom-end service sector work
which requires emotional labour the relationship between such la-
bour and migration is woefully under-theorised (Dyer et al., inpress).
In our conversations with migrant nurses we found evidence of
country-specic professional cultures and identities. Nurses
trained abroad expressed surprise at the way nursing in the UK
downplayed the importance of attitude or emotional engagement.
Joy explained how nursing in the UK is constructed as involving
knowledge and skills, to the exclusion of attitude. She explained
what she meant by attitude:
Attitude is how you approach the patient, how you feel
youre working. But here [in the UK] it is only skills and
knowledge. Attitude [is] how you interact with the patient
or like when you communicate to the patient, how is your
facial expression? How is your body language? (Joy, nurse,
female, Philippines)
She felt that the emphasis on knowledge and skills neglected an
important aspect of nursing:
[It is also important to] be pleasant with my words, differ-
ently, be transparent, be trustworthy, establish the
patientnurse relationship. Attitude is most for me. The
skills are there, the knowledge is there but if youve got a
negative attitude, that can affect your thinking and your
emotions, and your [way of] doing things.
The emphasis on knowledge and skills is a response by the UK
nursing profession to the lack of recognition of emotional labour
or attitude. However, it serves as evidence of differences en-
trenched within the professionalised work of nursing. A differential
valuing of this particular aspect of their work is one cultural differ-
ence nurses must work within.
The context in which emotional labour is performed is
important in shaping the workers experience of emotional
S. Dyer et al. / Geoforum 39 (2008) 20302038 2033
labour (Kang, 2003; Seymour and Sandiford, 2005). Different
professional constructions of the emotional labour of caring
is one such context. Another is a neo-liberal organisational
managerialism. It is to this we now turn.
4.1.2. Prisoners of love: lling the shortfall
As discussed above, the neo-liberalisation of healthcare entails a
rationalisation of caring to a series of tasks. However, care by its
very nature is highly context dependent and involves responding
to the needs of the cared-for. In customer-orientated bureaucra-
cies it is frontline workers who must resolve these tensions in
their interactions with those they care for. In this sense, workers
perform the hidden work which enables rationalisations to (ap-
pear to) work. For example, workers described responding to the
needs of patients without families:
Some people they havent got a family and like myself I was
giving more care to the people who havent anyone, because
they dont have a visitor, they dont have anyone looking
after, doing right thing, because some people come in and
check, you know? But some people havent got that and that
I think in myself [I] was saying, you know, make more effort
and we do the care, because I will do this and we will talk to
them. That can be hard, it was emotionally, it was very emo-
tional. (Habiba, health care assistant, female, Somalia)
Suchworkis hidden because it is not formally recordedor rewarded.
Often the gaps workers ll are those left by the organisation and
its rational differentiation of tasks. A cleaner described taking the
time to talk to people on the wards that she is cleaning:
I love to help old people as well. Yeah, I have a pity for old
people, so I go there and Ill make them breakfast and tidy
the ward, like mop and clean the sink and going in their
room, clean anything, check toilets, soap and stuff, so Im
used to it. . .I like caring, sometimes I go there and I sing
for them. (Amber, cleaner, female, Jamaica)
Ambers description of her working day highlights the importance
of not assuming a narrow denition of caring work. As a cleaner,
Amber is not obviously employed in caring work. However, her
working day is spent in close proximity to patients and she nds
soft (i.e. non-monetary) rewards in caring for patients. Expressing
similar sentiments, Krzysztof, a Polish porter, describes acting as a
translator to newly arrived Polish immigrants who are in hospital:
A lot of Polish will come to the hospital, it is growing, so I can
see that Im useful, some of them dont speak English at all,
they are really distressed and a newplace, everything is new,
different. (Krzysztof, porter, male, Poland)
Our ndings provide support for Duffys (2005) argument for the
use of wider denitions of caring work. The emotional labour re-
quired by bottom-end service work is less visible than in other more
obviously nuturant caring work and many migrant and BME work-
ers are found undertaking this work. However, this is more than a
contingent relationship. It is precisely because workers with low
autonomy in the labour market undertake this work that their car-
ing work remains hidden. Cleaners, porters, and HCAs are the work-
ers who are paid the least and experience the most precarious
working conditions (Datta et al., 2006). They are employed to clean
oors, empty bins, move patients around, wash patients. However,
such a list of tasks does not capture the lived reality of their working
day. Because workers are customer facing they must manage pa-
tients (and their families) needs and expectations. As demon-
strated by Habiba, Amber, and Krzyszof, sometimes workers will
respond by providing care. At other times workers will not provide
care but they must manage the emotions that such a denial will
provoke in themselves and patients (Solari, 2006). The caring work
these workers perform, as prisoners of love, out of feelings of duty,
empathy, or human decency is hidden but is necessary to the func-
tioning of the healthcare system.
4.1.3. Intense emotional labour of body work
Working in the context of a hospital shapes the demands on
workers and the coping strategies available to them. The intensity
of the emotions encountered arises from the centrality of the hu-
man body, in particular damaged or needy bodies, in the hospital.
Workers describe the intense emotions entailed by their working
lives. Habiba, the HCA quoted above, who used to work in an old
peoples home, used the termhard work to describe the emotional
involvement she has with people at work. She went on to say:
I saw someone die with the civil war. I havent seen someone
dying naturally and that was hardest. I was heartbroken
because the home, the nursing home the old people were
dying a lot, you could see two or three people dying in one
day and so [I was] heartbroken, you know. Sometimes youre
so attached with someone and then you know and it was so
hard for me. (Habiba, HCA, female, Somalia)
The emotional labour undertaken by workers can be intense. Some
people we spoke to described not being able to cope with such dif-
cult emotional situations. In an example of a worker refusing to
provide emotional labour, Parnel explains:
The. . .howshould I say, the most difcult situation that I cant
manage is if the patient is. . .if theyre deadandI needtoinform
the family, I cant manage that. . .I cant say because. . .that days
sometimes I call the doctor or I call the senior sister. . .its really
difcult to say that. (Parnal, nurse, female, India)
A working life that involves such emotions clearly extends beyond
service with a smile. The human body, particularly in it vulnerable
and needy states, is a source of much anxiety, embarrassment, and
fear. Undertaking emotional labour in a context where illness and
death are the stuff of the everyday raises particular challenges for
workers.
4.2. Caring work: body work
In this section we examine how the body work requirement of
caring work structures the hierarchical relationships at work and
the construction of this as work suitable for migrants. We draw
out four aspects of undertaking caring body work. First, we de-
scribe how hierarchies at work rely on being able to mark distance
from the bodies of patients. Secondly, we show how many migrant
workers nd body work difcult because of cultural understand-
ings that its proper location is in the familial realm. Thirdly, we de-
scribe the associations workers feel are made between being
migrants and dirty work. Finally, we examine the difculty in t-
ting this work in to the schedules of modern healthcare. This
neo-liberal organisation makes body work particularly undesirable
for workers.
4.2.1. Hierarchies of work
Workers at WCH described a hierarchy of work in the hospital
where doctors occupy the most prestigious positions, nurses the
middle ones, and HCA and cleaners
1
the bottom ones. We argue,
1
Following Twigg (2000a) we include cleaners in the category of body workers, c.f.
Isaksen (2002).
2034 S. Dyer et al. / Geoforum 39 (2008) 20302038
in part, that this hierarchy reects deeply held ideas about caring
body work and an equation that is made between dirty work and
the workers that undertake it.
Dress codes and uniforms in the hospital play a role in marking
which workers are involved in body work. Naresh described how
certain clothes are associated with doctors:
I never come to the hospital without a tie. . .yes, obviously
people do recognise you if you have the stethoscope. It chan-
ges. . .they realise that youre a doctor. If you dont have a
stethoscope they say who are you?, then I have to tell
them Im a doctor. (Naresh, doctor, male, India)
Wearing a stethoscope is a literal displayof the distancingtechniques
available to doctors. This display andwearing a tie, a piece of clothing
associated with white collar work, signals to others that this individ-
ual is not involved in messy or unbounded caring body work.
The increasing (medical) professionalisation of nursing includes
not wearing a uniform. Senior nurses, for example those working in
nurse-led clinics, such as Daniela, also wear outdoor clothes:
Im dressed as the doctor. I think patients associate outdoor
clothes with doctors and stethoscope. I think many of them
are not familiar with the fact that nurses are examining
patients now. (Daniela, nurse, female, Malta)
The association of smart ofce wear distances the worker from the
caring body work of feeding and washing. It links to the bounded
interaction of examining patients. The two roles are constructed
as mutually exclusive and relational. The body worker is the assis-
tant to the superior professional.
The implications of undertaking body work can be seen most
acutely for nurses for whom there is a tension between distancing
and embracing but redening such work (Ashforth and Kreiner,
1999). Nurses descriptions of the hospital hierarchy exhibited an
ambivalence towards body work. Catherine, for example, said she
thought patients and their families can be quite rude to nurses be-
cause they see them just as the doctors helpers. She described pa-
tients relatives doubting what she told them and demanding to
talk a doctor. She disputed this construction of nursing, seeing her-
self as a medical professional just as doctors are. However, she
used the notion of dirty work to stress her superiority to HCAs:
Theres the health care assistants, theyre doing feeding,
washing. Its like an assistant to the nurse, you know, the
dirty work. (Catherine, nurse, female, Philippines)
Work on the bodies of others, feeding and washing, is read as me-
nial and dirty. In some senses, Catherines ability to delegate body
work to another secures her professional status. However, as we de-
scribe below, nurses themselves do undertake body work.
4.2.2. Cultures of body work
To the surprise of nurses trained abroad, nursing in the UK does
often involve body work. In the countries where they had been
working previously (the Philippines and India) nursing involved
medical rather than caring duties. Joy described nursing in the
UK as the complete opposite of the Philippines. Discussing arriv-
ing in the UK, Catherine explained:
I didnt realise that you have to wash the body and every-
thing. Back home we dont do it, washing patients. We dont
really do it. Its a relative doing it. (Catherine, nurse, female,
Philippines)
Those nurses trained in India and the Philippines expressed a differ-
ent cultural understanding of caring body work. Such work is
thought to be a duty of relatives and as belonging in the domestic
and familial domain. This disjuncture in conceptualisations has
been shown to increase the stigma of undertaking such work for
pay. Discussing Zimbabwean expatriates working in care homes.
McGregor (2007, p. 808) observes:
Most felt that care for the elderly should be a family matter
and was part of the duty children had towards their parents,
and should not be commodied. They were highly critical of
the way British society treated its elders: many thought that
families who put old people in homes were abdicating their
moral responsibility by discarding or dumping their par-
ents; that the elderly should be looked after in their childrens
homes by relatives out of love, not put in an institution and
cared for by people they did not know, working for money.
There are echoes of these conceptions in some of the sentiments of
nurses described below, of themselves and their elderly charges
being dumped. Workers own cultural expectations about the
proper context of body work (a familial one) and moral judgement
about the treatment in the UK of the elderly further stigmatise this
work in their eyes.
4.2.3. Dirty work/ers
Hospital body work by its very nature deals with the un-
bounded body and is often messy and dirty. Workers described
the difculties of cleaning people and, in particular, those involved
in cleaning human waste. Amber, a cleaner, described the experi-
ences of cleaning the public areas of the hospital:
I do all the toilets and sometimes it gets me mad because the
mental health people as well come over, then we have pee on
the ground, theres sick on the ground, they will
vomit,. . .there was blood all over the place. . .my job for
me! I have to do it, sometimes theres poo on the ground,
you have to take it up and you have to clean it. Its my job isnt
it? [laughing] Sometimes it makes me sick. [laughing] Before
you eat and before you do anything, you wash and then you
use a (alcohol) gel. (Amber, cleaner, female, Jamaica)
Joy, a nurse, echoes Ambers feelings:
[Is there anything I dont like about my job?] Yes, waste,
handling waste, body waste, thats the only thing. Some-
times it feels that. . .even though were used to it but there
are times that where probably were going to end up not
feeling very well but youre still capable of working, and
sometimes Ive felt that, only in rare occasions but most of
the time because were used to it, we can look at it, but if
its too much like all splattered on the oor, sometimes just
waste, Im only a human being, sometimes I get sick with
waste. (Joy, nurse, female, Philippines)
Joys plea that she is only human is telling. Working as a nurse she
has to undertake tasks that transgress social codes of behaviour.
However, rather than being compensated for unpleasant work or
rewarded for socially useful work, her work is devalued by associa-
tion with dirt.
Workers felt that they, as migrants, were employed to under-
take dirty work that British-born workers are not prepared to
do. Had describe the view of people in his home country:
In Morocco they said listen, if you go to Europe, like a
domestic or sweeping the roads or what ever, you will nd
a job quickly [snaps his ngers] because the English people,
they dont want to do this type of job. So they give them to
foreigners. (Had, cleaning supervisor, male, Moroccan)
S. Dyer et al. / Geoforum 39 (2008) 20302038 2035
Carla, another cleaning supervisor, echoed his comments: They
(British-born workers) dont want to do it.. Commenting on the
work of cleaners, a doctor made a similar observation:
Its not a nice, its not a fun job, its hard work and its long
hours and I suspect folk who do have other options, will take
it and other people will say Id rather not do the job but I
always nd it interesting that foreigners will nd some work
todo, not that Imcastingaspersions onanyone, Imjust think-
ing most of the cleaning staff, I cant actually think of any
other. . .theres one lady I know whos British-born, the rest
are all from overseas. (Eileen, doctor, female, South Africa)
Migrant workers are typically recruited for posts that are hard to ll
and so nurses moving to the UK found themselves working in low-
er-status specialisms, such as geriatrics, regardless of their training
or expertise. Asked what she felt on arriving in the UK Catherine de-
scribes a disappointing experience:
Because they throw me in South side where the old building
is. They would shufe the staff and they put me to [elderly]
Ward which is like. . .its not permanent and theyre throw-
ing patients, mostly like having mental problems or really
waiting for a nursing home and everything, and its really,
for one, its not really good conditions of where it is, its an
old building down there, its not happy to work with because
all patients are complaining, what is this style of work?,
its like a ship going to the. . .you know? (Catherine, nurse,
female, Philippines)
She was expecting a beautiful hospital but felt dumped in wards
in bad conditions working with patients who no one else wanted to
work with.
Workers employed a number of strategies to mitigate such an
identication. The most common was stressing the dignity of earn-
ing a living and supporting their families. Asked what she liked
about her job, Joy answered:
I like it, its tiresome but I like it because I just learnt to like. I
just learnt to like it. I dont know the specic reason, I cant
think of a specic reason why I like it, I just learnt to like and
love my job. Probably because this is my source of income
and I dont know other job except nursing. (Joy, nurse,
female, Philippines)
Similarly Amber says:
I feel proud of my uniform because it gives me my food so I
dont hide my uniform, I pick up my uniform, anywhere in
the NHS I feel so proud. (Amber, cleaner, female, Jamaica)
Other workers stressed the satisfaction they gained from caring for
people. Habiba, who would have trained as a doctor but was pre-
vented from doing so by civil war, said:
The best thing about my job is, when the person is very sick
and getting better and going home thats my, I feel good to
see, we did something and that person is going home, you
know thats my best thing. (Habiba, HCA, female, Somalia)
Similarly, Iresh, a nurse, describes committed and fullling
caring work:
The best thing? Yeah. . .I think care of patients. I can be
friendly with them. I do help as much as I can. The doctors,
they only [have contact with patients] for some time, they
only are doing doctors rounds. I know. . .I get to. . .I know
them completely, I talk to them and they know what is hap-
pening. (Iresh, nurse, female, India)
Workers derive self-respect from a variety of sources; from their
ability to support their family, humour, and stressing the value
and fullling nature of their work (Ashforth and Kreiner, 1999; Kre-
iner et al., 2006). This, though, is undertaken within the context of a
society and an organisation which poorly remunerates this work.
These migrant workers undertaking dirty work in the NHS feel
stigmatised within the workplace by their work and associations
made between their status as migrants and the work that is appro-
priate for them.
4.2.4. Caring body work as non-routine
Body work might seem to be an aspect of caring work amena-
ble to the rationalisation of neo-liberal healthcare. Meeting phys-
ical needs, such as feeding and bathing, seems to break down into
tasks in a way that emotional labour just does not. However, our
informants highlighted how non-routinisable the tasks of body
work such as feeding and bathing are. The people in hospital
need, in Kittay et al. (2005, p. 433) words care more urgently
and more completely than usual (some more than others). Fit-
ting such care into a schedule of discrete tasks is problematic
for workers.
Many of the workers we spoke to organised their working life in
order to avoid the stress of undertaking strictly timetabled body
work. Being low in a hierarchy often involves having little auton-
omy or control over the organisation of their working day. This is
particularly stressful for workers because it is they themselves,
not their managers, who come face-to-face with their clients.
The people we spoke to described changing shifts or wards in an
attempt to avoid difcult-to-schedule body work. Joy, for example,
described working night shifts because it did not involve washing
patients:
Oh dear, if you have to thoroughly wash, it takes about 15
30 min, it depends on how, you know, how dirty they are;
how difcult (they are) to move. Because sometimes when,
after washing them, they poo again. I have to go back again
and wash them. (Joy, nurse, female, Philippines)
In another example, Habiba, a health care assistant, explained that
she prefers working on a surgery ward because she can plan her
time:
(You know) exactly whats coming and what youre doing all
the time. Youve got a list. Youre doing everything in a par-
ticular hour and you know who needs this and who needs
that. But (in other wards) most of them is elderly, they have
fell down and broken leg, broken and they cant stand up at
all and its not. You have to, you need someone, a nurse to be
with them all the time. (Habiba, HCA, female, Somalia)
Within a rationalised and bureaucratic system of delivering health-
care unpredictability makes body work stressful for the workers.
The workers we spoke to described, where possible, organising their
working lives so as to avoid body work. This is work that is poorly
paid and understood as lowly. We can conjecture that such work is
stressful for workers in part because it is work on the bodies of hu-
mans, and that it is also work with people. As such workers are re-
quired to simultaneously undertake emotional labour. When an
incontinent patient needs washing again not only is the workers
schedule disrupted but they must manage their feelings of stress/
annoyance/anger and disgust as well as the patients embarrass-
ment or shame.
2036 S. Dyer et al. / Geoforum 39 (2008) 20302038
5. Conclusion
In this paper we have argued that caring work is devalued
through multiple mechanisms. We have employed a twofold char-
acterisation of caring work in order to describe and thus de-natu-
ralise the devaluation of caring work and its association with
femininity. We have shown howit suffers, like much customer-fac-
ing service sector work, through the lack of recognition of emo-
tional labour. We have argued that this plays out in particular
ways when the emotional labour is of the intensity required by
healthcare work, and when the organisational context of manage-
rialism rationalises care to a series of tasks. Further, we have ar-
gued that caring work is devalued by the associations between
body work and dirty work. Rather than being rewarded for under-
taking socially necessary and difcult work, workers are stigma-
tised by the work they undertake.
The strategy of not presupposing which workers undertake car-
ing work has been shown to be valuable for cutting across hierar-
chies of care. We have shown that caring work in hospitals is
undertaken by cleaners and porters as well as by nurses, by those
not expected, as well as those expected, to provide care. Our aim
is not to romanticise this work or these workers. Certainly, these
workers can and do refuse to meet the demands and needs of pa-
tients and their families. However, the examples of a porter provid-
ing translation for newly arrived Polish migrants or a cleaner
taking the time to chat with elderly patients as she cleans the ward
demonstrate the extent to which emotional labour is hidden by
hospital hierarchies and illustrate what it means for workers to
be a prisoner of love. These peoples experiences are important
in highlighting how workers respond to managerialist organisa-
tional contexts. The workers we spoke to described, where possi-
ble, choosing to work the shifts most amenable to a
rationalisation of care: night shifts or on wards requiring the least
body work.
We began this paper by observing that care has been theoreti-
cally neglected and socially undervalued. This has been possible
because historically, using the economists terminology, there has
been a surplus of care. Society has been organised in such a way
that care was provided within familial and domestic relationships
and so the costs were hidden. However, it is becoming increasingly
difcult to ignore questions about care when a care decit is cre-
ated by more men and women working for wages in advanced
industrial economies, and by aging societies. Our aim here has
been to use this moment to challenge the devaluation of care
and caring workers. Among the problems facing the world in the
21st century, the provision of care a seemingly mundane prob-
lem is of huge signicance. It is not one that scientic innova-
tions will resolve but is instead an issue about labour relations,
gender and discrimination, and, ultimately, about social justice
for both the workers who perform such valuable labour and their
charges.
Acknowledgements
We would like to thank all of the workers at WCH who took
time to talk to us, to acknowledge the support of the ESRC grant
number RES 225 25 2001. We would also like to Yasmin Gunarat-
nam and those who refereed the paper for their thoughtful com-
ments on earlier drafts of this paper.
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