From the ‘shop floor’ to the interview: Using metaphors to uncover invisible emotional labour in emergency department nurses

Abstract

This paper aims to offer methodological insight into the reflexive use of metaphors that assist in revealing the emotional labour of health care staff to themselves and to the researcher. It focusses on the method utilised for these semi-structured interviews, targeting the engrained and emotive experiences of emotional labour using metaphors. Taking metaphors from the ethnographic observation, ‘to’ the interview setting, proved a stimulating tool for lively discussion and narrative sharing. This approach offered an invaluable and enlightening tool for exploring the nurse’s experiences, it gave them a point of reference to discuss their challenging and personal experiences. It can offer other researchers, and particularly those studying ‘invisible’ labour (by subconscious nature or lack of physicality) a novel approach to data collection. The empirical study underpinning this article set out to explore, in particular, the ‘invisible’ emotional labour undertaken by nurses working within the emergency department (ED) setting. This is a clinical and nursing speciality facing sustained pressure in the English National Health Service (NHS) – a challenging and distinctive environment to nurse. Two EDs were used as the case studies for an in-depth ethnography (one District General Hospital and one University Teaching Hospital and Trauma Centre). As part of this, the 18 semi-structured, formal interviews were completed with ED nursing staff (to explore their experiences of emotional labour) and data was collected over a 6 month period.

Introduction

Metaphors are powerful in daily life, they offer an instrument for explaining and translating experiences. Despite their significance, their utility is commonplace, ordinary and without recognition (Parsi, 2016). Metaphorical terms and phrases ‘form our conceptual system and thus play a central role in defining our everyday realities’ (Tietze et al., 2003: 37). They present a route to understanding how we conceptualise our experiences and how we make meaning of this reality (Kuntz and Presnall, 2012). They can therefore, be of particular strength in helping individuals to communicate the concealed, through translation of a phrase which is well-known (Gowler and Legge, 1989) and often holds shared meaning.

Metaphors have long been relevant within healthcare, outside of research and methodology. With reference to disease, metaphorical terms related to the military and war have routinely been used to describe the relationship between patient and their illness. For example, patients ‘battling’ against cancer (Parsi, 2016) and ‘winning the war’, describing the affiliation between individual and illness, in finding a cure for conditions such as HIV (Nie et al., 2016). Such usage is not without consequence. With focus turning to the patient for instance, there is pressure to personally battle and triumph against the disease. As also noted by Nie et al. (2016), the frequent and ingrained war related metaphorical terms are ironically used when the ultimate focus on health care is healing (Parsi, 2016).

Existing knowledge of metaphors as a research methodology focusses largely on the examination of metaphors when analysing data, the participant’s use of metaphorical terms and the interpretation of this use. Such studies can offer insight into organisational life, culture and identity. As argued by Carpenter (2008), they give researchers the opportunity to study phenomena from a unique and creative perspective. Using metaphors to analyse data, in terms of their generation and production, has been seen to fall within two categories (Cassell and Lee, 2012). Metaphorical terms that are ‘imposed’ or ‘projected’ (also classified as ‘inductive’ and ‘deductive’) during the analysis phase.

The work of Aita et al. (2003: 1422) argues that:

If the process of inquiry requires reflection or thinking through a given situation, the thoughts that arise are grounded in language. Language is a cultural, social experience that carries a commonly understood set of meanings, beliefs, values, and traditions that use words as symbols.

As argued by Cassell and Lee (2012), most methodological studies of metaphors in organisation and management literature focus on the deductive application of metaphors during analysis. At the same time, because these approaches utilise transcripts (once data collection is completed) there is no opportunity to challenge these interpretations if a) they are inductive and assigned by the researcher/s or b) deductive, and explicitly shared by the participants in the data. Either way, there is no space to ‘probe’ and unpack the metaphors further (Tosey et al., 2014).

Despite these valuable applications of metaphors in qualitative analysis, there, therefore remains a gap in our understanding. We understand little of the methods which elicit ‘naturally occurring metaphors’ (Tosey et al., 2014: 630). Furthermore and most crucially, studies are yet to examine the contribution metaphors can make when they are deductively driven from the data and then taken back to the participations. Here lies a rich opportunity for not only checking assumptions about the applicability, acceptance and interpretations of the metaphors, but also as a means for collecting fresh insights, using the metaphors as a proactive starting point for lively discussion. This is a novel contribution to the literature of metaphor use in qualitative enquiry.

This paper also argues that metaphors are particularly helpful in studying the hidden and at times ‘invisible’ experiences of staff in healthcare. These work experiences are arguably ‘taken-as-given’ (see Iedema et al., 2013) and present researchers with a challenge methodologically. Directing healthcare workers attention to work which has become ‘unconscious and habitual’ (Leslie, 2014) is argued as fundamental to unearthing the complexity of contemporary practice.

This study found that taking metaphors offered a method for uncovering a form of unconscious nursing work. Taking metaphors ‘from’ periods of clinical observation (the so called ‘shop floor’ in the emergency department (ED)), back into the interview room offered a powerful tool for stimulating emotive conversation and ‘uncovering’ the ordinarily concealed and unconscious labour of nursing.

Emotional work, and specifically the theoretical concept of emotional labour, products of Hochschild’s (1983) ‘The Managed Heart’, offered those studying the workplace a new ‘vantage point’ to explore workers emotion (Wharton, 2009). Emotional labour, in contrast, is emotion work undertaken to meet the requirements and expectations of an organisation – the labour element resulting from a form of paid employment: ‘the management of feeling to create a publicly observable facial and bodily display; emotional labour is sold for a wage and therefore has exchange value’ (Hochschild, 1983: 7).

This exploration is particularly relevant in healthcare, where emotion management is complex as well as routine, emotional labour recognises the (paid) additional form of labour associated with caring for people who are sick (James, 1992). Emotional labour is therefore, an intrinsic component of nursing practice in particular (Bolton, 2000; Gray, 2008; James, 1992; Mazhindu, 2009; Phillips, 1996; Smith, 2012; Timmons and Tanner, 2005). Such management of emotions is undertaken in response to competing expectations – when the nurse’s behaviour (thoughts and feelings) do not align with those expected (imposed by society, the profession and individual organisations), they ‘do’ emotional labour (Bolton, 2000; Chou et al., 2012; Theodosius, 2008) to suppress and/or change true emotion.

Nurses are described as ‘emotional jugglers’, able to present a spectrum of different and appropriate faces (Bolton, 2000: 97) with the aim of remaining ‘professional’ outwardly. Nurses ‘calibrate their performances according to the frame of action, choosing whether to match feeling with face’ (Bolton, 2000: 97). More specifically:

. . . As a distinctive occupational group nurses are particularly adept at changing faces; seemingly effortlessly moving from cynical to sincere, from backstage to frontstage. They are able fully to embrace certain aspects of their allocated role, whilst distancing themselves from others. . .

(Bolton, 2000: 98)

The challenges effecting the NHS have changed since its introduction in the 1940s. Many of the contemporary issues are well publicised, including underfunding, advancements to available treatments, changes in patient need, expectations and demographic, amongst others (Ham, 2018). The increased need for efficiency and throughput through services (whilst meeting the expectations of patients and their relatives), add to the enormous and unwavering pressures experienced by staff (The Kings Fund, 2020). The COVID-19 pandemic has only exacerbated these challenges.

Despite this, the operational pressures facing the NHS are rarely considered alongside the emotional component of caregiving. We understand very little of how the nature and intensity of emotional labour required by staff tasked with delivering care is moderated by these pressures and strain, particularly in contemporary practice.

An area of healthcare practice offering a ‘window’ (Hou and Chu, 2010) into the acute challenges facing healthcare is that of emergency care. EDs in are struggling to meet growing patient demand and there has been an upward trajectory of patient attendance over the last 70 years. Together with the ‘generic’ health care challenges, the ED has its own distinctive pressures (NHS England, 2018), including intense governmental time-critical targets (such as the 4-hour wait, and ambulance turnaround times) and a vastly diverse and variable patient population. At the time of writing, EDs in the English NHS (and throughout the UK) are experiencing their worst ‘performance’ on record (shown through various time-critical quality indicators (such as the well-publicised 4-hour target; Edwards and Cowper, 2022). Practically speaking, this means staff managing overcrowded departments, patients waiting in ambulances with no space for them to be offloaded and patients ‘stuck’ in ED unable to move through the hospital system.

These considerations, together with the nature of the ED (usually a 24-hour service without prior appointment, and no cut-off to the number of patients who are seen) present complex ethical and social challenges for staff as they strive to meet the demands of the service and their patients (Basu et al., 2017). Working in this environment, and with these challenges is likely to influence the emotional component of the role and subsequent emotional labour. Despite this, the application of emotional labour to ED was largely missing from current knowledge. In response, this empirical research used the ED case study to explore and conceptualise emotional labour within ED nursing. Our earlier papers (see Kirk et al., 2021, 2022) conceptualise the emotional labour in this context. This paper aims to offer methodological insight into the reflexive use of metaphors that assist to revealing the emotional labour of health care staff to themselves and to the researcher.

Studying the emotional component of the nurse’s role, is, due to the nature of emotional work, distinctive when comparing the study of a more tangible element of labour (e.g. the completion of physical tasks). Emotional labour is one of the many forms of ‘invisible work’ undertaken by nurses. The invisibility of this work can include task completion out of sight of others, or be due the actual invisibility of the work itself, such as the mental work involved in prioritising and planning care, known as organising work (Allen, 2014).

Invisible work is also ‘unseen’ due to its lack of value, or the skill assigned to it (Allen, 2014). This is the case for emotional labour, taken for granted and often left unsupported by health care organisations. By its concealed nature, it is difficult to quantify, and even describe and therefore study. Allen (2014: 19), argues:

Nursing has many features that make visibility problematic. It is often assumed to rest on the natural caring talents associated with women and it involves bodywork and engagement with intimate aspects of people’s lives and death, making it difficult to talk about. . .

Not only is this work invisible externally, but staff are often unaware that they themselves are ‘doing’ it. The may be unaware they manage their emotions, or may be unaware of how intrinsic it is to their work. In the case of emotional work, and emotional labour specifically, nurses are likely to find their role emotionally draining, but are unlikely to understand why – their suppression of emotion is likely to be ingrained and sub-conscious. This presented an interesting challenge as a researcher, how do we explore a form of labour which is concealed? Not only to those observing, but also to those experiencing it? How do we help them describe, explore and articulate these experiences?

Methodology

The empirical study sought to gather the experiences of ED nurses emotional labour, examining the frequency, ease and intensity of the emotional labour. The intention was to understand the moderators of this labour and the ‘rules’ driving it. In particular, exploring how the distinctive environmental and institutional factors, aesthetic characteristics, organisational dynamics, gender customs, patient population and their expectations inform the labour.

I sought to observe and speak to staff in the ED, witnessing their work and collecting their spoken experiences. I was keen to give emphasis to their perceptions and understanding of their professional role, their work and the challenges within this. I wanted to explore and understand the values, expectations and beliefs which they perceive to drive their behaviour. I sought to uncover the accounts of their experiences of ‘doing’ emotional labour in ED through both ethnographic observation and semi-structured interviews.

Observation

An ethnography was undertaken, using two EDs. Ethnography offered emersion into the ED setting. This was an invaluable opportunity to actualise the lived experiences of these influences in the field, witnessing behaviours and relationships amongst the ED staff. Observation allowed for these salient and innermost themes to come to the forefront. The aim was to explore, understand and interpret the emergency nurses’ experiences, beliefs and perceptions (Delamont, 2007), addressing the likely disparity between individuals’ accounts of their experience and the direct observation of this in practice.

One district hospital (District ED) was used and one large teaching ED (Teaching ED), both within the NHS in England – 200 hours of observation were completed in total over a 6 month period. Both EDs were split into different areas depending on the severity of illness or injury. All of these areas were observed, to witness the variety of work completed by staff. This included the minor injuries areas, assessment areas, resuscitation area and the ‘majors’ area of the ED (a space in which those patients who were not appropriate for minor injuries or resuscitation care were treated). Observation started by ‘setting the scene’ of each individual area. This observation was focused on the work of the ED nurses. This included the physical visibility and invisibility of the staff working within it, how they moved around the space, specific environmental features, noise and atmosphere. Following this period of scene setting, observations then moved on to focus on the physical tasks and none physical work undertaken by staff; taking part in informal conversation with staff to understand their physical and mental work and how this sat alongside the interpretations made during observation.

Interviews

To accompany these observations, 18 formal interviews were also completed across two hospital sites. They included a range of ED nurses relating to age, gender, seniority and experience. These interviews ran concurrently to the observations. Using interviews as part of a combined approach with observation helped to give an understanding of the context behind the collected narratives (Mason, 1996). It offered a sense of orientation with the scene-setting of the first-hand observation. This gave me the opportunity to delve in and examine the respondents’ recounted experiences in the interviews within a deeper contextual framework. The process of checking and reaffirming observations and interpretations with healthcare staff to ensure understanding also assisted with the quest for quality.

Initial questioning focused specifically on the characteristics which staff use to describe the ED nurse, and also those characteristics which ensure a nurse is ‘successful’ in this environment. These interviews offered the room to explore staffs’ perceptions of the emotional challenges of their role. Furthermore, it provided an opportunity to unpack the definitions assigned to highly emotional, and less emotional experiences, and how both are managed. Questioning surrounding the perceived relevance of gender was explored during the interviews too, and its relatability, consequences and influence upon the management of emotions.

Although the questioning outlined in the topic guide offered a useful starting point, it was apparent after the first two interviews that the approach was unlikely to be effective in unravelling the ED nurses’ experiences of emotional labour, particularly opening up a deeper perspective of these experiences. The nurses were confused and disengaged with standard questioning relating to their emotional experiences which seemed deeply supressed and innate.

In response, metaphors offered an opportunity to help the nurses share their concealed experiences of emotional labour, through a well-known phrase (Gowler and Legge, 1989). Practically speaking, field notes taken from observation from both sites and were re-read. Metaphorical terms used directly by ED staff were drawn out directly from the observational data. These included a variety of metaphors such as ‘firefighting’, ‘warzone’, ‘dungeon’ and ‘bunker’ amongst others, all used by the ED nurses during informal conversation (during periods of formal observation).

These phrases were then used as a tool within the remaining interviews – offering them to the staff as a point of conversation. Following initial questioning, the respondents were then presented with one metaphorical term at a time. They were asked if they could relate to it in the first instance, dependent on their response, further questioning took place. The purpose of this questioning was to unpack the understanding and interpretation of the metaphor and their associated experience.

Irrelevant of the degree of familiarity to the metaphor, the phrases helped to provoke lively conversation in the interviews – this could be seen through the nurses engaging language, facial expressions, body language and explicit feedback relating to the interview approach. Even when the nurses felt they could not relate to the metaphor, the further follow up questioning was still unravelling – why they didn’t relate and describing their experiences of this feeling of disconnection towards the metaphor. To aid the process further, I also showed visual pictures/interpretations of the metaphors to each participant including:

• A cross-sectional image of a swan, swimming serenely on the surface of a lake and paddling underneath the water.

• A ‘warzone’ depiction, showing male soldiers in combat, the background included fire and smoke.

• A 1920s assembly/production line in which female manufacturing workers stand shoulder to shoulder.

This combined approach prompted rich discussion in the interviews, revealing insights arguably inaccessible without these metaphorical triggers.

Data analysis

The interview recordings were transcribed and analysed. Formal coding began with a non-cross-sectional approach to explore the distinctiveness of each source (Ritchie, 2013). The initial nodes encompassed a mixture of descriptive, analytical and potentially theoretical recurrences. However, this was an iterative process, which evolved: as confidence developed and further familiarisation occurred, the analytical and theoretical nodes were most prevalent. A refined list of nodes and sub-nodes was established from each individual source.

A broader cross-sectional approach then allowed for the unveiling of common patterns across the entirety of the data. This phase of the analysis honed in on the use of metaphors and the patterns they revealed. Once a set of nodes had been honed for the remaining dataset, the deployment of diagrams, charts and visual representations of the data was undertaken, showing the relationships and connections.

Two final concepts were reached: ‘Moderators of ED Nurses’ Emotional Labour’ and ‘ED Nurses’ Speciality-Specific Feeling Rules’ (see Kirk et al., 2021, 2022). The discussion section of this paper will use data extracts from both concepts to illustrate the increased depth of data and understanding gathered by using metaphors – taken from the ED ‘shop floor’ to the interview. Some of the most pertinent examples are offered below including the A&E ‘Swan’, ‘Warzone’ and ‘Assembly line’.

Findings and discussion

A&E ‘Swan’

The ‘A&E swan’ phrase was used initially by an ED Nurse (District ED) during a period of observation in the resuscitation area. The nurse used this phrase to describe the demanding work undertaken to ‘appear’ calm under any circumstance (like a swan, above water), when internally she felt panicked or anxious. She related these feelings of anxiety to the swan’s webbed feet, under the water and out of sight, which she described as paddling ‘frantically’. This phrase was then taken into the one-to-one interviews, asking other staff if they could relate to the phrase and if so, how. An image of a swan swimming was offered alongside the metaphor during interview, the swan was swimming calmly on the water but paddling fast underneath the waterline. Other nurses also described their relatable experiences at length in response. The nurses felt a strong connection to the image, describing past and present experiences which they associated with the image. Some nurses engaged deeply with the metaphor, laughing at its familiarity and describing how routinely they ‘felt’ like the swan in their work; ‘oh yeah’, this is a ‘normal’ part of my role, I was told.

The ED nurses shared how stressed they felt internally, wanting to scream with fear, but knowing they had to keep this form of emotion ‘at bay’ (ED S/N Sara, District ED); sharing explicit examples of emotional labour (Theodosius, 2008). They described when, irrelevant of how they actually felt, they must not show this feeling outwardly, particularly to the patients and families they were caring for, but also to other colleagues – ‘just like the swan’. On showing the Swan image to ED Sister Ellie (District ED) she nodded knowingly. This then prompted her to share experiences of managing a full resus area at work, where the sickest patients in the ED are cared for. Ellie explained how she juggles endless time-critical tasks and responsibilities, but suppresses her emotional experiences.

Holding the Swan image in her hand, another ED Sister Cathy (Teaching ED) explains the feelings she associates with the metaphor. Feelings of pressure she experiences internally – having to juggle managerial tasks with overseeing clinical care, but not outwardly showing this stress to others. The metaphor helped her to articulate her experiences. On a recent shift, she was overseeing the care of seven acutely unwell patients, including a baby who had stopped breathing, and a young woman who had suffered a cardiac arrest. Cathy describes how intensely stressed she felt, responsible for patient care, whilst also dealing with managerial responsibilities and organisational pressures (such as time-critical targets). I ask her how she manages this type of extremely busy situation, she replies – ‘it’s this A&E swan’ – on the surface all calm, underneath, going like mad! With this, she peddles with her arms at speed, frantically, like the feet of a swan swimming through the water. She states ‘we are taught to show we are coping’ – whatever the circumstances. Here, the metaphor helped Cathy to conceptualise and make meaning of her experiences (Kuntz and Presnall, 2012).

Other ED nurses share similar experiences of managing their emotion, the Swan metaphor prompts conversation, particularly in relation to how internal feeling is disconnected to what is being observed outwardly by others (the swan swims serenely on the surface). Often, the Swan metaphor relates to staffs experiences of supressing feelings of anxiety or panic. ED S/N Sally shares this experience on discussion relating to the A&E Swan:

Respondent:

Yeah, that’s the exact thing [the Swan] that I always describe to everybody. When they always say that ‘you don’t look panicked’.

Interviewer:

Do people say that to you?

Respondent:

Yeah, sometimes if you’re in resus in a situation. . . They always say that you don’t look panicked. And I just say, ‘I am inside.’

Interviewer:

. . .what kind of situations?

Respondent:

The other day, I had a situation where I had a little three-day old baby that I had to take into resus. It was not very responsive, and I’m not a children’s nurse. It was on of them situations where you think. . . I do not want to be the one looking after this.

Interviewer:

On the outside would anyone know you were feeling like that?

Respondent:

No, no, the parents thought that I knew everything about children and they wanted me to stay with them. But on the inside, I could go ‘help’. I think you’ve got to be quite good at doing that here.

Interviewer:

Any others?. . .

Respondent:

Yeah, all the time if it’s really busy as well, you have to look like you’ve got it all under control and that it’s not a stressful, panicked situation. You have to act like everything is fine.

(ED S/N Sally, District ED, Formal Interview)

‘Warzone’

A further metaphor used to describe both the nature of the ED nurses work and the environment more broadly, was the phrase ‘Warzone’. A nursing assistant explains on my first morning in the ED, ‘we are soldiers and A&E is the battlefield’ – he describes A&E as a ‘warzone’ (N/A Steve, District ED, Informal Interview). Again, this metaphor was then taken into the formal interviews and offered to the ED nurses as a tool to describe and reflect on their work. The metaphor was accompanied with a related image, a battlefield with active fighting taking place and evidence of the destruction of war surrounding the soldiers.

Observation had established previously that the ED setting was incredibly busy and noisy in terms of workload, but also other sources of visual and audible stimulation. The ED tone is set from outside and on entering the waiting room, where the visitor is greeted by clues to the potential volatility and unpredictability of the setting. The colour red is introduced as are many terms associated with combat, such as the phrase, ‘Warzone’ – phrases which do not align with traditional perceptions of healing and nursing care.

The nurses frequently experience threat and violence, and these metaphors help them to describe their experiences and related feelings through this well-known phrase (Gowler and Legge, 1989). Many of the nurses related strongly to this phrase when introduced to them during the one-to-one interviews. There is a sense of acceptance when they are shown the ‘Warzone’ image. Specific examples and experiences were diverse – unlike the A&E swan, ‘Warzone’ was associated with a greater set of experiences and there was a degree of creativity (Carpenter, 2008) and deep reflexivity within the answers shared. Some used the term to describe the ED in relation to the general intense nature of ED and seemingly relentless workloads.

I’ve use it [the phrase warzone] quite a few times, when you’ve got trolleys everywhere. . . full of patients and you don’t know where to turn next. What to do for who next, and I have said it’s like being in a warzone because you can imagine it. That’s what it would be like in a field hospital. . . what do I do next?. . . you know it’s dangerous but you’ve just got to do the best you can do. And I’ve heard other people use that term as well. Just how it makes you feel but something kicks in and you just get on with it.

(ED S/N Bev, District ED, Formal Interview)

For other nurses, the ‘Warzone’ metaphor prompted them to draw on specific patients they had cared for, many related to managing aggression and ‘drunkenness’ from patients. For many of the nurses who shared their experiences during the interviews, direct aggression was seen as an expected part of the nursing role in the ED. This echoes national data, showing that ED staff experience rates of both physical and verbal abuse that are significantly above the national average, when compared to other healthcare workers (NHS Security Management Service, 2010).

The numerous descriptions and examples of combat and aggression management given by the ED staff at both sites, experiences which are not routinely associated with the warm relationships and good-natured expectations of nursing and care delivery. The nurses used the metaphor as a way to share their stories of ‘battle’ like experiences with individual patients, such as being attacked physically (punched, kicked, etc.) or abused verbally by patients. War related metaphors are often used in health research (Nie et al., 2016; Parsi, 2016), despite the assumed disconnect behind their connotations and those of healthcare which are assumed as often dichotomous.

The Warzone metaphor began to build a picture of the ED context and culture, the opposite of healing and at peace. On observing the image, many shared a routine sense of volatility and combat and talked about how the ED attracts masculinity and suits those from a military background, in response to the metaphor and related image. Perhaps unsurprisingly, staff from armed service backgrounds are seen to fit in well to the ED workforce:

A&E nurs[ing] does attract a certain type of person I would say. . . we see a lot of army medics come through the [ED], sort of people who are. . . armed services, whether that’s medical or nursing, and they seem to fit. . .

(ED S/N Tom, Teaching ED, Formal Interview)

‘Assembly line’

During an early period of observation, Adam, an ED Nurse at Teaching ED tells me that his work feels like working on an assembly line in a factory. He is working in the initial triage area, the first stop for patients who have arrived to the ED via ambulance. The emphasis here is placed on moving patients through and out of the space (achieving flow) and preventing a build-up of patients within the ED – this work seems to be unending. It also limits the degree of interaction and relationship the ED nurse has with each patient. Perhaps unsurprisingly, this metaphor also prompted lively conversation during the one-to-one interviews. Accompanying the metaphor was an image of a working factory with workers making clothes. The workers stood closely together, clearly working quickly on a garment before handing the garment over to their co-worker and ‘along’ the assembly line until it was complete. Adam talks openly with frustration ‘at’ the Assembly Line image, pointing at it, his despair palpable:

The ambulance crews book a patient in. That patient then will wait until one of the triage bays [is available]. The patient will then be moved into that bay, either transferred onto a trolley or already on a hospital ED trolley. The crew will then hand over the patient to us. We will then assess the patient. . . decide on their treatment options or any investigations that the doctors will then need for later on. Perform them and then move them to the appropriate area in the department. Even though they have the ambulance crews with them, you need to make sure if they do need any treatment, you get it started soon. There’s pressure to move the crews along, get them out and get the patients handed over . . . . The crews will just be coming back in again exactly the same way in one big flood, and you’ll be in exactly the same position again. Then there’s pressure from inside the department from the nurse in charge or the doctors. . . Why are things taking so long?

There is a big time element, which puts a lot of pressure on you because the idea is that these people are meant to be handed over within eight minutes of arrival. Within 15 minutes of the ambulance putting their handbrake on outside, the crew are meant to be in, transferred, handed over and then back out in their vehicle. . . Then can you imagine on this particular day we had patients coming into the cubicle who’d been booked in for an hour and a half. It’s hugely frustrating. When it gets to that stage. . . relentless. . . powerless about the situation. . . you get the pressure from the crew standing there staring at you and all I can think of. . . is. . . ‘Why aren’t you working a little bit faster?’ What I’d like to say to them is ‘please come and try working here for twelve and a half hours’.

(ED S/N Adam, Teaching ED, Formal Interview)

ED S/N Bev (District ED) also felt passionately about the experiences she related to the Assembly Line metaphor. On seeing the image, Bev spoke at length about how her care delivery responds to the lack of time available and how this makes her feel about her work. Here, Bev found comfort in her use of the metaphor, a means of sharing emotive and challenging experiences through a commonly understood and often shared meaning (Aita et al., 2003: 1422). It helped her to disclose and articulate her experiences, potentially with less fear of judgement as the metaphor offered a ‘way in’ to sharing an experience which she felt unsatisfied with:

I’ve actually used that term (assembly line) it’s like a production line of patients. . . you’ve got [ambulance] crews coming in constantly. . . later in the day it will be constant, constant. You take handover from the crew, do the basics, move on to your next patient. Take handover, do the basics, move on to your next patient. You might not even see that patient again. Sometimes the crew’s come back in and say ‘what happened to so and so’ and . . . I don’t know, because it’s all about keeping the flow of the department going, in some people’s opinion. Which you do have to do, but it means there’s a definite lack of care there, I would say. . . . . .I go home feeling very unsatisfied because you’ve not cared for people, you’ve just checked their observations, given them any immediate treatment they need but the actual caring aspect of it, you’ve not really done any of that. . . it becomes quite monotonous and boring actually. Cause you’re not getting involved with your patient, you’re just doing the basics.

The Assembly Line metaphor used her prompted Bev’s experiences of caring for patients in a way she found dissatisfying, the metaphor offered the starting point for her narrative sharing. Like many of the metaphors used during interview, it gave her an invaluable, relatable phrase through which she could define and shared her realities of nursing in the ED.

Conclusions

Metaphors present a route to understanding how we conceptualise our experienced reality and how we make meaning of this reality (Kuntz and Presnall, 2012). Despite this, existing enquiry of metaphors in research methodology focusses largely on analysing data, including the participant’s use of metaphorical terms and the interpretation of this use.

This paper offers new methodological insight into the reflexive use of metaphors that assist in revealing the emotional labour of health care staff to themselves and to the researcher. Firstly, it illustrates the invaluable contribution metaphors can make when they are deductively driven from the data and then taken back to the participations. As noted above, here lies a rich opportunity for not only checking assumptions about the applicability, acceptance and interpretations of the metaphors, but also as a means for collecting fresh insights, using the metaphors as a proactive starting point for lively discussion. By offering participants a familiar phrase, we present an opportunity for them to share their experiences of their relatable reality, and the meaning behind these experiences.

This method can offer other researchers, and particularly those studying ‘invisible’ labour (by subconscious nature or lack of physicality) a novel approach to data collection. This is a second distinctive contribution to the literature of metaphor use in qualitative enquiry, by their ability to reveal subconscious or invisible labour. Much of the work undertaken by nurses in contemporary practice is invisible, this is either through the physical invisibility of the work, or/and the recognition it is assigned (James, 1992). Emotional labour is a form of invisible work; routine and often complex but often overlooked in contemporary nursing practice (Smith, 2012). These forms of work, by their nature, are difficult to study, embedded and often innate to nurses work.

Although this paper focussed on using metaphors to uncover ED nurse’s experiences of emotional labour, it is likely that this approach would also prove useful in many other areas of research outside of healthcare. This includes any professional group who carry out work made invisible. At the same time, studying challenging or emotive topics are also likely to benefit from this approach, offering participants a ‘route in’ to sharing their experienced reality of intimidating topics.