The socio-cultural context of care delivery and the management of emotions in the fertility clinic

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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
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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

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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.

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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.

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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.

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• 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

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• 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.

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Post doc work stimulated by this comment

• There is a moral imperative for nurses to create
  trustworthy, honest and authentic relationships
  (De Raeve 2002).

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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.

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• A distanced or bounded relationship can be
  understood as a defence against the anxiety of
  emotions raised in the nurse-fertility patient
  relationship.

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• 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).

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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

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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

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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

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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 weve always done
  it this way

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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.

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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).

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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)