A Qualitative Study of the Impact of Emotional Labour on Health Managers
Boucher, C. (
ualitative Study of the Im pact of E m otional
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Independent Researcher, Melbourne, Australia
The objective of the study was to examine how surface acting is used by middle
managers to manage the emotional displays of executives in the health industry
in Australia. The research was located within a social constructionist
epistemology and the theoretical construct used to structure the study was
surface acting. Data was generated through qualitative interviews with 49
middle managers. Analysis was undertaken using grounded theory and thematic
analysis. The main finding was that unlike male managers, female managers
took on the role of managing the emotional displays of senior staff and used
surface acting as the means of doing this. They expressed optimism, calmness
and empathy even when these were not the emotions that they were actually
feeling. It is argued that the propensity for female managers to take on the role
of managing the emotional displays of powerful others demonstrates the extent
to which gender stereotypes still persist in the health system. The long-term
impact of this is often detrimental in terms of female middle managers
wellbeing. This is the first study to look at how surface acting is used by more junior
staff to moderate the behaviour of executives. Keywords: Emotions, Middle
Managers, Surface Acting, Gender Differences
The health service management literature appears to be publishing more studies
examining the emotion work performed by people who are leaders and managers in
(Schat & Frone, 2011)
. Concepts such as emotional labour
and emotional intelligence
(Cherniss & Goleman, 2001)
are re-appearing in new guises, such
as the discussion of toxic organisations
and psychopathic managers (Applebaum,
Semerjian, & Mohan, 2012).
What has received less attention is the emotional labour that is routinely performed by
health service middle managers as part of their day-to-day job role, not involving patients
(Barron & West, 2007)
. Descriptions of the ways middle managers employ emotional labour
are largely missing from the health service management literature
. Nor has
the literature described the ways middle managers use emotional labour to manage the
emotional displays of executives and senior medical practitioners or how gender might be a
factor in this. This paper attempts to fill this gap by describing how health service managers
employ surface acting, in an attempt to influence the emotion displays of more senior staff.
Although this study took place in Melbourne, Australia, the phenomena under study,
specifically surface acting and, more generally, emotional labour, gender relations, authority
relations, the relative status of health professionals, and the impact of organisational culture on
employees’ well-being, appear to be of interest globally. They are of interest in a range of
(Batinic, 2010; Sohn & Lee, 2012; Yin, 2012; Zhang & Zhu, 2008)
(Lindorff, 2001; Näring, Briët, & Brouwers, 2006; Torkelson & Muhonen, 2004; Winstanley
& Whittington, 2002)
It is not being suggested that the findings are generalizable across other cultures and
settings, but it is reasonable to suggest that they would be of interest to others given universal
interest in the phenomena described above.
This study did not look at the emotion work that health industry leaders (such as
Medical Directors or Nurse Leaders) engage in when dealing with patients, clients or their
families. The intent of this study was to explore the use of surface acting when middle managers
engage with their superiors. The research question was: How is surface acting used by middle
managers to manage emotion displays by executives and senior staff. Middle manager refers
to those in positions with line responsibility but who are not part of the executive (e.g., Nurse
Unit Managers, Clinical Directors, Allied Health Managers). Superior refers to health service
executives, senior medical staff and other bureaucrats, who had significant authority but may
or may not be in a line management relationship with the middle manager.
introduced the term emotional labour in 1979 to describe emotion
work done in a paid work setting. She has described three types of emotional labour, genuine
emotions, surface acting and deep acting. Surface acting involves managing the expression of
one’s own feelings. The worker uses facial expression, tone of voice, gestures, etc., to
demonstrate emotions different to those actually being felt. The emotions demonstrated
through surface acting are usually more “positive” than those actually being felt, and the aim
of surface acting is to influence the subsequent emotions demonstrated by the other person in
a positive way
The study of surface acting has mainly been undertaken in female dominated
professions, especially the “caring” professions such as nursing
(Haycock-Stuart, Kean, &
. The exploration of surface acting has continued to focus largely on women
and in many ways emotional labour has become synonymous with women’s work, especially
in the caring and service professions
. Recently the use of the concept has been
expanded by some authors to include.
Impact of Surface Acting on the Actor
Prior studies suggest that a number of characteristics of surface acting influence how
engaging in it is experienced, both short and long-term. These studies have also demonstrated
(though not without some equivocation), that gender has an effect on the longer-term impact
of engaging in surface acting. The review below summarises the literature on the interaction
between surface acting and gender.
Several studies have shown that engaging in surface acting (as opposed to expressions
of genuine emotion or engaging in deep acting) appears to pre-dispose workers to stress and
(Barron & West, 2007; Biron & van Veldoven, 2012; Chu, Baker, & Merrmann,
. Most studies also indicate that women experience these consequences to a greater extent
(Barron & West, 2007; Johnson & Spector, 2007; Sloan, 2012)
. While most of these
studies have not specifically studied female managers, it seems reasonable to assume that
managers’ responses would be little different to other female workers
Johnson and Spector (2007)
studied customer service workers in a range of industries
and found that when women were surface acting they reported more detrimental outcomes such
as reduced affective wellbeing, less job satisfaction and greater emotional exhaustion than did
men. Others have reported similar outcomes
(Blau, Bentley, & Eggerichs-Pucell, 2007;
Goodwin, Groth, & Frenkl, 2011; Grandey, 2003; Lui & Song, 2010; Scott & Barnes, 2011;
Walsh & Bartikowski, 2013)
Barron and West’s (2007)
study looked at men and women employed in “caring
professions” (defined as work roles that involved personal interactions that were emotionally
laden). According to the findings of their study, being a woman and being a manager were both
factors that contributed to a greater likelihood of feeling exhausted and stressed than being a
male in a non-management role.
There is ample evidence to indicate that in many cases, surface acting by women as part
of their work role does increase the likelihood that they will experience negative outcomes such
as emotional exhaustion, stress and burnout. There is also evidence that managers are just as
susceptible to incur these outcomes as other workers
(Humphrey, 2013; Humphrey, Pollock,
& Hawver, 2008; Iszatt-White, 2013)
The argument above articulates the theoretical context in which this study took place.
At a personal level, the origins of this study can be found in the twenty-five years I have spent
working with health professionals and my growing interest and concern about how the nature
of the work impacts on their emotional well-being.
I do not have a health background. I have worked with health professionals in both a
consulting and academic capacity since 1989, initially just by circumstance and later by design
as my interest and expertise in the area grew. Most of this work has been in the public health
sector and with nurse managers and allied health managers. Most have been women. While
the tasks have been varied, I have become increasingly aware of how often the participants
discussed the emotional side of their work. Because my role was not focussed on patients, the
discussions invariably seemed to turn to the management of relationships with colleagues and
I was struck by how difficult many of these relationships appeared to be. This did not appear
to be of as much of a concern to managers working in other industries who I also taught or
In the 1990’s I undertook a long project in a health service that involved the use of
reflective practice as a management development tool
. This gave me the
opportunity to spend considerable time per fortnight, over almost a year each time, with groups
of managers, exploring the issues of greatest concern to them. Invariably the issues gravitated
around managing people and in particular, managing their own and others emotions. I became
increasingly concerned about the emotional well-being (and in some cases, mental health) of
some of the participants and in an attempt to help them, found the framework of emotional
labour and it proved useful for me and the participants. It seemed to me that an inordinate
amount of emotional energy was being spent by these managers every day in managing the
moods, attitudes and personalities of their staff and colleagues and that this was different to
what I saw in other industries. I also began to wonder in what ways the nature of the work
performed and the gender composition of the workforce might have an impact. It seemed to
me that, for some reason, the emotional investment made by these managers led to them
becoming tired, and depressed and in the course of my work with them, I saw a number of very
good people simply burn out and give up.
My interest was not initially focussed on how these managers’ interacted with their
superiors. I was not as aware as I should have been of the frequency and importance of these
interactions partly because my work with them was mostly about how they managed their
subordinates and their relationships with peers. It was only when I began to analyse the data
that the critical nature of these interactions began to emerge.
I was looking for ways to help these managers better manage their emotions at work,
to limit stress and burnout. What emerged was a more general concern about the damaging
nature of power relationships in the industry.
Methodology and Methods
This study was undertaken in Australia during 2012-2013 and drew participants from a
wide range of health service organisations located in Melbourne and regional and rural
Victoria. The research project was approved by the University Ethics Committee and also by
the Ethics Committees of three of the health services from which participants were recruited.
Table 1 below describes the interview participants.
Epistemologically, the research was located within a social constructionist approach
. Constructionists view knowledge and truth as created, not discovered by the
. Thus they hold the view that reality is socially defined and that this
reality refers to the subjective experience of every-day life, how the world is understood rather
than to the objective reality of the natural world.
As reflected in the research question, the aim was to articulate the subjective lived
experience of surface acting of the research participants and to come to understand how they
thought it impacted on their well-being. It was not concerned with objective issues such as
measuring the amount of surface acting that was occurring.
Methodologically, a qualitative approach was employed. Although quantitative
questionnaires have been developed that examine surface acting and its impact o
(Yang & Chang, 2006
), this cohort (managers) had not been studied previously, nor had
interactions with superiors been examined. All previous studies that used questionnaires had
focussed on employees working with customers/clients rather than with other employees and
so it was deemed necessary to adopt an approach that would allow themes other than those
found in the extant literature and included in existing questionnaires, to emerge.
Data was generated through unstructured interviews. Unstructured interviewing is
recommended when the researcher has developed enough of an understanding of a setting and
his or her topic of interest to have a clear agenda for the discussion with the informant, but still
remains open to having his or her understanding of the area of inquiry open to revision by
(Minichiello, Aroni, & Hays, 2008)
. In this case, the researcher had already
undertaken a number of projects that had touched on the topic of surface acting in healthcare
settings. She was also familiar with the literature so had a good understanding of the
phenomena, though as described above, in different contexts. She had not explored the use of
surface acting with superiors, nor had she found this described in the literature. Unstructured
interviews created an environment that allowed for the emergence of themes previously
described in the literature and those that were unique to the situation being researched.
The length of the interviews varied from around and hour to just over two hours. The
researcher’s prompt to the participants was to ask them to describe experiences in the
workplace where they felt they displayed emotions that were different to the ones they were
actually feeling. The context in which this occurred and the impact it had on them was then
explored, as was their understanding of why they engaged in this behavior. After the first few
interviews had been analyzed, the theme of using surface acting with superiors was identified
and a more structured approach was taken to exploring this theme. All participants were
prompted to describe instances where they used surface acting with superiors, although as will
be explained later, this phenomenon was limited almost entirely to the women in the study.
Participants (see Table 1) were recruited through the researcher’s professional networks
and through snowball sampling.
Note: Direct reports are the number of staff the participants directly manage. In some cases, these direct reports
would also manage other staff.
The researcher had extensive professional connections to a number or private and
public health services in Victoria. She was able to arrange for an email to be sent to managers
inviting them to take part in the study. Approximately 2000 managers would have been
contacted in this way and about 120 responded. A sample from this group was selected for
interview with the aim of having as diverse a group as possible. More women than men were
interviewed for several reasons. The health industry is predominantly female. Over 75% of the
respondents to the emails were female. As mentioned earlier, it became clear very quickly that
the theme of greatest interest was gendered, was more likely to occur with older managers and
with nurse managers. Five interviews occurred as the result of snowball sampling
Aroni, & Hays, 2008)
. It was more difficult to recruit participants who were not nurse managers
and so those non-nurses who took part in interviews were asked to approach, on the researcher’s
behalf, any of their colleagues who they thought might be interested in taking part.
All interviews were recorded and transcribed verbatim using Dragon Dictate. The
researcher annotated the transcriptions to reflect non-verbal data such as tones of voice, body
language and visible emotions. The purpose of this was to ensure that the data analysis took
full advantage of the additional information made available by conducting face-to-face
(Minichiello, Aroni, & Hays, 2008)
The data was analyzed using an analytic induction approach
from the existing literature on surface acting formed the basis of an initial set of categories
(Crabtree & Miller, 1992)
and a line-by-line approach was used to code the data under these
categories. Grounded theory techniques
(Coffey & Atkinson, 1996)
were also used with the
first ten interviews to identify any additional themes. Fourteen additional themes were
discovered and these were incorporated into the existing categories or formed new categories
into which the data was sorted. The results are presented in the form of a set of themes drawn
from both forms of analysis and a “grounded theory” as such was not developed. The use of
grounded theory techniques contributed most to the identification of interactions with senior
staff being a key theme and then to the description of how, for the female managers, these
interactions differed from other interactions, as described in Table 3.
The outcomes of the study demonstrated the significance of gender and its influence on
the amount and type of surface acting engaged in with superiors. The characteristics of the
interactions with superiors that the women described as having the most impact included the
predictability of the interaction and the foreboding this created, the intensity of emotions
expressed by the other person and the others’ disregard for accepted display rules, the amount
of surface acting as compared to the expression of genuine emotions and the need to be
particularly attentive to display rules with regard to one’s own demeanour. A most interesting
discovery was the very negative impact of surface acting interactions with superiors that
involved all of the above but also required the female managers to take into account the power
relationship that existed and the potential longer term consequences of the interactions. As
expected the women also reported that the interactions had impacts that were detrimental to
their well-being such as stress and emotional exhaustion.
The Differences in the Interactions of Male and Female Managers with Senior Staff
Distinct differences were found in the ways male and female managers described the
ways they engaged in surface acting with their superiors. Table 2 below summarises those
Role taken on
As part of
It’s part of the management role, in
my job description, to
communicate with people and
know what is going on with them
I don’t take work home,
I’m really clear about that…and I
don’t think about it until I come
back into the office (Daniel).
You shouldn’t get too close to the
people you work with. Even other
managers have different stuff they
want and you can be in conflict
He is just obnoxious - rude, loud and
abusive. I hate it and hate it most when he
loses it in public (Jennie).
At least of she takes it out on me she’s not
abusing the cleaners or the catering people
I don’t really talk about work at home
because (husband) is not really keen on it
and gets annoyed…says I’m obsessed and
need to learn to let go. (Amy)
It’s like when someone tells them off and
he throws a tantrum. Except he doesn’t do
it is the CEO’s office, he comes to me
Women reported many more conversations about relationships, and older women (50+)
talked about taking on the role of mother (or even Mother Teresa) or agony aunt, especially
when referring to interactions with younger staff (such as young executives). The male middle
managers almost unanimously described interactions that continued for a relatively short time
(three to five conversations over a few weeks). The men were also more likely to suggest a
solution to the other person or refer them to someone else. This appeared to be a way of
avoiding having to engage in longer-term surface acting with the other person.
In addition to the characteristics commonly reported in the literature that are typical in
surface acting interactions (e.g. expressing positive emotions even when these are not felt), the
female participants described several additional factors that seemed to be critical in the impact
that surface acting with their superiors had on them and these are summarise in Table 3.
Female managers shielded the public and more junior staff from public displays of
anger by moving angry executives into private offices and then talking with them. They
empathised with frustrated senior staff to build rapport and in return they were able to garner
More than 75% of the older female leaders talked about regular interactions with senior
staff that involved surface acting. These interactions were endemic when nurse leaders
comanaged clinical services in tandem with senior doctors and they principally involved allowing
the other person to “sound off” or “let off steam.” Their rationale for engaging in these
interactions was either to protect others from what they viewed as inappropriate displays of
emotions or to build “brownie points” that they could later use as social credits to support
decisions they made
. Only two male participants reported any similar
The interactions usually involved expression of a good deal of anger and/or distress by
the superior, were about workplace and personal issues and occurred spontaneously. The types
of events that elicited these outbursts included anger at other peoples’ behaviour, anger at or
distress about decisions of the executive or other leaders in the organisation, anger about the
behaviour of their peers, anger or distress, bought about by general frustration with matters
such as workplace rules and policies, limits to their authority and general workplace issues
(such as parking arrangements, quality of staffrooms, etc.). The female managers who took part
in this study expressed annoyance, anger and frustration at having to put up with these outbursts
but continued to do so and responded with patience, sympathy and concern (surface acting).
Of the six additional characteristics found to be present when female middle managers
were surface acting with senior staff (as compared to men), four have not been described before
in the more general literature on emotional labour. The female managers discussed how
knowing in advance that a surface acting event might (or would) occur, filled them with
foreboding. They would become pre-occupied, thinking about what might happen and
attempted to develop strategies to minimise the impact of it on them and sometimes on others
in the vicinity. They described how these interactions often involved their superior expressing
much more intense emotions (usually anger), than was normal for an employee in their
organisation, and that this was not just confronting in itself but also represented a disregard for
norms around professional conduct and a general disregard for organisational display rules.
They also described how the unequal power relationship between themselves and the senior
manager meant they felt compelled to engage in the interaction and also to express empathy
even when they did not feel it. They also described hiding the anger they felt at what they
perceived to be unprofessional and at times, immature behaviour.
In summary, not only did the female managers engage in more frequent and longer
surface acting interactions with senior staff than did the male managers, they were also more
negatively impacted upon by them in terms of their well-being. They were subjected to intense
emotional outbursts that they felt compelled to tolerate because of the organisations’ emotional
display rules, to protect others from inappropriate behaviour, and because of the power
relationships that existed.
Both men and women leaders in this study reported that they engaged extensively in
emotional labour (and in particular, surface acting) but appeared to do so in somewhat different
ways. Women reported that they were more likely to engage with individuals over a longer
period of time. The men on the other hand, reported that they mainly saw their roles as helping
to solve a problem and/or referring the person to someone who was more expert or could be
more helpful. Both of these findings are consistent with previous studies undertaken in the
health sector and beyond
(e.g., Bolton, 2001; Chu, Baker, & Murrmann, 2012; Grandey, 2003;
Johnson & Spector, 2007)
Brotheridge and Lee (2002)
identified duration, frequency, intensity and variety of
surface acting interactions as factors that contributed to the impact that it had on individuals.
This study appears to support their finding that these factors are important in determining the
ways in which surface acting can be detrimental. The women in this study who engaged in
surface acting more often, more intensely, for longer periods, and with a wider range of people
than their male counterparts appeared to experience more negative consequences.
It is clear from the data that one critical way in which the female manager’s experience
of surface acting was different from that of male middle managers was the extent to which it
occurred with senior staff. Women were more likely to engage in “faking” emotions in an
attempt to pacify superiors. This seemed to occur as a mechanism for dealing with aggression
and gaining the future cooperation of these powerful people, but meant the female managers
interviewed in this study were subject to intense expressions of anger and frustration and the
use of language that would normally be unacceptable in most workplaces.
that the higher the status of a person in an organisation the more likely they were to express
genuine feelings such as anger and frustration and that this was particularly true of men in
senior positions. This study appears to confirm her findings, though using the lens of surface
acting to explore the impact of this is new.
Liu and Song (2010)
found that the level of aggression shown by the other party
did not seem to be a factor on the impact of surface acting, I would suggest that this study may
offer another perspective. They studied call centre workers and customers, and unlike the
managers in this study, presumably the interaction was relatively anonymous, of short duration
and one party did not have considerable power over the other. In this study the interactions
with senior staff were often frequent, regular and involved a considerable power differential.
has written about the impact that senior executives can have on staff and less
senior managers when they behave in an aggressive fashion. This study seems to support the
view that interactions that require managers (in this case female managers) to engage in surface
acting in the face of aggression from their superiors does have significant negative implications
This study, like others
(e.g., Yanchus, Eby, Lance, & Drollinger, 2010)
demonstrate that women are more likely than men to experience stress and burnout when
engaging in surface acting. Previous findings that women often also take on emotion work in
the home and that this negatively affects their ability to cope
Bakker, & Demerouti, 2012; Yanchus, Eby, Lance, & Drollinger, 2010)
, so it is reasonable to
suggest that they experience a “multiplier effect.”
The study took place in only one industry and engaged only with health professionals
working in Victoria. The extent to which the findings are of use in understanding surface acting
in other contexts is difficult to determine. There is some support to suggest that the situation
is similar in the healthcare industry in other parts of Australia
(Royal Australasian College of
, and that surface acting is a technique used by managers in other cultures
(Humphrey, Pollack, & Hawver, 2008)
However, given the nature of the method, the results of unstructured interviews are
difficult to replicate
. This does not mean though, that the findings are not
(Minichiello, Aroni, & Hays, 2008)
and that this was not the most appropriate
way to undertake this study, and this argument was made earlier.
It is known that dealing with negative emotions in the workplace effectively is critical.
Frost (2003, p. 219) refers to the people who do this as toxin handlers as states that “It is brave
work done by empathetic managers…” This study appears to demonstrate that the women
managers in this study did the bulk of the managing of toxic emotions by engaging in surface
acting, thus performing a critical role, but taking the risk of being damaged by it, especially
through engaging in frequent, long term, surface acting in an attempt to manage the emotion
displays of senior staff.
The findings of this study and the review of the literature suggest that the surface acting
performed by managers is of benefit to the organisation (and most of those who work in it).
However, this research suggests that it can be detrimental to some of the women managers who
do it, in terms of stress and job burnout in the longer term. This raises a range of ethical and
pragmatic dilemmas. Is it appropriate that in an essential industry such as health, women are
paid to perform a critical task, but by them doing so they risk their careers and at times their
According to this study, one of the most problematic occurrences of surface acting for
these female managers, and the most difficult, was interactions with their superiors. A
potentially very effective strategy to eliminate the need for them to engage in such behaviour
would be to remove the cause of this surface acting. This is particularly important given the
growing recognition of the negative impact of “toxic managers” in general
this could be done given the inherent rigidity of the power structures in healthcare settings
(Fulop & Mark, 2013)
, however, is hard to imagine.
If elimination of such behaviour is not feasible in the short term then the findings of
this study have implications for Human Resource Management professionals, professional
bodies such as the Royal Australasian College of Surgeons (RACS) and the Australian Medical
Association (AMA) and their equivalents in other countries, and Boards of healthcare
organisations who have duty of care to all of their employees, including managers.
HRM professionals are charged with ensuring that their organisations are safe and
healthy workplaces. This includes addressing issues that impact on psychological health
(AHRI, 2016). If it is necessary for employees to undertake psychologically risky work, then
appropriate safeguards need to be put in place. The women managers in this study reported
that they received little or no formal or informal support from their workplaces. Although
previous research has been equivocal about what supports staff undertaking surface acting
need, there is evidence that interventions such as mentoring
and per support
through reflective practice
, help. The implementation and promulgation of
employee assistance programs has also been shown to be of benefit in industries where
psychological harm can occur
(Employee Assistance Professional Association of Australasia,
. In the health industry, these programs could be extended to include non-clinical related
Professional bodies such as RACS, the AMA and the Australian College of Health
Services Executives (ACHSE) represent those who engage in the demonstration of
inappropriate emotions in the workplace. They also have a role to play. RACS has recently
commissioned a report into discrimination, bullying, and sexual harassment in the practice of
surgery and their subsequent strategies could be extended to the heath workforce more
generally. The Australian Nursing and Midwifery Federation has traditionally been very good
at protecting the interests of nurses but may need to pay more attention to the welfare of
members who are nurse managers.
Ultimately, Boards of healthcare organisations have duty of care to their employees and
a pragmatic interest in having functional managers and a cohesive management team
. They must act to ensure they ethically manage their senior staff in the same
ways they do to protect the interests of their other staff and their patients. This may involve
requiring their senior managers and executives to be more considerate about how they interact
with their colleagues.
satisfaction in Chinese higher education. Communication Education, 57(1), 105–122.
Carlene was formerly Associate Professor of Health Services Management at RMIT
University in Melbourne, Australia. Her research explores the experience of difference in
organisations and how people use emotions to negotiate their workplace identity.
Correspondence regarding this article can be addressed directly to:
Copyright 2016: Carlene Boucher and Nova Southeastern University.
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