Management of Emotions in Accelerated Medical Relationships

Obling, Anne Roelsgaard Doctoral Thesis Management of Emotions in Accelerated Medical Relationships PhD Series, No. 8.2012 Provided in Cooperation with: Copenhagen Business School (CBS) Suggested Citation: Obling, Anne Roelsgaard (2012) : Management of Emotions in Accelerated Medical Relationships, PhD Series, No. 8.2012, ISBN 9788792842435, Copenhagen Business School (CBS), Frederiksberg, https://hdl.handle.net/10398/8419 This Version is available at: https://hdl.handle.net/10419/208805 Standard-Nutzungsbedingungen: Die Dokumente auf EconStor dürfen zu eigenen wissenschaftlichen Zwecken und zum Privatgebrauch gespeichert und kopiert werden. Sie dürfen die Dokumente nicht für öffentliche oder kommerzielle Zwecke vervielfältigen, öffentlich ausstellen, öffentlich zugänglich machen, vertreiben oder anderweitig nutzen. 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If the documents have been made available under an Open Content Licence (especially Creative Commons Licences), you may exercise further usage rights as specified in the indicated licence. https://creativecommons.org/licenses/by-nc-nd/3.0/ Anne Roelsgaard Obling PhD Series 8.2012 PhD Series 8.2012 Management of Emotions in Accelerated Medical Relationships copenhagen business school handelshøjskolen solbjerg plads 3 dk-2000 frederiksberg danmark www.cbs.dk ISSN 0906-6934 Print ISBN: 978-87-92842-42-8 Online ISBN: 978-87-92842-43-5 Management of Emotions in Accelerated Medical Relationships Doctoral School of Organisation and Management Studies Management of Emotions in Accelerated Medical Relationships Anne Roelsgaard Obling Copenhagen Business School Doctoral School of Organisation and Management Studies February 2012 Anne Roelsgaard Obling Management of Emotions in Accelerated Medical Relationships 1st edition 2012 PhD Series 8.2012 © The Author ISSN 0906-6934 Print ISBN: 978-87-92842-42-8 Online ISBN: 978-87-92842-43-5 The Doctoral School of Organisation and Management Studies (OMS) is an interdisciplinary research environment at Copenhagen Business School for PhD students working on theoretical and empirical themes related to the organisation and management of private, public and voluntary organizations. 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No parts of this book may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or by any information storage or retrieval system, without permission in writing from the publisher. 1 CONTENTS Acknowledgments ......................................................................................................... 6 Preface ........................................................................................................................... 8 Chapter 1: Introduction ............................................................................................ 10 Why emotions and why now? .................................................................................. 13 The importance of analysing practice ...................................................................... 17 Structure of the thesis ............................................................................................... 19 Notes on the format of the analyses and their audiences ......................................... 23 Chapter 2: Organising cancer illnesses in the Danish health care system ........... 25 Introduction .............................................................................................................. 25 From melancholy to present forms of organising cancer illnesses and their treatment ................................................................................................................... 26 Introducing the terms ‘packaged care’ and ’accelerated cancer pathways’ ............. 29 Introducing the ‘soft’ dimensions of accelerated cancer pathways ......................... 34 Chapter 3: Theories about emotions in organisations ........................................... 38 Introduction .............................................................................................................. 38 Emotions and epochal battles in social sciences ...................................................... 39 Weber and emotions in bureaucracy ........................................................................ 42 Parsons and the conduct code of ‘affective neutrality’ ............................................ 45 Elias and historical processes of ‘social restraint towards self-restraint’ ................ 48 2 Goffman and the staging of a cynical performer ..................................................... 52 Hochschild and the search for an unmanaged heart ................................................. 57 Strauss and invisible, informal emotion work ......................................................... 63 Literature on emotions in health care ....................................................................... 65 Bridging the divide: Emotion and rationality in health care ................................. 67 Working within the divide: The colonising of ‘sincere’ emotions in health care 73 A combined theoretical framework to the study of emotions in organisations ....... 77 Chapter 4: To study emotions - Focusing, gathering and writing up material on emotions ...................................................................................................................... 82 Introduction .............................................................................................................. 82 The situatedness of the PhD and my access to a cancer clinic and its occupants .... 83 Defining my object of inquiry: From foci to a developing focus on emotions ....... 87 Gathering material on emotions ............................................................................... 93 Problems of involvement and detachment in the study of emotions ....................... 98 Writing on emotions ............................................................................................... 101 Chapter 5: The ‘compassionate’ doctor - Emotional injunctions to medical professionals in accelerated medicine .................................................................... 105 Introduction ............................................................................................................ 105 The approach to the management of emotions in work and organisational settings ................................................................................................................................ 109 Method .................................................................................................................... 113 Accelerated cancer pathways and the conceptualisation of the ‘stand up patient’ 114 3 Emotional injunctions to doctors in accelerated cancer pathways......................... 116 Individual professionals and ‘one shot available’ for managing patients’ emotions ................................................................................................................................ 121 Discussion .............................................................................................................. 125 Concluding thoughts .............................................................................................. 128 Chapter 6: Training of controlled empathy in accelerated cancer care ............ 131 Introduction ............................................................................................................ 131 Theoretical framework ........................................................................................... 135 Material and methods ............................................................................................. 137 A presentation of a training workshop ................................................................... 138 The situatedness of the workshop ....................................................................... 138 Invitation to join the workshop ........................................................................... 139 The training sessions ........................................................................................... 141 Staging the role-playing scenarios ...................................................................... 144 First stage performance: A patient who is emotionally cold and distant ............ 145 Second stage performance: The relative who is too emotionally involved ........ 148 Discussion .............................................................................................................. 150 Conclusion .............................................................................................................. 153 Chapter 7: Doctors’ emotional experience and challenges in accelerated medical work .......................................................................................................................... 156 Introduction ............................................................................................................ 157 4 Theoretical framework ........................................................................................... 160 Method .................................................................................................................... 163 Procedure ............................................................................................................. 163 Emotions in accelerated cancer care ...................................................................... 165 The professional role of a doctor ........................................................................ 165 Emotional experience and challenges ................................................................. 168 Techniques to manage the emotions ................................................................... 171 Emotions in standardised work procedures ........................................................ 174 Conclusion .............................................................................................................. 177 Chapter 8: The negotiation of the sick role - general practitioners’ classification of patients with medically unexplained symptoms .................... 181 Introduction ............................................................................................................ 181 Classification of illness .......................................................................................... 184 Theoretical framework ........................................................................................... 186 Data and methods ................................................................................................... 188 The sick role and social problems .......................................................................... 191 The sick role and problematic personality ............................................................. 195 Discussion .............................................................................................................. 197 Chapter 9: Conclusion ............................................................................................ 202 Theoretical intent and contribution ........................................................................ 204 Practical concerns ................................................................................................... 211 5 Future research ....................................................................................................... 213 English summary ....................................................................................................... 216 Resume af afhandling ................................................................................................ 222 Appendix A: Interviews in the cancer clinic and its surroundings ........................... 227 Appendix B: Observations in the cancer clinic and its surroundings ....................... 228 References ................................................................................................................. 229 12 ‘Providing information about possible adjuvant treatment’. The written tasks of the nurses are different from those of the doctors. They are described as ‘showing care and psychological support and being sensitive to reactions/frustration and taking action upon those feelings’ and, ‘talk with the patient about expressing thoughts and feelings in regard to surgery result/new surgery’. The presenting nurse patiently works her way down the two columns of specialised work tasks; reading out loud every written point on the slide and going through the material as going through a grocery list on a refrigerator door. A senior doctor starts giggling and the audience of the meeting turns around to face her. She explains herself: ‘I find it rather funny that this model program shows an almost urgent need to record that you nurses constantly conduct care work and psychosocial support to the patients. It’s almost like it isn’t one of the most profound tasks of doctoring to practice care and empathy in our everyday work. Perhaps, compared to you, we just don’t need to record it every time we truly engage in care work. Don’t you think that we [the doctors in the clinic] are empathic towards our patients? Don’t we display empathic responses? Or is the problem that we, according to your standards, are not empathic enough in the multiple encounters we have with our patients?’ The senior doctor continues shaking her head while commenting on the PowerPoint slides, asking questions to the progressing presentation, while the nurse in front of the white board starts looking pretty annoyed and slightly resigned, as if she knew it would come to this. She has lost the attention of the audience and during the rest of the presentation, the doctors discuss in smaller groups how absurd it is for the nurses to proclaim the right to do ‘sincere’ care work and record proceeding acts of empa- 13 thy and emotions, while taking care of patients. The model program, which, apart from scheduling and outlining tasks of nursing in a typical breast cancer patient track, also addresses tasks of empathy work, is nevertheless fully demonstrated and later backed up by heads of department as a piece of ‘solid documentation’ of the accomplished work carried out in the clinic. Why emotions and why now? This thesis is about ‘empathy’, cancer illnesses, doctors and a increasingly persistent request for emotions in accelerated medical relationships. It is concerned with exploring the relationship between emotions in a cancer clinic and forms of professional conduct therein. A recurring line of argument in the thesis is that ‘questions of emotion’ offer ways through which we may come to understand how activities of individual human beings are interlinked with forms of social life. This means ways to consider the active, shaping influences between individuals and social, medico-scientific and political worlds. Furthermore, the attention to these questions – or more specifically to behaviour, feelings, gestures, impressions, sentiments, manners, affects, expressions, and etcetera, and the codes, norms and values directing and regulating them – can help us understand how individuals emotionally express and experience themselves in specific historical moments, organisational contexts and social situations. The case in question, the cancer clinic and its inhabitants, seems like a particularly apt case for studying empirically these themes, because of the recent introduction of so-called accelerated cancer pathways in the Danish health care system. And why is that? The treatment of cancer illnesses is increasingly organised in terms of accelerated cancer pathways or ‘cancer packages’ (The National Board of Health, Denmark, 2008a). These so-called packages are part of a larger strategy to improve the overall health outcome by offering patients fast, effective and efficient care. The packages are characterised by streamlined patient flows; extremely standardised ac- 14 tivities; better techniques of micro-surgery and medication; early hospital discharge of patients; a growth of registration and documentation practices; a renewed focus on patient information and communication and implementation of waiting time policies. In addition, I will argue, they entail an increased regulation and training of the ‘soft’ side of the professional-patient relationship, e.g. ‘empathic communication’ and ‘interpersonal respect’. In an atmosphere of rationalised and standardised medical work processes and performance measurement technologies, I want to suggest that the development of cancer treatment regimes has created some challenges in relation to the clinical encounter and questions of emotion therein. Moreover, I want to argue that the reason for this lies at the heart of what is known as contemporary modes of governance, where key characteristics are distributed accountability, audibility and efficiency (Power, 1997; Miller and Rose, 2008). This, I want to argue through the thesis, is inextricably linked with concerns of framing the direction and content of the clinical encounter, and hence, concerns about regulating the emotional engagement between doctors and patients. Medicine is generally a field in which emotions are contested, negotiated, managed and produced, and the importance of emotions in health care has long been recognised by medical practitioners. However, its role in accelerated medical relationships is less straightforward. A natural consequence of today’s attempts of rationalising medical practices may be conceived as pushing doctors in a direction of less emotional engagement and more objective detachment from the clinical encounter. The rearrangements of the pathways leave little room for the provision of emotion management, and often leave us with the impression of a ‘cold’ doctor. What patients yearn for is empathic, engaged and responsive doctors who understand and attend to their personal needs (see, for example, The Danish Survey of Patient Experiences, 2010). Patients, relatives and lay people in general complain about a lack of ‘empa- 15 thy’, ‘responsiveness’ and ‘compassion’ in clinical encounters. They request engagement, communication and extra-personal attention and empathy from the practitioners. This call for more ‘warmth’ in medicine has not been overheard. Both medical practitioners and scholars within the disciplines of medical humanities or narrative medicine agree that there is a need for recognising and offering ‘psychosocial support’ and ‘empathy’. Notions of the ‘empathic healer’ (Bennett, 2001); the ‘empathic practitioner’ (More and Milligan, 1994) or the ‘compassionate practitioner’ (Gilbert, 2009) have emerged. Consequently, medical professionals are called upon – not only to be efficient and effective and to cure diseases and save lives, but also to perform ‘authentic’ or ‘deeply felt’ emotional engagement in interactions with patients. Perhaps symptomatic, political debates regarding the rearrangements of cancer illnesses and their treatment mainly focus on the managerial aspects of streamlining the pathways such as the coordination of diagnostics and treatment processes across occupations, units, hospitals and sectors. One example is ‘Governance of cancer pathways’ (Dansk Sundhedsinstitut, 2008), which focus on the importance of ‘well-defined standards for appropriate waiting times and quality; systematic monitoring and consequences of dismissing targets’ (2008: 5). However, as is evident from the complaints from patients and practitioners, there is a concurrent need for better managing also the implications of the rationalisation and standardisation of clinical pathways on the way patients and professionals feel and cope during the treatment processes. I conceptualise this as a call for management of emotions in doctor-patient relationships. So far, this theme has predominantly been addressed in relation to the psychological and social comfort work done by nurses. Nursing practice is a textbook example of how professionals manage emotions in health care organisations, and, as a particular field of study, this has been covered at lengths. Far less so is this the case when we focus on doctors. Therefore, the focus of this thesis is to zoom 16 in on emotions in medical care, especially in relation to the conduct of doctors in a contemporary organisational framing of less time and calls for more empathy. What is striking in the previously described morning meeting in the cancer clinic is the straightforward articulation of emotions in a context of a presentation of the recently rearranged pathways for cancer patients. Concurrently with the rationalisation of the pathways, which is manifest in the presented model program, the emotional aspects of the pathways emerge in the contexts as significant objects of interest. In the pictured example, we see how the presenting nurse tries to purify the conception of empathy, understood as empathic responses and empathic behaviour, from other work tasks in clinical practice. She furthermore monopolises it as a property of the nursing profession. However, her presentation is aggressively obstructed by a doctor who claims that empathy is already comprised in medical care. The doctor calls empathy a ‘profound task of doctoring’ and she claims that empathy cannot be separated from other skilful competences of a doctor, such as clinical reasoning or decision-making. The situation turns our attention to the possible connections between forms of empathy, rationalisation efforts – such as attempts of speed and standardisation – divisions of labour and professional conduct. In trying to address this relationship, I use a simple analytical principle as my guide: to avoid the injunction of a priori distinctions between ‘emotion’ and ‘reason’; ‘emotionality’ and ‘rationality’; ‘passion’ and ‘logic’, and so forth. In the history of Western thought there is a long tradition of separating emotion from reason, seeing them as opposites and as different kinds. Emotions are often taken into account as something irrational that is perverting or disrupting reason. A classic example is Descartes’ placing of emotions in the corrupt body and rationality or reason at the centre of human identity. It is the emotions, passions and sentiments that are ‘the harm of this life’, because they are not an integral part of the mind and cannot in any way be absorbed into strict science (Rorty, 1986: 533). However, as argued by Jaggar (1989), the relationship between emotion and rationality has never been categorical 17 and the split between them not absolute. The metaphor of a charioteer steering a wild horse, originated by Plato in Phaedrus, is an enduring characterisation of this relationship between emotions and reason. Reason is the charioteer; emotions are the horses he tries to steer. In this model, emotions must be managed and directed by reason. This is not the same as stating that emotions need to be suppressed. Only an idiot would not express anxiety in precarious, frightening situations. However, even lifethreatening situations are thought possible to stabilise through the channelling of appropriate emotions. Here, according to the interpretations of Plato, emotions have a function in the establishment of social order, which is also captured in the metaphor of a charioteer and his horses: imagine the function of the former without the powers of the later. To avoid taking over the ‘work of purification’ (Latour, 1993: 31) in this study of emotions and, for instance, cementing problematic distinctions between emotion and reason, I will instead try to explore how such distinctions arise and become stable in various organisational contexts. Adopting such an approach also implies that it becomes impossible to separate emotion and reason from the specific historical moments and social situations in which they emerge. Hence, attention is paid to techniques and practices of individuals and how individuals use forms of emotionality, in what situations and for what purposes, instead of focusing on some restricted dichotomies that circumscribe how emotion or rationality might be described and understood on an abstract, metaphysical level. This theoretical attention leads to an interest in exploring the relationship between emotions in a cancer clinic and forms of professional conduct therein. More specifically, I centre on the following research question: how is emotion framed, trained and performed by doctors in accelerated medical relationships? The importance of analysing practice The thesis addresses the everyday work of doctors in a cancer clinic. What I will present is an account of how doctors perform medical care in a tense climate of rationali- 18 sation and standardisation processes at a public hospital in Denmark. I argue that health care organisations are governed as profound territories of different and diverse concerns, and, in addition to this, I intend to show how changes of organisational contexts have massive implications for both professionals and patients – with an empirical focus on the former. My concern is political in the way that it addresses the concerns of practitioners in a concrete work setting. By political, I refer to an argument put forth by Clegg. He writes: ‘there is an ethical dimension to [...] organisation studies [...] the organisation analyst has a responsibility towards the subjects of that science. When we investigate organisations we also address the impact of major structures of society on the lives of ordinary people’ (Clegg, 2002: xxvi). The thesis focuses on the changing conditions under which doctors are made to work. As the analyses, developed in later chapters of this thesis, will show, traditional ideals of medicine (such as objectivity and affective neutrality) will be called into question when attempts of transforming the health care sector anew necessarily include its professions and the conduct of its practitioners. As such, the thesis must be considered a work of critique, even though the criticism is not directed towards the medical profession per se. Instead, the thesis intends to lend support to clinical medicine. In her ethnography of atherosclerosis, Mol (2002) highlights in a similar way that her work ‘lends support to clinical medicine’ (2002: 183). She exemplifies this attitude with the statement that ‘surgeons only open up bodies if they think they can gain a curing result by doing it’ (ibid). The position of Mol is nonsentimental because, in her work, doctors’ conduct is investigated by looking at the practices – or in Mol’s own terms – the enactments constituting the medical activities in questions. Inspired by this attitude, I intend to go along with the key objective of doctors in the cancer clinic, which is to diagnose and prospectively cure people suffering from malign cancer illnesses, and engage directly with the individuals who undertake important and often lifesaving medical care. Hence, it may be possible to 19 support the ideals of clinical medicine and address the critique towards the changing techniques and technologies of contemporary health care practice. I have no intention to produce a comprehensive account of medicine in general; that is, of how doctors think about and carry out medicine. Rather, I concentrate on just one element of medical care, namely how emotion is framed, trained and performed in a cancer clinic. The academic interest in emotion and the management of emotions is by no means new. Neither is the interest in the issue set in health care. There is a large and ever-growing literature on emotions and health and emotions and organisations – also literature that use hospital settings as research sites. Nevertheless, today’s strong focus on effectiveness and efficiency in Western health care services and a pressure on public organisations, such as hospitals, to rationalise, evidence base and optimise their performances, reinstate the academic interest and posses new questions concerning emotion. And yet, among the things I hope to bring to this rising interest in emotion – in healthcare as well as in organisation studies – is a caution against sustaining the dichotomies being produced in, or as a response to, such rationalisation attempts. Instead, I will argue, there is need for empirical studies of the way emotions and rationalisation are co-developing in different forms. Structure of the thesis The questions of emotion are guiding the thesis and framing the individual chapters. The thesis is divided into two parts – a frame (Chapter 1-4 + 9) and four articles (Chapter 5-8). The frame begins with a description of the organisation of cancer illnesses and their treatment in the Danish health care system. Accordingly, Chapter 2 introduces the concept of ‘accelerated medicine’ and it explains the development of the so-called ‘cancer treatment packages’. It further introduces the issue of emotions in accelerated cancer care and it pays attention to how questions of emotion arise from the empirical context. 20 Moving on from here, Chapter 3 deals with theories of emotions in organisations. In this chapter both classic sociological literature and more recent theories of emotions, social order and organisations are addressed. In addition to this, I review texts that focus especially on emotions in health care practice and discuss how some of these texts fall short in their approach to emotions because they tend to elevate emotions to the disregard of rationality and rationalistic activities. The chapter then moves towards a preliminary draft of my own theoretical approach, which is further developed in the remaining chapters of the thesis. Chapter 4 explains a number of methodological challenges which accompany my qualitative study of emotions in a cancer clinic and its surroundings. It describes the situatedness of my PhD project and my access to the clinic and its occupants, and it explains how my object of inquiry developed over time – from foci to a developing focus on emotions. It also contains a relatively clean description of the conducted fieldwork; of the qualitative methods and the amount of material used for this research, and it describes how each analysis in the thesis takes smaller parts of the empirical material as its point of departure. Finally, it discusses problems of ‘involvement’ and ‘detachment’ (Elias, 1987) in the study of emotions and it pays attention to a kind of ‘methodological vocation’ which is described as the vocation of researchers to approach emotions without sentimentality. In summary, Chapter 2-4 move steadily towards the analyses of the relationship between emotions in a cancer clinic and forms of professional conduct therein. The analyses are structured into the headlines ‘framing’, ‘training’ and ‘performance’ of emotions in order to analyse in detail the frames, techniques and practices which direct and regulate the conduct of doctors in everyday, accelerated medical relationships. I will now briefly address the aim of the four analyses. Afterwards, I will make a few comments on the relationship between them. 21 Chapter 5 explores how emotions are framed in medical relationships and it addresses how this framing equips doctors to act in certain ways in particular situations. Using the development of accelerated cancer pathways and a wide range of health care reform documents as an empirical case, the chapter explores how doctors are encouraged to become more emotionally available to patients. As the chapter demonstrates, this call for emotionality is accompanied by increasing demands on doctors to manage the emotions of others in recordable, measurable and standardised ways. To be a compassionate doctor involves an exhibition of a particular emotional behaviour in medical relationships, what Elias calls a ‘controlled de-controlling of emotions’ (Elias and Dunning, 1986: 44), namely that of a ‘sincere’ or ‘authentic’ behaviour which doctors are required to enact and to be committed towards. What this points to, I argue, is a set-up where health care reform documents encourage room for personal and unique concerns in medical relationships while expecting maximum acceleration and standardisation of these relationships. Chapter 6 continues the investigation of questions of emotions through a discussion of how empathy and responsiveness, as specific techniques of emotion management, arise as the outcome of well-structured forms of training and practice in the cancer clinic. The chapter focuses on a training workshop in ‘empathic communication’ through which doctors from the clinic learn to recognise and control the emotional frame of doctor-patient interactions. It addresses how the training and practice of communicating empathically in these interactions rely on standardised scripts, which in turn direct and cultivate the conduct of the doctors involved. In line with the argument in the previous chapter, it concludes that humanistic values increasingly become the target for techniques of micro-management such as qualitative measurement and performance audit. In other words, the chapter argues that attempts to improve ‘soft’ dimensions of medical services entail a further standardisation of these aspects. 28 diotherapy, systematic therapy, and follow-up for early-stage breast cancer. The clinical guidelines are used by the doctors in their daily medical work and they guide clinical judgment and medical decision making processes in the treatment of patients. These guidelines became fundamental building blocks for the cancer treatment packages to which I now turn. In 2000 the clinical focus on cancer illnesses and their treatment was directly coupled to economics, and political and customer concerns. In 2000, The National Board of Health, Denmark (NBH), introduced the national: ‘Cancer plan: Status and suggestions for initiatives concerning the treatment of cancer’ (NBH, 2000). The cancer plan report was initiated by The Danish Ministry of Health as a consequence of a public debate concerning the overall quality of cancer services in Denmark compared with other Nordic countries. An epidemiologic task force found that Danish cancer patients had a lower change of surviving their cancer illnesses viewed in a five years perspective compared to patients in their neighbouring countries (2000: 37–46). The report concluded, among other things, that new ways of organising cancer treatment – including ‘the organisation of work and work methods’ – may raise the quality of cancer services and thus lead to a reduction in mortality (2000: 13-18). Furthermore, the report stated that accelerated diagnostic procedures and surgical interventions are significant means to improve these services and thus improve their outcome. The report also recommended the implementation of breast cancer screening programs. Between 2000 and 2005, the screening programs were implemented nation-wide. In addition, in 2001, the Danish Government introduced a ‘waiting time guarantee’ assuring every patient with suspicion of cancer a right to get diagnosed by a specialist within two weeks. And from the day of diagnosis to the day of treatment, the waiting times were limited to maximum two weeks. The waiting times were politically defined and covered a diverse range of cancer illnesses (also cardiovascular illnesses were covered by the guarantee). 29 However, the implementation of various means to improve the outcome of the services provided was not without problems. The introduction of politically defined waiting times led to the problem of keeping the waiting time promises. And the screening programs led to an increased amount of women diagnosed with early stages of breast cancer which raised the total healthcare expenditure on cancer treatment services. Also demographic changes, such as an ageing population in need of cancer treatment brought about by increasing life expectancy, had a financial impact on the health care system. Generally however, these organisational challenges were not met with a huge supply of financial resources to the cancer field. Instead, they were met with concrete attempts of organisational change, as I will turn to next. Introducing the terms ‘packaged care’ and ’accelerated cancer pathways’ In 2005, in continuation of the first cancer plan, the NBH published a follow-up plan with the name ‘Cancer Plan II’. It specified a new organisation of cancer care in the Danish health system and described how concrete organisational actions were connected to centralised monitoring systems in order to systematise cancer care services across hospitals departments, sectors and individual practitioners. An important aim of this second report was to ‘provide a well-organised packaged trajectory to cancer patients on the highest possible international quality level without unnecessary waiting time’ (NBH, 2005a: 10). The report understands the term ‘well-organised’ in relation to activities which are planned and performed by health professionals in a focused manner and with a high degree of application. This entails that necessary resources must be assembled. The report wrote that ‘taking departure from a range of well-organised work tasks and patterns of co-operation makes it possible to establish a patient trajectory where the individual patient – without unnecessary delays and efficient allocation of resources – is offered an uninterrupted series of treatment from general practise to involved hospital departments’ (2005a: 7). This series of diagnos- 30 tic and treatment procedures, the report recommends, must be organised in ‘packages’: standardised, accelerated pathways. In this way, the term ‘cancer packages’ (in Danish: ‘Kræftpakker’) is introduced as standardised trajectories to patients who are suffering from cancer illnesses and which ensure that the majority of the patients diagnosed (or with suspicion of a diagnosis) within specific cancer categories (e.g. lung cancer; breast cancer or gastric cancer) can be offered the same ‘package’ of therapeutic processes, and can expect a minimum of delays at hospitals and across primary and secondary health care sector. The organisational design of ‘cancer packages’ was intimately associated with another widespread concept of ‘accelerated medicine’, which also took form in these years. Both concepts emerge from an ambition concerning the establishment of economic, effective and efficient patient trajectories in the health delivery system. The overall focus of the concept of accelerated medicine is an optimisation of the organisation of professional work processes through increased interdisciplinary teamwork, implementation of technological interventions (for example micro-surgery) and formalisation of communication and patient information. Through these means, the concept aims to reduce the patients’ length of hospital stay and hence release resources and capacity to be used elsewhere in the public health care sector (The Secretary of Ministers, 2007). I use the term ‘accelerated medicine’ as an assemblage term to capture core connotations of the concept, such as ‘packaged diagnostic and treatment’; ‘optimised care’; ‘accelerated trajectory’, ‘fast track surgery’ and ‘early recovery’. I also intend to use the terms ’accelerated clinical pathways’, ‘optimised clinical pathways’ or ‘treatment packages’ more or less synonymously through the text. Under guidance of NBH, task forces were appointed to develop the concept of ‘cancer packages’ within specific illnesses. In 2008, a ‘Breast cancer package’ report saw the light of the day (NBH, 2008a). The report described a standard trajectory for breast cancer patients – from they visit the general practitioner in primary care, get diagnosed at the hospital, undergo surgery and adjuvant treatment to control 31 programs and palliation. Processes of nursing care, communication and patient information are also specified in the material. In the trajectory description, psychosocial support procedures are explained as essential for the outcome of the trajectories. These kinds of procedures are defined in a separate document as ‘the health professionals’ specific efforts in relation to psychological, emotional and existential dimensions of the entire trajectory’ (NBH, 2008c: 5). The efforts are integrated with the clinical actions of the trajectory as concrete work activities which must be performed by the doctors in relation to every patient undergoing diagnostic and treatment in breast cancer clinics. The trajectory description, which determines activities of accelerated clinical cancer pathways, is evidence based, national and nation-wide guidelines and recommendations, or so the report says (NBH, 2008a). In cases where no evidence is available, the trajectory descriptions are based on ‘best available practice’. In the particular case of breast cancer illness, it is the previously mentioned DBCG guidelines that support most of the actions in the trajectories. This model explains the treatment phase of the trajectory and its different work activities (clinical, logistic, information, specialty, monitoring): Clinical action Logistic action Patient information Medical specialty Monitoring Pre-examination in the outpatients clinic Booking: surgery Delivery of diagnosis Plan for further action Informed content Summoning: surgery Surgeon Monitoring: informed content Hospitalisation Surgeon Monitoring: treatment start 32 Surgery Surgeon Histology result Pathologist Decision: Chemotherapy, hormonal treatment and radiotherapy Booking: consultation in the out-patients clinic Summoning: Consultation in the outpatient clinic Multidisciplinary team Consultation in the out-patient clinic Booking: Oncological preexamination GP: Epicr isis (case summary) Surgeon Monitoring: surgical treatment finished Model 1: A trajectory model, NBH, 2009a: 22 The rubric ‘patient information’ describes in bio-medical terms some concerns about the diagnostic moment and judgments about treatment plan. The rubric ‘clinical actions’ describes the various forms of clinical activities in objective pathological categories. In the breast cancer trajectory model two formalisation aspects are present: detailed and precise specification of tasks and responsibilities of medical specialties and individual practitioners within an ordered process line of medical work. Every performance of the trajectory is specified and the performances are routinely monitored. Furthermore, it is co-ordinated and integrated via a complex IT-based system that makes it possible to measure the output of the cancer programs on a central- 33 ised level. This is to measure the development in productivity rates and to measure ‘the time span from hospital referral to treatment’ (NBH, 2011). The treatment phase of the program and a specification of time standards coupled to the different work tasks can be presented like this: 0 Day. Managing patient referral; booking of patient-doctor consultations and examinations 3 Day. Preliminary examination (including clinical examination); patient information; patient interview (nurse, anaesthetics, physiotherapist); eventual supplementing picture diagnostic tests 6. Day. Patient time to use for reflexion 6. Day. Valuation of co-morbidity 7. Day. Surgery (hospitalisation and (optimal) discharge of patient) 8. Day. Eventual discharge of patient Model 2: A treatment phase model, NBH, 2009a: 13-15. This is a standard example of a trajectory in a cancer clinic, running from the moment a patient is examined for breast cancer, receives a cancer diagnosis, undergoes surgery and is discharged from the hospital. This leaves the doctors in the clinic with eight days to make an exact diagnosis; to make preparations; provide emotional or psychosocial support; remove the cancer tumour, stitch up the patient and discharge the person from the clinic. The trajectory description codifies general processes of a breast cancer trajectory, as opposed to clinical guidelines which function more as specific tools or practices in a medical line of work. So-called ‘time of sequences’ of the trajectories are written in the left column of model 2. These time estimates are 34 also measuring points from where the clinic is hold responsible for meeting or failing to meet the standards. The cancer clinic in my study was well-prepared for the introduction of these ‘cancer packages’. From programs of accelerated medicine, manifest in the clinic by concepts of fast track surgery and early recovery (Kehlet and Dahl, 2003), the clinic had already developed local initiatives for accelerated procedures which included standardised drug modules (to prevent post-operative pain and nausea), technical interventions (early removal of drainage tube) and changes in patient passages between department units – for example, most patients are removed directly to the clinic ward instead of trespassing through the hospital’s recovery ward (Gärtner, 2010; Mertz et al., 2009). Procedures of extended information to patients had also been implemented. The nurses for instance now call the patients after their discharge to make sure that newly operated patients are generally well-functioning according to standards of physical and emotionally recovery. It is not hard to detect how the cancer clinic and the conducts of its doctors and nurses follow strictly formalised rules in the accelerated cancer pathways. In addition to this well-ordered line of activities, another important dimension in the cancer clinic has been standardised and accelerated: something which in the trajectory descriptions goes under the names ‘psychosocial support procedures’, ‘communication’ and ‘patient information’. I will now turn to this issue. Introducing the ‘soft’ dimensions of accelerated cancer pathways Simultaneously with the introduction of the two national cancer plans, a report issued by the Danish Ministry of Interior and Health was published under the headline ‘The patient’s encounter with the health care system’ (The Ministry of Health and Interior, 2003). It says in the report that it focuses on ‘so-called human relations, which are often referred to as “the softer values” of health care services’ (2003: 3). Furthermore, it explains that it aims to improve these soft dimensions of medical care 35 through initiatives to rearrange professionals’ work activities. The report suggests that hospital departments promote an organisation culture where professionals possess competences to recognise the ‘values, feelings, assumptions and thoughts of the patients’ (2003: 8). To be able to promote and frame such a culture in the clinic, the professionals need to undergo ‘supervision, training and education in a variety of communication techniques’ (2003: ibid). The report recommends that professionals ‘display sincerity, responsiveness, trust, engagement’ in the practical execution of diagnostic and treatment procedures (2003: 9). It states that the individual professional must provide the way for patients to ‘display their emotions in a spontaneous way’ in their encounters with the health system (ibid). Professional involvement in the provision of cancer services implies ‘combinations of emotional and practical conduct’ (2003: 32), the report explains. This kind of professional conduct is likewise promoted in a report from The Danish Cancer Society (KB), simply covering ‘The world of the cancer patient’ (KB, 2006). Based on an extended patient satisfaction survey, the report articulates cancer patients’ need for an improvement of health services: ‘Cancer patients far from receive the optimal treatment they need. Especially their needs as individuals and human beings are often let down or left unrecognised’ by the health care system (2006: 2). This call for improvement of cancer services thus includes an improvement of the health care workers’ psychosocial or therapeutic competences. The workers need to understand the individual patient as ‘a unique person instead of merely a number in the line of patients in the trajectory’ (2006: 17). As described in the report, one way to meet the patients’ needs is through the improvement of communication or communication skills. The report especially appraises ‘good communication which includes empathy, respect, responsiveness, and time and engaged presence of professionals’ (2006: 16) as a significant element in the organisation of accelerated cancer pathways. Here, communication is understood both as a practical skill – for example in relation to the delivery of information – and as a therapeutic skill which may help 36 to improve ‘cancer patients’ psychological, emotional and spiritual health’ (2006: 15). Through the medium of communication, doctors can become emotionally available to cancer patients. The ‘National Cancer Plan II’ (NBH, 2005a) refers explicitly to the recommendations of these reports, and the above mentioned ‘soft’ dimensions of medical care are written into the cancer plan’s appendix. In this way, the recommendations are also represented in the breast cancer trajectory description under the headlines ‘patient information’, ‘communication’ and ‘psychosocial support to patients and relatives’ (NBH, 2009a). In the description, this inclusion of these dimensions are furthermore emphasised as proper work. The definition suggests that it takes continuous efforts and time to include these dimensions as ‘an integrated element of the entire achievement which is – and should be – offered to patients in every phase of the illness trajectory’ (2009a: 28). In the local cancer clinic I have researched, it is widely acknowledged among the doctors and nurses that for instance communication and information play a significant role in the accelerated treatment pathways. These activities are therefore not only evident in the generic trajectory descriptions. They are also written into the clinic’s local procedure plans (see for example The Cancer Clinic, 2009). To be able to meet the aims of early recovery and discharge in the pathways, the patients are required to understand the various steps of the trajectory in detail. This includes that they are prepared to make an informal approval of the services offered, to undergo treatment and leave the hospital shortly afterwards. The clinic’s procedure plans describe in what way the patients who undergo accelerated procedures of diagnostic and treatment will be prepared by doctors and nurses in the clinic for the coming interventions. This preparation work is explained on a practical level (‘inform the patient about diagnosis and treatment’) and on an emotional level (‘communicate with the patient about the need to express feelings and thought in relation to the cancer illness’). As also emphasised in the trajectory descriptions, the delivery of information 37 and psycho-social support to patients is monitored alongside, for instance, a recording of clinical activities. The clinic’s local monitoring process involves that these elements are written into a patient record system in a standardised language in order to be externally extracted – for example when the clinic receives audit visits from the hospital’s department of quality or international accreditation agencies. In 2012 the cancer clinic and the surrounding hospital will be accredited by the Danish Quality Model (IKAS, 2009). The cancer clinic has been accredited four times since 2000. In relation to previous audit rounds, the delivery of standardised forms of psycho-social support and communication will, according to centrally placed audit officers at the hospital, be a new, important topic of interest for the accreditation agency. Central to this procedure is the quantitative measurement of doctors’ manners and behaviour within medical relationships. The rest of this thesis will mainly be devoted to examining these so-called ‘soft’ dimensions of medical care. My argument will be that the development of accelerated cancer pathways involves some means of adjusting the conduct of doctors. These means may insert new emotional injunctions to doctors, which involve that certain emotions are explicitly framed, trained, performed and monitored in the clinic for the purpose of improving the overall service outcome of the cancer trajectories. 44 ber’s theorising on questions of emotion gives way to thinking about particular work settings and the forms of conduct which emerge from these settings. Du Gay challenges the ‘dehumanisation thesis’ by stressing that the emphasis upon depersonalisation in Weber’s work, for example when Weber (1978) writes ‘that bureaucracy develops the more perfectly, the more completely it succeeds in eliminating from official business personal, irrational, and emotional elements’ (see full quote written above), is a commitment to the purpose of the office, independent of personal idiosyncrasies. For Du Gay (2000a), the stress on impersonality as a crucial feature of bureaucratic rationality in Weber’s descriptive analyses, is not tantamount to a denial of humanity or emotional relations as long as ‘these do not undermine the ethos governing the conduct of that office, through for example, opening the doors to corruption or encouraging inappropriate forms of patronage’ (2000a: 75). If we follow this line of thought, we see how Weber does not dismiss emotions as such, as long as they do not set aside formal procedures of the office. In this regard, a good medical professional for example, is ‘impersonal’ in a manner which is objective, so she or he is able to attend to the matter at hand. Hence, the conception of impersonality also refers to professional work activities and the professional (bureaucratic) capacity to treat for instance clients as cases, without paying attention to their status or personal attributes, such as type of personality or (deviant) character. This is clearly the case in the cancer clinic, where doctors must decide upon cases unaffected or unbiased by personal relations. The bureaucratic regulation of emotions has two main purposes. First, it shields the employees from getting (too) emotionally involved in particular cases. Second, it protects the recipient of bureaucratic services, the person who attend the office for help, from being judged according to the office holder’s personal motives. To some, the preoccupation with emotions in Weber’s work – as a companion to reason – might be a surprise in the light of readings of more traditional understandings of Weber and his genealogy of the Berufsmench. However, his concep- 45 tion of rationality and rational action might not be a definitive. Most obviously, Weber’s analyses of ‘charismatic authority’ (1978: 241-245) demonstrate how processes of rationalisation do not lead to a disappearance of emotions or an emotional deficit. Instead, emotions are redistributed in a variety of different forms of conduct through social life. Reason and emotion, in short, are never entirely separable. According to Hennis (2000), Weber himself was horrified by ‘the emergence of which was the central theme of his studies: the arrival of the “specialists without spirit” and – perhaps even more topically – “sensualists without heart”’ (2000: 80). Certainly, Weber does allow for emotions in the bureaucratic office as long as they are a part of rational work processes and not, for example, an exercise of personal patronage, based on holistic beliefs or magic talents. We also see how the management of emotions in public administrations has profound value for the social order and for the purpose of the organisation to stay intact. Weber (1978) shows in his analyses of the bureaucratic organisation, how possible conflicts emerge if a substantive justice is oriented toward some concrete instance and person, because it will unavoidable ‘collide with the formalism and the rule bound and the cool “matter-offactness” of bureaucratic administration’ (1978: 980). Hence, we see that Weber in relation to the relative positions of reason and emotions points to the fact that there are serious amounts of (emotion) work involved in being impersonal and ascribing impersonality to social interaction and, therefore, we also see how this vocation of detachment becomes a central issue of concern in both his writings and in relation to the research manners he applies to the study of social realities. Parsons and the conduct code of ‘affective neutrality’ As inheritor of Weber, Parsons’ theorising also embraces emotions. The tendency to see emotions and rationality as opposite ends of a continuum is perhaps more persistent in the work of Parsons than it was the case in Weber’s work. This is mainly due 46 to Parsons’ emphasis on the process of modernity as a long-termed history of rationalisation of social relations – without exceptions. Parsons is preoccupied with exploring the conditions of possibility of human conduct in modern society. His understanding of modernity is inspired by Tönnies and his distinction of Gemeinschaft (i.e., community) and Gesellschaft (i.e., society) as a way to understand the transition from pre-modernity to modernity as a move from nature to society. Parsons argues that this transition implicated a transition from emotions to reason. Drawing on an analysis of Tönnies’ social typology, Parsons believes that ‘community’ is characterised by affectivity while ‘society’ is characterised by affective neutrality. The pattern variable points to the rules and values, which determine the activities of social actors in specific situations. In this regard, his concept of ‘affective neutrality’ also refers for instance to the specificity of emotion (or affect) management that is expected or appropriate in given organisational forms of interaction. For example, contact with other individuals in a bureaucracy is maybe most effective when devoid of emotions and characterised by ‘affective neutrality’. According to Parsons, ‘affective neutrality’ is a significant feature of professionalism and professional work practices. In one of his descriptive analysis, he deals explicitly with modern medical practice and its practitioners (see Parsons, 1951: 428-79). The functional specificity or the affective neutrality of the medical profession enables medical individuals to perform their clinical tasks ‘without regard for persons’. Parsons writes: ‘[Affective neutrality] enables the physician to penetrate sufficiently into the private affairs, or the particular nexus of his patients to perform his function. By defining his role in this way it is possible to overcome or minimize resistances which might well otherwise prove fatal to the possibility of doing the job at all’ (1951: 459). 47 In contrast, affectivity points to the expression of gratification of emotions or an individual pursuing of ‘any interests private to himself as distinguished from those shared with the other members of the collective’ (ibid). Following the latter perception, we may conclude that Parsons did not deny the presence of emotions. Rather, he delegated emotions to the private spheres – for example the sphere of the family or friendships. From this follows that if individuals anyway go public with their emotions, these emotional outbursts can be interpreted as disturbances to the social system. In sum, we see how Parsons’ conception of rational (i.e., instrumental) actions contrasting expressive action (i.e., emotional) may frame the relationship of emotion and rationality as being that of two opposites. However, if this was the case there would be no reason for including his theorising in the framework of this thesis. Instead, and very much like the interest of Weber, Parsons is preoccupied with how public office holders keep inappropriate feelings at bay in their professional work activities and how they manage to sustain an image of a certain kind of person. Ideally, the vocation of ‘affective neutrality’ provides the conditions of possibility for a doctor and his patients to meet on impersonal ground in the medical encounter. Parsons provides us with a conception of the clinic that is hemmed in from personal beliefs and value-laden judgments. This particular kind of space furthermore leaves issues such as economic status and personal attributes free of observation. He writes: ‘It is also important that doctors should not let their personal dislikes of particular patients be expressed in a poorer level of treatment or even positive “punishment”. And doctors would scarcely be human if they did not take a dislike to some of their patients’ (1951: 459) As indicated in the quote, Parsons also acknowledges that this functional setting is heavily challenged in doctor-patient relationships. The emotional expectations of the 48 patients and their families, which are typically sources of hope and frustration, are contested in medical practice – and especially in situations where no explanations or treatment suggestions can be provided. The doctor must then work hard to regulate the emotions of frustrated individuals. The powerful attachment that patients express through their emotions in a medical encounter may be hemmed in effectively by the doctor if she or he adheres to a professional attitude of, for instance, ‘affective neutrality’. From another point of view, physical intimate situations can also provoke emotional reactions (e.g., disgust, anxiety) in professionals. Here the professionals must work through various techniques to sustain themselves as professional persons. However, because of the particular function of the medical encounter, Parsons suggests that doctors – even though they are expected to have a purely rational orientation to undertaking their work – are constantly susceptible to personal responses in their intimate dealing with others human beings. This makes Parsons’ theorising on medical practice an apt work for this thesis, because he situates the delicate balance between emotional expectations of individuals and professional codes of conduct in the very heart of the doctor-patient relationship. Elias and historical processes of ‘social restraint towards self-restraint’ Weber’s interest in emotions at work in specific socio-historical settings is continued in the work of Elias. As registered recently, Elias’ influence on organisation studies is considered minimal and to date his approach has been largely neglected by the field (see for example Van Iterson, 2009). This is puzzling because the broad interests of his historically informed account of The Civilizing Process (Elias, 2000) – ranging from the account of modern state formation and changing standards of manner and morality, to forms of affect-control and self-constraint in social relations – provide enough intellectual goods to engage with empirical oriented organisation studies. Elias’ work sheds light on the forms of emotion management and bodily control, which emerged as part of the historical processes of rationalisation. He emphasises 49 how emotional standards are depending upon specific social arrangements, practices and techniques rather than being essential properties of a human being. This is interesting in relation to the questions raised by this thesis, since Elias’ work provides the means to understand the emotional conduct of doctors ‘outside’ the individual practitioner. He offers a position that turns our attention to tendencies in our society, which insert for instance demands for ‘compassion’ as a normative performance allotment in today’s professional bureaucracies. A core theme in Elias’ work is how changes in power structures are reflected in changes in the ‘psychological make-up of people’ (2000: 369). He links the notion of civilité or civilization to changes in codes of conduct, and shows how emotions are increasingly controlled in rationalised (i.e., civilised) societies. By doing this, he develops Weber’s (1978) historical view on bureaucracy, and the impact of rational practices on the organisation of the social sphere and interpersonal relationships. In his work, Elias links an emergent notion of civilité with changes in the production and display of emotions, or, as also Goffman later turns his attention to, changes in how individuals go public with emotions. One of Elias’ core points is that, as processes of civilisation have developed, so have demands for emotion management increasingly become internalised. He demonstrates how rules of behaviour and manners became both far more complex and far more controlled since the Renaissance, as particular evident in the emergence of the modern state and the ‘civilised’ individual. Elias writes: ‘As more and more people must attune their conduct to that of others, the web of actions must be organised more and more strictly and accurately, if each individual action is to fulfil its special function. Individuals are compelled to regulate their conduct in an increasingly differentiated, more even and more stable manner’ (2000: 367). 50 The development of an increasingly complex web of social interdependencies in turn makes it necessary for individuals to constrain and manage their emotions – both of the self and of others – and hence an increasing social restraint towards self-restraint was established (Van Krieken, 1990, 1996). Elias pin-points how the experience of certain emotions, such as embarrassment and shame, emerged as bodily expressions in the sixteenth century and encouraged individuals to increasingly repress their passions and to constrain themselves from the vantage point of others. Certain feelings then gained status as instruments of control of self and others. As regulatory rules they were accepted out of fear of losing out in the ongoing competition for status, power and economic resources and not least out of fear of feeling shame and embarrassment in front of others. The behaviour associated with civilité was hence directed to the regulation of the conduct of individuals. What was getting rationalised in these civilising processes was, according to Elias, not only the product of individuals, but primarily ‘the modes of conduct of certain groups of people’ (Elias, 2000: 412). This included proper table manners of people eating together, gestures, facial expressions, ordinary dressing and handling of natural bodily functions, such as spitting rules and how to blow one’s nose in public. Consequently, specific codes of habits of thinking and patterns of affectcontrol are characteristics of particular organisations. Elias demonstrates this argument empirically in French court societies, the nuclear family and areas of sport and leisure. At the court, for instance, highly detailed codes of emotion management and bodily comportment were developed that served to distinguish individuals in terms of their social status. For a knight to sustain his ‘knight status’, he was dependent on a rationally calculated adherence to certain codes of manners and rules of impression management (Kuzmics, 1987). Whereas previously in history, violence or emotional outbursts were met with affect, now, calculated situations were met with calculated appearances. 51 It is important to mention in this context that Elias’ theory of the civilising process of human conduct does not involve a repression of emotions or emotional life as such. In other words, Elias’ historical analyses of changes in personality structures and socio-political changes and of how these correlate involve an analysis of how the experience of some emotions (e.g., embarrassment) expands and how the experience of others emotions involves restraints (e.g., anger) in Western societies. What started out as merely external control in the name of monitoring gradually became internalised through the entire structure of society as the conscious ability of individuals to automatically regulate instincts and bodily and emotional expressions. By studying manner books from different eras, Elias furthermore analyses the development from external social restraints on manners and etiquette to a more informal approach to emotional conduct. However, as Elias emphasises, the shift from social restraint towards self-restraint implies often more well-choreographed and socially sanctioned rules of appropriate emotional display. In others words, codes of conduct have become less rigid and more differentiated but at the same time new demands to the ‘affect-economy ‘(Elias, 2000: 399) have emerged, which includes the emergence of highly sophisticated techniques of emotion management. This development has been given further notice in the work of the Elias follower, Wouters (1986, 1999), who describes the processes of ‘informalisation’ of emotions like this: ‘the relaxation of the social codes [...] in combination with increasing social demands on self-control; it implies a change in the patterns of social control and self-control and also a higher level of reflexivity on the part of individual people (1999: 416-417). The expression resembles the one used by Elias when he speaks about processes of ‘constrains to be unconstraint’ (Elias, 2000: 365-379). It indicates that processes of self-constraints have not only become more flexible, at the same time they have also 52 become stricter in recent developments of controlling emotions. These dimensions take on new forms in our current era of for example self-help culture. The wellknown situation where a self-help coach says: ‘just be your natural self in order to give other people the impression of the person you really are’ does not represent a loosening of emotional display, but rather represents a refinement of emotion codes through seemingly more ‘natural’ or ‘sincere’ practices. The coach’s call for ‘authentic’ behaviour or ‘just-be-you-behaviour’ may employ lots of calculated (emotion) work on behalf of the client. In sum, the work of Elias contributes to an understanding of emotions at work in specific historical and organisational contexts. It may provide us with a preliminary lens to look through when we analyse for instance processes of formalisation and informalisation of feelings in a hospital setting. His perspective draws attention to how the conducts of doctors and the exhibition of specific emotions in medical relationships are interwoven with social rearrangements of cancer illnesses and the introduction of new forms of governance in relation to medical practices and manners. Goffman and the staging of a cynical performer Elias provides an excellent platform from which to understand the historical mouldering of emotions through processes of rationalisation. His preoccupation with the sociological concern for the relationship between human agency and the social world is manifest in his preoccupation with social formations of individuals. His sense of selfhood and the formation and regulation of individuals’ conduct – including the display and expression of emotions – is also well developed in the work of Goffman. Goffman was, as his work clearly demonstrates, not exactly embarrassed in his dealings with emotions. The main thrust of his micro-sociological perspective on emotions may be his explicit focus on the daily, step-by-step efforts, taken on by each member of society to constitute a functioning social and interactional order. He 53 proposes that emotions are socially constituted and actively managed on a daily routine basis by reflexive individuals who freely participate in the creation of all kinds of emotional performances. Goffman’s perspective challenges the traditional way of thinking about human agency and social structures and we may see how emotions become a cornerstone in that manoeuvre. Goffman (1959) writes: ‘As human beings we are presumably creatures of variable impulse with moods and energies that change from one moment to the next. As characters put on for an audience, however, we must not be subject to ups and downs […] a certain bureaucratization of the spirit is expected so that we can be relied upon to give a perfectly homogenous performance at every appointed time […] we are helped in keeping this pose by clamps that are tightened directly on the body, some hidden, some showing (1959: 6365). Goffman stresses the role of the situation; the frame and the interactional order, which give direction to human conduct. As such, a situation always carries with it an official frame of what it is appropriate to feel. This frame is set within a wider structure of values, norms and cultural beliefs in which individuals work effortful trying to make emotions and frame consistent. Within this frame individuals can act in a strategically and calculated fashion appropriate to the situation. Like Elias, Goffman’s work implies that there are generic emotions of everyday life, such as embarrassment3 and shame. He understands embarrassment as the disparity between self-identity and social identity; i.e., a threshold between at the one hand the way individuals see themselves as competent members of society and at the other hand the way others see them (Goffman, 1956). As an experienced emotion and bodily expression, embarrassment is an important element of rational action. Embarrass3 The emotion embarrassment plays a central part in especially Goffman’s early studies (Goffman, 1956; 1959; 1961). He argued that embarrassment had ‘generic properties of interaction’ (1956: 264). 60 Hochschild challenges Goffman’s concept of surface acting by focusing on how individuals cope with emotion rules and emotion ideologies and how people are forced to engage in behaviour that arouses negative emotions (e.g. stress, alienation). Surface action refers to a strategy of pretending to feel for instance happy, when one does not feel happy at all, and hence the emotional display of happiness is merely a display act. Deep acting in contrast, takes us one step further away from the stage on which we ‘just’ play a character. Hochschild (1983) writes: ‘For Goffman acting is surface acting. The actor’s mental focus is on the slope of a shoulder, the angle of a glace, or the tightness of a smile; not on any inner feeling to which such gestures might correspond [...] we need a self with a developed inner life ‘(1983: 226). In building upon the work of Goffman, she is also adding to his work by focusing on the inner voices of actors. She writes: ‘The emotion-management perspective fosters attention to how people try to feel, not, as for Goffman, how people try to appear to feel’ (Hochschild, 1979: 560). By doing emotion work and comply with feeling rules, individuals try to alter their inner state and what they feel ‘deep down’. In contrast with ‘surface acting’, deep acting describes the actual work on individuals’ emotional state. For example, an individual can try to change her expressive behaviour such as trying to cry so as to accommodate her inner feelings. According to Hochschild, Goffman is black-boxing both emotional reflexive actors and social structure, who is the origin and causes of change in codes of conduct in his work. Her focus on ‘the self as emotion manager’ (1979: 555) is a way to install a battling inner self in micro-sociological theory. It is a self which is capable of feeling; who knows what to feel in specific situations and who is capable of managing own feelings. However, I find it analytically difficult to differentiate between what individuals consider belonging to them (for example feelings representing their 61 ‘inner’ selves), socially appropriated feelings, and feelings that are displayed for public exchange and consumption (e.g. Wouters, 1989). We see how the inner/outer distinction is well-developed in Hochschild work when she distinguishes between the commodification of (phony) emotions as capitalist properties and an authentic inner self with sincere feelings. The demands to corporately restricted emotion management result in ‘the issue of estrangement between what a person senses as her “true self” and her inner and outer acting becomes something to work out, to take a position on’ (Hochschild, 1983: 136). By drawing a relatively sharp distinction between private, emotional self and emotional demands of public jobs, Hochschild notices that ‘emotional labour poses a challenge to a person’s sense of self’ (ibid). I will argue that one of the main problems in drawing this distinction, is the idea that ‘authentic’ and ‘sincere’ private emotions are entities belonging to a self-contained self (reconsider Elias notion of ‘homo clausus’ – see Elias, 2000: 474) which must be protected against occupational exploitation. Hochschild never applied her emotional labour perspective to the medical profession or to nursing. Especially the latter would have been a natural expansion of her empirical inquiries into the study of emotions at work. One of the reasons for this omission might be found in the way she constructs the argument of professions and professional codes of conduct in the discussion of emotional labour and jobs (see Hochschild, 1983: 56-76). To limit emotional labour to specific jobs, she includes three criteria in her theoretical framework – first, face-to-face or voice-to-voice contact with the public; second, the requirement that employees should produce a particular emotional state in another person; and third, methods of supervision and training of the employees which allow the employer a degree of control over the emotional activities of employees (1983: 147). Compared to a flight attendant, Hochschild notes that doctors do have personal contact in public and they try to affect the emotional states of others, but they do not work with an emotional supervisor immediately at hand. She writes: ‘Rather, they [doctors] supervise their own emo- 62 tional labour by considering informal professional norms and client expectations’ (1983: 153). Surprisingly, when Hochschild talks about emotional labour as efforts or work undertaken in most service jobs, it in reality comes down to include only a few emotional labour jobs such as flight attendants, hairdressers and beauty stylists. She clearly makes the limitation to serve her focus on gender and social status: the exploitation and cost of emotional labour, typically goes on in lower income, female jobs. In building this argument, she seems to ignore emotional labour of ‘true’ professions, which is where this thesis makes an empirical contribution to her work. In sum, Hochschild’s contribution to the work of Goffman is to demonstrate how individuals do not simply manage their emotions to give off a good impression, but also how they are forced to violate their ‘inner’ feelings to comply with situational feeling rules that are inherent in certain job profiles. Her idea of deep acting includes that individuals take on laborious work to alter their ‘inner’ feelings so these feelings fit with outer expectations and social norms. The latter concern is linked to broader questions of individuality, power and social structure, and Hochschild connects emotional labour to a ‘dark side’ of (capitalist) ideology in Western societies. According to this approach, we can think of emotion as a covert resource which can be exploited and regulated like money, knowledge or physical labour. Those who perform emotional labour thus become subject to ‘the rules of mass production’ (1983: 198). From this follows that also our feelings now emerge as targets to colonising attempts and organisational control, and thus nothing is sacred to capitalist exploitation. Despite illustrating ideas about how organisations use feelings, we see how Hochschild’s approach to emotions is open for criticism on a number of accounts, because her theoretical grounding in the image of the self as a self-sufficient and quite independent being, exhibits some problematic conceptual traps. Especially her distinctions between inner/outer; public/private and ‘manufactured or fake feelings’/’authentic or sincere feelings’ have had widespread appeal in studies of emo- 63 tions in health care, where they reclaim sincere or authentic feelings from cooperate attempts of control, manipulation and various forms of management. I will return to this issue later in this chapter. Strauss and invisible, informal emotion work Next, I will turn to the writing of Strauss and his conception of sentimental work in his sociology of organisations. He may provide us with a missing link in relation to Hochschild’s theorising, which enable us to approach emotion work done by professionals (doctors) not only as work done for a wage but as work required for other activities to be done both effectively and with respect for the individuals involved. In Social Organisation of Medical Work, Strauss and his co-authors (1997) explicitly focus upon work in relation to the management of illness trajectories as specific organisation phenomena. The concept of trajectory is used to analyse social interaction and it refers to the ‘complex interactive acts required to manage that course, along with the consequences or outcomes of that management’ (Corbin, 1991: 33). The concept has profound value for Strauss et al.’s approach to the organisation of work because it allows him to break the overwhelming category of work into pieces and interactive acts and to explore their consequences for actions and, not least, for how actors respond to changing conditions. In the specific work on illness trajectories and chronic illness, Strauss et al. (1997) claim that the work of physicians, nurses and associated technicians has been ‘radically and irrevocably altered by today’s prevalence of chronic illnesses’ and the technologies developed to manage them’ (1997: Preface). On this background, the authors ask ‘how, in detail, has that work changed’ (ibid.). In order to focus explicitly on work and change in work, the authors brake down work into different categories of work, such as ‘Machine work’; ‘Articulation work’; ‘Comfort work’; ‘Safety work’ and ‘Sentimental work’. What counts as work in this optic, ‘does not depend a priori on any set of indicators, but rather on the definition of the 64 situation’ (Star and Strauss, 1999: 14). For instance, to die with grace in a busy medical ward can under some circumstances be defined as a kind of legitimate work and keeping a marriage going may be fun, but it also involves tremendous amounts of work. The fundamental pluralism of action paths in workplaces, such as trajectories or marriages, means struggle, conflict and negotiation on an everyday routine basis about what should be done in a given situation – and by whom. One category of work is Sentimental work. According to the authors: ‘Sentimental work presents an ‘important, varied, often subtle, and sometimes very complex type of work [...] and is present as ingredient in any kind of work where the object being worked on is alive, sentient, and reacting’ (Strauss et al., 1982: 254). A great deal of ‘real medical activities’ depends on sentimental work (1982: 274), especially the main line of diagnostic and therapeutic treatment in a trajectory will be affected if sentimental work is not done or is done ineffectively. For example, the doctors have to manage the emotions of patients while they are continually making mutilating bodily interventions such as taking biopsies and provoke other situations which involve great physical pain. Sentimental work is likewise evoked to ward off patient anxiety for instance in cases where a diagnosis of cancer is disclosed and the doctor tells the patient not to worry too much. Like physical labour, sentimental work requires experienced, skilled and reflexive work, which is subject to divisions of labour. Sentimental work is often considered invisible mainly due to its informal, ad hoc status in medical work. By invisible, I refer to work that is not actually seen (consider Goffman’s notion of back stage work) or work that is kept secret, regarded as shameful or dirty, taken for granted or performed ‘when those engaged do not think of it as involving work’ (Strauss et al., 1997: 148). Strauss et al. show how sen- 65 timental work, regarded as invisible work, appears in health care organisations in the service of managing and shaping patient trajectories. Opposed to Hochschild’s account, there is nothing extraordinary or alienating in sentimental work. It is necessary work to be undertaken by professionals, patients and relatives. Furthermore, Strauss et al. argue that sentimental work and the baseline for doing this kind of emotion work have been profoundly affected by changes in the medical organisation, for example by rearrangement of patient trajectories and technological developments. Strauss and his co-authors suggest that emotion management is a common feature involved in ‘technical’ medical work, not only expressed in the work of lower middle-class, female work, as suggested by Hochschild, but also in work conducted by professionals such as university teachers, politicians and doctors. The authors demonstrate how one may approach emotions in the social organisation of everyday medical work similar to the way one approaches other organisational phenomena. Emotions do not have a magical or sacred status in the organisation. Instead, they constitute an important part of rational medical action. Thus, sentimental work may be regarded as a mundane, routine activity that professionals (doctors, nurses) must take part in either ‘because it is necessary to get the work done efficiently or because of humanistic considerations’ (Strauss et al., 1997: 129). I think the last sentence is important here in relation to a side-ordering of efficiency and humanistic considerations in medical activities. This idea of a side-ordering of various considerations becomes especially important later in the thesis when I analyse various forms of emotion work in the accelerated cancer pathways, and where so-called ‘soft’ dimensions of care, such as attention to the patients’ psycho-social well-being, are intertwined with concerns of productivity and performance measurement. Literature on emotions in health care One of the areas in which research on emotions has been most developed is health care. Within this research field, micro-interactional processes of the management of 66 emotion in everyday routine work have been studied and linked to broader discussions of how social and cultural factors impinge on the formation and regulation of the conduct of health care workers. There have only been few empirical studies directly examining the role and function of emotions outside of the nursing profession in the overall area of health care (see Mann, 2005 for an overview of the literature on emotion work and labour and nursing). This is probably due to the assumptions many researchers have in relation to the ‘caring’ role of the nursing profession. One reason why the study of emotional aspects of, for instance, doctoring is undeveloped may be that researchers have been inclined to adopt a dichotomy articulated within the nursing profession itself that traditionally sees emotion work as belonging to the caring role of nurses while doctors are detached from that sort of things and only are involved in processes of giving information about technical interventions (e.g. Smith and Gray, 2000). I have expressed the facilitation of emotional division of labour previously in this thesis, e.g., the introductory story from the cancer clinic, where a nurse took ownership of the expression of empathy. One of the core issues of theorising on emotions has in previous sections been addressed as the issue of a longstanding bifurcation between emotion and rationality. This debate continues to be reflected in empirical studies of emotions in health care and I will therefore next turn to authors who 1) intend to bridge this divide and authors who 2) continue to work within this divide. Bridging the divide. In short, the literature, which I have chosen to engage with here, has a profound attention to the complex intertwinement of emotion and rationality in relation to emotions at work. It addresses the importance of emotions to basis purposes and values of health care organisations. Working within the divide. Second, I also engage with literature that explores how nurses react to structural and economic changes in the work place in relation to their ‘felt’ and displayed emotions. I ask the reader to reflect on how these ‘felt changes’ 67 of nurses are reframed in the reviewed articles in relation to a notion of ‘authentic’ feelings. The texts to be examined reflect these two core positions. Each of them will be taken up in turns. Expositions by the various authors will be highlighted as they speak to those positions. Last, I will sum up this listing and point forward to how I intend to approach emotions in my empirical inquiry. Bridging the divide: Emotion and rationality in health care ‘Emotion is rarely seen as systematic or structured and is often used as a contrast with rational’ argues James (1989) in a text on nurses’ regulation of feelings in a hospice setting (1989: 17). According to James, this polarised thinking presents an image where rationality is hold supreme and where emotion is seen to contain negative connotations of unpredictability and irrationality. From this perspective follows that emotions are seen as an uneasy fit with organisational values of efficiency, standardisation, time tabling and performance measurement in health care organisations. In order to pave the way for a more coherent image of rationality and emotion, James suggests that for the most part the management of emotions is a routine, predicable social process that relies on conscious, skilful work rather than on ‘personality’ or ‘natural skills’, as Hochschild suggested. In emphasising the management of feelings within social processes, such management is a day-to-day matter, relying on professional codes of conduct. The dichotomous nature of rationality and emotionality, which is evident from a public/private or outer/inner separation of the two concepts, is also challenged by Bolton (2001). Set against a backdrop of structural changes affecting the British public sector services in the late 1990’s, Bolton demonstrates how nurses working in a NHS trust hospital are able to juggle the emotional demands made to them by presenting different faces to patients. Sometimes a smiley face is displayed, sometimes a humorous face is needed and sometimes a professional face makes the social interac- 68 tion work. Nurses can therefore be described as emotional jugglers. They are able to wear ‘masks’ and present professional demeanour, while at the same time being emotional present and fully engaged in the interaction order of the hospital setting. Compared to flight attendants or service workers in a call centre, nurses are ‘knowledgeable agents’, as Bolton writes elsewhere (2005: 103). The difference comprises that nurses are ‘capable of mixing all forms of emotion management according to rules other than those solely controlled by the organisation’ (ibid). This capacity for emotional juggling enables nurses to fulfil their job obligations, which are compatible with the instrumental goal orientation of for instance processes of productivity, while providing emotional care for individual patients. Bolton does not theorise through a distinction between ‘public’ or ‘commercialised’ feelings on one hand and ‘authentic’ or ‘genuine’ feelings on the other hand. Instead, care workers can present a ‘smiley happy’ face as part of their job without this face necessarily signalling a commodified feeling that is packaged to be consumed by the patient. Bolton highlights in her work some of the contradictions of emotions at work, but she does it in a way which I define as a ‘non-sentimental’ approach to workplace emotions. Through a critique of Hochschild’s concept of emotional labour, which Bolton thinks is inadequate for capturing the complex emotion management of professional care workers, she also scrutinises the assumption of normative control of emotions in Hochschild’s work. This form of control implies that consumer capitalism has ‘appropriated all of our feelings so there is no longer any room for sentiments, moods or reactions that have not been shaped and commodified via the “commercialisation of intimate life”’ (Bolton, 2005: 2). The non-sentimental approach to emotions does not emphasise some emotions, for instance those of the private sphere, to the disregard of other emotions, for instance those of the work place. Hence, it would also be a mistake to approach professionals’ detached performances as ‘cold’ performances, devoid of compassion or ‘real’ feelings. I think the important argument Bolton makes here, is that it takes the same amount of hard work for nurses 69 to stay detached as it takes for them to appear, for instance, compassionately engaged. Both kinds of professional appearance involve rational, skilled performances of social actors. The body of research argues that emotions are important social components in organisational functioning of health care organisations. Rather than being ‘illogical’, ‘irruptive’ forces, emotions enrich the attainment of organisational outcome, such as the outcome of the medical encounter. Emotions are central to both patient care and are necessary for health care professionals’ participation in clinical work procedures. Accordingly, a central study by James (1993) pays attention to the management of emotions during the disclosure of a diagnosis of cancer. James argues that ‘cancer is a particular apt disease to review in order to analyse the management of emotions in health care organisations’ (James, 1993: 96). Emotions are evoked within a diagnosis of cancer because of the diagnosis’ physical implications and its social consequences. The consequences of the disease for the individual patient mean that the disclosure of a diagnosis is not just about passing on information, but is also a mean to regulate the disbelief, fear and chaos a diagnosis often evokes. The doctors, who have knowledge of the cancer illness, also have the power and responsibility to regulate and manage the feelings surrounding the disease. According to James, professional care workers learn skills of emotion management commensurate with their position and role in the hospital organisation. She observes some of the techniques through which emotions are managed in a cancer unit, and she makes these techniques applicable to ways of organising emotions in the hospital organisation. The techniques include: the use of particular kinds of space and time (e.g., the waiting room, the medical encounter, the time table); consequent denial of negative emotions; limiting the amount of information released (e.g., holding back information of survival prognosis); formal and informal disciplinary rules (e.g., the regulation and expression of ‘professional’ feelings, such as feelings of the ‘caring’ nurse), and hierar- 76 tion. Recently, I read in my morning newspaper about a journalist who claimed that ‘females are by nature both more empathic and more soft’ (Dagbladet Information, 2011). This obviously false distinction between male and female feelings, which facilitates a gender division of emotions and emotion work, is also present in studies on emotions and professions in health care. This latter body of research on the nursing profession is noteworthy in relation to its rather sentimental attitude to thinking about emotions in health care. Here, emotions are typically approached as 1) properties which have been colonised by the ‘system’, ‘capitalism’ or ‘bureaucracy’, or as 2) properties which have been lost in a current environment of managerialism and now must be brought back into practice. In other words, the literature tends to envision emotions as personal properties that can be used, manipulated and controlled in the hand of others – for example in the hands of the ‘system’, the ‘organisation’, the ‘bureaucracy’, and so on. From this follows that individuals must resist the organisation and protect their ‘real’ feelings from getting colonised by others. Emotions can be approached as a site of resistance or the last frontier from further standardisation and commoditisation. The perspective emerging from this division locates emotions in a private sphere where each individual has the responsibility of providing shelter from the outer realm. In retaining a theoretical grounding of emotion in the human being instead of in the social realm, the perspective provides support for the idea that emotions are isolated, individual entities. This polarised thinking presents an image of bureaucratic organisational life devoid of emotions, where ‘authentic’ emotional experience, which is embedded in the individual, is opposed to ‘manufactured’ or ‘commercialised’ feelings, that is dictated by ‘the organisation’. Such accounts, I argue, may then continue to essentialise emotions and to sustain a dichotomous way of thinking of emotions in health care. 77 The number of analytical challenges, which seem to accompany the interest of emotion in organisations, points to the importance of developing a nuanced theoretical framework which does not limit itself to a restricted focus on ‘individual feelings’ on one side and ‘organisational rationality’ on the other side. To bridge this divide, one therefore needs to leave the attention to authenticity, interiority and individuality of emotions behind. In the next section, I will suggest how we may approach emotions in a way that avoids this kind of conceptual entrapments. A combined theoretical framework to the study of emotions in organisations Time has come to draw from the various approaches, points and concerns that I consider fruitful for a balanced and nuanced approach to the study of emotions in organisations. This chapter has reviewed several major perspectives to address questions of emotion. A possible way to summarise this chapter is to lend the word to Wittgenstein (1999 [1957]) for a short comment. In his investigation of philosophical problems, Wittgenstein criticises general explanations of inner feelings and private sensations, and he points to the circumstance that, for an utterance of an inner feeling to be judged meaningful, it must be possible in principle to subject it to public standards and rules of a specific context. Describing the form of a philosophical problem, he writes: We ask “What does ‘I am frightened’ really mean, what am I referring to when I say it?“ And of course we find no answer, or one that is inadequate. The question is: “In what sort of context does it occur?” (1999: 161) This rather simple example has two significant aspects. First, to be ‘frightened’ or to feel ‘fear’ is dependent on social situation or context. Second, though Wittgenstein 78 does not indicate it directly here, emotional expression and experience of ‘fear’ is grounded in possible historical continuities and discontinuities in a long-termed history of emotion codes or standards of emotional behaviour and restraints. The meaning of ‘I am frightened’ is therefore not fixed in stone, but is rather, to some reasonable extent, context varying. A contrasting position would search for the essence that lies behind the appearance of a phenomenon, such as seeking to discover the reality behind the bodily expression of fear. The ‘fear phenomenon’ would then be traced as an innate essence in individual biology and only secondly would one starts to situate emotions in the social realm. One of the key characteristic of the sociological theory on emotions, that I have reviewed in this chapter is the stress on the contingent character of emotions, depending on variables such as context, particular situation, historical time, culture and trends. Instead of approaching emotions as universal stables, the literature emphasises the performative value of emotions in particular social arrangements. Following this perspective, it becomes possible to trace and diagnose contemporary forms of emotionality or changes in social conduct as depending upon complex historical circuits of individual, cultural and social relations. Emotional expression then follows from the social arrangements and power relations that surround it. In order to sum up my inspiration from the sociological theory on emotions, I have listed some key points which have major influence on my exploration of questions of emotion in the cancer clinic and forms of professional conduct therein. First of all, some of the important learned lessons: Emotions are produced effects rather than essential dispositions Emotions emerge through assemblages of a larger scale (societal patterns, power structures and psychological make-up of sentiments) Emotions are produced through organisational codes of conduct and standards of regulation and affect-control 79 Emotions serve as a function in maintaining social order Emotions can be worked at by individuals to produce a reasoned social Emotions are an essential part of professional work and as such a part of professionals ethical handling of individual person cases Emotions may enrich the attainment of organisational outcome My own theoretical approach, as developed in the remaining chapters of the thesis, attempts to bring together many of the foci developed under the headline of ‘emotions as historic, cultural and social constitutions’. This overall theoretical framework then signals an orientation towards constructivism. A constructivist perspective regards emotions as a series of relative constitutions, which are dependent upon the socio-historical settings in which they occur. These components are contested and reframed at the level of everyday practices of individuals and organisations. Emotions are shaped and experienced by human interactions; they are framed and reproduced through social practices. The perspective implicates that emotions are never seen as an independent reality, relying upon a universal vocabulary. Instead, it emphasises the plasticity of emotions in relation to their characteristic of being components in the production and co-production of social reality. When one acknowledges that emotions are socially constituted, one also implicitly pays attention to the productivity of emotions, based on the simple argument that emotions both are practice and are constitutive of the possibilities for practice (Williams, 2001). By making this claim, it becomes possible to pay attention to what it is that count as emotions, which means to look at emotions as more or less specific practices, procedures, products and configurations and, not least, as concrete processes of social world making. If we understand emotions through this constructive/constitutive lens, as I do in the thesis, the point is not so much to debate the onto- 80 logical status of emotions6, but rather to turn the attention to how emotions and emotional expression become manifest in specific socio-material processes of organising. Rather than repressing emotion as the ‘other’ of reason, this perspective on emotions demonstrates the mutually constitutive relation between reason or rationality and emotion. Instead of being irrational or an expression of irrationality, emotions function as cues and markers that form a necessary orientation system fundamentally enabling perception of reality and, ultimately, forms of rationality (Townley, 2008 – see also Jagger, 1989). The strength of the emotion perspective may therefore be its ability to transcend forms of dichotomous ways of thinking about rationality and emotions in social sciences. Furthermore, it might even provide the way to deal with a central sociological concern with regard to the relationship between personal troubles and public issues of social structure (Williams and Bendelow, 1998). The perspective includes asking questions about how individuals’ activity and experience are interlinked with codes of conduct that are themselves historically and socio-culturally grounded. In this way, emotions are interlinked with and shape relations of power and the governance of social conduct. My theoretical approach addresses the importance of emotions to basis purposes and values of health care organisations. This perspective emphasises, in line with other researchers, that emotions are no adjunct to work and the instrumental goal orientation of work life (e.g. Putnam and Mumby, 1993; Ashforth and Humphrey, 6 I find it necessary to mention a few, but important omissions here. First, I will not be defining ‘feelings’, ‘passions’ and ‘sentiments’, ‘mood’, temperaments’ or explaining their relationship to emotions. It has the consequence through the text, that I make use of the words ‘feelings’ and ‘emotions’ as if they were one and the same. Second, I have more or less ignored the question of biology. Emotions have long been a ‘hot’ topic of affective sciences. In disciplines such as neuroscience, the search for distinct emotional systems and universal emotions (e.g., rage, distress, excitement, happiness) is developing. However, with reference to the constructivist/constitutive approach to emotions, I assume that emotions are not simply psychobiological phenomena, but are historically formed components of social action. Third, I will mention the discussion on affect and emotion as another important omission. I intend to use the two terms as if they were interchangeable. More than anything else, I think the uncompromising distinction in terminology – between emotion and affect – has more to do with intellectual heritage and the need to distinguish oneself from other groups of academics, than with actual conceptual difference. In this project, I am not concerned with drawing radical terminological lines, which make it difficult to engage with operational practices and lived experience of individuals towards which I have turned my attention. 81 1995; Fineman, 1993, 2006). In fact, many rational strategies of health care are pursued on highly emotional grounds and what we describe as rational, for instance in medical relationships, is in fact very emotional. The approach described here involves what I term a ‘non-sentimental’ attitude to thinking about emotions in organisations. This attitude embraces both emotionality and rationality in its conceptualisation of organisational activities, focusing on how management of emotions are formulated and formed through training and practices in particular contexts and circumstances. In this way, I attempt to stay clear of the analytical ‘dangers’ addressed in the very beginning of this chapter. 82 Chapter 4: To study emotions - Focusing, gathering and writing up material on emotions Introduction In the previous chapter, the management of emotions in work and organisational settings has been conceptualised through the thinking of a distinctive group of sociologists and through the review of emotion studies, particularly in relation to health care. The way emotions are approached in the literature has been shown to have an impact on how one understands emotions in empirical inquiries. This is methodologically significant since emotional conduct is difficult to observe and understand. For researchers who seek to emphasise the work that goes into the management of the emotions, it is useful to study emotions and emotional practices in organisations using a variety of research methodology, including ethnographic methods. However, before describing the methods and the amount of material used for this research, and before reflecting upon how the selection of methods enabled me to gather material on the research core topics, I first need to confront a more pressing matter. Namely, how did I come to define my object of inquiry in the first place? This is an important question, since the answer both leads back to an explanation of my personal kind of access to the researched organisation, and points forward to a methodological discussion on how to study emotions in work places. Therefore, this chapter begins with a description of the situatedness of my PhD project and my access to the cancer clinic and its occupants. Next, it explains how I defined my object of inquiry. Then, it moves on to reflect on how to study emotions and discusses the problems involved in this process, including problems of detachment and involvement in social science studies. Finally, the chapter recollects how writing up material on emotions becomes a reflexive act of generating emotional conduct in organisational life, and how this writing process may also be approached as an affective separation from the field of study. 83 The situatedness of the PhD and my access to a cancer clinic and its occupants In this section, I will describe my relations with and access to a cancer clinic and its occupants. I will do this through an explanation of the situatedness of my PhD project, because this situatedness also determined the access to my field of inquiry. Furthermore, I will explain how my type of access both became a problem as well as a solution to defining my object of inquiry. The personal biography provides further means to discuss how research on emotions in health care comprises certain methodological challenges. As previously mentioned, a major centre7, located at the university hospital in Denmark, where I also conducted the research, has funded a larger part of my PhD project in a partnership agreement with Copenhagen Business School. Before beginning this study, I worked four years at the hospital as an internal consultant in the centre’s administrative unit. Originally, I had started working in a Cochrane Collaboration unit8. Looking back on this job experience, I think my current occupation with soft dimensions of medical care somehow counter intuitively derived from this initial work with golden standards of medical research methodology, such as clinical algorithms, meta-analyses and Cochrane reviews. I hope to shed light on the rationale behind this reflection as the chapter develops. On the basis of an educational background in the humanities, I was later employed in the centre as a consultant in communicative affairs to support both the heads of the centre and the centre’s clinical staff members in order to improve the external and internal communication with political institutions, clinical collaborators, patients and lay people in general. The job title provided access to what I like to think of as the hospital’s engine room. My perception of this engine room comes close to Goffman’s (1959) dramaturgical under7 In Denmark, university hospitals are typically structured into medical and surgical treatment centres, diagnostic centres and administrative centres, hold together by a managing committee. 8 The Cochrane Collaboration is an international network where its members work together to develop, update and promote systematic reviews which are based on evidence based research methodology. The reviews are published online in a database which is called The Cochrane Library (see also www.thecochranelibrary.com). 84 standing of a ‘backstage’ region, which in his terms is an organisational region where: ‘[…] the team can run through its performances, checking for offending expressions when no audience is present to be affronted by them; […] poor members of the team, who are expressively inept, can be schooled or dropped from the performance. […] the performer can relax; he can drop his front, forgo speaking his lines, and step out of character’ (1959: 115). One can compare the hospital’s engine room to the outpatient consultation room that a patient attends if he or she for instance needs to be tested for hypertension. The latter region gives the person access to a concrete work setting where particular actions and roles are performed. This region is what Goffman terms the ‘front region’. However, the front does not immediately give access to the place where the hospital organisation typically constructs its ‘illusions and impressions’ (1959: 114). I mention this here, because through my ‘free access’ to the hospital, I not only had access to various confidential material on the hospital organisation, such as policy-making reports, standard contracts for surgical and medical treatment units, financial overviews and strategic visions for future treatment developments. In this engine room, I also had access to staff members’ reflections and discussions about how they experienced, thought and felt about doing different kinds of work at the hospital; how they felt about changes, and what they thought about new managerial attempts to regulate their conduct. When I changed status from consultant to PhD researcher, the scene of my everyday life shifted from the hospital to the university, but a very useful peephole remained open into the hospital world. The consequences of this kind of access are worth some reflexion because it may have affected the way I came to approach the front regions of the hospital. 85 A deal was set up. When I signed the PhD contract with Copenhagen Business School, I also signed a contract with my former work place. As part of my PhD contract, I agreed to work eight hours a week at the centre. During the contract period, I was thus enjoying a weekly workday at the hospital, where I frequently went to meetings with administrative colleagues and meetings with clinical staff (doctors, nurses, secretaries and dentists). Parts of my work schedule lay in extension of my previous consultant tasks within communication, and I also continued to rely on my personal contacts. I had previously collaborated with some of the doctors and nurses from the cancer clinic. I had met the clinic’s head of research (the person was also the former head of clinic) through a common involvement in developing the centre’s research profile. This person presented me to a research group at the hospital, who was interested in breast cancer illnesses and their treatment, including diagnostic methods, surgical techniques, nursing care, exercise and early recovery, anaesthesia, pain and vomiting medication. The group was led by a concern for ways to improve interventions to make patient trajectories both more effective and more efficient. The meetings in the group whetted my appetite for a sociological investigation of accelerated medicine. I found that new ways of organising cancer illnesses at the hospital were not without consequences for the conduct of medical practitioners in their day-to-day work. I will return to this issue later in the chapter. When I decided to do a PhD, the head of research granted me official research access to the cancer clinic and its occupants. He also introduced me to the staff members when I later arrived on the ward. At the hospital, I had my own desk and my own computer and a sign on the office door with my name on it. In the beginning of the PhD, my consultant job was to facilitate change processes in the centre, especially in relation to processes that had to do with the merger of clinical units. However, as I got more involved in my fieldwork, I needed to withdraw myself from these process facilitation tasks, and from then on, I spent most of my weekly workday writing official documents, newsletters, 92 trajectories. Greco introduced me to her systematisations of the field and helped me to find my own place in emotion studies. When I later returned to Copenhagen, long conversations with my supervisor, Signe Vikkelsø, stimulated me to extend the range of my thinking. Especially her continuous pin-pointing of the importance of detailed empirical descriptions, inspired me to look into emotions as they anticipate in concrete practices in the cancer clinic. This likewise helped me to understand how emotion work takes place alongside other aspects of medical work; each aspect mixed up with one another, and each aspect equally necessary for the line of medical work in the cancer trajectories to be carried out successfully. The shift from various – way to many – foci to a developing focus on emotions induced alterations in my methods and material. The earlier work generally assembled two types of evidence: 1) material on changes in the organisation of cancer treatment – the character of speed, the value of evidence, the methods of accountability, and so on – and 2) unstructured observations of practices, such as doctors ways to relate to principles of evidence based medicine in their daily activities. In the further process of defining my object of inquiry, the developing focus on emotions included that my methods and material increasingly focused on: 1) the description of how and when emotions occur as social components in practice and for what purposes, and 2) the examination of how doctors experience and understand emotions in various parts of their conducts. As a result, the inspiration from literature on ‘performance measurement’ and ‘audit cultures’ transmuted into a concern of locating contemporary demands for certain emotions and emotional expression within their specific social contexts. In this way, attempts to govern the conduct of doctors through various techniques – for instance through audit devices – were linked to the issue of how doctors anticipate more or less rationalised forms of socially sanctioned explanations and ambitions. 93 Gathering material on emotions In relation to the refinement of my object of inquiry, the next step of my fieldwork was a series of 14 semi-structured interviews with doctors in the cancer clinic. Compared with my previous explorative interviews, which aimed at gaining knowledge of the formal organisation of accelerated cancer pathways, in this interview series I wanted to talk with the doctors about their personal (i.e. individual) understanding of emotional aspects of their work in the pathways. Concurrently with my own empirical research, I had been working with a colleague, Nanna Mik-Meyer, on an article based on a larger qualitative interview study, concerning how general practitioners (GPs) approach patients with medically unexplained symptoms (MUS). Our main argument in this article was that GPs not only use traditional biomedical diagnostic tools when attending patients with MUS, they also rely on their personal opinions and evaluations of a patient’s particular circumstances in deciding whether the patient is legitimately sick or not (see Chapter 8 for the entire argument). Due to these findings, I was riveted by the ambivalence of emotions in one of the core practices in medical ‘truth making’ practice; namely medical diagnosis. In extension of this article, I wanted to explore in further detail how doctors in the cancer clinic experience emotions and the way emotions form part of their professional conduct. Current ways of organising technical aspects of medical work in the trajectories may also affect the organisation of emotional transactions in the trajectories, and as a result affect how doctors experience and understand emotions, or so was my hypothesis. Following a constructivist perspective on the study of emotions, I had no intention of trying to trace what the participating subjects ‘really’ felt or to determine the authenticity and ‘under-the-surface’ feelings of the informants. Instead, I was interested in their presentations of personal biographies of emotional experience and emotional challenges. My initial interview guide was constructed so as to provide an understanding of doctors’ views on and responses to their work life, and to understand how these people frame and reframe emotional injunction in their work. I was 94 interested in ‘how it feels being a doctor’. Characteristic of a constructivist inquiry, the attention in the interviews was focused on the activeness of the interviews. This is not a new catchword to qualitative interview methods. Holstein and Gubrium (1997, 2002) argue in their work on interview method that all interviews are active interviews, hereby emphasising that the interview is not so much a neutral conduit or a knowledge container as it is a unique site for producing reportable knowledge. The constructivist phrase ‘all meaning is socially constituted’ (Berger and Luckmann, 1966; Garfinkel, 1967) gains momentum in active interviewing method, because it here becomes obvious that meaning and meaning structures are actively assembled in the interview encounter through interviewer and respondents’ collective accomplishments. The emphasis on process in the interviews also included that the questions I asked in the interviews varied a little from interview to interview because the respondents conceived the questions asked differently. However, except differences in respondents’ ways of answering questions, I tried not to lose too much track of the research topics guiding the interviews and the content of my questions, and how these were understood and communicated by the respondents. All interviews (with exception of a few clarifying interviews in the beginning of the research) have been audiorecorded and transcribed. Shorter interviews during participant observation were not recorded. Neither were more spontaneous conversations. In addition, notes on some of these conversations were written during the fieldwork. I also revisited the doctors in the clinic. When emotions are approached as contingent social components, depending on social situation, context and historical time, then the ability to understand emotions at work is highly depending on methods to identify and describe how the conduct of doctors is organised in specific situations. At that time, I found fieldwork in the clinic to be a reliable choice of method because in order to observe how individuals can both ‘affect’ and ‘be affected’ in social interaction, and to recognise the complex interweaving of emotion and reason which makes up the course of doctors’ job, I needed to be part of the context. Importance 95 was hence given to direct ‘in situ’ observation of concrete sequences of activities in the clinic (see also Goffman, 1989; Baszanger and Dodier, 2004). However, compared with my previous fieldwork, I now had my attention focused on the situations in which doctors offered emotional services or responses aiming to facilitate patients in particular situations. In other words, I paid attention to how doctors managed emotions in relation to patients, relatives – and not least themselves – in the cancer clinic. To sum up, my fieldwork in the cancer clinic was spread out over almost two years from June 2009 to January 2011. First, I talked with several people to gather material on the historical development of the accelerated cancer pathways. In addition to these interviews, I later interviewed doctors in the cancer clinic to explore more directly how they experience and understand emotions at work. The appendix shows the entire list of interviews (see Appendix A). The interviews are indexed with anonymous names and I refer systematically to those names throughout the thesis. Second, I made observation of a training workshop in ‘empathic communication’. I have field notes from this workshop with doctors and nurses from the cancer clinic, and I have three transcribed interviews with heads of the cancer clinic and the consultant who facilitated the workshop. In addition to this material, I have a collection of documents from the workshop (invitation letters, teaching material, work shop presentation). From my previous employment at the hospital, I have material from workshops of a similar kind, where doctors were trained in having difficult conversations with patients – for instance conversations about poor diagnosis or future health perspectives. Third, I have observed lots of encounters in the cancer clinic (conferences, operation theatre, ward rounds, and etcetera) and I have spent 15 days observing patient-doctor interactions in the cancer clinic’s outpatient consultancy rooms. 96 The appendix shows the type, location and frequency of my observations (see Appendix B). Finally, I have listed all the official documents I have used through the thesis in the appendix (see reference list). The document material include policy documents, clinical guidelines and practice recommendations, strategy reports, patient satisfaction surveys, medical textbooks and practice journals and locally circulated information material such as letters and e-mails. Material is also drawn from attending both academic and practitioner conferences on the organisation of cancer illnesses and their treatment. Starting out from various foci on medical work to a developing focus on emotions, I began more systematically to ask the question: how is emotion framed, trained and performed by doctors in accelerated medical relationships?, Each chapter or article in the thesis takes as its point of departure a smaller part of the fieldwork, and each chapter deals in particular with one of the above raised concerns. Chapter 5 deals with policy documents gathered in the early stages of the project that inset emotional injunctions to doctors and I analyse how doctors in the cancer clinic reframe these injunctions. Chapter 6, which is preoccupied with analysing how certain emotions are trained in the clinic, draws on material from the training workshop. Chapter 7 and 8 are both preoccupied with a concern of how emotions are enacted by doctors. However, the two chapters take different material as their point of departure. Chapter 7 relies on the small semi-structured interview series with doctors in my clinic, while chapter 8 relies on a larger interview study with GPs in the primary health care sector. Even though the chapters vary in their ways of engaging with the fieldwork, they also overlap and – that is the aim – enrich each other. Of course this sometimes means that they appear repetitive, which I think is one of the article-based thesis’ main structural challenges and therefore not unique to my particular thesis. 97 I think every researcher is occupied with defining when his or her material collection is sufficiently satiated to successfully carry out the research project. In his writings on ‘intellectual craftsmanship’, Wright Mills (1959) argues that, once one has decided upon a topic and has entered it, one does not need to ‘study’ it, because suddenly it will appear to be everywhere. I experienced this insight in relation to my process of gathering material, because suddenly also apparently unrelated issues emerged as casting new light on the research and its discussions. For example, it occurred to me during an academic seminar that fellow researchers within organisation studies have recently started to argue that we, as researchers, should strive for putting back feelings into our research methods. I noticed that personal characteristics of the researcher, which are closely tied to emotions such as ‘authenticity’ or ‘sensitivity’ or even ‘love’, were brought forward by some of the participants as a methodological solution to an apparent ‘coldness’ or ‘detachment’ of social scientific inquiry. Some of the arguments, which were brought forward in these discussions, had a similarity to the arguments of ‘more emotionality’ in relation to the conduct of doctors in the cancer clinic. The two different settings – that of cancer treatment and that of social science research – thus seemed to share a language of emotions, in which some emotions were approached as more gratifying than others. At the time, I remember that I found these arguments strange. Anyhow, they deserve attention in relation to some methodological problems concerning involvement and detachment that I have faced in this study of emotions. I will next turn to this issue. 98 Problems of involvement and detachment in the study of emotions One cannot say of a person’s outlook in any absolute sense that it is detached or involved (or, if one prefers, ‘irrational’, ‘objective’ or ‘subjective’). Only small babies, and among adults perhaps only insane people, become involved in whatever they experience with complete abandon to their feelings here and now; and again only the insane can remain totally unmoved by what goes on around them. Normally adult behaviour lies on a scale somewhere between these two extremes’ (Elias, 1987 [1956]): 3, my emphasis). In an essay concerning knowledge in social sciences, Elias (1987) discusses some methodological difficulties in relation to how the researcher should be engaged with her object of inquiry. In relation to this, he discusses the terms ‘involvement’ and ‘detachment’. The terms do not refer to two separate sets of human attributes, such as one psychological or emotional and the other scientific or rational in character. Instead, he argues that one cannot separate the two phenomena and he denies that any sane adult could be either wholly involved in or wholly detached from what goes on around them. Thus, according to Elias, it is not possible to obtain any ultimate detachment or complete objectivity in relation to studies of social arrangements. What Elias draws attention to here, is the double character of demands to researchers within social science studies. On the one hand, the researcher’s ability to sustain affective neutrality and detachment is crucial for carrying out her scientific work. On the other hand, the researcher’s sense of sensibility and her affective experience of particular situations and participants, contribute to the production of the knowledge of social processes which comes together in the research. I think this double character is worth some consideration, especially in studies like mine in which one of the aims is to redescribe the public sphere as saturated with emotions. The methodological 99 challenge consists in doing this from an ‘affectively neutral’ stand point and without being ‘gripped’ by emotions. And how does one manage this? To keep a distance from taking over the statue-like figures of ‘involvement’ and ‘detachment’, as being radically in opposition to each other, I have tried to study emotions: 1) without sentimentality, and 2) with sensibility to the performative value of particular contexts. In making this kind of methodological vocation, I have foremost tried to stay clear of any sentimental approaches of either bringing back emotions into medical practice or of protecting certain emotions in this practice. This does not mean that I have intended to replicate historical attempts at separating reason or rationality from emotion in social sciences, where a foregrounding of the former tends to silence the characteristics of the latter and hence leave it out of empirical studies in the context of work and organisations. Instead, I have paid attention to the relatively contingent character of emotions, consisting of the dependence upon variables such as social situations, historical time, and institutional context. To study emotions without sentimentality is easy to say but difficult to invoke in practice. Because what and whose emotions do we, as researchers, operate through when we attempt to categorise some practices as more emotional than others or when we attempt to highlight a particular emotion in empirical descriptions to the disregard of other emotions? In a previous section on ‘approaching emotions’, I referred to Wittgenstein’s explanation of how we may approach emotions as ‘meaningful emotions’ in relation to the expression and understanding of emotions in social life. The core of his argument was that the role and function of particular emotions vary across contexts. From this followed that emotions are of many types and may have different intensities in human conduct. To take a glaring example, in a novel, the American novelist Raymond Carver (1995) discusses the category ‘love’. The title of his novel is perhaps not surprising: ‘What we talk about when we talk about love’. He describes an interchange between two married couples and their discussion of ‘love’. He writes: 100 ’There was an ice bucket on the table. The gin and the tonic water kept going around, and we somehow got to the subject love. Mel thought real love was nothing less than spiritual love […] Terri said the man she lived with before she lived with Mel loved her so much he tried to kill her […] I picked up Laura’s hand. It was warm, the nails polished, perfectly manicured. I encircled the broad wrist with my fingers, and I held her’ (1995: 138-139). ‘Love’ is definitely an emotive word. In the above written quote, it conveys something of the author’s experiences. However, the statements, ‘real love was nothing less than spiritual love’, ‘loved her so much he tried to kill her’ and ‘I encircled the broad wrist with my fingers, and I held her’ also give texture to the meaning of the individuals’ feelings of love. The first sentence presents a transcendental definition of love, while the next sentence presents a more extreme, pathologic version of the word. The last sentence is somehow placed in-between the two previous sentences. On one hand it presents a physical expression of love. On another hand, it contains some uneasiness, especially uttered in the last four words ‘and I held her’. In offering these interpretations, the reader is no blank sheet. It is precisely by these reconstructions that the signs of the sentences are imputed with a certain kind of emotionality. Hence, our own identity or biography matter in emotion inquiry. The researcher’s emotion work is both a part of the approaching and the validation process (Fineman, 1993; 2006). The relative embeddedness of researcher and the researched objects in emotion inquiry is not only a mean to reflect upon the nature of emotions. It is also a mean to address a political concern. Because whose emotions do we actually resonate with when we ask questions of emotion in our research? The significance of the expression of certain emotions may be attached to a moral labelling (Goffman, 1990b). 101 In one of the articles in my thesis, I draw on an example of a patient who ‘expressed too much aggression’ and a patient who ‘was cold and did not express any emotion at all’. The doctors in my clinic presented these examples as examples of deviant emotional outbursts and hence as not appropriate for the representation of a ‘patient’. Other sources, for example newspaper articles, public statements from patients, and debates in psychiatric circles might represent these emotional events very differently, depending on interest. If we take emotions to be shaped through social processes of all sorts, then we are necessarily confronted with ‘many possible voices to represent feeling and emotion’ (Fineman, 2006: 688). As emotion researchers, we must therefore try to avoid foregrounding a particular language, for instance a language of ‘sentimentality’ and pay attention to how the framing and enactment of emotions also are a kind of moral currency. The above account has introduced some of the problems of conducting research that is sensitive to claimed characteristics of emotions and to altering contexts. I have shown some of the general problems in emotion research (focusing, gathering, appreciating emotions). At the same time, some specific research problems in the context of my personal biography were highlighted, such as my role as researcher and my problems in relation to involvement and detachment with my field of inquiry. Writing on emotions In relation to the above considerations on ‘involvement’ and ‘detachment’, I acknowledge that I have my own emotional investment in this PhD project, even though I have tried to stay clear of the spirit of a ‘passionate sociology’ (Game and Metcalfe, 1996). My methods have definitely generated ways of talking and writing about and presenting emotions in the scrutinised contexts and my involvement has contributed to a production of an awareness of social constraints in specific interactions. However, research and writing activities are always a subjective matter, and as I have tried to show in this chapter, my own preoccupations and interests are inflected 108 requiring such competences ‘it may be that the physician’s most potent therapeutic tool is the self, which is attuned to the patient through engagement, on the side of the patient through compassion, and available through reflection’ (2001: 1899). Doctors are thus required to turn to individual patient cases with ‘passionate’, ‘personal’ and ‘engaged’ commitment. In this article, I want to pursue the argument that public health care reforms and the request for medical professionals to exhibit ‘compassionate’ care, and forms of ‘empathic’ engagement raised in medical humanities literature, are hardly distinguishable: both inset emotional injunctions to medical professionals, which include a call for doctors to become more emotional available to patients and to exhibit a particular emotional behaviour in medical relationships, namely that of a ‘sincere’ or more ‘natural’ behaviour. On one hand, we see a movement towards rationalisation of medical services, tied to tropes of ‘effectivity’, ‘quality’, ‘standardisation’ and ‘audit’. On the other hand, we have a movement towards a heightened degree of emotional sensitivity required on the part of individuals, encouraging a seemingly emancipation of emotions in medical relationships. I will argue that the current framing of the role of emotions in medical work, and an apparent relaxation of emotional codes of conduct in this work, is manifest concurrently with formalised attempts to manage the emotions of patients in recordable, measurable and standardised ways. The latter tendency hence represents increasing constraints towards processes of emotional control in medical work and new modes of clinical governance rather than a loosening of emotional behaviour and manners. The paper explores this assertion through an analysis of recent health care reforms. These reforms are understood as framing the role of emotions in medical work. In particular, I focus on the changing emotional demands the treatment concept which I term ‘accelerated medicine’ impose on doctors and on how doctors are expected to exhibit a variety of emotional skills in patient-doctor interactions, as for ex- 109 ample the exhibition. The inquiry draws on empirical data material from research on the introduction of accelerated cancer pathways in a cancer clinic at a major university hospital in Denmark. The article is structured as follows: First, political and managerial documents issued by, among other agencies, The National Board of Health, Denmark (NBH), describing the organisation of the accelerated cancer pathways and the institutional framing of the role of emotions in these pathways, are reviewed. Second, attention is paid to the possibilities for doctors of managing patients’ feelings (and own feelings) in the rearranged pathways. The approach to the management of emotions in work and organisational settings To approach emotional injunctions to doctors in accelerated cancer pathways, I will use an Eliasian perspective on emotions, however without applying his greater framework of figuration sociology to the inquiry. His perspective is worth exploring in order to draw attention to how professional codes of conduct and exhibition of emotions in medical relationships are interwoven with the introduction of new modes of clinical governance in relation to cancer illnesses and their treatment. This section first explains some core elements of ‘The Civilizing Process’ theory (Elias, 2000) to understand socio-historical developments of formalisation and informalisation of emotions in processes of civilisation. Next, the section departs from the Elias follower, Wouters, to explain how we today witness an increasing demand for ‘smoother’ manners in health care organisations while these manners increasingly are formalised in measurable, standardised ways. A core theme in Elias’ work is how historical changes in power structures are reflected in changes in the ‘psychological make-up of people’ (2000: 369). Elias links the notion of civilité or civilization to changes in human codes of conduct and demonstrates how emotions are controlled in rationalised (i.e., civilised) societies. By doing this, he develops Weber’s (1978) historical view on rationalisation, bureauc- 110 racy, and the impact of rational practices on the organisation of the public sphere and interpersonal relationships. Elias describes the social advantages of ‘those able to moderate their affects’ (2000: 370) and he demonstrates how specific forms of ‘affect control’ and ‘management of the emotions’ are products of dual developments of socially instilled agencies and self-restraint. These modes of regulation are different from earlier versions of external control such as physical force or acts of extreme violence. In his view, the increasing functional differentiation of society has since the Renaissance caused an expanding mutual dependence of its members, which has led to a social necessity for controlling one’s feelings in public. One must interact and ‘be hospitable to a potentially vast array of others’ (Newton, 2001: 488), which also includes that one must interact with a ‘smooth’ face within employment and professional settings. Also Weber stressed what he saw as a dual process of rationalisation and emotional self-restraint in the emergence of modern societies. Indeed, one of the strengths of bureaucracy was that its employees would follow standardised rules and procedures ‘without regard for persons’ and conceal personal (i.e. individual) feelings, such as love and hatred, in dealing with human affairs (Weber, 1978: 600). In relation to emotions, and in conflict with many readings of Weber, the emergence of the bureaucratic organisation was not equal to a development of emotional deficit. Weber acknowledged that emotions are an essential part of professional office work, but he argued that emotions must be controlled in matters appropriate to an ethic handling of office cases. However, Elias goes even further than Weber in emphasising the importance of affect control as a constitutive element of modern societies. New patterns of emotion management are connected to the development of peoples’ increasing capacities of foresight, calculation and control. This also includes the capacity of individuals to observe and regulate themselves from the vantage point of others and to understand that expression of emotions has social consequences. Elias demonstrates for instance how the experience of repugnance and embarrassment en- 111 courages individuals to increasingly repress some passions in public encounters (e.g., anger, rage) while it opens up the possibility of the expression of other emotions (e.g., sympathy, happiness). The key objective here is that in professional work consisting of rational, bureaucratic actions, emotions are not as such neglected. Instead, emotions are increasingly being mouldered as part of the development of rational human agency. This happens in a complex interplay where people balance their emotions vis-a-vis others. Likewise, as also Goffman (1959) has described, people need to attune their conduct to that of others and their ’web of actions must be organised more and more strictly and accurately […] in an increasingly differentiated, more even and more stable manner’ (Elias, 2000: 367). Emotions, passionate impulses and desires undergo a civilising process with the result that they become increasingly formalised. The behaviour associated with civilité is shown to be directed towards the regulation of the conduct of individuals through detailed behaviour rules. Elias explains through lengthy empirical inquiry into etiquette books of the upper middle class in Europe from the late Middle Ages to the Renaissance, how highly refined rules of etiquette, such as how to eat meat and use knife and fork at a table, how to undress in the bedroom and how to blow one’s nose and spit in front of others represent a transformation of human manners. He argues that through the civilising process these formal standards of socially sanctioned emotional behaviour are gradually replaced by more informal – and often more implicit - codes of conduct as an ‘increasing social restraint towards self-restraint’ (2000: 365). In addition to Elias’ theory of civilising processes and the ‘commingling of patterns of conduct’, Wouters presents the argument that self restraint today has become both more skilled and more subtle. He refers to this trend as ‘informalization’ (Wouters 1986; 1999; 2009). The term refers to ‘the relaxation of the social codes [...] in combination with increasing social demands on self-control; it implies a change in the patterns of social control and self-control and also a higher level of reflexivity on the part of individual people’ (1999: 416-417). The expression resembles 112 the one used of Elias when he speaks about processes of ‘constrains to be unconstraint’ (Elias, 2000: 365-379). It indicates that processes of ‘self-constraints have not only become more flexible, at the same time they have also become more strict’ in recent developments of emotions control (Wouters, 1986: 1). According to Wouters, this trend gained momentum in the 1960’s and 1970’s, but is anyhow still one of the main characteristics of the civilising process. If we draw upon the Woodstock Festival as an example, we might get the impression that the festival and its surroundings’ emancipation rhetorics include a radical emancipation of emotions, since the refinement of self-restraint implies less rule-based standards of emotional behaviour and more ‘naturalness’ in expressions. But Wouters argues that informalisation implies a ‘different pattern of self-restraint [which] demanded not only greater sensitivity to varieties and greater flexibility in social conduct, but also a higher level of self control’ (1986: 1). The apparent relaxation of emotional control and the performance of seemingly natural or relaxed ‘decontrolled’ actions go hand in hand with a refinement of emotion management: such is the argument. Where do we see empirical evidence of informalisation in present-day work settings? According to Van Iterson et al. (2001) fieldtrips to public offices, such as tax bureaus, social welfare offices and hospitals, may give one the impression of a ‘lowered acceptance of power and status differences, abating ceremony in meetings’ and ‘increasingly relaxed interaction’ between people in the observed places (2001: 507). The authors also draw our attention to ‘the growing tolerance for informal clothing, the use of first names and colloquial speech, confessing private feelings and expressing emotions [...] and in general the blurring of the boundaries between “work life” and “private life”’ as examples of aspects of informalisation processes (ibid). In addition, Van Vree (2011) points to transformations of the ways in which people behave in professional meetings to provide evidence of the informalisation trend. Generally, dominant meetings manners – regulated by rigid rules and customs to keep polite manners and to control meeting participants when social tensions increased - 113 have become smoother, easier and more flexible. However, whereas meetings have lost some of the formal characteristics, attending meetings now places greater demands on one’s own initiative and feeling of responsibility. Informal meetings codes constitute just another set of pressure on how to behave, which might be experienced as even more restraining than previous formal rules. Participants in meetings must still act appropriately in front of others, but it is becoming more complicated what kinds of rules are guiding their behaviour. People thus need to find an agreeable balance between formal and informal behaviour; between formally defined standards of professional behaviour and informally unstated concerns of ‘truly engaged’ behaviour. To sum up, processes of informalisation do not represent a loosening of emotional display or more relaxed emotion codes, but rather their refinements through seemingly more ‘sincere’ or ‘natural’ practices. Health care reforms which demand more ‘empathic’ engagement or more ‘authenticity’ of doctors’ conduct, call for research attention, because they might tell us something important about the organisation of refined professional behaviour in health care organisations. Method The article is based on reflective analyses of material from a study concerning the management of emotions in accelerated medicine, which was completed in Danish health care services between June 2009 and January 2011. The selected material in this article provides evidence relating to some of the consequences of recent rearrangements of cancer care in Denmark, especially in regard to the emotional demands that these reforms impose on doctors working within cancer services. The Danish study supplements previous studies from especially UK National Health Services (NHS). The analysis has the following structure. First, I review documents issued by The National Board of Health, Denmark, The Danish Government and clinical 114 articles published in practitioner journals, using a relatively simple ‘informed content analysis’ (Prior, 2003: 21). The documents contain detailed trajectory descriptions and I focus on their definitions of technical, social and psychological components of medical work in the trajectories. The sources of data are approached to analyse ‘the active contribution of texts to organizational processes’ (Cooren, 2004). The document material is selected in relation to its status as public reform material, which is exemplified in policy documents such as The National Cancer Plan I-III and The Health Packet 2009. As reform attempts, these documents have brought about new ways of organising health care processes as essentially a matter of changing existing routines to provide efficient and effective cancer diagnostic and care, or so the explanations go. In the material, particular categories are highlighted, which are categories of ‘empathic’ engagement and ‘compassionate’ care, such as, ‘empathy’, ‘authenticity’, ‘engagement’, ‘responsiveness’, and so forth. The second stage of the analysis builds upon interview and observational data from a cancer clinic to discuss the practical circumstances of managing the feelings of others in the programs of accelerated medicine. Accelerated cancer pathways and the conceptualisation of the ‘stand up patient’ In Denmark the organisation of cancer illnesses and their treatment have recently been rearranged to improve the provision of health care services to patients with cancer. The National Board of Health, Denmark, has introduced two national ‘Cancer Plans’ (NBH, 2000; 2005a) and an outline for Cancer Plan III has been approved at The Danish Governments annual budget proceedings (The Danish Ministry of Finance, 2010). A fundamental element of the Cancer Plans is the implementation of the so-called cancer treatment packages (in Danish: ‘Kræftpakker’) to optimise therapeutic procedures and minimise delays at hospitals and improve continuation and coordination across the primary and secondary health care sector. The treatment package concept bears close resemblance to the widespread concept of ‘accelerated medi- 115 cine’10: both emerge from an ambition concerning the establishment of economic, effective and efficient patient trajectories in the health delivery system (Roelsgaard Obling, 2010). I intend to use the term ‘accelerated cancer pathways’ or ‘trajectory programs’ throughout the article to minimise confusion to the reader. Accelerated cancer pathways have been developed as an attempt to contain costs in an era of rising health care expenditures, limited financial resources and a political attention towards matters of public concern, such as empowering patient choice (‘patient-centredness’ rhetorics) and reducing waiting times for diagnostic and treatment. The trajectory program also seeks to meet clinical objectives by reducing the mortality rate of Danish cancer patients. The immediate effects of the implementation of the trajectory programs have been noticeable in regard to more rapid diagnostic and treatment procedures (NBH, 2010a), reduction of length of hospital stay11, standardisation of clinical procedures across hospital units, quality improvement initiatives concerning for example standardisation of after surgery recovery procedures, and new administrative processes of documentation and performance measurement (NBH, 2010b). A pervasive concern in the trajectory programs is what I term the stand up patient concern. Opposite to a traditional concern, where the patient must restore her bodily malfunction through bed rest and a non-defined length of hospital stay, the ‘stand up patient’ concern promotes the notion that patients become more ill if they stay in their (hospital-) bed for too long. Thus the point is here that the length of their hospital stay must be reduced. From this also follows that patients may get cured more efficiently through accelerated diagnostic and treatment processes, where wait10 I intend to use the terms ’accelerated clinical pathways’, ‘optimised clinical pathways’ or ‘treatment packages’ more or less synonymous through the text. All terms indicate an occupation with continuation and standardisation in a given line of treatment and therapy, and focus on economics, quality and performance measurement. The term ‘accelerated medicine’ is used as an assemble term to capture core themes of accelerated cancer pathways, such as ‘packaged diagnostic and treatment’; ‘optimised care’; ‘accelerated trajectory’; ‘fast track surgery’ and ‘integrated care’. 11 The general length of hospital stay for women who has been surgical treated for breast cancer has recently been reduced from 3,6 days to 1,2 days (Gärtner, 2010). This also includes women who had been operated for a tumour in the breast and where the whole breast has been removed. 116 ing times – including recovery time - are reduced while they are hospitalised. The patients’ efforts to regain strength are transferred to locations outside the hospital – for example to private homes or rehabilitations centres. In a document issued by the Danish Government concerning quality reforms in the public sector it is stated that the result of the accelerated programs is ‘that patients faster can get back to a normal life’ (The Secretary of Ministers, 2007: 1). The health benefits to the patients are invoked as the key driving agent of the reform, but means of resource allocation also lie in the centre of these reforms. Advocates for the ‘stand up patient’ concern focus on accelerated trajectories as a future way to organise illness trajectories that will include ‘optimised quality and economics with a reduction of hospital beds as a derivative consequence’ (Kehlet and Hoejgaard, 2004: 4707). Emotional injunctions to doctors in accelerated cancer pathways An essential part of the accelerated cancer pathways is the introduction of new modes of clinical governance, i.e., new forms of controlling professionals’ activities in clinical work. The activities in the accelerated cancer pathways are organised by written ‘trajectory descriptions’ which in detail determine how doctors ought to diagnose, treat and inform patients in the pathways. As originator of the trajectory descriptions, The National Board of Health, Denmark, describes in a policy document the aim of introducing the accelerated cancer pathways in the public health sector as that of providing ‘optimal’ services along a variety of parameters. It says in the document: ‘The aim of “cancer packages” is to provide optimal diagnostic and treatment to patients in regard to shorten the pathways and hence improve prognosis, quality of life and decrease the anxiety caused by waiting time, where the cause of delay is unknown’ (NBH, 2008a: Foreword) The term ‘packages’ defines ‘patient pathways, where every step is organised as time and content well-defined events, which follow a pre-booked trajectory plan’ (NBH, 117 2005a). Furthermore, NBH emphasises that it is of crucial importance to ‘diagnose and treat most [cancer] patients in very fast trajectories’ (NBH, 2008b: 1, my emphasis). The descriptions show how hospitals must adopt ways to streamline and accelerate patient flows through what resemble methods of lean management and business process redesign. In other words, it is performance and management practices similar to those used to reduce financial costs, improve quality and address problematic bottlenecks in the Japanese car industry. The contention is that tight process control and closely integrated operations are more productive (Lowe et al., 1997). The trajectory descriptions, which determine clinical work procedures as well as social and psychological aspects of these procedures in the accelerated cancer pathways, are mainly based upon evidence based, national and nation-wide clinical guidelines and recommendations12. They consist of detailed procedure descriptions of the pre-hospital care phase of the pathways (for example pre-diagnostic examinations in primary care); the diagnostic phase; the treatment (surgical) phase; and the adjuvant phase. But descriptions of more general elements in relation to rehabilitation, palliation, provision of nursing care and delivery of patient information (NBH, 2005a; NBH 2008a) are also included in the documents. A closer look at one of the descriptions, namely a description of the organisation of breast cancer illness and its treatment sheds light on the treatment phase of the program (NBH, 2009a: 15): 0 Day. Managing patient referral; booking of patient-doctor consultations and examinations (3 days) 12 Clinical guidelines are frequently used by doctors in their daily medical work. The guidelines typically guide medical decision making processes in the treatment of patients. Typically in cancer programs, the nation-wide clinical guidelines are developed by a professional society which is in charge of keeping the guidelines up to date and who are responsible for communicating the content of these guidelines to doctors across the private and public health care sector working within the field. See for example the work of The Danish Breast Cancer Group (http://www.dbcg.dk/). National clinical guidelines are developed by The National Board of Health, Denmark. The clinical guidelines support the various actions in the patient pathways and are thus a fundamental part of the development of the cancer ‘trajectory descriptions’. See for example the NBH document on ‘Connection between clinical guidelines and ‘trajectory descriptions’ (NBH, 2009b). 124 ining the lymph nodes under the armpit; prescribing medicine for nausea and vomiting): the provision of ‘empathic’ engagement must be recorded in the patient record system. David explains this request for recording practice: ‘In a modern hospital, where everything is measured and controlled, one must always record one’s conduct. This includes a registration of the exhibition of empathy. If you are not willing to do this, the clinic’s spending account may get reduced by the hospital management, because then we are not able to document that we spend our time in the consultancy rooms providing sincere care. If your job is to manage an emotional problem of a patient and if this problem is not measurable, then you get into deep troubles in cases where you need to explain your rationale for doing things to others, for example in auditing. We thus need to write down what we do. By doing this manoeuvre we also make sure that everybody follows the same standard procedures’ A possible reading of this statement is that clinics or hospital units that record their public exhibition of ‘emphatic’ engagement most effectively in the record system are likely to keep their granted budget, since they can prove that the consultancy time spend in the clinic is spend managing ‘an emotional problem of a patient’ and they can thus prove that they meet diverse interests, such as political and managerial pledges and clinical objectives. It also embraces lay expectations towards ‘being met by the doctor as a whole person instead of a case among many others’. On the doctor’s part there was not any irony in the statement with regard to this rather contradictory dimension of the provision of empathy. The ‘soft’ dimensions of his work must be surrounding by the same quality standards and biomedical rationality as the ‘harder’ aspects of his work, or that is the impression he gives. 125 Various forms of emotional conduct not only has to be recorded in patient records, as written confessions of engagement to secure the annual budget, but must furthermore be recorded as part of the concerns of a national quality plan, entitled Quality First (Region Hovedstaden, 2010). This quality plan outlines ten strategically objectives for ‘bringing the patient in focus’. One of these objectives is that patients ought to feel safe, respected and understood when discharged from the hospital. To facilitate that this objective is followed at local department levels, an annual performance measurement of how individual professionals manage to make patients feel confident before hospital discharge has recently been implemented (I draw here on an internal auditing document from a university hospital in Denmark, 2010). The annual assessment of the management of patients’ feelings is introduced together with initiatives to educate doctors in knowing the emotions of others through medical training and communication courses. Through this training, the doctors are expected to be able to manage the emotions of patients both more effectively and more efficiently. Discussion As has been shown, the occupation with various forms of engagement in accelerated medical relationships is saturated with demands of efficiency, quality and new techniques to improve the outcome of the pathways. Herein lays an apparent peculiarity: the more the importance of ‘compassionate’ care is stressed in accelerated medical work and the more emotional display of the doctor is focused upon, the more emotions become subject to measurement, standardisation and control. These manoeuvres are easily understood on a paper level. Putting them into practice proves a lot more difficult, because how does one actually measure the delivery of for example ‘sincere, ‘empathic’ engagement? In the beginning of the article, I quoted the two English scholars, David A. Buchanan and Louise Fitzgerald (2011), for rhetorically asking how the delivery of compassion in patient-doctor interactions is to be measured and by whom. The previous quote from a doctor suggested that when there is no hard 126 data available, the obvious response is to generate some, and thus to measure empathic responses and emotional behaviour alongside other clinical interventions. There is nothing radically new in suggesting that for patient-doctor interactions or professional-client interactions to succeed it requires emotion management on the part of professional workers to regulate the feelings of patients or clients in public meetings. For instance, it takes elaborated effort to reduce feelings of alienation when patients attend the medical system (James, 1993; Lupton, 2003b; Bolton, 2005). Management of emotions typically operates through what Elias terms ‘emotion codes’ or ‘codes of emotional display’. These codes are socio-historical constructed and are hence up for steady historical and cultural unravelling. In the context of this paper, doctors apply emotion codes of medical rationality to handle patients’ feelings when a patient attend the clinic for advice about, and treatment of, complaints. These codes are typically internalised norms and values regarding the experience and expression of emotions, which are learned through vocational training, supervision and hours of clinical practice experience (Smiths and Kleinman, 1989). As such the emotion codes function as standards of socially sanctioned behaviour regulating the experience and expression of patients’ emotions (not to forget the regulation of doctors’ own feelings) in the different diagnostic and treatment phases of the accelerated cancer pathway. While there is nothing groundbreaking in suggesting that the managements of feelings is a necessary part of doctors’ work, it is the very presentation of emotions in the trajectory descriptions of accelerated medical work which represents a significant trend. The descriptions contain a promotion of for example ‘good’ communication and ‘responsiveness’ as effective, personal competences of the doctor, and moreover as competences which are currently lacking in medical relationships. The trajectory descriptions’ occupation with reducing waiting times and with treating patients more rapidly leads to the concern that human components of the programs are missing. Hence, emotional competences of the doctors ought to be developed to bring back the ‘human’ components into practice. In fact, these compe- 127 tences are presented in the descriptions as crucial for the success of the pathways. The emotional competences promoted by the reviewed documents issued by the National Board of Health, Denmark, are competences in tune with contemporary values of ‘empathic’ engagement or ‘authentic’ engagement, which are promoted by the medical humanities literature. This kind of literature, as explained in the introduction, exactly requests doctors to engage authentically with their patients and to engage themselves ‘entirely’ (i.e. they ought to deploy skills of social intimacy) in the consultancies in order to provide efficient treatment and care (e.g. Charon, 2001; Shafter, 2009). If we accept that the trajectory descriptions can be viewed as insetting demands of specific kinds to emotional behaviour in the accelerated pathways, then the implications of emotional injunctions to doctors’ work are significant. This includes formal standards of interactional behaviour to use for example in precarious situations where the doctor ought to deliver a cancer diagnosis to a patient as well as more informal concerns of dialogue-based, responsive behaviour to utilise in meetings where the aim for example is to ‘empower’ the patient and her ‘inner’ strengths in the treatment process, or to calm her down if her world is falling apart, provoked by her illness. That is, I argue, an insertion of both formal and informal rules of emotional behaviour in relation to public meetings between professionals and patients. First, as formal rules the trajectory descriptions compel the doctors to act correctly according to a set of formally defined standards – and of course according to professional emotion codes. Second, as informal rules the descriptions inset demands to the doctors to behave accordingly to a set of unstated, flimsy, yet strongly expected ways of behaving, for example through ‘empathic’ engagement or ‘compassionate’ care. This commits doctors to find a delicate balance between formal and informal emotional behaviour while they respond to the needs of their patients. Following this Eliasian perspective, it may be argued that the distinct emotional injunctions, which are promoted in the trajectory descriptions, may repre- 128 sent a further step in processes of civilising emotions and, what is more, the descriptions inset a quest for the strategic and deliberate elicitation of particular emotions, while it simultaneously frame the role and experience of other ‘inappropriate’ emotions. During this most recent phase of social development, the challenge of doctors is to regulate their conduct, not only by means of professional ideologies, clinical guidelines and rigid rules of standardisation, but also by means of conscious reflexion on deliberate expression of emotions. The further civilisation of the conducts of doctors may lead to increasingly more complicated and more extensive modes of selfpresentation in medical relationships. A possible outcome of this could be a higher risk of job burnout or morale fatigueless within the profession of medicine. Concluding thoughts The aim of this paper was to show how recent health care reforms and the introduction of accelerated cancer pathways inset emotional injunctions to medical professionals. Through review of documents and other qualitative material it has been demonstrated that these reforms require that medical professionals exhibit particular emotions in patient-doctor interactions and that the management of patients’ feelings is conducted in ways that can be recorded and be subject to quality improvement. The core of the papers’ argument is the apparent contradiction between the emotional injunction to doctors to become emotionally available to patients and the fact that this availability (for the provision of empathy and authenticity) itself must be measurable and rationalised. The request for emotions and emotional behaviour in medical work is not as simple as it might sound. On one hand, the trajectory descriptions for example ask us to pay attention to emotional engagement; it asks for ‘authenticity’ and ‘sincerity’. The descriptions encourage doctors to display and experience ‘sincere’ emotions while providing various medical services to patients. And they furthermore ask the doctors to use ‘themselves’ in this process. This is in tune with the lay paraphrase 129 ‘patients want real, unique people not robots when they attend the health care services for help’. On the other hand, the descriptions anticipate the need for making this emotional appearance measurable and subject to quality improvement, and hence they frame emotions in patient-doctor interactions as something, which can be managed, evaluated and measured. Urges for formality and informality of emotional behaviour in medical work complicate what it is exactly that is expected of doctors in public meetings (e.g. Van Vree, 2011). The emotional injunctions inset by recent reforms of the public health care sector hence promote both a ‘humanisation’ ideal and a ‘standardisation’ ideal in the management of emotions: the reforms expect doctors to be compassionately engaged while they also expect them to display emotions in extremely regulated ways that are measurable and can be benchmarked across department units and health care organisations. Present trends of ‘compassionate care’ may be seen as a trend where emotional restraints are cast off in favour of more self-expression and liberated emotional expressions of ‘empathy’, ‘authenticity’, ‘engagement’ and ‘responsiveness’. Wouters (1989) however, argues with reference to Elias that this development can more accurately be seen as a tendency of ‘controlled de-controlling of emotions’ (1989: 106). The complexity of medical procedures in the accelerated cancer pathways and discourses of ‘compassionate’ care and more ‘human’ engagement, result in increasing emotional control rather than in the loosening of ways of emotional behaviour of medical professionals in the public health care sector. If one interprets the emotional injunctions issued by the National Board of Health and other public agencies from the vantage point of Elias, the discourses of emotionality and the realisation of a ‘compassionate doctor’ is just a further evolutionary step in the long-term structural development of societies and the changes in peoples’ social character. The emotional injunctions to medical professionals appear contradictory when we situate them in the clinical environment of the accelerated pathways in which they are brought to work. The health care reform documents encourage proc- 130 esses of standardisation while expecting room for personal and unique concerns; they emphasise intimacy while expecting maximum acceleration of services; they advocate for looser or more relaxed forms of emotional behaviour while strengthening regulation and control of others’ and own emotions; they grant attention to the individual patient while expecting streamlined flows of patient cases, and finally they demand reflexively orchestrated ways of managing emotions while reducing the available time for this kind of work down to ‘one shot available’. Somehow counterintuitive, then, it seems that emotions and the management of emotions play a significant role in organisational structures that systematically both accelerate and reduce human interactions in public meetings, while intending to make these interactions more ‘human’. 131 Chapter 6: Training of controlled empathy in accelerated cancer care Abstract This paper uses the dramaturgical lens of Goffman to explore the training of controlled empathy in accelerated cancer care. The paper focuses on a training workshop in ‘empathic communication’, during which doctors from a cancer clinic learn to recognise and control the emotional framing of doctor-patient interactions. Through a descriptive analysis, it addresses how communication techniques are rehearsed and it discusses the effects of this training. It is shown that the performance of communicating empathically relies on standardised scripts, which direct and cultivate the conduct of doctors. The paper concludes that contemporary reforming drives in public health care insert a renewed focus on humanistic values in medical interactions between doctors and patients, such as a focus on doctors’ modes of engagement in these interactions. However, these values increasingly become the aim of techniques of micromanagement such as qualitative measurement and performance audit. In other words, attempts to improve ‘soft’ dimensions of medical services entail a further standardisation of these dimensions. Keywords: Medical training, empathy, doctors, Goffman, cultivation of conduct. Introduction The paper explores the training of ‘empathy’ and ‘empathic responses’ in medical interaction. More specific, it focuses on how doctors’ management of emotions can be trained as a response to a current movement towards rationalisation and tighter control of medical work. In addition, the paper explores how this training may also be a response to a current movement towards making medical services – including interactions between doctors and patients - more human. 132 My empirical inquiry is situated in the context of present-day healthcare in Denmark. Recent introductions of managed care processes for the production and efficiency of public healthcare services have resulted in a reorganisation of cancer illnesses and their treatment in to accelerated patient pathways, focusing on clinical work procedures, quality improvement and documentation standardisation. In the Danish health care system, cancer illnesses are organised in so-called treatment ‘packages’. The purpose of the introduction of these packages is to reduce waiting times and organisational delays, speed up processes of diagnosing and treatment, and strengthen the coordination of patient treatment between hospital units and sectors. Attempts to organise the treatment of cancer illnesses into streamlined production units are not only present in Denmark but for instance also in the UK (e.g. Harrison and McDonald, 2008). On the one hand, the accelerated cancer pathways are part of a clinical strategy to improve the overall health outcome by offering patients safer and more effective care. On the other hand, the pathways are a symptom of New Public Management and managerial means to rationalise public services and directing the conduct of public professionals (Power, 1997; Du Gay, 2000b; Miller and Rose, 2008). Generally, the intention is to make health care organisations more accountable, more customer-oriented and more efficient in their use of resources. These requests for performance improvement involve a movement towards rationalising medical work. As a new mode of governance, these reforming drives not only concern the so-called ‘hard’ dimensions of medical work (EBM, clinical procedures, economic incentives, safety and audit tools). As an object of interest of this paper, the reforming drives also include a pronounced focus on ‘soft’ dimensions of medical services. I call these dimensions soft, because they, among other things, comprise the ways in which health care workers today are expected to make themselves emotionally available to patients through a facilitation of ‘partnership relationships’ between doctor and patient (Bub, 133 2004) and through ‘patient-centred’ interactions (Mead and Bower, 2000, Mead, 2002). The paper takes its point of departure in this configuration of today’s medical services and demonstrates how the ‘emotional availability’ of doctors becomes object for attempts of governance, intended to structure and control the interaction between patients and doctors as well as to cultivate the conduct of doctors. The body of the research presents material collected from a training workshop in ‘empathic communication’. Participants in the workshop were health care workers from a cancer clinic. The training involved that especially doctors participated in stage performances and were trained in performing ‘empathic’ responses in interactions with patients. The aim of the workshop was to make these relationships more efficient; to save time and improve the quality of care. The exact clinical ‘problem field’, which the training workshop was an answer to, is the difficult or serious communication act where details about diagnosis and clinical treatment plans are delivered in the medical consultation. An intrinsic focus in the accelerated cancer pathways is a focus on the development of communication skills, including empathic response skills. The assumption is that better communication between cancer patient and doctor not only improves the over-all health outcome, but also facilitates the accelerated procedures of medical interventions in the pathways. According to the imperative of effective communication, which is put forth by for instance official descriptions of the cancer pathways (The National Board of Health, Denmark, 2008a; 2009a), a good doctor masters various communicative competences. As a competence, communication can be used by doctors to help coordinate actions and emotion conducts between themselves and patients, and within themselves. Central to these ideas about communication competence is how communication can be mobilised as means of cultivating the conduct of the doctor (May et al., 2006). By claiming that problems in interactions 140 department and a medical training department at the hospital. Their meetings have resulted in a detailed training description and they have collectively constructed two illness cases. These cases are typical of emotionally challenging situations in the clinic and they frame the content of the later role-plays. Approximately one week before the workshop, the staff received a formal letter from their department heads informing them about time and location of the planned event. Workshop participation was mandatory (i.e., ‘On October the 8th, you need to attend a training course at 8.30 AM’), and the staff was divided in half so that they could join workshop in two shifts without completely closing down the clinic’s acute activities. A description of the training course was attached to the letter, which was signed by the consultants ‘who look very much forward to finally meeting everybody’. The purpose of the workshop was explained to staff members in the letter. It says: ‘Through the use of communication tools, participants will be able to structure and manage a difficult patient conversation, while being conscious about what they are bringing to the conversation – on both a personal and professional level – with respect to the patient’. The construction of a respectful conversation between patient and health care worker has often been conceptualised through the notion of ‘empathy’ and the development of skills of empathy and sympathy (Mark, 2005). The emphasis on learning skills of empathy is further explained in the invitation: ‘Achieving and controlling skills of empathic communication is not a question of personal style or of having the right personality traits [...] empathic communication skills result in effective consultation, satisfied patients and an increased overall patient comfort’. 141 The emotional components of communication involved in the service culture of health care organisation can be labelled ‘emotional labour’ (Hochschild, 1983). This includes the management of patients’ feelings through for instance recognised and controlled communication skills. The workshop invitation situates a need for the establishment of ‘patient satisfaction’ in the consultation between doctor and patient, and the question becomes how the training in techniques of emotion management can be effectively achieved at the workshop. The training sessions On a particularly rainy October morning, half of the clinic’s nurses and doctors gathered in a training facility. Department heads had joined a similar session the day before and were therefore not present on this particular day. In their role as hostesses of the event, the two consultants welcomed the participants and introduced them to the workshop activities. The workshop consisted of three separate sessions: an oral presentation on how to perform a serious/difficult conversation, a two-person teamwork (including discussions about and training of empathic communication skills in smaller groups) and role-playing scenarios with simulated patients. The first two sessions provided the education platform on which the subsequent role-playing scenarios were based. One of the consultants explained at the beginning of her oral presentation that: ‘It is not necessary to be a psychiatrist to use empathic communication. What is required is that you are self-aware of clues for empathy, as these clues arise during encounters. Typically, the clues will come from patients’ emotional outbursts, and these will be the clue to your empathic response. Today, we shall focus on training these emotional responses’. 142 The professional conversation, the participants were told, is a ‘patient-centred’ conversation. It takes as its points of reference both the patient’s knowledge and understanding of his or her illness, and the patient’s particular emotions. The patientcentred conversation consists of three parts: content (e.g., information about test results); process (e.g., facilitation of conversation) and relations (e.g., emotional support through active listening). The performers were taught about the importance of facilitating the conversation process while recognising the needs of the patient. The performers were also introduced to elements of crisis psychology. Empathy, or as they were told, the ability to identify with another person’s point of view and feelings, is an instrumental skill in health care worker-patient relationships through which the patient must be recognised and labelled as an emotional individual. Furthermore, empathy can be evoked to sustain the flow of medical situations. Once in a while during the presentation, the participants were told to practise small conversations in pairs. One of these exercises was, for instance, a mirror exercise, in which the teams were told to communicate an essential experience from the clinic to one another and then to re-tell the story in detail, mirroring every sentence and summing up the main content of the story. One of the participants took her point of departure in a recent experience with a young mother who had a very bad prognosis due to her progressed cancer illness. The doctor explained how she tried to facilitate this woman and how this was difficult because the doctor experienced that she was getting too emotionally involved in the situation on a personal level. After each story, audience had to tell the performer that his or her particular experiences were both meaningful and understandable. Their task was to show cues of empathic communication and thereby appreciate the emotions, values and reasoning of another person. Listening to others, or in this case mirroring another’s feelings and interpretations, was described by the consultants as crucial to the ability to prevent conflict during interaction. Moreover, active listening furthers the creation of cooperation between professionals and patients and facilitates intimate clinical procedures. 143 The next step in the program was to train emotional responses in order to evoke an impression of an engaged doctor in others. To focus on emotional responses, the oral presentation took the participants through the general rules of empathic communication, which they must follow in role-playing scenarios where serious messages (i.e., details on the diagnosis of cancer and treatment possibilities) are delivered to patients. Statements that facilitate empathy, the participants were told by the consultants, include queries (e.g., ‘How does this information make you feel?’ and ‘Can you tell me what you feel now?’), clarifications (e.g., ‘I want to make sure that we agree on this’ and ‘Do you understand why this next step is important?’) and responses (e.g., ‘I can understand what you feel’ and ‘It sounds like you are very upset now’). In pairs, the participants then discussed what tends to work and not work in interactions with patients in the clinic by drawing on their own experiences. Issues such as professionalism, emotional outbursts (e.g., anxiety or anger), recognition of patients’ feelings and control of conversations were debated and these topics were subsequently discussed briefly in a plenary session before the role-playing scenarios. One participant summed up his experiences from the exercise, clarifying that: ‘All of us must agree that the most important thing, no matter how much we talk about communication and attend to what the patients prefer, is that we rely on our professionalism. This means that we must act relatively certain and simultaneously try to be both intellectually and emotionally responsive, which also includes taking control with and guiding the content of patient encounters’. Goffman (1956) writes how ‘during interaction the individual is expected to posses certain attributes, capacities, and information which, taken together, fit together into a self that is at once coherently unified and appropriate for the occasion’ (1956: 268). 144 As stated by the participant in the quote, there is no discernable difference between one’s self presentation as intellectual (i.e., detached professional), who frames and control the interaction, and the presentation of an emotional self, who responds to the affective needs of a patient. However, what is important in this statement is the problematization of communication in relation to a classic conceptualisation of a doctorcentred model of medical consultation. The focus on communication may involve a refiguration of the consultation and the kind of work this particular situation involves on the part of doctors. The next item on the agenda was a staging of two role-playing scenarios. Staging the role-playing scenarios While planning the workshop, the department heads had identified two typical cases of emotionally challenging situations for the staff: one case in which a patient reacts emotionally cold and distant and another case in which a relative to a patient reacts emotionally inappropriate and is too emotionally involved. The two cases represent situations in which an individual fails to respond and give off a predictable impression to a predefined, scripted situation. The patient and the relative are presented as either not emotional enough or too emotional to match a general presentation of a ‘cancer patient’ and a ‘cancer relative’. The performers on the stage are: two professional actors who play the roles of respectively ‘patient’ and ‘relative’, male doctors who play the part of ‘doctor’ and female nurses who play the part of ‘nurse’. The stage is designed so it looks like an ordinary outpatient consultancy room. Before the role-playing scenario started, the consultants instructed the performance team to act ‘naturally’ as if the stage performance was taking place in the clinic. The team was also told to keep in mind the ‘props’ they had been given during the morning session on the rules of empathic communication. 145 First stage performance: A patient who is emotionally cold and distant The script of the role play is written down in handout notes, which the performers read through as if they were medical record sheets: ‘The time is 14:05 PM and in cooperation with the nurse, you are going to talk with a patient. Your task is to inform the patient about surgery and plans for further treatment, including the duration of the hospitalisation stay, the hospitalisation procedure, adjuvant treatment (radiotherapy) and pain therapy’. This first role-play was constructed to challenge the performers with an illness case, where the patient’s behaviour is described as deviant in terms of her cold attitude. The note further explains that: ‘The doctor has just been informed by the nurse that the patient has been complaining several times about the long waiting time and is now seriously upset. The patient is very annoyed with the system [the healthcare system]’. The role-playing then starts. The patient is an elegant middle-age woman, dressed in black and carrying a laptop handbag. She is clearly annoyed with everything and complains about why everybody seems to have ignored her during the long waiting time. The two performers, i.e., doctor and patient, engage in a conversation: Patient: I would like to know the exact date of surgery. I need to find somebody who can take care of my kids while I’m hospitalised. Doctor: I will find you a date in our booking system. You will be asked to attend the clinic around 7 AM on the day of surgery […] During the sur- 146 gery, we will take some tissue samples for pathology […] Next, I will demonstrate how we plan to do the surgery. Patient: I live together with my two kids. I’m divorced, and I have full custody. I need to have some answers – for example, how am I supposed to inform my work about my illness? Doctor: We have found a malign lump in your breast, and we need to remove it. We will make a surgical excision of your lymph nodes in the arm pit. I now want to show you how we make a so-called sentinel node procedure [He draws a rough sketch of the lymph node system]. Patient: It is difficult to comprehend what all this actually entails [...] Should I be worried about my future? Doctor: After the surgery, you will be offered radiotherapy. Radiotherapy is standard after-treatment to patients undergoing lumpectomy [...]. Now we should talk about the schedule of the day of your surgery. During the performance the doctor manages the various impressions that he earlier learned during the group exercises to facilitate empathy. He nods; holds eye contact; makes small conversation breaks, and tries to use the phrases that the performers have practiced to provide ‘active listening’. However, most of all, he seems to have captured the objective of ‘being in control of the conversation’. He neither asks the patient about her frustration against the ‘system’ and, perhaps more important, nor does he respond to the patient’s small cues to change the script - for example, when the patient wants to talk about her future prognosis and family situation. The doctor’s display of empathy is hence boiled down to a registration of the emotions of the patient and he tries to neutralise or manage the emotions of the patient, which he finds disturbing to their relationship. The doctor directly faces the audience and tells it that he perceives the patient as ‘being cold and non-responsive’. 147 In his opinion, she does not fit into the official ‘frame’ of the situation because her mode of appearance is deviant from for instance a presentation of a crying individual. The consultant interrupts the stage performance after approximately 30 minutes. At that time the performers have agreed on a treatment procedure and a date of surgery. They have also shook hands and said goodbye. The consultant credits the doctor for following his tight script of procedures and for delivering a clear message. One audience notices: ‘The performer [the doctor] did a very nice job. There is a lot of information to go through in our compressed patient interactions, and the performer managed to deliver the information details without getting tackled by the patient’s attitude problems’. The consultant then asked them, what would have happened if the doctor (an actor) had missed important bits of information. One of the participants answered: ‘Then we definitely need to see or talk to the patient again’. She continued: ‘These patients will make formal complaints about the quality of information; they will feel insecure and will have difficulty in letting us go, and perhaps they will turn down treatment offers. Basically, they won’t have any trust in our system. We also need to pay attention to the patient’s individual needs so that we can enter the provision of empathy in our medical records’. The example demonstrates how the doctors, on the basis of some standards of communication, are extremely occupied with the delivery of detailed information about the patients’ treatment possibilities and planned procedures. The more intimate matters concerning cancer illness and the effects on individuals’ lives are not a part of the script of delivering a treatment plan. Hence, the script does not evoke empathy in a classic interpretation of the term; rather it provokes what I term controlled or restricted empathy. In the last quote, it is furthermore noteworthy how one of the per- 148 formers couples various demands to the delivery of information, including the provision of empathy and the ability to turn to individual needs of those who attend the clinic for help. It may also point to how emotional expression or behaviour, such as skills of (controlled) empathy or sympathy, in today’s health care organisations needs to be performed in standardised ways in order to be recorded, audited and benchmarked across hospital department units. This thought is backed up in the interview data where a doctor (‘David’) stresses how the registration of the exhibition of empathy is connected to the clinic’s annual budget negotiations with the hospital administration. Second stage performance: The relative who is too emotionally involved The second stage performance was staged with performers similar to the first play (‘doctor’, ‘patient’), but with the addition of a family member. The stage script also resembled the first, but the key challenge was slightly altered. The script says: ‘You are delayed in your outpatient program and have not been able to attend the waiting patient and her relative before now. You have not met the patient before (a colleague has conducted a biopsy the previous week and delivered a diagnosis of cancer on that basis)’ In addition, the performers are told that the patient has brought along her daughter. This daughter has a background in nursing, and she is very emotionally affected by her mother’s diagnosis. The role-playing starts. The daughter has some difficulty in understanding why a mastectomy (i.e., removal of the breast) is a necessary step to secure her mother’s health outcome and she continually returns to this topic throughout the conversation. She also cries and offers some serious emotional-laden playacting. The doctor draws on various tricks to convey empathic responses to the daughter’s emotional outbursts - for ex- 149 ample by asking open questions: ‘How do you feel about receiving this information?’ and ‘Can you tell me about any of your thoughts right now?’, and by showing that he has recognised her feelings: ‘This is not easy, I know’ and ‘I understand that you feel upset right now’. However, the doctor is left somewhat confused 20 minutes into the role-play. By this time, he has already turned to the audience once to explain that ‘a curtain has dropped between me, the patient and her illness’. He also says that ‘the daughter clearly does not embrace my information’. The doctor then signals, that he is in trouble. He starts to blush and stumbles over his words and uses response cries such as ‘um’ and ‘uh’ and ‘oh’, which express that the interaction is in some kind of crisis. The result of a break down is serious, because the doctor risks losing ‘face’ in the presence of both fellow performers and audience. The consultant therefore breaks off the session to limit the extent of interaction damage and asks the performer directly what next step she proposes to reconstitute the emotional balance of those involved. The performer answers – probably in order to save his own show and ‘to successfully stage his character’ (Goffman, 1959: 203): ‘In a real situation, I would ask the patient to take off her clothes and physically show her by touching her why it is necessary to remove her breast. And then I would explain how choices in surgery techniques have consequences for her survival of the cancer illness [...] And then I would tell her to leave her daughter at home the next time we meet.’ The last comment makes the audience laugh. It is no coincidence that performers and audience at this point start to make fun of the situation. Reconsider Goffman, when he writes that ‘joshing sometimes occurs as a mean of releasing the tension caused by embarrassment’ (Goffman, 1956: 271). This ‘joshing’ laughter functions as a sort of channel of distraction, which the performers and the audience can use in turn as a way of emphasising that ‘this is not a real situation’ or in order to declare that what A case study of the Fashion and Design Branch of the Industrial District of Montebelluna, NE Italy 12. Mikkel Flyverbom Making the Global Information Society Governable On the Governmentality of MultiStakeholder Networks 13. 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Jakob Elming Syntactic reordering in statistical machine translation 20. Lars Brømsøe Termansen Regional Computable General Equilibrium Models for Denmark Three papers laying the foundation for regional CGE models with agglomeration characteristics 21. Mia Reinholt The Motivational Foundations of Knowledge Sharing 22. Frederikke Krogh-Meibom The Co-Evolution of Institutions and Technology – A Neo-Institutional Understanding of Change Processes within the Business Press – the Case Study of Financial Times 23. Peter D. Ørberg Jensen OFFSHORING OF ADVANCED AND HIGH-VALUE TECHNICAL SERVICES: ANTECEDENTS, PROCESS DYNAMICS AND FIRMLEVEL IMPACTS 24. Pham Thi Song Hanh Functional Upgrading, Relational Capability and Export Performance of Vietnamese Wood Furniture Producers 25. Mads Vangkilde Why wait? An Exploration of first-mover advantages among Danish e-grocers through a resource perspective 26. Hubert Buch-Hansen Rethinking the History of European Level Merger Control A Critical Political Economy Perspective 2009 1. Vivian Lindhardsen From Independent Ratings to Communal Ratings: A Study of CWA Raters’ Decision-Making Behaviours 2. Guðrið Weihe Public-Private Partnerships: Meaning and Practice 3. Chris Nøkkentved Enabling Supply Networks with Collaborative Information Infrastructures An Empirical Investigation of Business Model Innovation in Supplier Relationship Management 4. Sara Louise Muhr Wound, Interrupted – On the Vulnerability of Diversity Management 5. Christine Sestoft Forbrugeradfærd i et Statsog Livsformsteoretisk perspektiv 6. Michael Pedersen Tune in, Breakdown, and Reboot: On the production of the stress-fit selfmanaging employee 7. Salla Lutz Position and Reposition in Networks – Exemplified by the Transformation of the Danish Pine Furniture Manufacturers 8. Jens Forssbæck Essays on market discipline in commercial and central banking 9. Tine Murphy Sense from Silence – A Basis for Organised Action How do Sensemaking Processes with Minimal Sharing Relate to the Reproduction of Organised Action? 10. Sara Malou Strandvad Inspirations for a new sociology of art: A sociomaterial study of development processes in the Danish film industry 11. Nicolaas Mouton On the evolution of social scientific metaphors: A cognitive-historical enquiry into the divergent trajectories of the idea that collective entities – states and societies, cities and corporations – are biological organisms. 12. Lars Andreas Knutsen Mobile Data Services: Shaping of user engagements 13. Nikolaos Theodoros Korfiatis Information Exchange and Behavior A Multi-method Inquiry on Online Communities 14. Jens Albæk Forestillinger om kvalitet og tværfaglighed på sygehuse – skabelse af forestillinger i lægeog plejegrupperne angående relevans af nye idéer om kvalitetsudvikling gennem tolkningsprocesser 15. Maja Lotz The Business of Co-Creation – and the Co-Creation of Business 16. Gitte P. Jakobsen Narrative Construction of Leader Identity in a Leader Development Program Context 17. Dorte Hermansen ”Living the brand” som en brandorienteret dialogisk praxis: Om udvikling af medarbejdernes brandorienterede dømmekraft 18. Aseem Kinra Supply Chain (logistics) Environmental Complexity 19. Michael Nørager How to manage SMEs through the transformation from non innovative to innovative? 20. Kristin Wallevik Corporate Governance in Family Firms The Norwegian Maritime Sector 21. Bo Hansen Hansen Beyond the Process Enriching Software Process Improvement with Knowledge Management 22. Annemette Skot-Hansen Franske adjektivisk afledte adverbier, der tager præpositionssyntagmer indledt med præpositionen à som argumenter En valensgrammatisk undersøgelse 23. Line Gry Knudsen Collaborative R&D Capabilities In Search of Micro-Foundations 24. Christian Scheuer Employers meet employees Essays on sorting and globalization 25. Rasmus Johnsen The Great Health of Melancholy A Study of the Pathologies of Performativity 26. Ha Thi Van Pham Internationalization, Competitiveness Enhancement and Export Performance of Emerging Market Firms: Evidence from Vietnam 27. Henriette Balieu Kontrolbegrebets betydning for kausativalternationen i spansk En kognitiv-typologisk analyse 2010 1. Yen Tran Organizing Innovationin Turbulent Fashion Market Four papers on how fashion firms create and appropriate innovation value 2. Anders Raastrup Kristensen Metaphysical Labour Flexibility, Performance and Commitment in Work-Life Management 3. Margrét Sigrún Sigurdardottir Dependently independent Co-existence of institutional logics in the recorded music industry 4. Ásta Dis Óladóttir Internationalization from a small domestic base: An empirical analysis of Economics and Management 5. Christine Secher E-deltagelse i praksis – politikernes og forvaltningens medkonstruktion og konsekvenserne heraf 6. Marianne Stang Våland What we talk about when we talk about space: End User Participation between Processes of Organizational and Architectural Design 7. Rex Degnegaard Strategic Change Management Change Management Challenges in the Danish Police Reform 8. Ulrik Schultz Brix Værdi i rekruttering – den sikre beslutning En pragmatisk analyse af perception og synliggørelse af værdi i rekrutteringsog udvælgelsesarbejdet 9. Jan Ole Similä Kontraktsledelse Relasjonen mellom virksomhetsledelse og kontraktshåndtering, belyst via fire norske virksomheter 10. Susanne Boch Waldorff Emerging Organizations: In between local translation, institutional logics and discourse 11. Brian Kane Performance Talk Next Generation Management of Organizational Performance 12. Lars Ohnemus Brand Thrust: Strategic Branding and Shareholder Value An Empirical Reconciliation of two Critical Concepts 13. Jesper Schlamovitz Håndtering af usikkerhed i filmog byggeprojekter 14. Tommy Moesby-Jensen Det faktiske livs forbindtlighed Førsokratisk informeret, ny-aristotelisk τ ηθος-tænkning hos Martin Heidegger 15. Christian Fich Two Nations Divided by Common Values French National Habitus and the Rejection of American Power 16. Peter Beyer Processer, sammenhængskraft og fleksibilitet Et empirisk casestudie af omstillingsforløb i fire virksomheder 17. Adam Buchhorn Markets of Good Intentions Constructing and Organizing Biogas Markets Amid Fragility and Controversy 18. Cecilie K. Moesby-Jensen Social læring og fælles praksis Et mixed method studie, der belyser læringskonsekvenser af et lederkursus for et praksisfællesskab af offentlige mellemledere 19. Heidi Boye Fødevarer og sundhed i senmodernismen – En indsigt i hyggefænomenet og de relaterede fødevarepraksisser 20. Kristine Munkgård Pedersen Flygtige forbindelser og midlertidige mobiliseringer Om kulturel produktion på Roskilde Festival 21. Oliver Jacob Weber Causes of Intercompany Harmony in Business Markets – An Empirical Investigation from a Dyad Perspective 22. Susanne Ekman Authority and Autonomy Paradoxes of Modern Knowledge Work 23. Anette Frey Larsen Kvalitetsledelse på danske hospitaler – Ledelsernes indflydelse på introduktion og vedligeholdelse af kvalitetsstrategier i det danske sundhedsvæsen 24. Toyoko Sato Performativity and Discourse: Japanese Advertisements on the Aesthetic Education of Desire 25. Kenneth Brinch Jensen Identifying the Last Planner System Lean management in the construction industry 26. Javier Busquets Orchestrating Network Behavior for Innovation 27. Luke Patey The Power of Resistance: India’s National Oil Company and International Activism in Sudan 28. Mette Vedel Value Creation in Triadic Business Relationships. Interaction, Interconnection and Position 29. Kristian Tørning Knowledge Management Systems in Practice – A Work Place Study 30. Qingxin Shi An Empirical Study of Thinking Aloud Usability Testing from a Cultural Perspective 31. Tanja Juul Christiansen Corporate blogging: Medarbejderes kommunikative handlekraft 32. Malgorzata Ciesielska Hybrid Organisations. A study of the Open Source – business setting 33. Jens Dick-Nielsen Three Essays on Corporate Bond Market Liquidity 34. Sabrina Speiermann Modstandens Politik Kampagnestyring i Velfærdsstaten. En diskussion af trafikkampagners styringspotentiale 35. Julie Uldam Fickle Commitment. Fostering political engagement in 'the flighty world of online activism’ 36. Annegrete Juul Nielsen Traveling technologies and transformations in health care 37. Athur Mühlen-Schulte Organising Development Power and Organisational Reform in the United Nations Development Programme 38. Louise Rygaard Jonas Branding på butiksgulvet Et case-studie af kulturog identitetsarbejdet i Kvickly 2011 1. Stefan Fraenkel Key Success Factors for Sales Force Readiness during New Product Launch A Study of Product Launches in the Swedish Pharmaceutical Industry 2. Christian Plesner Rossing International Transfer Pricing in Theory and Practice 3. Tobias Dam Hede Samtalekunst og ledelsesdisciplin – en analyse af coachingsdiskursens genealogi og governmentality 4. Kim Pettersson Essays on Audit Quality, Auditor Choice, and Equity Valuation 5. Henrik Merkelsen The expert-lay controversy in risk research and management. Effects of institutional distances. Studies of risk definitions, perceptions, management and communication 6. Simon S. Torp Employee Stock Ownership: Effect on Strategic Management and Performance 7. Mie Harder Internal Antecedents of Management Innovation 8. Ole Helby Petersen Public-Private Partnerships: Policy and Regulation – With Comparative and Multi-level Case Studies from Denmark and Ireland 9. Morten Krogh Petersen ’Good’ Outcomes. Handling Multiplicity in Government Communication 10. Kristian Tangsgaard Hvelplund Allocation of cognitive resources in translation - an eye-tracking and keylogging study 11. Moshe Yonatany The Internationalization Process of Digital Service Providers 12. Anne Vestergaard Distance and Suffering Humanitarian Discourse in the age of Mediatization 13. Thorsten Mikkelsen Personligsheds indflydelse på forretningsrelationer 14. Jane Thostrup Jagd Hvorfor fortsætter fusionsbølgen udover ”the tipping point”? – en empirisk analyse af information og kognitioner om fusioner 15. Gregory Gimpel Value-driven Adoption and Consumption of Technology: Understanding Technology Decision Making 16. Thomas Stengade Sønderskov Den nye mulighed Social innovation i en forretningsmæssig kontekst 17. Jeppe Christoffersen Donor supported strategic alliances in developing countries 18. Vibeke Vad Baunsgaard Dominant Ideological Modes of Rationality: Cross functional integration in the process of product innovation 19. Throstur Olaf Sigurjonsson Governance Failure and Icelands’s Financial Collapse 20. Allan Sall Tang Andersen Essays on the modeling of risks in interest-rate and inflation markets 21. Heidi Tscherning Mobile Devices in Social Contexts 22. Birgitte Gorm Hansen Adapting in the Knowledge Economy Lateral Strategies for Scientists and Those Who Study Them 23. Kristina Vaarst Andersen Optimal Levels of Embeddedness The Contingent Value of Networked Collaboration 24. Justine Grønbæk Pors Noisy Management A History of Danish School Governing from 1970-2010 25. Stefan Linder Micro-foundations of Strategic Entrepreneurship Essays on Autonomous Strategic Action 26. Xin Li Toward an Integrative Framework of National Competitiveness An application to China 27. Rune Thorbjørn Clausen Værdifuld arkitektur Et eksplorativt studie af bygningers rolle i virksomheders værdiskabelse 28. Monica Viken Markedsundersøkelser som bevis i varemerkeog markedsføringsrett 29. Christian Wymann Tattooing The Economic and Artistic Constitution of a Social Phenomenon 30. Sanne Frandsen Productive Incoherence A Case Study of Branding and Identity Struggles in a Low-Prestige Organization 31. Mads Stenbo Nielsen Essays on Correlation Modelling 32. Ivan Häuser Følelse og sprog Etablering af en ekspressiv kategori, eksemplificeret på russisk 33. Sebastian Schwenen Security of Supply in Electricity Markets 2012 1. Peter Holm Andreasen The Dynamics of Procurement Management - A Complexity Approach 2. Martin Haulrich Data-Driven Bitext Dependency Parsing and Alignment 3. Line Kirkegaard Konsulenten i den anden nat En undersøgelse af det intense arbejdsliv 4. Tonny Stenheim Decision usefulness of goodwill under IFRS 5. Morten Lind Larsen Produktivitet, vækst og velfærd Industrirådet og efterkrigstidens Danmark 1945 - 1958 6. Petter Berg Cartel Damages and Cost Asymmetries 7. Lynn Kahle Experiential Discourse in Marketing A methodical inquiry into practice and theory 8. Anne Roelsgaard Obling Management of Emotions in Accelerated Medical Relationships TITLER I ATV PH.D.-SERIEN 1992 1. Niels Kornum Servicesamkørsel – organisation, økonomi og planlægningsmetode 1995 2. Verner Worm Nordiske virksomheder i Kina Kulturspecifikke interaktionsrelationer ved nordiske virksomhedsetableringer i Kina 1999 3. Mogens Bjerre Key Account Management of Complex Strategic Relationships An Empirical Study of the Fast Moving Consumer Goods Industry 2000 4. Lotte Darsø Innovation in the Making Interaction Research with heterogeneous Groups of Knowledge Workers creating new Knowledge and new Leads 2001 5. Peter Hobolt Jensen Managing Strategic Design Identities The case of the Lego Developer Network 2002 6. Peter Lohmann The Deleuzian Other of Organizational Change – Moving Perspectives of the Human 7. Anne Marie Jess Hansen To lead from a distance: The dynamic interplay between strategy and strategizing – A case study of the strategic management process 2003 8. Lotte Henriksen Videndeling – om organisatoriske og ledelsesmæssige udfordringer ved videndeling i praksis 9. Niels Christian Nickelsen Arrangements of Knowing: Coordinating Procedures Tools and Bodies in Industrial Production – a case study of the collective making of new products 2005 10. Carsten Ørts Hansen Konstruktion af ledelsesteknologier og effektivitet TITLER I DBA PH.D.-SERIEN 2007 1. Peter Kastrup-Misir Endeavoring to Understand Market Orientation – and the concomitant co-mutation of the researched, the re searcher, the research itself and the truth 2009 1. Torkild Leo Thellefsen Fundamental Signs and Significance effects A Semeiotic outline of Fundamental Signs, Significance-effects, Knowledge Profiling and their use in Knowledge Organization and Branding 2. Daniel Ronzani When Bits Learn to Walk Don’t Make Them Trip. Technological Innovation and the Role of Regulation by Law in Information Systems Research: the Case of Radio Frequency Identification (RFID) 2010 1. Alexander Carnera Magten over livet og livet som magt Studier i den biopolitiske ambivalens