‘You're on show all the time’: Moderating emotional labour through space in the emergency department

AIMS
This is the second of two papers conceptualizing emotional labour in the emergency department (ED). This paper aims to understand the environmental 'moderators' of ED nurses' emotional labour.


DESIGN
Ethnography, through an interpretivist philosophy, enabled immersion in the ED setting, gathering the lived experiences and narratives of the ED nurses.


METHODS
Observation and semi-structured interviews over a 6-month period. Two hospital sites (one district general and one major trauma centre) based in the United Kingdom.


RESULTS
Over 200 h of observation plus 18 formal/semi-structured interviews were completed. Environmental, institutional and organizational dynamics of the emergency department instrumented the emotional labour undertaken by the nursing team. Time and space were found to be 'moderators' of ED nurses' emotional labour. This paper focusses on the relevance of space and in particular, 'excessive visibility' with little respite for the nurses from their intense emotional performance.


CONCLUSION
Emotional labour is critical to staff well-being and the way in which healthcare spaces are designed has an impact on emotional labour. Understanding how emotional labour is moderated in different clinical settings can inform organizational, environmental and workforce-related decision-making.

one conceptualizing ED nurses feeling rules). This paper seeks to understand the 'moderators' of emotional labour in ED.

| Emotional labour in nursing
The concept of emotional work, and specifically the theoretical concept of emotional labour, products of Arlie Hochschild's The Managed Heart (1983), offered those studying the workplace a lens through which to explore workers' emotions. Various examinations of emotional labour since Hochschild's introduction have highlighted theoretical application and application to the fields of social psychology, organizational sociology and human resource management (Ashkanasy & Humphrey, 2011;Barry et al., 2019;Grandey & Gabriel, 2015).
The emotional labour of various professional groups has also been examined. Perhaps unsurprisingly, this has included those in healthcare and nurses; generically, it is well established in academic literature that nurses do emotional labour routinely in their practice (Smith, 2012;Theodosius, 2008). When nurses' feelings do not align with what is expected, they 'do' emotional labour in response, McQueen (2004, pp.103-104) states: When nurses do not feel as they think they ought to feel in particular situations, they engage in emotional labour to manage, control, or alter their emotional status to correspond with what they believe is appropriate for the situation.
The nurse acts as a social performer (Bolton, 2001), adapting to meet various needs. These terms align strongly with Goffman's (1959) 'presentation of self' and impression management, in which employees adopt a specific outward appearance of the expected emotions for the 'stage' whilst their true emotions remain supressed and out of sight (Bolton, 2001;Huynh et al., 2008).

| Emotional labour in ED
Despite this extensive body of literature, we know little of how nurses emotional labour is moderated and how emotions are managed in the ED environment. This oversight is amplified when considering the distinctive nature of ED. Here, nurses must manage a target-driven culture (e.g. the 4 h wait and ambulance turnaround times) whilst striving to maintain care standards. At the same time, the patient population served is uniquely challenging, with an array of diverse presentations and no 'cut off' to the number of patients who may present (24 h a day). Exposure to traumatic cases and violence is also frequent, ED staff experience rates of both physical and verbal abuse that are significantly above the national average, when compared with other healthcare workers (NHS Security Management Service, 2010). It is perhaps unsurprising that ED nurses are especially vulnerable to experiencing anxiety, depression and burnout (Adriaenssens et al., 2015)--despite these observations, thus far, the relevance of emotional labour in the ED has only been touched on in a broader study (Bailey et al., 2011). The research acknowledged the emotional labour undertaken by ED staff in the management of patients receiving end-of-life care in EDs.
Despite this insightful paper and other contributions to emotional labour theory, there remains a compelling space to understand the management of emotion in the ED.

| Moderating emotional labour
Theorists (Grandey & Gabriel, 2015) have explored factors which shape how, and to what degree, emotional labour is performed. They have identified the 'moderators' of emotional labour--physical and non-physical elements which affect the emotional performance in terms of intensity, frequency and, therefore, the personal impact of the labour. This examination of moderators has often focussed on relational considerations (Grandey & Gabriel, 2015), for example, an individual's psychological traits (emotional abilities or /values) (e.g. Diefendorff et al., 2011). The dominant perspective shows the negative implications of emotional labour will be less for employees who embody organizational values (Schaubroeck & Jones, 2000). At an organizational level, scholars have investigated contextual factors which influence experiences of emotional labour including; job status; the degree of autonomy in work; the financial rewards for the emotional labour undertaken; and the degree of social support available to employees (Grandey & Gabriel, 2015). This resource-based perspective acknowledges argues that emotion regulation will be less depleting (in terms of well-being) for an individual in a work setting in which has more resources available (Grandey & Gabriel, 2015). For example, the perception of strong organizational support systems helps to mitigate the negative effects of emotional labour and in particular, its influence on job satisfaction (Duke et al., 2009).
We might assume that environmental structures may also moderate employees' experiences of emotional labour. Despite this, a thorough exploration of various structural 'macro' elements (such as space and time), and their part in the moderation of emotional labour, is limited. Noting the pressures facing the ED, including overcrowding and a lack of resources, it is probably that these and other environmental elements act as moderators of ED nurses' emotional labour. This paper will concentrate on the exploration of these moderators in the ED environment.

| Aims
This study aimed to explore emotional labour in the ED with a specific focus on the theorization of specific environmental 'moderators' of nurses labour.

| Design
The ED offered a fitting case study to explore and contribute to the concept of emotional labour. Ethnography, through an interpretivist philosophy, enabled immersion in the ED setting, gathering the 'life world' (Gherardi, 2015) and narratives of the ED nursing team.
Data were collected by the main author and ethnographer (KK). The observation was non-participatory to manage clear professional/ ethical boundaries (as KK is a registered nurse). KK undertook direct and first-hand observations, using an ethnographic approach. This allowed room for the dynamism of the setting, workload and pace.
Semi-structured interviews were also undertaken with ED staff and the wider 'well-being' team. Two departments were used for a rich and illuminative dataset.

Observation at two UK EDs (this observation totalled 200 h):
Eighteen formal/semi-structured interviews with ED nurses (varying levels of seniority). Interviews were completed with ED nursing staff (a mixture of staff nurses, sisters/charge nurses).
Respondents needed to be actively working in the ED setting, but the sampling criteria did not stipulate age, level of experience or other demographic. Respondents were initially recruited via social-media, email and poster advertisement in the EDs--a 'snowballing' approach aided the latter half of recruitment, as participants shared their experience of interview with colleagues, prompting further involvement. See Tables 1 and 2 below for participant demographic.

| Data collection
Data were collected over a 6-month period.
Interviews followed a semi-structured format using a predefined topic guide. In addition to a standard approach to interview questioning, metaphorical terms were also drawn out of the observational data and taken 'into' the interview room. These terms (including: assembly line; juggling; A&E Swan; warzone) acted as a prompt for participants and  (Gowler & Legge, 1989). It is also important to note that participants were actively encouraged to challenge interpretations made by the researcher.
Considering the hectic nature of the ED setting, participants were encouraged to select a time and location which was most convenient for them. KK knew 4 of the 18 participants (from previous clinical work). Interviews were recorded via Dictaphone and then transcribed verbatim. All aspects of 'rigour' including KK's clinical experience will be acknowledged in the rigour section of this paper.
Observation (200 h +) was split throughout the different clinical areas in the ED (see Table 3 in Findings below). KK wore plain clothing and a hospital ID badge at both sites. All of these areas were observed to witness the variety of work completed by staff. The formal observation was restricted to the adult ED, although paediatric staff shared their experiences during the informal interviews. This included the minor injuries areas, assessment areas, resuscitation area and the 'majors' area of the ED (a space in which those patients who were not appropriate for minor injuries or resuscitation care were treated). All areas in the ED were observed from close-up or more- with the flow of care delivery (Kusenbach, 2003). It is important to note that the observation was completed both during the day and at night (in a 24-h timeframe). Notes were taken by hand and electronically, sometimes in bullet form to keep pace with the activity. These notes were then 'worked up' into more comprehensive accounts after the period of observation.

| Ethical considerations
Ethics approval was sought through the Health Research Authority in addition to university ethics and local R&D approvals (at both hospital Trusts). Each interview participant gave signed, informed consent. All participants details were anonymised and pseudonyms are given.

| Data analysis
NVivo 11 was used to manage the data. This included all observational notes together with interview transcripts adopting a 'triangulation' approach (Mason, 2017), bringing together data sources. In line with the studies ontology, a deeply reflexive approach adopting interpretivism was used to analyse the data (Mason, 2017). The process of analysis was iterative (see Hammersley & Atkinson, 2007) and began during data collection when notes were summarized and reflected on. The formal process of analysis began with coding and was non-cross-sectional, establishing preliminary themes (Mason, 2017). As re-reading took place, by the wider research team, codes were refined and a cross-sectional approach aided the reduction of nodes. After the team had established a final set of nodes and sub-nodes, the data were displayed visually through diagrams and charts, this prompted further analytic thinking, relating to relationships between nodes. Conceptual abstraction was achieved through progressive focusing (Hammersley & Atkinson, 2007). Throughout the process of analysis, the team worked collaboratively; critical for assumptions and interpretations to be challenged.
The data analysis process ultimately led to two overarching concepts-'Moderators of ED nurses emotional labour' and 'Specialty specific feeling rules' (see Kirk et al., 2021). For the purpose of this discussion, we will focus on the moderators. To further aid transparency, Figure 1: Refinement of Nodes: Moderators of Emotional Labour shows how this concept was reached.

| Rigour
Trust and rigour were achieved in this study through ongoing critique and transparency (Ritchie et al., 2014). Drawing on the 'Sociological Imagination (see Mills, 1959) offers the opportunity to prioritize selfawareness. This stance is particularly helpful considering the positionality of the researcher; KK is a registered nurse with ED experience.
It is important to note this, as with all ethnographies, the researchers past experiences, values and beliefs are intrinsic to the data generated, what is included and any omissions (Law & Singleton, 2013).
At the same time, the status assigned to KK during the research process and her interactions with participants, this changed depending on past relationships and their perception of whether KK was an 'insider' or 'outsider'. Stepping away from these dichotomous positions (Thomson & Gunter, 2011) and seeing this position as changeable, enhanced the process of reflexivity. Reflexivity has been fundamental to this study and striving for rigour. This reflexive stance has underpinned pragmatic steps (Mason, 2017) taken to ensure assumptions are challenged, both in and outside of the research team.
Interviews were treated as an interpreted social event (Hammersley & Atkinson, 2007). These recounted experiences were socially constructed narratives (Silverman, 2017), not descriptions of the actual events (Mason, 2017). The accounts were the result of the 'complex negotiation' conducted in the interview discussion (Gherardi, 2015, p.15). The opportunity to examine the ED nurses' experiences of emotional labour was offered when the data showed recurring themes (Mason, 2002). Gherardi (2015, p.23) argues that 'plausibility is the validity criterion for ethnographic research'. However, due to the subjectivity of the interpretation process, it is crucial that the researcher outlines all aspects of the methods involved and the data collected (Gherardi, 2015).
Achieving quality judgements in ethnographic research requires transparency with respect to these judgements, decisions and theorization (Ritchie et al., 2014). In response, examples of some mechanisms used for 'testing' assumptions were through combined data collection and analysis methods, ongoing team member checking and visual mapping.

| FINDING S
Our earlier paper (see Kirk et al., 2021)   The majors spaces offers little opportunity for time 'away' from patients. As such, the nurses must maintain their 'social performance' (Bolton, 2001), sustaining expected emotions for their patients (and colleagues) whilst their true emotions remain suppressed and out of sight (Huynh et al., 2008). A role in the majors space which amplifies this labour further still, is that of the nursing coordinator. This nurse is Interview) The nurse coordinator manages the staff and patients in the majors area. There is an expectation that (even when they feel stressed), those who are good at their job, must control and ultimately suppress their true emotion through their emotional labour. What amplifies the need and intensity of this emotional labour further is the excessive viability of the coordinator role. Their physical placement in the majors area means that they must not only suppress any tension to those immediately around her/him, but also other staff and patients in the ED. The 'space' (or lack of) between patients also moderates the ED nurses emotional labour. There is little physical space (distance) or space (in terms of opportunity/time) for the nurses to process emotion. This limitation on opportunity to process emotion from one distressing patient case, before moving on to the next, arguably intensifies the labour required for the 'next' patient, as articulated in the extract above from Adam. The lack of space between patients can result in intense emotional labour as the nurse attempts to hide sadness (in the example above, tears) from the new case.

(ED S/N Alison, Teaching ED, Formal Interview)
In the absence of protected off-stage spaces for the nurses, they seek out unconventional spaces to vent and for reprieve from their masked performance, these are often 'backstage' but still clinical. Ironically, the sluice room is often used for tears and other restricted emotional displays--an offstage space. This is a small space largely reserved for the disposal of waste products. It is a small, cramped and unpleasantsmelling room that to a certain degree is seen as less visible (and most certainly out of patient sight). Here, bodily waste is disposed of, along with staff members' emotional baggage. It provides an opportunity to vent and discharge away from the gaze of others. For some nurses, their emotional retreat and release are saved for spaces outside of the ED completely to 'let these emotions out': the hospital chapel or the car journey home alone.

| DISCUSS ION
This discussion will detail the key findings of this paper namely how the lack of space 'between' patients in the ED, and the excessive visibility of staff in the ED, moderates (and intensifies) staffs experiences of emotional labour.

| Application to ED: Space 'between' patients
Physical space in the ED is a social production that is lived, experienced and maintained by the staff (Tyler & Cohen, 2010). Viewing the ED as a system, and as a collection of spaces, fits with the organizational description offered by Halford and Lenoard (2005, p.661), seeing it as a 'configuration of multiple, distinctive and differentiated spaces offering different potentials for subjectivities.' Emphasis is placed on moving patients through and out of the space and preventing a build-up of patients in the ED--this spatial element adds to the sense of the ED as a conveyor belt that must keep moving, limiting the 'space' between patient interactions, moving from one, immediately to the next. Staff have no time to process one emotional experience before moving onto the next, this moderates their emotional labour as staff have to suppress emotion from previous cases to ensure they present the expected display to the next patient in their care. As argued by Peter and Liaschenko (2004), nurses in particular may desire to flee, but their place in the system, both geographically and morally (and in contrast to other healthcare professionals), prevents it.

| Application to ED space: Excessive visibility
The lack of offstage space and subsequent opportunity for reprieve from undertaking the described degree of emotional labour is of significance. These findings strongly relate to the work of Goffman (1959), where employees choose their performance based in part, on where they are located ('front stage' or 'backstage'). This is critical to ED nurses' emotional labour as the ED has little clinical backstage space away from the patient audience.
This is most prominent in large, open spaces where there is constant visibility from the patient audience and, most notably, their relatives. For many of the nurses, particularly those in charge of a specific space (e.g. the majors or resuscitation spaces), there is little if any respite or offstage/backstage opportunity--presenting a professional version of the 'self' (Goffman, 1959) is constant, irrelevant of stress experienced. This sociological understanding of emotion works with the idea that individuals consciously manage their emotions to follow the values and beliefs in a specific situation or community (Bolton, 2001). Goffman (1959) described this as 'face-work', in which individual actors have direct control over their 'performance' and the management of their emotional performance (Bolton, 2001). The performer is a 'harried fabricator of impressions involved in the all too human task of staging a performance' (Goffman, 1959, p.220). This fabricator is the 'character' with qualities to be shared--the performance is designed to evoke and display these qualities (Goffman, 1959).
The ED nurse suppresses myriad of feelings in to maintain the expected 'performance' and qualities (fearlessness, calmness and stoicism, amongst others, see Kirk et al., 2021) to those around them.
Most crucially, the visibility of the nurse to the various audiences increases the intensity of this emotional labour--a factor that was previously missing from exploration but is now seen as especially relevant to both physical and emotional work (Boyd, 2012). Rather than the duration of an individual interaction (Morris & Fieldman, 1996), the intensity of emotional labour is impacted significantly by the duration of front-stage period.

| Implications of excessive visibility and future research
Considering that we already know of the links between emotional labour and burnout/emotional exhaustion and intention to leave (Bartram et al., 2012), these findings are critical to contemporary nursing. This point is emphasized further still when we consider them against the workforce 'crisis' backdrop: record breaking stress, burnout, and absenteeism--compounded by the Covid-19 pandemic: sickness absence rates in the NHS are higher than in the rest of the economy (The King's Fund, 2018). The well-being of UK nurses is amongst the worst in the world (Aiken et al., 2012). Where nurse staffing is short and/or skill mix is poor, patient mortality is increased (Aiken et al., 2012;Griffiths et al., 2019).
The relentless nature of the ED nurses workload and the targetdriven culture of their practice result in little or no 'space' between emotive interactions (and emotional health is fundamental for nurses well-being). A probably remedy is a reduction in workload for ED nurses, which would offer up more 'space' to process emotional experiences. Considering the challenges of contemporary practice and workforce challenges, this solution will not offer immediate relief.
This argument is also relying on the assumption that staff have 'off stage' spaces where they can seek emotional reprieve (given the opportunity) as a remedy to excessive visibility. Further research is required to understand how these spaces might be designed, however, the findings from this paper suggest how important the physical design of healthcare facilities are for staff, as well as the patients receiving care. Staff need offstage spaces which are incorporated into clinical areas (rather focusing on break rooms or rest areas alone, which are often even harder to access). Here, they may retreat in-between patients, for non-contact patient tasks. As argued by Halford and Leonared (2003) in the absence of offstage spaces, nurses create 'internal private and personal spaces for themselves, free (or freer) from the ever-possible demands of others'.

| Limitations
This study generated an abundance of data and insights into the emotional labour undertaken by nurses in the ED setting. Despite the extensive nature of data collected, ethnography is limited for direct application to other settings (Seymour & Sandiford, 2005).
However, it is anticipated that findings will still be of great academic and practical value including healthcare settings outside of the ED environment.

| CON CLUS ION
Emotional labour is critical to staff well-being and the way in which healthcare spaces are designed has an impact on emotional labour. This paper argues that the ED calls for an extensive spectrum of emotional labour from the nurses working there. This labour is moderated by space in particular and most crucially, the lack of time 'between' patients and the excessive visibility experienced by staff.
This results in extensive periods 'on stage' with little or no 'off stage' reprieve. Understanding how emotional labour is moderated in different clinical settings can inform organizational, environmental and workforce-related decision-making, particularly in the design of healthcare environments.

ACK N OWLED G EM ENTS
The emergency nurses who were incredibly generous with sharing their time and insights for this project. Open access funding enabled and organized by ProjektDEAL.

FU N D I N G I N FO R M ATI O N
This study was funded as part of a joint funded PhD Scholarship through the NIHR Applied Research Collaboration and Centre of Health Innovation, Leadership and Learning and NIHR Applied Research Collaboration.

CO N FLI C T O F I NTE R E S T
None.

PE E R R E V I E W
The peer review history for this article is available at https://publo ns.

DATA AVA I L A B I L I T Y S TAT E M E N T
The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.

T WIT TER
Kate Kirk @KateLKirk