The unexpected return of alienation: job dissatisfaction, 'burnout' and work estrangement in the NHS.
| Author | Iliffe, Steve |
| Position | LOCAL GOVERNMENT AND THE NHS |
The concept of alienation has made a comeback in debates about rising job dissatisfaction and burnout in the health service. A Labour government could address these issues by empowering health workers.
In the twenty-first century, the concept of alienation has tended to drop out of political language in the UK, only to return from an unlikely source--the USA--and to an unlikely place--discussions of the NHS. According to Raymond Williams, alienation is one of the most difficult words in the English language, with specific but disputed meanings in a range of disciplines. (1) As a way of expressing the division between the individual and society, and the sense of workers as nothing more than cogs in a machine, it resonated with the experiences of the post-war decades. But, within a few years of the millennium, alienation had been deprived of the keyword status Williams had given it: it was deleted from the updated 'Keywords for Today' published in 2018. (2) As Stuart Hall remarked, alienation is 'a much used and abused word', but, we argue, it is one that is still useful to political debate today. (3)
The concept of alienation has resurfaced in the North American literature on problems of staff retention in the US healthcare system. (4) This wa s surprising, at least for UK observers, because--while alienation as a concept had entered American political culture following the emigration of members of the Frankfurt School (especially Marcuse) to the US--its original meaning had been muddied and obscured when it was investigated empirically. (5) Yet despite this lack of robustness as a category for social science, some researchers now argue that an explicitly Marxist concept of alienation 'should be the focal point for human resource management scholars in the twenty-first century'. (6)
This article explores the meanings and practical utility of the concept of alienation for the NHS. Health service staffing problems are not restricted to North America; England's NHS is also struggling with widespread workforce shortages. More nurses are leaving the profession than are joining it, with community nursing being particularly hard-hit. Not enough trainee doctors are progressing from basic to specialist training, leaving hospital posts unfilled. Many senior practitioners from several professions are taking retirement early, and the NHS is losing their accumulated knowledge just when it is most needed. Job dissatisfaction seems widespread, with professional and trades union bodies warning that patient safety is at risk from staff 'burnout'.
The current staffing crisis reveals an underlying and profound problem that a future Labour administration will have to face. The NHS tends to under-estimate the need for staff and over-estimate the availability of practitioners. (7) The House of Lords Select Committee on the Long-term Sustainability of the NHS noted in 2017 'the absence of any comprehensive national long-term strategy to secure the appropriately skilled, well-trained and committed workforce'; and it identified this as the biggest internal threat to the viability of the NHS. (8) An Interim NHS People Plan has begun to debate the options, but there is a lot of ground to make up, and a prospective Labour government will need to think strategically about how best to retain the commitment of NHS staff.
The nature of health-care labour
The scale of staff shortages is evident, but the nature of the work that NHS staff undertake and the causes of their dissatisfaction are less clear. Despite their very different jobs, in our view all practitioners carry out both 'immaterial' and 'emotional' forms of labour, which we explain below. These forms of work are carried out in organisations and teams that are struggling to accommodate more patients, increasing complexity of conditions, demands for greater productivity, and pressures for cost-containment.
Immaterial labour: Much of the work done by nurses, doctors and other health professionals is 'hands on'--examining, ordering investigations, operating, giving injections, dressing wounds--but all the physical effort depends on immaterial labour. (9) Immaterial labour requires judgement and discernment, openness of mind, and the ability to synthesise formal scientific knowledge with experiential knowledge. This immaterial work can be demanding and stressful, in that practitioners must think under pressure, but it is made more so by its content--seeing, talking about and living with the experiences of illness, fear, pain and death.
Emotional labour: A concept developed first by feminist scholars, this is the work (effort, planning, control) required to express organisationally desired emotions during interpersonal transactions. (10) At its most extreme this form of labour promotes brazenly insincere communications of the 'Have a nice day!' type, and generates stressful cognitive dissonance. (11)
Health professionals are less likely than, say, call centre workers to experience extreme cognitive dissonance through their emotional labour, and may be able to modulate their emotions so that they can express joy at a birth, anxiety at the diagnosis of cancer or sadness at a patient's death. (12) Nonetheless, they need to u nderstand and accommodate each patient's emotions, and learn which of their own emotions should be hidden from view during a clinical encounter and which should be manifested.
Those who learn how to modulate their emotional responses acquire the skill of 'deep acting', whilst the less emotionally flexible develop a 'surface acting' approach to face-to-face encounters. Deep actors experience job satisfaction because emotional labour creates...
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