Human Reproduction, Vol.28, No.5 pp. 1289– 1296, 2013
Advanced Access publication on March 18, 2013 doi:10.1093/humrep/det051
ORIGINAL ARTICLE Psychology and counselling
When biological scientists become
health-care workers: emotional labour
in embryology
R.P. Fitzgerald 1,*, M. Legge 2, and N. Frank 3
1
Department of Anthropology and Archaeology, Te Tari Mātai Tikanga Tangata o Nāianei me Onamata, University of Otago, PO Box 56,
Dunedin 9054, New Zealand 2Department of Biochemistry, PO Box 56, Dunedin 9054, New Zealand 3School of Medicine, University of
Colorado, Anschutz Medical Campus, 13001 E. 17th Place, Aurora, CO 80045, USA
*Correspondence address. E-mail: ruth.fi[email protected]
Submitted on August 12, 2012; resubmitted on January 22, 2013; accepted on February 4, 2013
study question: Can biological scientists working in medically assisted reproduction (MAR) have a role as health-care workers and,
if so, how do they engage in the emotional labour commonly associated with health-care work?
summary answer: The scientists at Fertility Associates (FA) in New Zealand perform the technical and emotional cares associated
with health-care work in an occupationally specific manner, which we refer to as a hybrid care style. Their emotional labour consists of managing difficult patients, ‘talking up’ bad news, finding strategies to sustain hope and meaning, and ‘clicking’ or ‘not clicking’ with individual
patients.
what is known already: Effective emotional labour is a key component of patient-centred care and is as important to the
experience of high-quality MAR as excellent clinical and scientific technique.
study design, size, duration: This is a qualitative study based on open-ended interviews and ethnographic observations with
14 staff in 2 laboratories conducted over 2 separate periods of 3 weeks duration in 2007. Analysis of fieldnotes and interviews was conducted
using thematic analysis and an NVivo qualitative database and compared for consistency across each interviewer.
participants/materials, setting, methods: The participants were consenting biological scientists working in one of
the two laboratories. Semi-structured interviews were conducted in ‘quiet’ work times, and supervised access was allowed to all parts
of the laboratories and meeting places. Opportunities for participant review of results and cross comparison of independent analysis by
authors increases the faithfulness of fit of this account to laboratory life.
main results and the role of chance: The study suggests that emotional labour is a part of routinized scientific labour
in MAR laboratories for FA.
limitations, reasons for caution: This is a qualitative study and thus the findings are not generalizable to populations
beyond the study participants.
wider implications of the findings: While little has been published of the emotional component of scientist’s working lives,
there may be a New Zealand style of doing scientific work in MAR laboratories which is patient centred and which incorporates much higher
patient contact and involvement than is experienced in other laboratories.
study funding/competing interest(s): This study was funded by a research grant from the University of Otago and was
also partly funded by a Marsden Grant administered by the Royal Society of New Zealand.
trial registration number: N/A.
Key words: emotions / embryology / patient centred care
& The Author 2013. Published by Oxford University Press on behalf of the European Society of Human Reproduction and Embryology. All rights reserved.
For Permissions, please email: [email protected]
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Introduction
like there is one kid . . . who lives one street down from us . . . who must
be 19 or 20 now, and I can remember him as a four cell, because he
was the first really good four cell that I saw . . .
(James)
This project explores the work of biological scientists working in medically assisted reproduction (MAR) with a view to considering their
labour as health-care work. The impetus for such an approach
arises from Keating and Cambrosio’s (2003) historical study of the development of post-world war 2 medicine in which they argue that scientific platforms have increasingly become the basic unit organizing
hospital services. Medicine they argue has thus changed its form
since then, to become a more scientific than clinical practice. The
result is that scientists become embedded in the social organization
of health care. Our research questions were framed as: (1) can biological scientists working in MAR have a role as health-care workers
and, if so, (2) how do they engage in the emotional labour commonly
associated with health-care work?
This question is timely for the patient-centred medicine movement
has recently spread its focus into reproductive medicine with Boivin
et al. (2012), van Empel et al. (2010) and Aarts et al. (2011) arguing
that the already arduous experience of MAR is made even more difficult by insensitive care provision. Some of the cited triggers for
client dissatisfaction with medicine include assembly line working
styles with discontinuity in scientific care providers, inadequate information, depersonalized service provision, overly bureaucratic treatment procedures and a general lack of empathy from staff. The
suggestion is that such poor quality care provision increases the cumulative effect of MAR on patients causing them to withdraw from treatment. However, much of this emergent literature on patient-centred
care in MAR emphasizes the role of doctors and nurses in care.
This, we suggest, implies missed opportunities to enquire into
whether scientists might also contribute to empathetic care provision,
although Boivin et al.’s note of ‘discontinuity in science care providers’
as a point of grievance for disaffected users of MAR is provocative.
Such then, is the background to our own study.
To provide more local context, the New Zealand provision of MAR
operates within a split funder/supplier model of health care with dual
public and private provision of service often by the same supplier.
Around 75% of all MAR clinics in New Zealand are currently run by
the private company Fertility Associates (FA—the locus of this particular
study) which treats both public and private patients. The public
provision of MAR in New Zealand is for two cycles only. Scientists
join FA from a diverse array of academic and employment backgrounds; some have PhDs which were forged during the creation of
MAR as a biomedical discipline, others more recently arrived, were
qualified with Masters degrees in embryology. If previously employed,
their prior backgrounds were often in pure research such as
animal-assisted reproduction or electron microscopy. The senior
scientists’ roles hold opportunity for research-led work, while more
junior appointees engage in more practice-led work. We have
chosen to use the term biological scientist or embryologist to describe
them although they also work in the fields of endocrinology and
andrology.
Of further note is that all of the FA scientists are strongly encouraged to make personal contact with their clients to convey results
Fitzgerald et al.
and explain procedures, rather than to work anonymously in a
remote laboratory with decontextualized reproductive material. As
our subsequent results will reveal, this created an environment well
suited to the production of ‘emotional labour’, a term we shall now
define, for it is integral to understanding the way in which scientific
labourers can also take up the practices of health-care workers.
Emotional labour was coined by Hochschild (2003 [1983]) to
explain the way in which employers, particularly in the service industries in the 1980s, required a certain emotional orientation on the
part of their employees towards their customers. This labour required
the accessing of authentic emotional memories and their reproduction
on cue as a routine aspect of one’s paid work. It was argued initially
that health professionals would have too much autonomy in their
work conditions to be required to engage in this type of coerced emotional performance, but more recent work on emotional labor has
argued the opposite, although such literature does tend to focus
only on ‘classical’ health-care workers such as doctors and nurses
(Fitzgerald, 2004, 2008; Theodosius, 2008; Ray and Street, 2010;
Svendsen and Koch, 2011; Ward and McMurray, 2011). However as
Armstrong et al. (2008) note, a wide array of ancillary service
workers in health care also provide emotional labour, some of
whom we suggest may be scientists.
Prior ethnographic studies of MAR clinics indicate that emotions are
a significant feature of this speciality and worthy of study. For example,
Franklin and Roberts note that the social effects of being a patient
seeking treatment is as though MAR were a type of emotional containment technology in that patients must maximize hope while simultaneously controlling and containing it (Franklin and Roberts, 2006:
p161). Likewise the social meaning of preimplantation genetic diagnosis (PGD), they argue in part at least, is as an emotional conversion
machine in which the clients’ grief of the past (lost pregnancies, desperately ill children) is converted into hope for the future (Franklin
and Roberts, 2006, p. 138). The voices of the embryologists in this
study were muted under the general term ‘PGD Team’ or ‘Staff’;
however, there are several references to the emotional burden of carrying out tasks such as speaking to patients of their results and the
need for honesty and kindliness (Franklin and Roberts, 2006: 206,
207) which resonate well with the evidence we will present of the
New Zealand embryologists’ experiences. Similarly, in Kerr’s (2012)
British study of public and private MAR services, she writes about
the context-specific nature of emotional labour for all workers in
these settings.
Methods
Data were collected during 2005, via two short ethnographic studies, each
of 3 weeks duration, conducted by the first author (a trained anthropologist) and third author (a graduate student anthropologist). The field sites
were two of the several New Zealand-based MAR clinics run by FA and
the ethnographers were allowed supervised access to the laboratories
and staff during this time for familiarization with laboratory routines and
opportunities to observe the scientists’ daily work practices. The researchers were also provided with an overview of the entire facility and were
allowed access to the standard patient information sheets and regular
scheduled staff meetings. The second author (a practising biological scientist) provided instruction and support in basic biology to the two social
scientists in the team. Interviews were requested with biological scientists
in each laboratory and 14 consenting scientists each participated in one
Emotional labour in embryology
50-min semi-structured interview with a fieldworker which covered the
following conversational topics in an open-ended manner: background
training, the constraints of working with human tissue, sensing the likelihood of success, responsibility, the qualities of a good and a bad embryologist, the nature of good and bad days at work, the effect of the job
on scientist’s understanding of ethics in reproduction and the nature of
family structure, guiding principles during complex decision-making, personal mottos about the quality of service, relationship with patients, emotionality in the workplace, the experience of time and the importance of
technique. The interviews were recorded, transcribed, anonymized, then
coded using simple thematic coding (Madden, 2010) working with an
NVivo (QSR International 2012) qualitative software analysis database.
The object of this process was to identify emergent themes with
common content from the group of interviews as a whole. The resulting
analysis was sent to the scientists in the form of a draft technical report.
The scientists were offered the opportunity to review and request amendments to the analysis and no significant changes were requested. The study
results were presented to a wider audience of embryologists at the scientific meeting associated with the Australasian Fertility Society Conference
and met with general agreement on the results, analysis and conclusions
from the audience. Ethical approval for this project was obtained
through the University of Otago Human Ethics Committee (reference,
June 2005).
A further necessary conceptual element to consider in our methods in
order to effectively answer research question one was the criteria upon
which it could be established that the embryologists were also working
as health-care workers. To this end, we used the degree of conformity
in self-reported work experiences by the scientists to those qualities
that mark the work profiles of excellent New Zealand based health-care
workers already established in a series of prior empirical studies by the
first author (Fitzgerald 2004, 2008, 2012). Specifically, these characteristics
were agreement on the object of care for the workers, recognition of the
core components of the meticulous delivery of technical aspects of care,
the requirement to routinely deliver emotional labour of an occupationally
specific type, a specific occupational habitus and a habit of introspection
and reflection on the quality of one’s care work.
Results
The object of care for these scientists was 5-fold: clients, reproductive
material, the scientific and bureaucratic system that underpinned their
work, the quality of the team dynamics and each scientist’s own internal state or ‘fitness to work’. Earlier New Zealand studies of care
workers have demonstrated that most care workers have only one
object of care. However, the scientists with whom we spoke
engaged in significant caring relationships with the clinic’s clients
whom they viewed as their patients. In addition to this, they also
treated the client’s reproductive material of which they viewed themselves to be the custodians. Their labour of care was thus uncomfortably divided between these different objectives. They also were
unusual as health-care workers for their simultaneous focus of care
upon the scientific and bureaucratic processes underpinning the practice of the clinic and their own internal state of mind as well as their
laboratory team dynamics. This steady attentiveness to their emotional and physical competency to practice came about because of what
they termed ‘the preciousness’ of the material with which they
worked (oocytes and embryos in particular). Mistakes with such irreplaceable material were simply not an option and any embryologist
would consider that to make two errors in an entire career would
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mean no longer being able to ethically justify one’s capacity to practise.
Technical competency is thus a taken-for-granted aspect of this work
and one that approximates perfection. The focus on the team dynamics as a concurrent object of care arose as a necessity because the
scientists interleaved their delicate work with other laboratory staff.
Thus, one scientist might denude an oocyte before storing it,
another might perform ICSI on it, while a third monitored its developmental milestones over the weekend prior to possible replacement.
Since the measure of success, a pregnancy, relied equally on everyone’s labours, it was thus in everyone’s interests to ensure the team
worked well. However, it was not only the team members who
must work well, as excellent scientific standards of quality assurance
must underpin all uses of reagents, laboratory equipment and procedure protocols. It was this additional area of responsibility that created
a similar care for systems and process as for people, oocytes and
embryos. In addition, the extraordinary physical dexterity and
mental alertness, which the practice of embryology demanded,
required that all possible hindrances to physical performance were
removed. For this reason, there was also a strong need to care for
the self, an unusual and healthy exception to the neglect of self that
can be typical of so many other health-care workers.
The relative degrees to which the scientists focused on each
element within their manifold object of care varied with position
(i.e. as team leader or senior scientist), and individual personal interests. However, all participants registered some concern for all of the
objects of care. This differs from previous studies of managerial and
clinical health-care workers during the New Zealand Health
Reforms (Fitzgerald, 2004), which revealed a clear division between
the object of care for managerial workers (as the system of care)
and traditional clinical workers (the patient). These scientist/healthcare workers it seems, hold both the system and the patient in
equal regard, we term this a hybrid care approach.
The quality of the resulting caring relationships was very high and
contained the hallmark aspects of the work of excellent clinical
workers (Fitzgerald, 2004, 2008). For example, the scientists recognized that part of their job satisfaction was derived from the delivery
of good quality care and the reciprocation of grateful thanks and the
‘buzz’ of a possible pregnancy. Clients were treated ‘as scientists
would like to be treated themselves’ and the highest expectations
were expected from carers; this was understood to be perfection in
the delivery of their technical skills along with an empathetic and
tactful form of emotional labour. Thus, our first research question
was clearly answered in the affirmative.
We consider now, answering the second research question by revealing the characteristic qualities of emotional labour that emerged,
from the scientists’ interview material, as germane to their work.
We begin by verifying through interview quotations the relevance of
emotion management in scientific work. We then go on to detail
the exact nature of emotional labour for scientists under subheadings.
The potential ‘cost’ of emotional labour to the employee was implicitly recognized by the scientists. In this regard they were similar to all
care workers for not even the most excellent of caregivers can supply
deep-seated empathetic engagement with clients through every hour
of their shift for the entire length of their professional life. When personal worries, extreme tiredness, or factory style impositions of
patient workloads intervene, excellent care givers resort to the manufacture of the desired emotional tone in order to respond to the moral
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Fitzgerald et al.
demands of their vocation. Furthermore for emotional labour to be
effective, it must be believable which also incurs a cost to the
worker as they routinely draw on authentic feelings in an inauthentic
contemporary environment.
All of the scientists who agreed to be interviewed recognized such
costs:
Scientist:
Interviewer:
Scientist:
Interviewer:
Scientist:
. . . sometimes I don’t know if you guys realize that we go
through so much emotion ourselves.
Yes, yes.
Um I mean there have been nights when I’ve not slept
when I first started.
Ahh I’m sure.
Tossing and turning, thinking and wondering you know if
am I going to have ‘good fert’ tomorrow or not.
This managed aspect of the emotional component of one’s work was
initially often a source of anguish; however, eventually as the scientists
gained competency in its practice, it became a source of great personal satisfaction. The emotional labour, we argue, was the result of the
distinctively ‘New Zealand’ organization of scientific labours in which
scientists met patients personally upon whom they were to assist
with IVF procedures (including oocyte pick up and embryo transfer).
They spoke to patients directly to advise them of the outcomes of
sperm samples, attempts at fertilization by IVF or ICSI, thawing of
embryos and the incubation of inseminated oocyte, and were involved
in patient information meetings and answering routine calls of general
inquiry about progress through a particular cycle (amongst other
duties). As with other New Zealand health workers previously
studied, the emotional labour was marked by a type of gift relationship
in which scientists provided empathetic support to patients regardless
of their own personal emotional situation at the time and in return
received the reciprocal gift of thanks, self-satisfaction and the empathetic enjoyment of the patient’s happiness or (with regard to receiving
bad news) at least the dignified consolation that the patient had been
treated ‘as they [the scientists] would like to have been treated themselves’. Of course the pleasure or ‘buzz’, as another scientist put it,
could also be about achieving the pregnancy as one recalled:
Scientist:
Interviewer:
Scientist:
Interviewer:
Scientist:
Yeah during my first two weeks, my first pregnancy [result]
were a couple of twins.
Ahh really?
Yeah X and X [twin’s names deleted] and I remember sort
of feeling quite chuffed and thinking but I made those two,
I picked—I just happened to pick those two right!
You picked them yeah, yeah.
Yeah and then they got frozen—they were IVF and ah I
think they had quite a good cycle but the fact that at
the end of the day they were the two whatever we only
chose them like. . .through the various criteria. But those
were the two that I chose ...
We turn now to the following subthemes which set out the generally
agreed details of emotional labour.
manage this was to recognize the intensity of the connection
with them at this point in their cycle: empathy went a long way
towards sustaining a scientist through an otherwise bruising emotional
encounter. For example, one worker recalled an incident in which
an external accident (outside the jurisdiction of the laboratory)
had caused the destruction of all of one woman’s embryos. The scientist still remembered passing on the news ‘and the woman said’
(mimicking a vehement and angry voice)—’that was OUR chances
for a family GONE! Now we’re not going to, you know
you’ve RUINED our chance!’ and I can still actually remember her
words . . .’.
Another useful tool was to try to ‘read’ clients to see how they
might respond to bad news: some clients wanted all the details and
kept ringing back again and again during the day to see if their situation
had changed, others were stoic and wanted the briefest of information
exchanges when the news was bad. The scientists all felt heavy
hearted in dealing with the latter group knowing that they probably
hung up the phone so quickly in order to weep for hours in private.
Occasionally, clients would add a further element of complexity to
the intensity of waiting for news, asking the laboratory to only
phone if the news was bad, but not ring at all if the news was good;
woe betide the scientist who forgot the code. In thinking of what
made the ‘good’ embryologist in an emotional sense, several of the
scientists spoke as one did, of the need for a personality ‘that
shouldn’t be . . . stressed easily—you should be very calm, dealing or
coping easily with any problem that you face . . . take a [she breathes
in slowly] deep breath’.
Sometimes a patient was difficult simply due to being given inadequate information and in this case, one worker noted that she
‘loved’ speaking to clients on the telephone: ‘Like I noticed in replacements, often the doctor says: ‘Ah your cervix is hiding today or your
cervix is anteverted’, and I think—ahh the patients will think that’s
BAD, they don’t realize that that doesn’t mean anything . . . It’s like
saying: ‘Your hair’s sticking up on end today and not to worry!’, and
so I love it when I can get on the phone . . . and kind of spend the
time with them and really go through it’.
Another scientist went on to classify the variety of ‘difficult’ patients:
those who failed to listen to instructions and injected the hormones
incorrectly, those who fail to phone back for their instructions,
and every so often a couple simply so annoying that everyone
wanted them to be pregnant just to be rid of them. Strong personalities were noted by another scientist as making couples difficult to
work with, but the converse was also true when certain couples
‘placed themselves entirely in your hands’. This level of responsibility
could become a burden. Finally, there were the desperately anxious
patients who rang many times in one day to check on the progress
of the embryos were often cited as a difficulty for no amount of
explaining seemed to convince them that to continue opening the incubator door would damage the very embryos they were wanting to
transfer.
Difficult patients
All of the scientists recognized that some clients were more ‘difficult’
to work with than others. Several situations could arise that made
patients ‘difficult’; as one scientist observed, the clients had very
high expectations and if the results were disappointing, it was up
to the laboratory staff to know how to handle it. One way to
‘Talking up’ bad news
The scientists also recognized the need for emotional labour in the
passing on of test results. Not all the laboratory results were positive
news for the clients and the embryologists were united in their efforts
to ‘talk up’ (in the parlance of the laboratories studied) disappointing
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Emotional labour in embryology
results. This was a significant and recurring source of emotional labour
in every working day. Furthermore, the line between giving hope and
yet remaining truthful about success was a difficult line to police. As
one scientist noted:
We really can only tell them scientifically what’s happened and the worst
thing is that you can’t . . . really do anything anyway because you’ve still
delivered them a big fat blow to their chances. I guess I . . . still wonder
if sometimes I’m a bit too—I try and be positive you know . . . Like, if
they say, ‘Oh, we only got one fertilized!’, well, rather than saying ‘Ahh
yes, the other ten didn’t fertilize! [I’d say] ‘Ahh, but it only takes one
you know. We’ve had plenty of one egg, one embryo, one baby!’ . . .
And sometimes I think maybe I give them more hope than I should,
[and I wonder] should I tone it down a bit? But I just, I just can’t say:
‘Ahh bummer you know, ONLY one!
The degree of talking up was very apparent to the authors as they sat
listening to these one-sided conversations. Sperm that had, in a
private conversation in the backroom of the laboratory, previously
been classified as ‘crap’ were described over the telephone more
like: ‘Well, while most of them are not very mobile, but, after a lot of
searching, we have found five, and those five look really good!’
Oocytes that in similar conversations were ‘dodgy’ and ‘ugly looking
things’ were transformed over the phone into ‘Well, the eggs are not
as good as they could have been but they are certainly good enough
for us to work with!’
Franklin and Roberts (2006, p. 145) note embryologists discussing
the same morphological characteristics of ‘good-looking’ versus
‘poor’ embryos in their British study of an IVF/PGD clinic. We consider that the colloquial language that described the poor quality reproductive material was an outcome of what the sociologist
Goffman (1973) speaks of as backstage language: a social location
(in this case the recesses of the laboratory where the public do not
go) in which the workers could temporarily set aside their professional
personas to achieve a transient relief from the tensions of interfacing
with patients holding high hopes of success in the face of bleak morphological assessments of embryo viability.
This type of language manipulation (from back stage to front stage)
was fairly common, but the important thing was to not give misleading
information. Scientists were also meticulous to congratulate couples
on achieving ‘fert’. This was because most scientists held an empathetic recognition that a positive ‘fert’ result might be the most such
couples ever achieved of the experience of pregnancy. Most of the
scientists also tried to indicate at the outset of the telephone call
whether the news was good or bad. This gave the couple an opportunity to come to terms with what they were about to hear and suitable cues were phrases such as ‘I’m sorry to tell you’ or ‘I’m afraid I
have . . .’. If the meeting was face-to-face, then the scientists attempted
a serious demeanour.
As previously noted, for most care workers, the demands of emotional labour are sustained by the gift of gratitude and confidence in
their abilities that excellent carers receive from the clients whom
they serve. The embryologists at FA were no different, as Sally
noted: ‘I think you can give bad news well and you can give bad
news badly and they’re never going to walk away feeling good about
it, but you don’t want to be the person that when the client remembers the incident, they remember how they were told by someone
in an insensitive manner’.
Strategies for hope and meaning
Most scientists found witnessing the clients’ unhappiness to be a
stressful and unpleasant part of the job, so much so that for some
the experience seemed to contribute to a degree of emotional
burnout in their work. In bleaker moments, when the pressure of a
string of ‘no ferts’ was hard to bear, scientists needed strategies to
maintain their positive focus on their work. For some, this meant refocusing their emotional energy into human interest in the endlessly
varied parade of personalities which the service brought to them,
for others the techniques were to separate out work experiences
from home experiences and contain a negative day within the confines
of the laboratory. Some scientists found that the counsellors at the
clinic provided a useful avenue of support, while some workers considered part time work to be the best solution. If at any point the
emotional balance of the work tipped from being buoyed up by the
pregnancies to becoming cast down by the lack of ‘fert’, then the scientist was at serious risk of dropping out of the work altogether.
Finding a strategy for redirecting these negative experiences was
thus very helpful but also highly individual and the normalization of
the use of the clinic counsellors at any time in one’s career, rather
than only at the beginning of it, was repeated by several scientists as
a potentially highly useful intervention.
This environment of unpredictability of outcome for individual
clients on a one-by-one basis, allied with reliance of group work to
achieve these outcomes, explained the frequency with which scientists
scanned what was colloquially termed the ‘baby book’: an official
document holding details of the number of cycles processed
through the laboratory and outcomes achieved such as ‘fert’, biochemical pregnancy, live birth, etc. Another route towards a selfsustaining practice however was through finding opportunities to
instil hope and comfort for patients who had ‘no fert’ through other
means. This might be as simple as ensuring patients had a review appointment with the doctor within several days of a bad result, or
explaining to a man with an unexpectedly poor sperm count, the possibilities of ICSI for their next attempt. Since it often took the first
cycle of IVF to find out the nature of the fertility problem, these conversations were delicate and emotionally loaded, but held great potential for supplying emotional support. Thoughtfulness and empathy in
caring could also be expressed in practical ways by taking a photo
of the oocyte for example if the pickup had been painful, so that
the client had something to look at to help her understand why she
went through all that pain. Franklin and Roberts previously cited
British study also noted specific examples of such thoughtfullness,
i.e. ‘Even the embryologists are really nice. Aren’t they?’ (Franklin
and Roberts, 2006, p. 206).
‘Clicking’ and ‘not clicking’ with patients
All of the scientists appreciated the diversity of personalities who
passed through their care, and learning how to respond with equanimity to ‘all types’ was an opportunity to practise some highly sophisticated skills in emotional labour. As one worker noted: ‘Some
patients open up quicker . . . just due to their personality and how
yours works with theirs . . . some you’ll never have a relationship
with you know’. This phenomenon of walking into a clinic room and
just ‘clicking’ with a patient is well known amongst health carers and
was also familiar to the scientists. As a scientist observed:
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When you’re first introduced . . . I can often tell that there is going to be a
little bit of a connection, and sometimes people can seem very cold and
distant when you first meet them, but then as soon as you’ve had the opportunity to give them some good news, say the next day sometimes, they
just warm up to you. And then, from then on, that’s all good. So um, so
it’s not always going to be obvious from the start, and sometimes they
take a little bit of time to get used to you, to warm up to you, and
then they kind of connect with you.
It is the moment in which it is clear that no ‘click’ will be occurring that
requires emotional labour to manage. Several techniques were
broached by the scientists for managing this: all of them drew on
their imagined or real understandings of the rollercoaster experience
of IVF. As another scientist observed:
Sometimes (when they are angry) they’re just getting back at a negative
outcome really. And really – they’re paying for a chance – it’s like
Lotto – it’s not like going to buy a motorcar and get something for the
money . . . you’re just getting a chance or a probability – so if they don’t
(become pregnant) they feel let down by themselves and by us and everybody and then they can hit back at us.
Interestingly, ‘clicking’ too well with patients could create its own little
repercussion of ethical dilemmas to do with equity in staffing the
laboratory over weekends. This was because patients sometimes
requested specific scientific staff to conduct their IVF procedures
with whom they felt a special connection from prior experiences.
Opinions amongst the scientists were quite divided about this situation, and it was noted that the unpredictability of final results (the
pregnancy) could certainly inspire a type of ‘magical’ thinking
amongst the patients. As a senior scientist noted: ‘there are patients
who, first cycle round, like they get 8 eggs and 7 fertilize and they
are very happy; and then second time around they get 4 eggs and 2
fertilize and they think life is unfair, and we haven’t done this well.
And it is just part of the process of life, which is unfair you know,
and it’s really hard for those people to let them know it is just
random’. Some scientists were wary of requests for specific
workers, as they disorganized the work schedule and the requirements for scientists to have regular opportunities for the refreshment
of leave. Others found the personal anguish behind the request
morally compelling which pushed them to acquiesce. But others
were dismissive of the wish for a personal connection to influence
an outcome, which was so clearly based only on technique and
chance. This was a clear example of the multifaceted object of care
for the scientists (self, oocytes, scientific and bureaucratic process,
patients, other works) creating a tension in their duties, which was
not easily resolved. Another point of tension was when development
did not proceed appropriately for the embryo and the embryologist
had to discard the embryo. Telling the patients that ‘baby is not
quite right, and so there is no point for us in keeping baby any
longer’ was difficult emotional labour that exacted a toll from the
scientists as they strove to incorporate such emotional moments
into the rhythms of an ordinary working day. [While it was initially surprising to hear an embryologist referring to an embryo as ‘baby’, this is
an indication of the scientists’ emotional labour which in this case, successfully softened scientific nomenclature in order to allow clients the
opportunity to conceive of their loss (and have it socially recognized)
as that of a potential child. This reveals the double language competencies (in science and public understandings of science) that the
scientists had developed through their care work.]
Fitzgerald et al.
Discussion
To date, we have found few studies that demonstrate biological scientists’ roles as carers and in some cases, the work of the embryologists
has been ‘black boxed’ and submerged within the wider IVF or PGD
team. An early work is by Peddie et al. (2005, p. 1947) discusses how
a group of Scottish women made sense of their decision to withdraw
from IVF treatment. They quote a woman observing: ‘Doctors are
very matter of fact, whereas the embryologists have more contact
with us. We were able to ask them questions that we didn’t feel comfortable asking the doctor. It was the embryologist that told us there
was a specific egg problem after the second failed attempt, and that
was helpful’. The previously cited work by Kerr (2012) included interviews with 17 UK embryologists who revealed aspects of emotional
caring in their work (termed ‘body work’ after Twigg cited in Kerr,
2012). Our work thus adds to this literature, along with the ethnographic study of IVF/PGD centres such as the previously cited Britishbased work of Franklin (1997) and Franklin and Roberts (2006), the
US-based work of Thompson (2005) and the series of shorter articles
(from Britain) exploring social and ethical aspects of PGD (Ehrich
et al., 2007, 2008, 2012).
The role of emotions (regulated or not) in the everyday working
experiences of scientists is not well studied (White, 2009) either
from a historical perspective, or within the present day (Shapin,
2008; Thérèse and Martin, 2010). Despite this, few practitioners of
science would deny the presence of feelings such as joy, excitement,
impatience, envy, etc. in scientific practice. Rigden and Stuewer
(2011) suggest that emotion is as relevant to the development
of excellent research as reason itself, while Pickersgill (2012) links
emotionality (and emotional labour) with the co-production of
ethical values in scientific practice. Mahoney (1979), several decades
ago, called for more investigation of the interior subjective states of
working scientists noting the discrepancy between the stated attributes of the ideal scientist (objectivity, rationality, open-mindedness,
superior intelligence, integrity and communality) and the actuality of
scientific practice.
Rare articles do discuss some of the emotional elements of care
provision particularly with regard to MAR. Van Empel et al. (2010),
for example, produced an empirically derived instrument for measuring and comparing the degree of patient centeredness in care provision in various reproductive medicine clinics. In doing so, their work
also provides feedback on what it is that the clinic clients expected
to be the most important aspects of their care and those elements
which needed improvement as well as those elements of care that
were well achieved. The questionnaire only considered doctors’ and
nurses’ labour but it did emphasize usefully the roles that empathetic
communicative strategies can play in excellent patient-centred IVF
care. Another relevant analysis of emotional labour is provided by
Hill (2010) who described, at great length, the role of what he
terms ‘emotional regulation’ in providing health care in the most
judgement-free manner. While his work does not review studies
from IVF clinics, he does discuss in detail the labour attached to one
of the themes identified for these embryologists, i.e. ‘the difficult
patient’ noting that such patients typically challenge the carer’s sense
of themselves as effective practitioners, threaten their control
(an issue also noted by Kerr, 2012) and create fruitless work. Of
further relevance to this study is his extended discussion of the
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Emotional labour in embryology
ways in which health workers ‘imagine’ themselves into more positive
professional relationships with patients whose injuries, ethnicity,
political opinions or social status triggered initial dislike or moral
concern. This persistent effort towards the highest professionalism
was very noticeable at FA as well. Finally, Hills’ article notes that
while most workers would agree that non-judgemental care with its
attendant ‘emotional management’ is the standard goal of health
care, there is very little work that investigates how individual
workers achieve it nor the costs that it exacts. Here Hochschild’s
(2003[1983]) work may be useful for it differentiates between deep
and superficial emotional labour. The superficial variety may be easy
to maintain but risks being considered offensive; as previously
noted, for emotional labour to be successful it has to be believable.
A deep version of emotional labour however created certain risks.
The proponent could become ‘lost’ in their staging and allow stage
crafted workplace emotions to bleed over into their private lives,
e.g. the embryologist who had nightmares pondering if she would
achieve good ‘ferts’ the next day. The worker can also remain very
aware of the crafted nature of their emotion performance, in a
sense compartmentalizing themselves to protect their private
worlds, but this may risk their development of a sense of inauthenticity
in the interpersonal encounters that marked their professional lives.
Finally, without respite and placed under time pressure or other workplace stressors, the gifted performer can risk ‘burning out’ if repeated
emotional performances do not receive the reciprocated gift of
gratitude.
To reflect on these results from the New Zealand studies of emotional labour in care work, the 5-fold focus of embryologist’s care
means that they are unlike more clinically based New Zealand healthcare workers (such as doctors and nurses) who focus entirely on the
patient or their relatives as the object of their care. Such workers generally do not have a dual concern for efficient process unless they are
involved in dual clinical management roles or engaged in the provision
of adjuvant particularly emergency clinical services such as diagnostic
radiographers (Park and Fitzgerald, 2011). Thus, it would be interesting to discover if this hybrid care practice observed amongst embryologists is typical of most scientists working in routinized clinical care
situations. It is not quite the same focus of care as discovered in the
study of New Zealand based cytogeneticists’ care work (Finlay
et al., 2004). These scientists held highly focused and somewhat personified views of the fetal cell cultures in their care along with a very
abstracted and generalized sense of care toward the pregnant women
whose amniocentesis material they cultured, which Finlay et al. termed
‘distant care’. They did however share with embryologists an attentive
and engaged interest in the best scientific practice; however, the focus
on interwoven technical labour was not as noticeable in Finlay et al.’s
account.
Conclusion
The scientists’ understandings of the roles, purposes and specific techniques of practice for their jobs align well with self-derived meanings of
excellent care from empirical studies of New Zealand health-care
workers. At FA, scientists are expert clinical carers as well as scientific
workers and provide excellent patient-centred care.
The object of care for these scientists is a hybrid phenomenon involving the reproductive material (about which they explain their
responsibilities as ‘custodians’), the patient/s seeking a pregnancy
(for whom they register empathy and provide meticulous technical
care) and, at the same time, the system in which the laboratories
operate (and in this regard, good care is maximum efficiency and adherence to best practice standards that are continually exceeded).
However, in addition to this, the biological scientists are also
focused on their own internal emotional states and on the communication and emotional tone of the interdisciplinary team of which they
are a part. While manipulating or managing the team dynamics has frequently been cited as an object of nursing care (Theodosius, 2008),
these biological scientists seem instead to be monitoring the quality
of the team relationship rather than engaging in specific remedies to
better it. At a recent Australasian conference where this paper was
presented, ‘trusting in co-workers’ emerged from the audience of
embryologists as a way of summing up this attention to the team.
Finally, the focus on one’s own interior emotional state (mentioned
by all scientists) is quite unusual for clinical workers. The lack of such
attention is sometimes cited as an attribute of medical workers and
definitely a contributing factor to occupational burnout. However,
the delicacy and time driven nature of the scientists’ technical cares
made it a moral requirement for them to acknowledge when their
physical or emotional competency dropped below an acceptable
standard. It is not clear if the extensive personal scrutiny of job applicants prior to selection accounts for this ability with self-care, whether
it is an unstated ethos of the wider team of laboratory workers and
thus is inculcated in new recruits, or whether it is an individualized
moral response to the preciousness of the material that the scientists
routinely work with expressed as the imperative to ‘first do no harm’
to this material through any personal unpreparedness or inattention to
one’s duties. The counselling staff and senior scientists played a useful
supporting role in assisting with this type of self-care, although team
leaders and personal friendships were another line of support.
Revealing this previously ‘hidden work’ of emotional labour we
hope will provoke a focus for professional self-reflection and an opportunity to institute appropriate support training in related skills
such as emotional intelligence. It can contribute to patient-centred
care in IVF, by recognizing that scientists, alongside clinical staff, also
offer valuable support to the clients in their care.
Internationally, further comparative studies on this topic such as that
of Kerr (2012) might answer to what degree these New Zealand
results reflect best practice for scientific workers in other MAR
centres. With the social organization of various laboratories, and the
recent interest in patient-centred care in MAR, it seems timely to consider to what degree should this care style be aspirational.
Acknowledgements
The authors thank the participating members of Fertility Associates, the
UORG Fund of the University of Otago, the Marsden Fund administered by the Royal Society of New Zealand and generous anonymous
reviewers.
Authors’ roles
R.P.F. and M.L. contributed substantially to the conception and design
of article, R.P.F., N.F. and M.L. contributed to acquisition of data,
1296
analysis and interpretation, contributed to drafting and revision of the
article and final approval of the article.
Funding
This study was funded by a research grant from the University of
Otago and was also partly funded by a Marsden Grant administered
by the Royal Society of New Zealand.
Conflict of interest
None declared.
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