The socio-cultural context of care delivery and
the management of emotions in the fertility clinic
Helen Allan
Division of Health Social Care
Faculty of Health & Medical Sciences
1
Emotions in the fertility clinic
• PhD – emotions and caring in a fertility clinic
• Post doc – boundary work in advanced nursing
fertility roles
• Post doc - Australia & New Zealand study trip
2
Context of my PhD
• What is lacking in the nursing and midwifery literature –
besides a consideration of the psychological socio-economic
and political structural factors which influence infertility
services more generally, and fertility nursing in particular – is
an in-depth exploration of the psychological and emotional
consequences of infertility for infertile people.
• It is the experience of emotions for infertile patients and
staff caring for them, and how these emotions are managed
by patients and staff which formed the main findings from
my study.
3
Emotions and work
• Fineman (2004) argues that descriptions of organisations are
often bland and do not paint a picture of the emotional
component of working life. He suggests that the study of
emotions at work allows two processes to emerge. Firstly,
people, their behaviours and the effects of those behaviours
come to the fore and become the focus of study. Secondly,
emotions are understood to be the main medium through
which people act and interact.
4
Findings
• Organisation of nursing work was anything but
bland and the organisation of nursing work and the
unit was shaped by the anxiety raised by emotions
evoked by the experience of being infertile and
caring for infertile people.
5
• The expression of caring behaviours by staff
depended on the use of space within the clinic
• Nurses, working mostly in the public spaces of the
clinic, use these public spaces to distance themselves
from patients’ emotions
6
• The organisation of the unit into public and private
spaces ensured that the potentially disruptive
emotions of staff and patients were controlled and
largely unexpressed or if expressed to,
unacknowledged by, the staff.
• The findings demonstrated the unseen work of the
unit i.e.: the management of emotions and how these
shaped care delivery.
7
Post doc work stimulated by this
comment:
• There is a moral imperative for nurses to create
trustworthy, honest and authentic relationships (De
Raeve 2002).
Seeing ‘distanced’ nurse-patient
relationships positively
•
Advanced roles include nurses undertaking tasks which
were formerly performed by doctors. Rather than limiting
the potential for intimacy between the nurse and the
fertility patient, we argue that such roles allow the nurse to
provide increased continuity of care
•
This continuity of care facilitates the management of
emotions where a feeling of closeness is created while at
the same time maintaining a distance or safe boundary
which both nurses and patients are comfortable with.
9
• A distanced or “bounded” relationship can be
understood as a defence against the anxiety of
emotions raised in the nurse-fertility patient
relationship.
10
• Intimacy is defined in the empirical literature as the
opportunity provided in “the basic work of nursing
[…] for a psychological closeness or meaningful
relationship between nurse and patient that may
hold therapeutic potential” (Savage 1995 :11)
• Nurse-patient relationships change ‘ordinary’ social
relationships and that there is a need to manage the
intimate and emotional nature of these clinical,
‘non-social’ relationships (Menzies 1970)
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Technologies and emotions
•
Empirical work suggests that the nature of the task
determines the level of intimacy (Tutton 1991)
•
The investigation and treatment cycle for infertile patients
is highly intimate and intrusive not only because it deals
with intimate areas of the body for both men and women
(Meerabeau 1999; Allan 2001).
•
It also deals with an intimate ontological area of being a
man or woman who is unable to conceive and bear
children (Franklin 1990; Pines 1990; Raphael-Leff 1991;
Christie 1998).
12
New nursing roles
• Support, inter professional working and the internal milieu
within the unit influence new nursing roles
– The internal milieu of the clinic facilitated role change because nurses
felt they were supported and that they had a real choice about
undertaking new roles
• Fragility of new nursing roles
13
Technologies and change: the patient at
a distance
• The expansion and consequent changes in the
delivery of care to couples seeking in vitro
fertilisation (IVF) in Australia and New Zealand and
the implications of these changes to service delivery
in the United Kingdom.
– Increased numbers of cycles
– Telecare – ‘call centre work’
– Management of patients at a distance
– Task allocation of nursing roles
14
Socio-cultural context of care delivery (health
care policy) and new reproductive technologies
are shaping care delivery:
• Tension between new technologies and care delivery
– call centre work – and ‘traditional’ nursing –
hands-on care
• Patient experience
• Less intrusive treatment cycles vs depersonalisation
• Medical control & profits
15
Routine practices
• The delivery of assisted reproductive technologies
(ARTs) are increasingly seen as routine practice and
we wish to explore the shaping of this ‘routine-ness’
of care.
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Meaning and structure of routines
• Routines
– structures which are enacted sets of rules and resources
that inform ongoing action (Giddens 1986); they shape
human actions and identity, which in turn re-affirm or
change structures
– Feldman (2002) sees routines as offering the potential for
organisational change, that is, they can be changed by
human action
– Becker ((2004) sees routines as also being about the
preservation of the past ‘we’ve always done it this way’
ARTs and routine-ness
• relationship between science and technology
(Thompson 2005);
• the use of technologies such as telemedicine (May et
al 2001; May et al 2006)
• the meanings such technologies have for
understanding the body in nursing (Barnard &
Sandelowski 2001; Sandelowski 2002; Barnard
&Sinclair 2006)
• the space for patient agency.
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Conclusions
• New technologies introduced to the treatment and
investigation of infertility, and in particular the
funding and widespread privatisation of fertility
treatment in Australia and New Zealand, have
contributed to new organisational routines which
are based on technological systems of care and the
construction of the distal patient.
Conclusions
• It appears that both spaces of the clinic and the
distant fertility patient model offer possibilities for
agency; on the one hand the distant patient model
offers possibilities for negotiating embodiment
while at the same time restricting the potential for
intimacy and care while the fertility clinic offers the
possibility of intimacy albeit negotiated and distant
while reinforcing the biomedical objectification of
the body (Allan 2007).
Challenges
• Challenge of how to achieve and sustain advanced
roles in the context of increasingly for-profit
business models of health care delivery, in turn
contextualized within capitalist societies.
• Infertility as a medicalised disease rather than a
social condition offers fertile ground for competing
professional interests.
• Hybrid roles of nursing (Sandelowski 2000)