1 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

2 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

3 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.

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

5 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.

6 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

7 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.

Post doc work stimulated by this comment: There is a moral imperative for nurses to create trustworthy, honest and authentic relationships (De Raeve 2002).

9 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.

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

11 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)

12 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).

13 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

14 Technologies and change: t he 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

15 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

16 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.

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

18 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.

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)