Managing the Costs of Emotional Labor in Emergency Ambulance Call-Taking
July 22, 2020
By Kathryn Muhlhan
Editor's Note: A column in the May/June IAED Journal represents the introduction to the following thought-provoking research paper by the same author.
It was her first day shift and as usual, Kristen had struggled to sleep the night before. She logged on a little bleary eyed, nodded to her team and asked when the coffee run was. The first beep in her ear gave her a jolt. Straight away, she knew she needed to focus. A thick Arabic accident was trying to pronounce long street names, yelling about a mum and baby who had been hit by a car. She took a breath in, and started to work. With a firm authoritative voice, she instructed her caller to slow down and give her the street names. After verifying the address, she opened ProQA and began getting details of the accident. Again, the caller started to panic. She gave some gentle reassurance, softening her tone and explained how it was very important that all the questions were answered. The job was accepted, the baby was not awake and not breathing. CPR needed to commence immediately. But something was wrong. She knew there were often barriers to CPR so she worked through them.
“We can do this together,” she assured her caller calmly. “Why can’t you reach the baby?” The seconds were ticking. Kristen was pushing down the anxiety rising from the pit of her stomach.
“In stomach, in her pouch…” the caller answered in her stilted English.
Suddenly it dawned on Kristen what she was dealing with. Reports from the crew that arrived seconds later confirmed it. On a deserted rural Victorian road, a car had hit a mother kangaroo and her joey.
Emotional labour is a large component of emergency ambulance call-taking[i] and a reason why people both love and hate the job. Emotional labour is required in many industries but the uniqueness of the emergency ambulance call-taking environment brings particular costs and benefits. The frequency, variety and intensity of the emotional labour performed, and the method used to perform it, all influence its impact on the worker. Many aspects of the role may energise call-takers such as the altruistic service provided, the satisfaction of performing a difficult job well, and sharing stories. However, the emotional labour of emergency ambulance call-taking also takes its toll on individual call-takers and may result in emotional exhaustion from emotional incongruence and emotional numbness. Individuals, teams and organisations that understand emotional labour and its effects, can develop strategies to maximise the benefits of the role and mitigate the risks. A strong and supportive team culture, belief in the role and education are some strategies that can help to manage emotional labour within emergency ambulance call-taking.
Using current research, and reflecting on my experience as an emergency ambulance call-taker and trainer, this article will look specifically at:
- What emotional labour is
- Workplace factors in emergency ambulance call-taking
- What tasks are involved and how are they carried out
- What is the impact of emotional labour on individual call-takers
- What strategies can be used to minimise costs and maximise benefits
WHAT IS EMOTIONAL LABOUR
Emotional labour is the expression or suppression of personal emotions, in order to elicit appropriate emotions and responses in a client, to fulfil the expectation of a particular paid role. Emotional labour exists whenever someone is paid to achieve a goal, and the achievement of this goal relies on the person’s interaction with another person. It is essentially the ‘people work’ involved in so many jobs. A certain level of emotional intelligence and training is required to perform the tasks of managing personal emotions and managing the emotions of callers. Emotional intelligence is ‘the individual's capacity to recognize emotions in self and other - including skills such as active listening’.[ii] Emergency ambulance call-taking is an emotional and communicative exchange between two people that is more than simply data entry. In the high-pressure environment of emergency work, call-takers’ and callers’ emotions must be analysed in seconds and appropriate responses decided upon immediately. Inappropriate emotions must be suppressed, and helpful emotions elicited both within the caller and the call-taker, in order to quickly facilitate the call. Enormous emotional tasks such as remaining professional while calming down a panicked mother, reassuring a scared child, encouraging a father to do CPR on their child, and remaining polite while being verbally abused, are all considered standard requirements of the job. Emotional labour is distinct from physical and cognitive labour.[iii] Emergency ambulance call-taking, though performed in a very safe and moderated physical environment, is emotionally demanding due to the frequency, variety and intensity of the personal interactions required.
The frequency, variety and intensity of calls create unique emotional labour requirements for the emergency ambulance call-taker. The role varies between calls, shifts and rotations. A high frequency of calls means there is less time to reset and recover emotionally or debrief with colleagues between calls. This unique working environment requires call-takers to manage a wide variety of people, problems and processes, all under time-critical conditions. Each type of call may require a slight adjustment in tone, speed, manner and process in order to facilitate efficient processing of the call. This requires enormous emotional agility by the call-taker. The intensity of each call is affected by its length, seriousness of the medical condition of the patient, number of patients involved, complexity of processes involved, the call-taker’s level of experience, the emotional state of the caller, and the emotional reaction of the call-taker. The call-taker has almost no control over the frequency, variety and intensity of emotional labour, and is required to learn the skills to manage the constantly changing demands of the role. There are however, two areas where call-takers have significant control over; managing the emotional state of the caller and the emotional reactions of the call-taker. These two tasks are the core of emotional labour and are managed using the processes known as surface acting and deep acting.
The emotional labour tasks involved in emergency ambulance call-taking are the call-taker managing their own emotions, and managing the emotions of their callers. Call-takers are required to manage their own emotions, using either surface acting or deep acting, in order to match organisational demands, community expectations, and most importantly in order to process the job efficiently. Call-takers are required to suppress inappropriate and unhelpful emotions, and generate appropriate and helpful ones. Managing their own emotions well helps call-takers to manage the emotions of their callers.
Managing Call-taker Emotions
An emergency ambulance call-taker needs to manage their own emotions in order to fulfil the requirements of their role. The emotions required are very different to a traditional face-to-face customer service role, where the customer is always right, and always served with a smile. Emergency ambulance call-takers need to take charge of the call to operate quickly and efficiently to organise help in a timely manner. When callers’ ring 000, sometimes screaming hysterically, the call-taker must control their own emotions of panic or fear and project a feeling of calm and professional confidence. Sometimes call-takers need to sound firm and assertive, other times gentle and caring. Choosing the right tone is crucial to getting a timely outcome. Call-takers who are naturally calm have to increase their emotional repertoire in order to generate firmness and urgency when it is required, while naturally assertive call-takers often have to develop sensitivity, sympathy and gentleness to use when appropriate. Good call-taking requires the call-taker to be agile in how they respond to callers, often trying a number of responses until one works, in order to get the caller to respond appropriately. Emotional labour involves 'judging how alternative responses will affect the other then selecting the best alternative'.[iv]
Suppressing inappropriate emotions is a significant part of the emotional labour of an emergency call-taker. When a job triggers an emotional response from the call-taker, they are required to put aside their personal feelings in order to provide appropriate care for the caller. When a job seems funny or ridiculous, they have to resist the urge to laugh. When the call is for a terrifying or awful event, the call-taker cannot sound horrified or distressed. When the caller is angry and stressed and starts verbally attacking the call-taker, they cannot sound angry or upset. When a call-taker gets their twentieth call for a fall on the same shift it is inappropriate to sound annoyed or frustrated. Instead call-takers are required to sound calm, professional and confident, reassuring their callers to ensure help is organised quickly. They are always required to treat each callers with respect and care. All these examples require emotional effort in order to suppress natural emotions that arise and replace them with emotions that help to get the job done. A call-taker can replace inappropriate feelings and generate appropriate ones through the processes of surface acting or deep acting[v].
Surface Acting & Deep Acting
Surface acting is a method of emotional labour where the worker acts in a certain way in order to meet the requirements of the job despite feeling emotions that conflict with those actions. When new to operating, call-takers are often scared and lacking in confidence and yet it is not appropriate to communicate these emotions during calls. Call-takers need to communicate confidence and the sense that they are competent and in control. In initial stages this comes under the category of ‘surface acting’ as the trainees have to ‘fake it’ until they truly feel confident in the processes and their ability to carry them out. While we expect that new call-takers will act confident before they feel confident for the benefit of their caller, if they do not eventually become confident in their ability to help every caller, they will have to continue to use the emotional labour method of surface acting. Surface acting is also a part of an experienced call-takers repertoire on days when they are not feeling appropriate emotions such as confidence and empathy. Surface acting creates incongruence between how call-takers are feeling and how they are acting. However, long-term surface acting can lead to emotional dissonance, cynicism, and low job satisfaction.[vi]
Deep acting is another way of performing emotional labour, and researchers agree that this is less likely to lead to emotional exhaustion.[vii] When call-takers actually feel the emotions that they are expressing, they are ‘deep acting’. Deep acting requires a call-taker to understand their role, and therefore act within the limitations of it. Call-takers understand that no matter how well they perform their role they cannot affect the volume or variety of calls that will present. Good call-taking does not reduce the amount of tragedy and illness in the world. Good call-taking can, however, provide a calm reassuring voice in the midst of someone’s worst day ever. Good call-taking can organise the best help in the quickest possible time. Most emergency call-takers first enter the industry because they want to help people. Reassurance, empathy and kindness expresses a call-taker’s genuine desire to help people. More importantly however, ambulance call-takers understand the need for urgency and therefore muster the emotional strength to hurry their callers even when it frustrates them. Understanding the role helps to reduce frustration. “The big picture is that deep acting generally does not hinder employee well-being, and there is evidence that it is associated with job satisfaction, organizational commitment, job performance, and ultimately better customer satisfaction”.[viii] When call-takers identify deeply with their role they can gain satisfaction from performing it and all the emotional demands that it involves.
Managing caller emotions
Call-takers control their own emotions in order to control their caller’s emotions. Callers may have a number of difficult responses to a stressful situation that the call-taker has to help them navigate. Callers may be aggressive or frustrated due to the stressful nature of the situation, and may take that frustration out on the call-taker by being rude or verbally aggressive. Callers often need to be calmed down so that they can think clearly, provide necessary information, and follow instructions. Alternatively, some callers do not want to engage with the difficult situation. They may go as far as to call the ambulance but then want to leave. Callers who are frightened, unsure or nervous may respond to gentle reassurance and encouragement. Finally, callers may become frozen by stress or fear, such as in the event of a major car accident, and may need to be shocked into action for the sake of those who are injured. Some callers must be strongly urged to care for patients by controlling their bleeding, repositioning them or performing CPR. Callers can feel frustrated, angry, stressed, scared, helpless, afraid and many other emotions. The call-taker has to manage the callers’ emotions in order to facilitate the communication exchange required to get help organised and maintain patient care until the ambulance arrives.
Call-takers’ who manage their own emotions well, are more equipped to manage their callers emotions. Deep acting is the most sustainable method by which to perform this key task. Both deep acting and surface acting as a method of performing emotional labour have an impact on the call-taker with both benefits and costs.
THE IMPACT OF EMOTIONAL LABOUR
There are both benefits and costs to the performance of emotional labour. The benefits can be high levels of job satisfaction with employees feeling energized by comic relief, a fix, and the ability to make a difference in people’s lives and contribute to society. The cost of emotional labour however, can be also be high. Emotional labour may result in exhaustion from emotional incongruence and emotional numbness. Well-managed emotional labour recognizes the costs and works to minimise these, while also putting in place strategies to maximise the benefits.
Just like the bricklayer who performs physical tasks and enjoys the physical benefits of a strong body, emergency call-takers get many emotional benefits from performing their job. Three ways that emergency call-takers are energized by their role are altruistic service, satisfaction from difficult jobs, and storytelling.[ix] Altruistic service is one of the main reasons most people join emergency services. They want to help people. There are many calls that really touch the heart and make call-takers feel like they are genuinely helping people. Sometimes call-takers are thanked by their callers. Other times the call-taker will get off the phone and know that they have done a good job, made a difference in someone’s life, or saved a life. These calls can leave a call-taker feeling energized. Call-takers can get feelings of satisfaction from handling difficult jobs well. An adrenaline rush is experienced when managing complex and intense jobs, and can leave call-takers feeling proud of their ability to cope under pressure. A difficult job early in a call-taker’s career may just be their first CPR. An experienced call-taker, with exposure to a wider variety of jobs, requires a greater challenge such as a major car accident with a difficult verification, multiple people and patients on scene, with fast-paced changes and updates to the job. Shared with colleagues as ‘war stories’ these experiences promote feelings of pride and job satisfaction. Storytelling about a range of jobs is also a benefit of emergency ambulance call-taking. Call-takers have a very privileged view into the weird and wonderful things people do that require emergency assistance. There are jobs where objects are stuck in unusual body orifices, bodies are stuck in strange places, or patients, on arrival of the crew, are found to be kangaroos, dogs or just figments of the caller’s imagination. Re-telling stories to colleagues about interesting jobs is one of the fun parts of the job. Though emotional labour can produce feelings of personal accomplishment and satisfaction there is often a cost.
Emotional labour can result in call-takers becoming exhausted from emotional incongruence and numbness. One in three emergency service workers in Australia experience high or very high psychological distress[x]. Emotional incongruence exists when a call-taker is required to act one way when they are feeling another, or perform ‘surface acting’. Emotional incongruence can lead to emotional exhaustion.[xi] Emotional exhaustion is a vicious cycle that leads to more surface acting that then leads to more emotional exhaustion. Another cost of emotional labour is ‘emotional numbness’.[xii] While a certain amount of emotional distance is required to manage the ongoing emotional demands of the role, numbness is more extreme and reduces the benefits felt from performing the role. Call-takers still have to endure shift work, time pressure, repetition, scrutiny, attention to detail, but when they become emotionally numb it can be more difficult to get excited over babies that are born, enjoy callers who are helpful and thankful, and appreciate the bravery of patients. The satisfaction of a job well done may be replaced by a cynicism regarding the impact of their work. Call-takers may withdraw from the fun and support of shared story telling with their colleagues. An emotionally numb call-taker will have to rely on surface acting to present appropriate emotions to their callers. Surface acting in turn produces more emotional exhaustion. Exhaustion due to emotional incongruence and numbness can be minimised by supporting call-takers to maintain a level of emotional wellness where they can continue to enjoy the benefits of the role.
There are both costs and benefits to the emotional labour involved in the role of emergency ambulance call-taking. The benefits include altruistic service, satisfaction from performing a difficult job, and storytelling. The costs include exhaustion from emotional incongruence and emotional numbness. Exhaustion can be minimized, and call-takers energized, by a strong and supportive team culture, belief in the role and education.
Three key strategies that can help protect emergency ambulance call-takers from exhaustion are a strong and supportive team culture, supported belief in the role, and ongoing education. A strong and supportive team culture supports call-takers through sharing of stories and modelling of emotional expression by more experienced members of the team. A strong and supportive team culture encourages self-awareness and self-expression. Belief in the role encourages deep acting which makes emotional labour more sustainable. Through education, individual call-takers can understand the potential impact of their role, both positive and negative, and therefore better equip themselves to manage. Education can provide a break from emotional labour, as well as increasing self-awareness, and providing coping skills. Teams and organisations can also be educated to manage the cost, and support the benefits of the role of emergency ambulance call-taking.
Strong and Supportive Team culture
A strong and supportive team culture helps to facilitate both emotional support and venting, which helps to prevent exhaustion. Emotional support is characterised by ‘the availability of close and confiding relationships within the workplace’.[xiii] Disclosure without fear of judgement, and exposure to more experienced staff to model appropriate emotional management are helpful. Call-takers need time to vent and let down their emotional guard, to express their disappointment, their lack of confidence, their fear, and their sadness. Expressing these emotions on a call is inappropriate, but they are all valid and common feelings that call-takers have and need the opportunity to express. In order to help facilitate this expression, call-takers need to develop a level of emotional intelligence where they can learn to perceive emotion, understand emotion, manage emotion and use emotion[xiv] both during calls and in their work relationships. Venting or emotional catharsis is a type of emotion-focused coping strategy. As these strong and supportive team relationships take time to build, emotional writing interventions[xv] can build emotional literacy and facilitate emotional expression when not facilitated through relationships. Developing new work structures that allow call-takers’ time away from the emotionally demanding front line of call-taking can help prevent exhaustion. A strong and supportive team culture is a key element in the management of emotional labour in emergency ambulance call-taking.
Belief in the Role
Belief in the role is also a key element in the management of emotional labour in emergency ambulance call-taking. Call-takers are the emotional muscle and frontline of emergency telecommunication organisations. Being frequently reminded of the importance of their role, helps to ensure they continue to value their role and feel appreciated for the service they provide. ESTA does this for ambulance call-takers by celebrating baby delivery calls in the media, and hosting the annual ‘Triple Zero Hero awards’ recognising child callers, with their call-takers, for their courage and contributions. Service and recognition awards also recognise ESTA workers for years of service and excellence in particular areas. Frequent reminders of the value of the call-taking role are required to cut through the monotony and tragedy that surround much of the work.
Autonomy within the role is an important part of maintaining belief in the role and reducing emotional incongruence.[xvi] Call-takers need to be encouraged to foster autonomy in a job that is restrictive, process orientated and highly monitored. Allowing call-takers to develop their own style of call-taking within the bounds of ProQA and business rules is one way to promote feelings of autonomy in the role. There are many ways to sound professional, authoritative and in control. Allowing individual differences in tone and manner help call-takers to feel less robotic which in turn reduces emotional incongruence. Stand up/sit down desks, as well as their obvious physical benefits, also encourage feelings of autonomy by giving call-takers a greater degree of physical freedom at their desks. ESTA Ballarat members continue to be creative in their attempts to shape their work environment and promote feelings of autonomy. Crocheted cactuses make uplifting additions to the call-taking pods without causing headaches to the OHS department. An art exhibition organised by a call-taker encourages self-expression, creative hobbies, and acknowledges the methods of energizing outside of work. A ‘Pets Photo-Gallery’ brightens up an otherwise dull, but often used hallway, and reminds workers of the emotional support they receive at home from their pets. Cook ups during the early hours of the morning foster the team spirit, help to keep team members awake and encouraged, and provide more opportunities to share stories and support each other through conversation. Fostering autonomy in emergency call-taking can be an individual act or attitude, a team effort or an organisational policy. Even small changes can make a difference. Belief in the role, fostered by an active ability to shape ones role and working environment, is a key to minimising the costs of emotional labour, and maximising the benefits.
Education is an important tool for supporting the benefits of emotional labour while reducing the costs. Education can help call-takers to recognize the benefits of their role and therefore take measures to protect those benefits. Education in emotional literacy can help call-takers to recognize and express when they are becoming exhausted. In the busy emergency services environment it is often left up to the individual for ask for help. Long-term employees can become so good at surface acting that no one realises that they need help, making their self-awareness even more important so they can reach out when help is required. When call-takers need breaks from the phone, short education packages or articles can provide respite as well as having the long-term benefit of improving skills and knowledge. Learning about emotional labour, mental health and self-care is an investment in the career of a call-taker while doubling as time for energizing. Self-awareness and self-care are key components to longevity in this industry. As demonstrated in Australian research, members of the emergency services industry are very supportive of colleagues but struggle to seek help for themselves in a phenomena known as ‘self-stigma’[xvii]. Addressing and breaking down self-stigma is crucial and education is one of the tools to achieving this. Education is necessary in order for call-takers to understand the costs and benefits of emotional labour, and help them to put in place strategies to manage them.
Multiple strategies can help mitigate the cost of emotional labour. Preventing exhaustion needs to be a priority in order to allow call-takers to continue to enjoy the benefits of emotional labour. A strong and supportive team culture, an intrinsic belief in the value of the role, and continuing education to strengthen and encourage call-takers throughout their careers are some key strategies to maintain emotional health and wellbeing in the role.
Emergency ambulance call-taking is both energising and exhausting. Call-takers are the emotional muscle on the front line of the organisation. Call-takers are communication specialists managing their own emotions as well as the emotions of their callers within a high-pressure time sensitive environment often with life and death results. The intensity, complexity, and personal nature of the work energizes call-takers with feelings of satisfaction from a job well done, a rush of adrenalin, and great stories to share. However, exhaustion can set in. The nature and volume of the work does not change no matter how hard the call-taker works. Satisfaction can turn to cynicism regarding the purpose and worth of the role. Maintaining emotional health equips call-takers to function well in the role and to continue to enjoy the benefits long-term. Individuals who are supported by their crews, believe in the intrinsic value of their role, and receive ongoing education, can continue to be energized by a role that is both demanding and satisfying.
[i] At Emergency Services Telecommunications Authority in Victoria, Australia, the role of call-taker and dispatcher are separate jobs performed by different people.
[ii] Mastracci, SH., Guy, ME. & Newman, MA (2015). Emotional Labor and crisis response: working on the razor’s edge. Routledge, London and New York, p.25
[iii] Gardett, I. (Presenter). (2018). Dispatch in Depth: You’ve got me doing emotional labor with Dr. Sharon Mastracci and Ian Adams [Audio Podcast]. Retrieved from http://soundcloud.com
[iv] Newman, M. Guy, M. & Mastracci, S. (2007). Recognizing the Emotion Work of Public Service. Public Management, 89(6), 26.
[v] Hochschild, AR (1979). The managed heart: commercialization or human feeling. Berkeley, CA: University of California Press, 37-48.
[vi] Maslach, C. (2003). Job Burnout: New Directions in Research and Intervention. Current Directions in Psychological Science, 12 (5), 189-192.
[vii] Lee, YH., Lee, SHB., & Chung, JY. (2019). Research on how emotional expressions of emotional labor workers and perception of customer feedbacks affect turnover intentions: emphasis on moderating effects of emotional intelligence. Frontiers in Psychology, 9:2526. doi:10.3389/fpsyg.2018.02526
[viii] Humphrey, RH., Ashforth, BE., & Diefendorff, JM. (2015). The bright side of emotional labor. Journal of Organizational Behaviour, 36, 749-769.
[ix] Shuler, S. & Sypher, B. D. (2000). Seeking emotional labor: When managing the heart enhances the work experience. Management Communication Quarterly, 14, 50-89. I have developed the benefit categories from Shuler & Sypher’s categories of ‘comic relief, a fix, and altruistic service’.
[x] Beyond Blue Ltd. (2018). Answering the call national survey, National Mental Health and Wellbeing Study of Police and Emergency Services – Final Report, 14.
[xi] Brotheridge, CM., & Lee, RT. (2003). Development and validation of the Emotional Labour Scale. Journal of Occupational and Organizational Psychology, 76, 365-379.
[xii] Maslach, C. (2003). Job Burnout: New Directions in Research and Intervention. Current Directions in Psychological Science, 12 (5), 189-192.
[xiii] Kinman, G. & Leggetter, S. (2016). Emotional Labour and wellbeing: what protects nurses? Healthcare, 4, (89), 8; doi:10.3390/healthcare4040089.
[xiv] Lee, YH., Lee, SHB., & Chung, JY. (2019). Research on how emotional expressions of emotional labour workers and perception of customer feedbacks affect turnover intentions: emphasis on moderating effects of emotional intelligence. Frontiers in Psychology, 9:2526. doi:10.3389/fpsyg.2018.02526;
[xv] Kinman, G. & Leggetter, S. (2016). Emotional Labour and wellbeing: what protects nurses? Healthcare, 4, (89), 8; doi:10.3390/healthcare4040089.
[xvi] Morris, JA. & Feldman, DC. (1996). The dimensions, Antecedents, and Consequences of Emotional Labour. Academy of Management, 21(4), 999-1001.
[xvii] Beyond Blue Ltd. (2018). Answering the call national survey, National Mental Health and Wellbeing Study of Police and Emergency Services – Final Report, 13.
Kathryn Muhlhan is an off shift workplace trainer at ESTA in Ballarat Victoria, Australia where I have worked for the past 4 years. I am passionate about training new ambulance call-takers and mentors, and about maintaining the mental health and wellbeing of call-takers and dispatchers. I can be contacted on Kathryn.Muhlhan@esta.vic.gov.au