Femininity at Work : Gender, Labour, and Changing Relations of Power in a Swedish Hospital 9789179243005, 9789179242497

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In Femininity at Work Rebecca Selberg gives new analytical perspectives and fresh insights into this area. Selberg situates the new conditions for nurses’ work firmly in the neoliberal transformation of the S ­ wedish welfare state. Nursing has undergone dramatic changes in terms of work intensification and new forms of subordination and class boundaries. At the same time, the nursing profession has embraced nurses’ new role as adjunct managers in running the clinics and taking on new responsibilities offered by New Public ­Management. The key contribution of Selberg’s work is her use of the concept of femininity. Through ethnographic explorations of material and ideological conditions of care work, she shows that gendered subjectivities can best be grasped by using the ‘plurality of femininities’ as a conceptual tool. Rebecca Selberg offers an empirically rich investigation of change and continuity in the relationship between femininity and care work among Swedish nurses. In addition to insights into changing conditions of care work within the public sector, the book makes a significant theoretical contribution through its analysis of how labour processes shape and are in turn shaped by femininities. Rebecca Selberg is a sociologist at Linnaeus University. Femininity at Work. Gender, Labour, and Changing Relations of Power in a Swedish Hospital is her doctoral dissertation.

Rebecca Selberg • Femininity at Work

This is a book about gender, labour, and changing relations of power in a Swedish hospital, and presents an ethnographic study of nurses and their work. Paid care work has been a domain of institutional compliance to male dominance, as well as a critical space for women to become economically independent and skilled.

Femininity at Work

Gender, Labour and Changing Relations of Power in a Swedish Hospital ●

Rebecca Selberg

femininity at work

Rebecca Selberg

Femininity at Work Gender, Labour, and Changing Relations of Power in a Swedish Hospital

Arkiv förlag & Arkiv Academic Press

Arkiv förlag & Arkiv Academic Press Box 1559 se-221 01 Lund Sweden street address Lilla Gråbrödersgatan 3 c, Lund phone (+46) 046-13 39 20 [email protected] www.arkiv.nu www.arkivacademicpress.com This title is also available in two print editions: isbn: 978 91 980854 2 6 by Arkiv förlag’s imprint Arkiv Academic Press 2012 with international distribution isbn: 978 91 7924 249 7 by Arkiv förlag 2012 with Swedish distribution

All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, without the prior written permission of the publisher, except in the case of brief quotations embodied in critical articles and reviews. Cover design by Jan Petterson and Sarah Katarina Hirani © Rebecca Selberg/Arkiv förlag 2012 E-book edition (PDF) 2017 isbn: 978 91 7924 300 5

Contents

Acknowledgements 9 1. Femininity at work: introduction  15

Why study paid care work and femininities?  19 Transformations 21 Intersectional interventions in analyses of work  29 Limitations of the study  32 Organisation of the study  34

2. Analytical approaches to work and subjectivity  36 Structuring jobs: femininities, masculinities at work  38 A contested concept: defining femininities  41 Organising inequality: identity and work  52 Care work  57 Body work: new understandings of re/productive labour  63 Conclusions 74

3. Researching from the standpoint of care workers  75

Feminist standpoints and institutional ethnography  76 Exploring the dynamics of fieldwork: the politics of hospitality  80 Conversations, dialogues and questions  87 The practice of interviewing and observing  89 Whose side am I on?  100 Making the case of an inequality regime  103 Analysing from a perspective  108

4. Places, spaces and contexts  113

Describing places  114 New millennium healthcare in Sweden  115 County 122 City 124 City Hospital  125 A partial view of a complex space  127 Continuity and change in spatial arrangements  131 Conclusions 138

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5. Ward 96: spaces, processes and cultures of work  140

A day at the workplace  147 Through and beyond labour: interactions in the workplace  159 A workplace ‘culture’?  168 Conclusions 175

6. Dynamics of femininities: life histories and embodied careers  176 Josephine 178 Danuta 185 Sara 190 Helena 195 Dynamics of femininity  199 Conclusions 203

7. Work intensification and interpellation of femininity  205 Work intensification at Ward 96  206 Interpellation: constructing seamless nurses  225 Interpellation and resistance  233 Conclusions 237

8. Distinctions in care work  240

Tensions and boundaries at work  241 Complex divisions of labour  245 Serving up as linked to traditional femininity  248 Serving within and out: neither maid nor waitress nor service machine  260 Distinctions in care work  268 Conclusions 270

9. Racism in the everyday and beyond  272

Everyday racism in the healthcare organisation  273 Language and tolerance  281 Processes of racialisation  285 Challenging everyday racism  296 Conclusions 304

10. Femininity at work: conclusions  307

Investigating the relationship between women, labour, identity  309 Gender, labour and power in the new millennium  310 Work and femininities  315

epilogue. Nursing beyond normative femininity?  321

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Sammanfattning 329 appendix 1. Informants  337 appendix 2. Interview guide  341 appendix 3. Documents studied  343 A note on terminology  344 References 345

Acknowledgements

To all of my informants: thank you for sharing your time, your energy, your thoughts and your experiences with me. I hope this book will contribute to bringing attention to the tremendous efforts involved in care work, and I hope your voices will break through and let more people know about your struggle for recognition. I hope women’s labour will some day be remunerated properly and performed in a context where it is not shaped by the divisions, tensions and alienations brought on by bureaucracy and hierarchies; where all kinds of knowledge are appreciated and recognised, and where whether something is or is not perceived as ‘women’s’ has no bearing on power or status whatsoever. My ambition has been to contribute to that end. I wrote this book in the hope of critically examining the ways in which gender restricts us, but all of you have showed that, truly, any one woman will transcend femininity in whatever way it is defined or conceptualised. This book is the product of several years of employment at ­Linnaeus University and the School of Social Sciences. My second thanks go to its Higher Research Seminar in Sociology, where I have presented several drafts of the study. It has always been to my great, great benefit. Gunnar Olofsson warned me at the beginning of this project that he is a grumpy guy, but really he turned out to be a dedicated and caring supervisor with whom I’ve enjoyed productive and exciting discussions on gender, class and work. He is an extremely knowledgeable sociologist and I am grateful for all his advice. My warmest thanks! Anna-Maria Sarstrand Marekovic is a great friend and, even though I always enjoy discussing sociology with her, I think our talks on everything but has been what has made me survive. Thank you! I would also like to express my gratitude to some of my colleagues at ­Linnaeus University who have been especially helpful. Anna Lund: for

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i­nvaluable advice and for being a role model in getting it all together: family, research, travel, consumption, the serious stuff and the fun stuff. Agneta Franssén: for pushing me to be reflexive about methods and methodology. Without you, I doubt I would have had the courage to actually enter ‘the field’. Ola Agevall and Svante Lundberg: for teaching socio­logy in irresistible ways. Per Dannefjord: besides the boring, administrative stuff where you came to the rescue – for reading my texts and commenting in ways that I always found most irritating (because I knew I had to deal with it). That latter part goes for Paavo ­Bergman and Mats Trondman as well. Linda Hiltunen, Sven Hort, Henrik ­Hultman and Magnus X Persson: for always cheering me on. The rest of the gang of (former and current) PhD candidates who shared this journey with me: thank you for being there, and for creating an intellectually stimulating environment. Eva Fasth: for helping me transition into the life of a doctoral student in Växjö. Catarina Gaunitz: for being the best, kindest and most generous administrative support a recklessly unorganised PhD candidate could rely on. The Swedish Council of Working Life and Social Research, FAS, sponsored me while I spent a semester abroad, and for that I am grateful. At Florida State University I found time and space for developing my research theoretically and methodologically. Had it not been for the generous support of my supervisor extraordinaire and dear friend Professor Patricia Yancey Martin, this book would have made a much weaker case for the difficult and challenging concept of femininity and its role in work organisations. Thank you for inviting me to your department, for taking the time to listen, to read, and to write with me. As you know, your work has been a great inspiration and you are a true feminist role model. As is Professor Irene Padavic, my host professor at FSU. Your advice on how to clear up my arguments made me a better writer. But more importantly, I would like to thank you for sharing your knowledge, insights and interest in issues of work, inequality, exploitation and social change. Thanks also to the rest of the Department of Sociology for welcoming me, and for letting me take part of your excellent graduate program focused on stratification and social justice. The research seminar Critical Studies in Sociology at Lund University has also provided me with an inspiring research environment.

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There, I have presented earlier drafts of this book as well as having benefitted from discussions on feminist and postcolonial theory and methodology. Thanks to all the participants, especially Joke Esseveld. The feminist autonomous network of friends loosely labelled ‘the Library group’ has offered me support, not least in the final stage of writing up my thesis. Our collective of researchers and activists within the women’s, the Left, the LGBTQ and the antiracist movements fills me with hope for new ways of organising knowledge production. Our meetings transcend dichotomies of private and public space by bringing theory and methodology closer to our homes as we sit around kitchen tables or occupy corners of a public library to discuss each other’s work, often with kids present. I would especially like to mention Sanna Lundberg, Louise Löfqvist and Maja Sager, who have read my work and trusted me with reading and commenting on theirs, to my great benefit. Towards the end of my time as a doctoral student, the Centre for Gender Studies at Lund University provided me with an intellectual home closer to my actual home. There, more people than I can list supported me, rooted for me, and kept me going. Thanks to all of you. It was Kerstin Sandell who invited me there to participate in her research project on inequalities in academia, and for that I am grateful. More than that, Kerstin has been a friend during the years as a PhD candidate, one of those firm friends who offer tough but sincere love and support. Sara Goodman, apart from being the generous head of department who invited me to stay on for a more extended period of time, also happens to be the kindest colleague and corridor neighbour one could wish for, and I am happy to have had her accompanying me during late night shifts at work. She has commented and offered important reflections on my project, and for that I am most grateful. Anna Olovsdotter Lööf supported me by sharing the horror of a rapidly approaching November deadline. Thank you for commenting on an early version of chapter 6. Helena Gyllensvärd keeps the Centre going administratively, and there is a fair amount of emotional labour involved in that task. Helena is one of those friends who will keep your head straight just by talking about fun things. Thanks also to my colleagues Ina Knobblock, Kristin Linderoth and Katrine Scott for support and interesting discussions.

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There is something extraordinary in sharing a passion for studies on work, gender, racism/antiracism and inequalities with a person who also happens to be a great friend and comrade, someone you can share a thousand laughs with during a single afternoon. That friend is Paula Mulinari. Looking forward to our next project, and the next one after that! Thanks also to the rest of my extended family, Anders Neergaard and the others, for always supporting me. Nela Porobic-Isakovic and Ida Janson have been with me for ages and it means more than I can say to know that they are always behind me. Thank you for being there, and for keeping me grounded in ‘reality’. I argue in the book that I had my earliest sociological training within the Left, and so I would like to thank all of the people in Ung Vänster who schooled me, and who taught me to read and write as a means of struggle (alongside talking, shouting, going to meetings, et cetera). I would never have made it here without you. I would also like to thank the brilliant people I worked with on the editorial board of the antiracist magazine Mana, for thinking out new ways of forming resistance. A special thank you to Natacha López, who reminded me of the strengths of journalistic writing and encouraged me to clear up my prose. Through Mana, I met my two favourite artists, Janne Petterson and Sarah Katarina Hirani, who collaborated in designing the (modernist!) cover of this book. A huge thanks to the both of you! Lucy Edyvean worked with my manuscript and made sure my sketchy American English was turned into significantly improved British English. It’s been a pleasure to work with you – thank you for putting up with my last-minute approach to writing up a thesis. David Lindberg at Arkiv also deserves big thanks for helping me with all things related to turning my manuscript into an actual, readable book. I have waited till the end to thank my supervisor Diana Mulinari, knowing full well I will never be able sufficiently to express my gratitude. There is no way I would have become a sociologist without her. She is an inspiration, and by that I mean that whenever I feel like giving up, I read one of her texts and I’m convinced again there is a point in doing sociology. I cannot think of a more important person to me in terms of my political and professional development, but, more importantly, I can think of few who mean more to me in life,

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period. Thank you for being my supervisor, and for being my friend – I so look forward to being your colleague. Without the loving support – moral, logistical, and beyond – from my families, I would never have been able to finish this project. My deepest thanks to my Bjäre-family and my Jämsunda-family for making this possible, and for always making me feel like it’s worth it. Axel and Nicke – as always, we did it together. I dedicate this book to my mother. Rebecca Selberg

1. Femininity at work: introduction

The best thing about our job is being able to take care of people. Getting to know people. The worst thing about our job is working with people. Yes! Because people are so difficult when they are sick. They are like children: they will test you. You realise that you are prejudiced, you realise that you don’t care about the patients if they’re too stupid, or too racist, or whatever. That’s tough, to discover that about yourself. The worst part of this work, too, is the salary. We have all this responsibility and we get nothing for it. Another thing is – you see, nurses are such wimps. We have the weakest union ever and we are the weakest union members, real wimps. Only good girls become nurses. They’re all snobs. It goes back to Florence Nightingale, these aristocratic women who would boss around working-class women, who were considered to be ‘strong as an ox’, while we nurses should be fancy and married and all this – yes, it’s true. I see these nurses at work and they are such girlygirls, do you know what I mean? … Still, I love being a nurse.

Nursing is a profession with a history of complex negotiations of gendered subordination and class boundaries. As nurse Azime expresses in her statement quoted above, nursing has been constructed ideologically through notions of class-appropriate femininity, heterosexuality, and racial and cultural stereotypes (Mohanty 2003: 142). Paid care work has been a major domain of institutionalised forms of compliance to male dominance, but it has also formed a critical space for women to become economically independent and skilled. At the same time, the value of care work has been historically contested, not least because of its location at the crossroads between public and private. Care workers are also involved in managing boundaries of the private, as they perform their labour on and in relation to live bodies, using their own bodies as instruments of production. Consequently, the care labour process plays out in a space marked by temporal contrariness, emotional response, and ambivalent positions of power and subjugation.

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This study explores the relationship between labour performed on and in relation to bodies and the ways in which gendered practices are maintained, reconfigured and challenged within the organisation of work. ‘Femininity’ refers here to the collective patterns and configurations of practices structured through relations of gender (­Connell 1995). What unites femininities within a social milieu, Connell (1987: 179) suggests, is “the double context in which they are formed: on the one hand in relation to the image and experience of a female body, on the other to the social definitions of a woman’s place and the cultural oppositions of masculinity and femininity”. The focus of this study is the ways in which femininities are produced in the context of care work in the Swedish public sector, paying specific attention to ward nursing under neoliberal ruling relations.1 Connell (1987: 181) has conceptualised nursing as “an element of the sexual division of labour, an occupation blending a particular version of femininity with the technical requirements of the job”. I label this particular version of femininity normative, calling attention to the ways in which some forms of femininity that are linked ideologically to motherhood and the moral mission of the welfare state are privileged in relation to other forms of femininity. What I want to understand is how women relate to and embody femininity at work, and in what ways their work shapes subjectivity. This question has been explored in settings where men dominate (such as Willis 1977), and although there are ethnographies dedicated to this issue in relation to women workers (such as Westwood 1984), many of the studies on nurses have focused on the women doing care, rather than on the ways in which conditions of care work frame and interpellate varying forms of femininities. Further, it has been argued that women “have become ideal neoliberal subjects” (Newman 2012: 6) and that femininity is a form of cultural capital beginning to have “broad currency”, especially in the labour market, as demands for feminine skills such as communication is increasingly emphasised (Adkins 2003: 31, see also Pringle 1998: 8). As Wolkowitz (2006: 9) has pointed out, ‘work’ is a contested concept within sociology, not least because of feminist interventions expanding the notion of work to include unpaid caring. I use ‘paid work’ to refer to employment as a formalised relationship within a 1.  By ‘ruling relations’ I refer to the translocal social organisation of dominance.

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specified place, thus excluding other forms of waged work. I view care work as a specific form of body work, an analytic concept I use to locate nursing in relation to a variety of practices involving interactive service employment. Body work is work that “focuses directly on the bodies of others: assessing, diagnosing, handling, treating, manipulating and monitoring bodies, that thus become the object of the worker’s labour” (Twigg et al 2011: 1). Care in this respect revolves around body work performed on or in relation to sick, injured and/or elderly bodies (including bodies giving birth). I use Yeates’s (2004: 371) definition of care work as activities undertaken to “promote the personal health and welfare of people who cannot, or who are not inclined to, perform those activities themselves.” While I do recognise unpaid care in the private sphere as work, this particular study is focused on commodified care work performed by a specific set of carers who are employed within the Swedish public sector. Thus by ‘care workers’ I mean employees performing care work: predominantly nurses and assistant nurses. In this sense, it is a descriptive rather than analytical concept. ‘Medicine’ and ‘nursing’ refer to the professional and theoretical fields related to doctors and nurses, including researchers, respectively. Following Acker (2006a: 446), I differentiate between occupations and jobs: “occupation is a type of work; a job is a particular cluster of tasks in a particular work organisation”. I am interested in the ways in which a neoliberal and globalised economy and related management technologies are enforced on, manoeuvred and enacted by nurses in the public sector, and how relations of class, gender and race/ethnicity structure nurses’ actions in and experiences of the work and its organisation. I link these issues to central debates within sociology and gender studies on the role of embodiment and masculinities/femininities in what has been called late modernity (Adkins 2005). By exploring these issues ethnographically I attempt to theorise the construction of femininity through paid work within a specific context marked by the ascendancy of ­middle-class women who act from a contradictory position (Wright 1997) of both class domination and professional subordination in times of institutional change. I begin with the experiences of nurses in order to explore the ways in which they are connected into “extended social relations of ruling

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and economy and their intersections” (Smith 2005: 29). While experiences speak from a specific location in a specific time and place, it is the relations that organise these experiences that can “be demonstrated to be general” (Campbell 2006: 91). What can Azime’s reflections on the pros and cons of her job convey about care work under neoliberal ruling relations? Her quote points to the relationship between class, labour, identity and formations of femininity developed over time within the hierarchies of healthcare and in relation to gendered and racialised divisions of labour. It illustrates the tensions between different groups of care workers, divided by internal hierarchies and organisational structures, education levels and class backgrounds. It also identifies the efforts involved in emotion management, and illustrates that caring for others is not an inherent ability; nurses do not automatically and unaffectedly feel empathy for everybody. By talking about the experience of discovering that it is hard to care for some, Azime also hints to the responsibility of care workers on the floor to resolve “the intrinsic tensions between the rational organisation of their work and the more unpredictable demands of patients” (McDowell 2009: 165). In talking about the weak trade union and its “weak members”, she points to the difficulties of forming resistance from a location that is expected to be altruistic; indeed from which altruism has been cherished as a skill, a jurisdiction, a form of capital in relation to other professions and other groups of women (Land & Rose 1985). And in relation to that, she identifies that class shapes formations of femininity and consequently the expectations on different bodies to carry different weights, responsibilities and embodied fantasies within and outside the work organisation. But despite all this – the tension, the hard work, the misrecognition and the complicated relations involved – Azime loves her job. It is important to her. In this regard, she contradicts claims from within the social sciences that consumption rather than production forms the critical site for construction of self-identity (McDowell 2009: 11). It is by paying attention to experiences of nursing under neoliberal hegemony that I set out to explore issues of identity, compliance and resistance to relations of ruling and inequality in the new millennium. The aim of the study is to analyse the embodiment of normative forms of femininity in nursing within a changing healthcare

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organisation, and to explore the role of femininity in the reproduction and contestation of relations of power within the workplace. The questions I pose in order to explore these issues are: – How does the organisation of labour in a public hospital setting intercede to create and reproduce varying forms of femininities? – What kinds of boundaries are created to define normative forms of femininity for nurses? – Which role do categories such as gender, class and ethnicity have in shaping and regulating women’s positions within the hierarchy of the healthcare organisation? – What is the relationship between normative forms of femininity and strategies to cope with, enact and resist neoliberal transformations of healthcare and changing conditions of work? While I argue that these questions are relevant in order to understand the production and reproduction of inequalities in our time, I recognise that they are far from new. Neither is this the first study to identify nursing as a piece of women’s history, as a paradox of emancipation and systematic devaluation, and as an instance of both solidarity and conflict between different groups of women (see, for example, Andrist 2006, Davies 1995). There have in fact been plenty of studies on the topic. So why another one?

Why study paid care work and femininities? I have been told on numerous occasions by researchers that my topic is irrelevant. It’s over-studied, over-theorised, a big been-there, done-that within sociology and gender studies. I realise this is an unorthodox way of introducing a dissertation, but let me just repeat some of the arguments I’ve heard as to why this study is redundant. First of all: there is like a thousand studies on nurses, power relations at hospitals, medical professions, et cetera. The best and the brightest feminist sociologists have already explored these issues (such as Judith Lorber). Oh, and

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before the feminists came, the best and the brightest sociologists overall (those are the male ones) already had uncovered the core issues in the medical/care professions and the question of interactions within hospitals (canonised fellows such as E.C. Hughes, Howard S. Becker, Talcott Parsons and Andrew Abbott). Swedish sociology in particular produced a final say on all things related to gender, power and hospital work with the analytically cohesive, accessible and well-circulated Doktorer, systrar och flickor (‘Doctors, Sisters and Girls’) by Gerd Lindgren in 1992. “Why would you want to do the exact same study as Lindgren already did?” one sociologist asked me at a conference sixteen years after the publication of that study. The arguments presented to me by postcolonial and feminist scholars, on the other hand, focused on the problem by paying attention to and opening up a space for white, privileged women’s experiences. “Do you really want to be responsible for the production of yet another study on white middle-class and respectable workingclass women – to what end?” one postcolonial researcher asked me at a seminar, adding that it was highly problematic that Swedish feminist scholars continued to ignore subordinated and stigmatised groups and their experiences. I mention these expressions of disapproval because I think they speak to the current interest formations within sociology and gender studies, in which femininity is under-theorised (Dahl 2012), and the field of feminist working life studies underemphasised (Mulinari & Selberg 2011). Further, queer theory and masculinity studies have contributed to making the category of women marginal to the field of gender studies (Gunnarsson 2011). But it wasn’t just sociologists who thought it was a poor choice of study. Even the nurses felt I was asking obvious questions. Their general position was that no one ever listened to their experiences, no one in power cared about their abilities and harshening conditions, and no one recognised their labour except the individual patients they helped day in, day out, and whose gratitude they relished. Even so, it would probably be more interesting to interview their male colleagues, many of them said, some offering to contact a couple of male nurses on my behalf. And so here I was, doing this study that many seemed to think was uninteresting, too obvious. What is there to be said about women who do women’s work in the public sector?

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It is true, of course, that during the last thirty years an impressive body of research has illustrated the complex interplay between healthcare as organisation and gender as analytical category (Lorber 1984, Pringle 1998, Lindgren 1992, 1999, Johansson 1997, Albinsson & Arnesson 2000, Brush 2000, Davies 2001, England et al 2002, ­Simpson 2009, Cohen 2011). Women’s positions as employed caregivers within the Swedish welfare state have been explored in a number of studies (cf. Szebehely 1995, Franssén 1997). Care work has been analysed from various perspectives and its specific conditions and logics within the S­ candinavian model of welfare provision have been dissected (­Waerness 1983, 1984). My dissertation is inspired by the knowledge produced by such earlier research, but expands the analytical framework by asking the question of if and in what ways inequality regimes and gender practices shape and are (re)shaped within the healthcare organisation by processes of neoliberal globalisation and social and political changes within the Swedish welfare state.2

Transformations One of the reasons why I chose this topic, and for the necessity of socio­logists and gender scholars to pay continued attention to issues of the interplay between care as paid work and gender as practice, is the institutional transformation of the public sector. Globalisation, the transformation of the welfare state, and public sector resource depletion have changed the conditions of the labour market and restructured the contents and organisational contexts of care work. These changes have both macro and micro effects (Ferlie et al 1996), and the outcomes have magnified power asymmetries on both levels:

2.  I use the term ‘regime’ to categorise a dynamic but historically specific set of “interconnecting organisational processes” that produce and recreate relations of power in a certain way and with certain effects (Acker 2006a: 109). The concept of inequality regime, developed by Acker (2006a, 2006b), refers to the ways in which class, gender and racial inequalities are produced and reproduced within a specific organisation. While recognising that these categories are interrelated, it is possible and sometimes necessary to focus in on one of them specifically. Thus when I talk about gender regime or ethnic regime, I refer more loosely to the “overall pattern” of gender or race/ ethnic relations within an organisation or nation state (Connell 2006: 838).

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… there is an evident consensus that women in particular were affected during the 1990s with regard both to an unfavourable development in the psychosocial work environment, and to income distribution – due to a strong relative decline in public sector salaries. In addition, healthcare personnel have reported a more marked increase in psychological demands during the whole decade, and a corresponding loss of influence from 1995 onwards, in comparison with other Swedish employees. From the perspective of international downsizing research, the stressors for employees are described in similar terms of growing work demands and reduced control, combined with job insecurity, loss of trust, and an accompanying later increase in sickness and absence (Hertting et al 2005: 108, references excluded. See also Ds 2002:32).

In the following section, I will outline the background and context of these changes and explain some of the forces behind the new conditions of work in the Swedish public sector.

The neoliberal turn in the Swedish welfare state Up until the 1990s, the Swedish public sector expanded continually. Between the years of 1960 and 1985, the entire national job growth was generated by increased levels of hiring in the public sector, primarily among women (Ringqvist 1996, Sundin & Rapp 2006). However, the historical notion that public sector employment represented a secure or even permanent position changed dramatically when about 200,000 jobs disappeared in the six years following the economic crisis in the 1990s (Eliason 2011). Unemployment rates skyrocketed during the crisis, from a historical low of 1.5 percent in 1989 to over 8 percent in the mid-1990s; in 1995, it was suggested that an unemployment rate of 7 percent represented an acceptable rate according to official interpretations of NAIRU-models (Josefsson 1997).3 Whilst the employment rate in the private sector bounced back and continued to rise until the year 2000, it remained stable in the public sector, which itself now seems to have been permanently diminished (­Eliason 2011). The crisis legitimised demands for radical cutbacks within social security systems and in the public sector (Hasselbladh et al 2008: 8), especially since the cause of the crisis was described as the result of social democratic politics and the Swedish model itself. With its strong unions, ideals of redistributive welfare, and inefficient public sector, 3.  NAIRU refers to “non-accelerating inflation rate of unemployment”, for an overview see also Lundborg et al (2007).

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Swedes had been compelled to “live beyond their means”, according to the dominant narrative (Sverenius 1999: 31, Harvey 2007: 114). The way out of the crisis, policymakers advised, were neoliberal reforms. Harvey (2007: 2) defines neoliberalism as: [the] theory of political economic practices that proposes that human wellbeing can best be advanced by liberating individual entrepreneurial freedoms and skills within an institutional framework characterised by strong private property rights, free markets, free trade. The role of the state is to create and preserve an institutional framework appropriate to such practices. Furthermore, if markets do not exist (in areas such as … education, healthcare, social security …) then they must be created, by state action if necessary.

From a neoliberal perspective, the sizable public sector was hampering the Swedish economy. Policymakers argued that lack of competition and economic incentives for increased efficiency, partnered with secure employments and ‘liberal’ rights to industrial action, caused employees and administrators to waste resources. The Lindbeck Commission, tasked with evaluating the Swedish economy in the aftermath of the crisis, argued that the process of tying a large segment of the labour market and a majority of employed voters to the public sector had not only triggered Social Democrats to defend its expansion beyond reason; it also affected the wage formation and the tax levels, which supposedly had increased the depth of the crisis and dampened the growth in the private sector (SOU 1993:16, see also Hasselbladh et al 2008: 54, Gustafsson 2000: 111f, Sverenius 1999: 16ff, Hugemark 1994). In the decades preceding the crisis the balance of class forces, according to Harvey (2007: 112), was “stabilised around a strong centralised trade union structure that bargained collectively with the Swedish capitalist class directly over wage rates, benefits, conditions of contract, and the like”. The 1970s had been a decade of labour movement advancement; not only had Swedish labour law expanded to reach into the workplaces, yielding unions some influence over company practices and decisions, but the Meidner Plan had been launched by the Trade Union Confederation and Social Democrats, which would impose “a 20 percent tax on corporate profits [that would] flow into wage-earner funds controlled by the unions to be reinvested in the

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corporations” (ibid.). The threat against the capitalist class ­propelled a massive propaganda campaign from the employer federation, which had little effect during the 1980s when unemployment was at an alltime low, union density was high, and the support of the Swedish model intact. In 1991, after the failure of Social Democrats to break the economic stagnation, a conservative government was elected. This time, unions were pressed back, and agreed to “exercise wage constraint in order to raise profits and encourage investment” (ibid.: 114). Now the “real shift towards neoliberalism” came, as the conservative government deregulated the banking sector, cut taxes and committed to privatisations. The Central Bank “switched its mission to fighting inflation rather than maintaining full employment” (ibid.). In what has been described as a case of path dependency, the Social Democratic party consolidated and sustained the deregulations, privatisations and public sector rollbacks (Harvey 2007: 115). The EU membership further established the neoliberal agenda. The neoliberal turn of the 1990s thus marked the end of traditional Social Democratic labour market and economic policy. In its place, a new politico-­economic orthodoxy formed, one dedicated to inflation control, deficit reduction and balanced budgets, rather than full employment. ­Gustafsson (2000: 98) calls it “the ideological dismantling of the ­Swedish model”; Harvey (2007: 115) calls it “circumscribed neoliberalism”, noting that the Swedish public has “remained broadly attached to its welfare structures” (ibid.). The crisis of the 1990s and the following development of the welfare state especially affected underprivileged groups as gendered and racialised class polarisation increased; single mothers, migrants, young adults, children and working class families with children, women, specifically those who were or had been employed in the public sector (Ds 2002:32: 10ff). At the end of the decade, workers, women, and migrants (categories that often intersect) still experienced poorer health, lower wages and greater financial problems (ibid.).

New Public Management During the 1980s and 1990s the transformation of the welfare state intersected with the “international management revolution” that called for radical changes in the public sector with the aim of reduc-

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ing costs, implementing pseudo-market mechanisms and improving services (Montin 2012: 2). These changes within public sector organisations, which took place in most Western countries during the 1990s, are commonly referred to as New Public Management (NPM). NPM involves not only changing management techniques and accounting models, but also implies “a more fundamental shift in norms and beliefs concerning the public sector and its relation to the private sector” (Blomgren 1999: xi), as public sector organisations model their governance on private companies. The principal argument is that profit in private business stimulates productivity through “the o­ wner’s effort to discipline the labour force and the ability of the entrepreneur to identify new solutions” (Gustafsson 2000: 101). Because no easily identifiable profit can be produced through the work performed in public organisations, NPM emphasises cost reduction (Hasselbladh et al 2008: 60). Thus key to NPM is the introduction of quasi-­markets and contracting-out, as well as stressing the role of active management, which thereby challenges trade unions and public sector professional groups such as the medical profession (Agevall & ­Jonnergård 2010). The emphasis on management extends to the audit process, and includes a focus on performance measurement (van Thiel & Leeuw 2002). Decentralisation and cost control are linked processes as the responsibility of cutting costs is moved down within the organisations, leaving low-level managers to handle savings measures (­Hasselbladh et al 2008: 59). Increased use of financial control mechanisms represent the most radical change in Swedish public sector management since the 1980s, according to Hasselbladh et al (ibid.), who point out that while the state has not regulated practices in this area, the so-called budget balance demand has enforced stricter local priorities, which has created a continuous chase for funds. Further, decisions that used to be handled by political mandate have moved down in the organisation, and “have thus often come to appear as value-neutral, technical measures” (ibid.). In their summary of the implementation of NPM regimes in the Swedish public sector, Hasselbladh et al capture what others have called “the double-edged sword” and the hybrid character of NPM as it prescribes “both more autonomy and more central control at the same time” (Christensen & Laegreid 2007: 8).

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In Sweden, processes of professionalisation accompanied NPM reform. Consequently, nursing aides and assistant nurses lost their jobs in great numbers: assistant nurse positions decreased by 37 percent between 1993 and 2001. At the same time, the number of physicians and registered nurses increased by nine and five percent respectively (Hertting et al 2005), marking a change towards increased professional dominance of care work processes.

Work intensifications Throughout the West, public sector employees have experienced work intensification and increased levels of inequality since the neoliberal turn to NPM and austerity ideology (cf. Hasselhorn et al 2003, ­Hertting et al 2005, Willis 2005, Wilkins 2007, Gardulf et al 2008, Eliasson 2011, Bejerot et al 2011). In Sweden, the number of available inpatient beds has been reduced, while the volume of patients has remained more or less steady. The average length of hospital stay has decreased notably since the 1990s, not only because of public sector resource depletion, but also due to developments in the medical field and the introduction of more effective treatment methods (Hertting et al 2005). Willis (2005: 256) argues that in the case of nurses, labour speedups are “bolstered by the impact of work intensification on other groups working alongside nurses, be they doctors, allied health professionals, or cleaners”. Nurses in Sweden consequently report difficulties in coping with intensified labour processes and decreased resources, causing them among other things to feel stressed and anxious, to burn out, and to have breakdowns at work (Stockholms läns landsting 1999, Glasberg et al 2007, Arbetsmiljöverket 2012). Thus within this highly feminised segment of the Swedish labour market, employees have been facing increasingly complex labour processes, growing workloads, and drastic organisational changes in terms of new models of management and stricter day-to-day economic realities for over two decades. When it comes to the nursing profession, occupying as it does an ambiguous position within the healthcare organisation, the effects have been varied. Blomgren (1999) analysed through three empirical studies the effects of NPM on the nursing profession and nurses’ work-

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ing conditions in Sweden. Her data showed that, in trying to cut costs and increase efficiency, hospital clinics chose not to prioritise timeconsuming practices related to nursing. Thus for ward nurses on duty, time became an issue in such a way that patient care suffered. “This outcome reflects the fact that economic logic helped to reproduce the subordinate position of nursing in relation to medicine,” Blomgren notes (1999: xv). On the other hand, new managerial regimes reinforced the positions of nurse managers, whose responsibilities expanded as clinics were assigned delineated economic obligations. Further, quality assurance programs contributed to strengthen nurses’ jurisdiction, providing them with an abstract field of knowledge – a central feature of the professional system and thus a positive development in nurses’ professional aspirations (see also Abbott 1988). The trade union identified that new managerial regimes necessitated clarification of the nurse’s role in the healthcare organisation, and emphasis was put on rendering nursing visible through stressing the importance of documentation (see also Agevall & Jonnergård 2010: 124). In conclusion, research has illustrated that NPM has had contradictory effects on nurses, as it seems to simultaneously maintain their subordinate position and confirm the historical misrecognition of care work; make work more complex by putting pressure on nurses to produce care with shrinking resources while adding administrative duties; as well as reshape the hierarchical organisation by expanding nurse managers’ responsibilities and strengthening nursing as a profession in its own right.

Changing inequality regimes Entwined with the neoliberal shift in the Swedish welfare state is the development towards a more democratic gender regime. This is a phenomenon of global dimensions. While the notion of globalisation is contested within the social sciences, most scholars agree that structural transformations of production, reproduction and the nationstate have occurred in recent years (cf. Walby 2009), and that at the core of these developments are dramatic changes in gender relations towards more democratic gender regimes globally (Therborn 2004). In her study on the genealogy of gender equality politics in Sweden, Tollin (2011) argues that the neoliberal hegemony was established side

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by side with the feminist breakthrough in public policy in the 1990s. Tollin notes specifically that calls for privatisation in the public sector were publicly motivated by the actualisation of discourses on gender equality and women’s liberation. Within the healthcare sector, these contradictory developments are noticeable through nurses’ entry into management positions and women’s entry into medicine. Processes of neoliberal globalisation (Sassen 1999, Sklair 2002) have also transformed the social composition of the healthcare staff by increased numbers of migrant physicians and assistant nurses. While much attention has been directed towards ‘intercultural meetings’ between patients of migrant background and presumably Swedish, white care professionals, none of the feminist researchers who have explored over the last few years aspects of construction of masculinity, femininity and care work in Sweden have paid any attention to racism and changes within the ethnic regime of hospitals (cf. Lindgren 1992, 1995, Franssén 1997, Davies 2001, Robertsson 2002, 2003). This is so despite the fact that one of the major transformations in the Swedish welfare state involves changing patterns of migration. The conditions and experiences of migrants in Sweden, shaped in part by processes of neoliberalism and commitment to EU policies of ‘managed migration’, Schierup and Ålund (2011) argue, have come to mark the end of Swedish exceptionalism; the idea of a tolerant, egalitarian and multicultural welfare state has eroded in the face of growing extremist populism, a racially divided labour market and urban segregation. The new patterns of migration have on the other hand transformed the ethnic regime of the labour market towards a more diverse workforce. Some 20 percent of the Swedish population are either foreignborn or second-generation, as pointed out by Schierup and Ålund (2011), and this has made an impact on the healthcare organisations not just in terms of the diversity of those seeking care, but also in terms of the people providing care. In 2007, when I started doing my fieldwork, 26.2 percent of all doctors working in public sector (county) healthcare were born abroad, although very few seemed to make it to management positions (SKL 2007, Dagens Medicin 2007). 9.3 percent of the nurses, 11.7 percent of the assistant nurses and 7.8 percent of the physiotherapists employed in this sector had migrant backgrounds during that same year (SKL 2007).

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The conditions of care work and the structural arrangements of the healthcare sector have been transformed since the 1990s. On the one hand, there is increased inequality and class polarisation, partnered by work intensifications and related ill-health, and, on the other hand, a move towards gender equality and racial/ethnic diversity. This study is a result of the ambition to examine the ways in which such changes intersect with and reshape power relations and gender practices within Swedish hospitals, specifically pertaining to nurses.

Intersectional interventions in analyses of work With this study I attempt to contribute to the fields of sociology and gender studies not only by investigating the practice of gender and work in times of neoliberal change, but also by weaving together different theoretical strands dedicated to exploring and destabilising categories and interconnected hierarchies. Intersectional studies have theorised the experiences and modes of subjectivity marked by exploitation and “psychic and material violence” (Alacorn quoted in Brah & Phoenix 2004: 78), notably through important contributions on race and racism (Collins 2000), imperialism (McClintock 1995) and colonialism (Mohanty 2003). But the ambition to decentre and contest normative subjects and categories has also produced critical examinations of whiteness and privileged positions (Frankenberg 1993, Ahmed 2007), and I locate my study partly within this tradition. I am however mainly inspired by materialistic understandings of intersectionality, and following Lutz et al (2011: 8) I see this perspective as a challenge to explore the “different social positioning of women (and men) and to reflect on the different ways in which they participate in the reproduction of these relations”. At the core of this study, then, is an ambition to contribute to the understanding of how normative forms of femininity are both regulated and contested, produced and maintained in the everyday lives of nurses within neoliberal ruling relations, and I draw on multiple theoretical traditions to exemplify how a focus on paid work can shed new light on issues of subjectivity from an intersectional perspective. The field dedicated to analysis of the body/work nexus (­Wolkowitz 2011: 178) has contributed to opening up new ways of theorising

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s­ubjectivity and embodiment under capitalism. By drawing on both Marxist and poststructuralist feminist theory, scholarship on interactive service employment (such as McDowell 2009) and embodiment in paid employment (such as Wolkowitz 2006), I attempt to explore the ways in which worker subjectivities are formed in relation to managerial imaginations, the desires of clients, as well as gendered divisions of labour and notions of heterosexuality, masculinity and femininity (McDowell 2009: 60). Feminist analyses of organisations have incorporated and expanded intersectional approaches to explore the ways in which organising processes produce inequalities in the workplace on the basis of gender, class and race/ethnicity (Acker 2011). My study draws on these theories in order to investigate how work, organisation and gendered subjectivities constitute each other.

Beginning in the everyday lives of people This study begins in the everyday lives of people, specifically women employed in care work. As Mohanty (2003) has argued, women have historically been denied the identity of workers and have been continually located outside of narrow concepts of ‘the economy’. With the establishment of neoliberal hegemony, class and work have been deemed unimportant in the lives of people (Amin 1997). Guided by the tradition of institutional ethnography, which proposes to start investigating the social from the viewpoint of people’s everyday lives, I argue that the changing conditions of work that (mostly) women do in the public sector are not only relevant, but constitute a pressing issue for sociologists and feminist researchers. My commitment is to what is important to people in their everyday lives, and work – whether it is considered productive or reproductive – is fundamental in this regard. So is the quality of and access to healthcare, and the public sector in general, as a space for services in which a faint but nonetheless still present and operating democratic principle rules: these are workplaces, and services, owned by the public. They are also the places to which women have entered in large numbers to be part of the formal labour market. These spaces of work have shaped generations of women as they have formed parts of their identities and many of their skills within jobs that have been constructed ideologically through notions of classed and racialised forms of femininity and masculinity (Mohanty 2003: 142).

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My argument is that despite the tensions surrounding the category of woman, and despite the shift away from issues of paid work, women doing women’s jobs in times of change is a central issue for feminist research.

Ethnography of work The study enters into a dialogue with the tradition of institutional ethnography, a method of inquiry rooted in feminist epistemology. By starting from the standpoint of women, institutional ethnography aims to explore the ways in which people are connected into “extended social relations of ruling and economy and their intersections” (Smith 2005: 29). Institutional ethnography investigates practices, empirical linkages and coordinated work processes in an effort to identify and change the social relations that create inequalities (DeVault & McCoy 2006: 19). Interview data and observations are used to gain entry into the social organisation of experience: how are participants’ actions and talk conditioned (Campbell 2006: 95)? Thus analysis begins in experience and “returns to it, having explicated how the experience came to happen as it did” (ibid.: 91). Experience is understood as a form of dialogue that is produced from a specific location in the world and, in this case, within the healthcare organisation. The sociological significance of nurses experiencing and dealing with new demands on work and identity is what it can tell about ruling practices in today’s labour market (Burawoy 1991: 281). But I also identify with Marxist and feminist worksite ethnographies, that have contributed to sociology and gender studies by exploring the connections between different spheres of life and the construction of identities (such as Burawoy 1979, Pollert 1981, Glucksmann 2009 [1982], Westwood 1984, Ong 1987, Kondo 1990, Salzinger 1997, Bergman 2010). The study builds on data collected over five years, between 2006 and 2011. During that time, I interviewed 19 nurses (including 2 nurse managers), 5 assistant nurses, 5 physicians, and 3 physiotherapists. The semistructured interviews lasted between 1–3 hours. All of the informants worked at hospitals within one County Council. The interviews mostly took place either at the respondents’ workplace or in their home. In addition to interviews, I conducted fieldwork at one of the hospitals in the County, here called City Hospital. Initially, the workplace

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observations took place in different wards of the hospital, where I shadowed a nurse or an assistant nurse (and in one case a physio­therapist) for two half-shifts each (between 4 and 6 hours, a total of between 8 and 12 hours per ward). I visited the wards on different days, and covered different shifts. Like Czarniawska (2011: 95), I find shadowing a fitting technique in work environments such as hospitals, where work is not always spatially demarcated but, rather, ‘on the move’. I performed observations in this manner in a paediatric ward, an emergency intake ward, a psychiatric ward, a surgical day clinic, a birth clinic and two surgical wards. I then proceeded to do fieldwork for a more extensive period of time at one of the surgical wards, here called Ward 96, which treats mainly pre- and post-operative cancer patients. I spent a little more than 100 hours at this ward, excluding the times I went there to conduct planned interviews with nurses. I shadowed mainly nurses but also two assistant nurses and the nurse manager. I covered all shifts, including two full night shifts when I shadowed a nurse. During the observations at Ward 96, I talked to nurses, physio­ therapists, nurse managers, nursing students, a cleaner, an aide who mainly worked in the ward kitchen, as well as three doctors. I sat in on staff meetings, rounds, a nurse manager meeting for the surgical division of the hospital, as well as coffee breaks and lunches in the staff lounge. I was in contact with the nurse manager during the entire period of fieldwork and conducted a total of 5 unstructured interviews with her, in addition to the first planned interview I conducted before beginning the fieldwork. Towards the end of my fieldwork, I was invited to share my findings at the ‘staff education day’, and I took notes of the nurses’ responses to my analysis of the data collected at their workplace.

Limitations of the study The focus of this study is hospital work, particularly the kind of work that nurses perform in hospital wards. The ward I have used as a case, Ward 96, is a specialised surgical ward where much of the work includes advanced medical technology. As I already noted, I use the term ‘care workers’ as a descriptive category referring to assistant nurses and nurses, and this is because the kind of care work performed in this

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workplace is different from the kind of care explored in feminist studies on, for instance, home-helpers (Szebehely 1995) or assistant nurses and auxiliaries in nursing homes (Franssén 1997). It is important to note here that the nursing profession is increasingly diversified (Blomgren 1999), and this means that nurses’ work can be focused on different types of ‘tasks’ and different forms of care. Nurses have been made (and have formed a professional project around being) responsible for the interventionist moral duties of the Swedish welfare state, notably through their role as child health nurses and midwives. These are the functions that work to measure and document children’s and mother’s bodies and capabilities according to standardised charts, and to provide families and mothers with advice on how to care for healthy children and how to form and organise a ‘normal’ family life. These positions have consequently been identified as highly normative and normalising positions (Hörnfeldt 2003, Sarkadi 2009). School nurses, district nurses and other nursing positions that mainly deal with social support of mostly healthy people also play an important role in representing the moral authority and moral guidance on health, sexuality, food, exercise, alcohol- and tobacco use, et cetera. These nurses are central actors in formulating and disciplining communities, and they are in a position of power to reproduce notions of normality in ways that few other occupations can. However, these are not the nurses I have interviewed. The nurses I studied, while obliged to promote health and healthy living, work with specific diagnoses and specific parts of the body in an environment where the disease is acute and often life-threatening. As nurses they have the same basic training as a child health nurse, for example, and they belong to the same profession. At least by association they are involved in the same project of moral guidance. But as I will illustrate, the nurses in my study have little organisational space and little time to exert much ‘direct’ moral guidance over patients or kin; they deal with the acute conditions caused by or linked to severe diagnoses such as cancer or hernias. They are, however, responsible for boundary work in relation to patients and occupy a position that is in some control over the bodies they work on. This study is focused on femininities that are naturalised, un-contested. While I argue that a study like this can set an example for critical explorations of varying forms of femininities, masculinities, male

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femininities and female masculinities, I have chosen to deal with femininity in forms and contexts marked by gender cohesion. I welcome contributions that choose other avenues of analysis, but set the limitation of this particular study on the gender project of a naturalised femininity, and what I will call normative femininity in particular. The study deals with work and labour processes, and the ways in which femininities are shaped through and in turn shape experiences and organisations and practices of labour. This means that I have limited the attention towards patients, and have decided not to explore patients’ experiences of the care provided, or of the quality of interactions with care workers from this perspective. I recognise, however, that care work and nursing is interactive work, and it is impossible to view this labour as independent from interactions with patients; body work is a mutually formative process where all involved actors and their bodies shape the course and outcomes of work. Patients are present in the study, but their role is not at the centre of attention. It is important to note, though, that the consequences of for example work intensifications affect patients tremendously; their health and lives are what is at stake in this regard.

Organisation of the study While institutional ethnography proposes to begin in the experiences of people, this is not necessarily the best way to present research. I have allowed for my presentation to take the opposite form. This chapter has located the study within a broader context of social change and feminist sociological research. It has set out the aim and research questions that guide the following chapters. The next chapter, ‘Analytical approaches to work and subjectivity’, will discuss the concept of work and provide an overview of the multiple ways in which research has conceptualised various forms of labour and its gendered regulations of working bodies involved in care work processes. Chapter 3 introduces institutional ethnography and the epistemological as well as practical challenges, issues and decisions involved in the research process. The aim is to provide the reader with an understanding of how the study was carried out, and to contribute to the

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field of feminist methodology by critically examining and reflecting upon the means by which the study came to be. Chapter 4, ‘Places, spaces and contexts’, illustrates some of the ways in which the inequality regime operates concretely through spaces of work. The main purpose is to locate City Hospital in an economic and political space. The chapter begins with a summary of institutional transformations of the Swedish healthcare system. In Chapter 5, ‘Ward 96: spaces, processes and cultures of work’, I discuss work processes and cultures of the ward in which I spent most of my fieldwork, a surgical ward at City Hospital. The following chapter, 6, ‘Dynamics of femininities: life histories and embodied careers’, explores dynamics of femininity in care work from the individual life histories and gender projects of care workers, illustrating the tensions involved in embodying normative femininity and the narrow space that exists to be included in the category of ‘normal’, successful employed women. After that I analyse in Chapter 7, ‘Work intensification and interpellation of femininity’, labour speed-ups in the face of resource depletion, and illustrate the contradictory demands and aspirations from within the nursing collective that together create and maintain processes of work intensification. Chapter 8, ‘Distinctions in care work’, discusses the ways in which notions of gender and femininity become core issues in the creation and recreation of the boundaries regulating women’s position and careers in organisations. The chapter enters into a dialogue with scholars writing on interactive service employment and argues that, while body work is a productive frame for analysing labour and embodiment, it risks underemphasising hierarchies of work and, crucially, hierarchies of (body) workers. The last empirical chapter, 9, ‘Racism in the everyday and beyond’, focuses on experiences of racism and strategies of anti-racism in the workplace. This chapter illustrates through empirical investigation the tensions and conflicts that arise as the public sector increasingly relies on a diversified workforce, and as the ethnic regime of the nursing collective changes. The final chapter concludes the study and identifies the central contributions of the thesis.

2. Analytical approaches to work and subjectivity

Nurses are predominantly female. On Ward B there was only one male nurse, reflecting this. As a consequence, it is not possible to carry out gender analysis in this book (Theodosius 2008: 25).

In the previous chapter, I introduced this study by reflecting on a statement from Azime, a nurse employed at a county hospital in S­ weden. What I was curious about when I talked to her was if and in what ways she drew on “feminised scripts and performances” (McDowell 2009: 53) while doing care work. My interview with Azime centred on the conditions of labour and in the ways she felt work affected her, but also how she thought she affected her job performance and workplace by bringing in skills from other arenas of life. What is the relationship between exterior and interior categories in care work (Tilly 1998: 75ff), specifically when it comes to femininity? Interior categories refer to “a particular organisation’s internally visible structure”, while exterior categories originate outside and beyond particular organisations. Often, exterior categories shape interior categories. Applied to the hospital, interior categories are, for example, occupational groups such as nurses, doctors and cleaners. Exterior categories include gender and race/ethnicity, and within the organisation these categories overlap: Matching interior with exterior categories reinforces inequality inside the organisation that does the matching. The creation of a well-marked interior boundary itself facilitates exploitation and opportunity hoarding by providing explanations, justifications and practical routines for unequal distribution of rewards. But matching such an interior boundary with an exterior categorical pair such as white/black or citizen/foreigner imports already established understandings, practices and relations that lower the cost of maintaining

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the boundary. It borrows potent scripts and common knowledge. Emulation thereby reinforces exploitation and opportunity hoarding (Tilly 1998: 76).

Thus historically in Sweden nurses have been white women and doctors white men; cleaners have been and still are disproportionately racialised. This is beginning to change, though, as will be discussed later on. But in sum, the hospital provides an excellent example of an organisation that emulates categories. This, no doubt, is also why there exists a vast body of research on women and men in nursing and medicine. And while I find Tilly’s conceptualisation of interior and exterior categories useful to work with analytically, I want to move away from the focus on the categorical pair of men/women. Rather than thinking about gender as a categorical pair in this sense, I wish to explore how relations of ‘caring’ intercede to create and maintain divisions between women (see also Batnitzky & McDowell 2011: 182) by understanding the specific interpellation of femininity produced within nursing. Nurses are predominantly female. On the ward in which I did my fieldwork, there was only one male nurse and he worked the midnight shift. Far from making it impossible to analyse gender, this opens up an empirical space for investigations into the relationship between femininity and commodified caring. It also offers a challenge: to capture analytically the nuances of variations of femininities in a context wherein ‘feminine’ is naturalised, taken for granted. This chapter will focus on the concept of work and analytical approaches to care as waged labour. The aim is to frame the empirical analysis theoretically by defining and explicating concepts located in materialist as well as poststructuralist traditions, that help uncover the connections between interior and exterior categories of gender, work and identity, specifically in the naming of nurses as bearers of what I call a normative version of femininity. Beyond this aim, the chapter is written in a spirit of wanting to create a dialogue between Marxist and poststructuralist feminist theory and sociology(/ies) of work. The general idea of this chapter is to unite those theoretically diverse contributions that all can assist in putting paid work and gendered and racialised class at the centre of gender studies again (Mulinari & Selberg 2011). I also want to expand feminist thinking on the concept of femininities, and show that a focus on women’s experiences and women’s work need not be focused on the reproduction of unified

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categories. Nonetheless I argue that such experiences are important in understanding the ways in which identity and a common ground in subordinated and contradictory locations can form the basis of political agency (Newman 2012: 5).

Structuring jobs: femininities, masculinities at work Through the work of feminist-organisation scholars, research has established the gendered feature of work and occupations. Acker (1990) pioneered this perspective by challenging the notion of organisations as rational entities, devoid of assumptions about bodies. Instead, Acker argued that organisations are intrinsically gendered and that notions of gender and sexuality permeate their everyday practices to the benefit of certain bodies: notably white, heterosexual men. Consequently, organisations create and recreate inequalities through their structures, practices and culture. Relations of work are gendered through a variety of mechanisms and processes, Acker (1990: 145f ) argues, as “the structure of the labour market, relations in the workplace, the control of the work process, and the underlying wage relation are always affected by symbols of gender, processes of gender identity, and material inequalities between women and men”. Since Acker’s groundbreaking work, feminist research has illustrated through empirical investigations the ways in which “gendered practices and assumptions are embedded in organising processes” (Acker 2006a: 105), and has proved that while masculinity is associated with strength, rationality and cerebral capabilities, femininity structures often less well-regarded jobs (McDowell 2009: 53) and is associated with emotions, dexterity, inferiority and accommodation (Kanter 1977, Pringle 1988, Salzinger 2003). Acker, along with other researchers on gender, work and organisation (Jeans et al 2011), has since moved in a direction of recognising complex inequalities. Acker has developed this approach through the analytical model of inequality regimes of organisations: All organisations have inequality regimes, defined as loosely interrelated practices, processes, actions and meanings that result in and maintain class, gender and racial inequalities within particular organisations. … I define inequality in organisations as systematic disparities between participants in power and control over goals, resources and outcomes; workplace decisions

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such as how to organise work; opportunities for promotion and interesting work; security in employment and benefits; pay and other monetary rewards; respect; and pleasures in work and work relations (Acker 2006b: 443).

The inequality regime of an organisation corresponds to the history, politics and economy of the surrounding society, and because of this such regimes are various, complex and changeable. Thinking in terms of organisations’ inequality regimes is a conceptual strategy for examining the production and reproduction of complex inequalities within organisations. Even though it treats the inequality regime as specific to a certain organisation, the analysis is based on an understanding of organisations as embedded in wider relations of power and inequality, and the approach allows for exploration of patterns of inequalities as they extend beyond the analytical unit and the experience of those working within the organisation at hand. This way of thinking about control, compliance and organising processes that produce inequality has been important in my analysis of interviews and observations with care workers. As the feminist analysis of gender, work and organization has expanded during the last 30 years, focus has shifted from organizational structures and their impact on women and men to the processes of gendering (Acker 1990, Jeans et al 2011). Current analyses of gender regimes tend to include explorations of how varying forms of femininities and masculinities are inscribed and interact in hierarchical organizational structures (Cheng 1996, Martin 2001). According to Theobald (2002: 106), feminist approaches are often concerned with the way in which gender relations are at the core of organizations; thus, organizations can not be understood without analyzing “the interactions by which males and females are established as different groups (and thus assigned to different types of work and jobs) and the ways in which male dominance is attained, maintained and reproduced through power relations”. Thus what feminist research has argued is that gender, just like class and race/ethnicity, is at the core of organisations and a key feature of structures and processes of work. This is the theoretical framework for my empirical investigation, which is founded on the premise that employees’ identities are formed through the dialectic relationship between the workplace in which they partake, the actual labour

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­ rocesses they are involved in, the power relations that frame them, p and the positions and experiences that they occupy and make outside of paid work. Identities, then, are not stabilised as people enter paid work but rather “open, negotiable, shifting and ambiguous” (­McDowell 2009: 54), and they are, as Brah and Phoenix (2004: 77) point out, not “objects but processes constituted in and through power relations”. Occupations are associated with and shaped through assumptions of varying forms of masculinities and femininities. I draw attention to the variability because ‘women workers’ and hence notions of femininity can be preferred in different workplaces and for different reasons, depending on context. Workers can, in other words, be sought after to perform different kinds of femininities; the same goes for men and masculinities.1 For instance, in Salzinger’s (2000) study on ­maquiladoras, femininity is linked to docility and efficiency, but also to desirability, as the panopticon-like factory locates male supervisors as voyeurs and workers as sexual objects. The women in the factory that Salzinger studied performed a kind of emphasised femininity (Connell 1987), which demanded that they used makeup, short skirts, high heels, nail polish and dressed their hair. Other women workers may be called on because they are associated rather with mothering; I argue that nursing is constructed through this version of femininity, in contrast to what goes for other women working in the service sector or in the maquiladora studied by Salzinger, in which notions of docility, touch, availability of bodies, et cetera, take on other forms and meanings. Thus gendered identities are context-dependent and temporally specific (McDowell 2009: 55); but most often, as Butler (1999) has pointed out, they are embedded and produced within dominant representations of heterosexuality.2 1.  Women who enter into male-dominated occupations have to negotiate both femininity and masculinity, as they upset gender assumptions (cf. Bergman 2010). As has been illustrated in studies on male nurses, they also need to negotiate notions of femininities and masculinities, and often feel like they have to assert themselves as masculine, heterosexual men; thus they actively construct masculinity in a context wherein gender is associated with women. This is not always to their disadvantage, however, as research has illustrated that male nurses tend to ride ‘glass escalators’ and receive structural rewards within the organisation (cf. Robertsson 2002). Much research exists on this issue and I will not discuss it in detail, see for example Dahle (2005). 2.  The reason I argue that they are ‘most often’ produced as heterosexual is because, as Nilsson (2011) has illustrated, sexual scripts can vary within different workplaces.

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What does it imply, then, to argue that femininities and masculinities shape and are shaped by organisations of work? After having presented an earlier version of this manuscript, I was asked: what has femininity got to do with women? The question is based on critical assessments of notions of prediscursive categories from which gender is derived; that is, the idea that ‘femininity’ is linked to a biological fact, an essentialist assumption.

A contested concept: defining femininities The risk of essentialism in deploying the category of woman has been at the core of feminist debates during the last three decades. I take my point of departure in acknowledging the centrality of these debates (see Crosby 1992, Brah & Phoenix 2004, Butler & Weed 2011) for the understanding of gender regimes. Butler (1999), to take one especially influential critic of the category of woman, argued that gender discourse produced by feminist politics striving to represent “the group of woman” obscures “the social and discursive production of identities” (interpreted by Young 1994: 716). In Gender Trouble, Butler (1999) identified how processes of substantialising gender were rooted in notions of internal coherence, demanding a stable and oppositional heterosexuality. Butler, according to Young (1994: 716), identified “ways that essentialising assumptions and the point of view of privileged women dominate much feminist discourse, even when it tries to avoid such hegemonic moves”. Is there no way of speaking about women without establishing a normative subject? The category of woman is central in reproducing and transforming relations of ruling. Along with Young (1994: 718), I argue for the need of acknowledging and analysing the presences and experiences of collectivities in order to “maintain a point of view outside of liberal individualism”: The discourse of liberal individualism denies the realities of groups. According to liberal individualism, categorising people in groups by race, gender, religion and sexuality and acting as though these ascriptions say something significant about the person, his or her experience, capacities and possibilities, is invidious and oppressive. The only liberatory approach is to think of and treat people as individuals, variable and unique. This individualist ideology, however, in fact obscures oppression (Young 1994: 718).

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There are political as well as analytical reasons for thinking about women as a collective of some kind: it allows for ways of naming and examining disadvantage, exclusion and oppression without attributing these inequalities to individuals. However, there is also need to speak about collectivities without ending up in essentialism. Young suggests conceptualising women not as a group but as seriality. A group, according to this way of thinking, is made up of people who are united by actions that they undertake together. The project of a group, Young asserts, is a collective project, and it is mutually acknowledged that the project can’t be undertaken individually. An individual’s life and actions are in large part structured by groups. Building on Sartre, Young (1994: 724) argues that “groups arise from and often fall back into a less organised and unself-conscious collective unity” – a series: Applying the concept of seriality to gender, I suggest, makes theoretical sense out of saying that ‘women’ is a reasonable social category expressing a certain kind of social unity. … Seriality designates a certain level of social existence and relations with others, the level of routine, habitual action, which is rule-bound and socially structured but serves as a prereflective background to action. Seriality is lived as medium or milieu, where action is directed at particular ends that presuppose the series without taking them up self-­ consciously. Thus, as a series woman is the name of a structural relation to material objects as they have been produced and organised by prior history. … Women are the individuals who are positioned as feminine by the activities surrounding those structures and objects (Young 1994: 728, italics in original).

Does this mean that femininity can only be expressed by those positioned as feminine in this sense? Martin (1998) posed this question to Connell (1998), who like Young argued that there is a connection between ‘male’ and ‘female’ bodies with the constitution of the series of women and the social practices of gender.

Gender as practice Connell (1987) disentangles the relationship between biology, sexuality and gender through an emphasis on practice, and this is the framework within which I’ve developed my analysis of experiences and gender projects in care work. “The knot of natural difference”, Connell (1987: 66) suggests, is the assumption that the reproductive dichotomy is “the absolute basis of gender and sexuality in everyday

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life”; an assumption that was unchallenged for a long time, even by many feminists and social scientists. Gender is a social process just like class is a social process, and, in both, the body is implicated: in class through the labour process and “the function of the body as tool”, and in gender and sexuality through a negation of natural patterns in practical transformations (ibid.). Acknowledging the body and the natural world as implicated in class relations does not prevent us from viewing them as historical, Connell asserts, and no more “should the implication of the body in gender relations through sexuality prevent us from seeing the historicity of gender” (ibid.: 77). But there is a connection with nature and the reproductive dichotomy, and the connection is precisely human practice: In the practice of labour, the natural world is appropriated by human beings and transformed, both physically and in terms of meaning. In the practices of sexuality and power, as well as certain kinds of labour (for example nursing), the human body itself is an object of practice. … Practice issues from the human and social side of the transaction; it deals with the natural qualities of its objects, including the biological characteristics of bodies. It gives them a social determination. The connection between social and natural structures is one of practical relevance, not of causation (Connell 1987: 78, italics in original).

I bring up Connell’s argument on the relation between body, reproduction and gender first of all because it provides a conceptual ground for her theoretical work on femininities and masculinities, and second because it positions her in relation to Butler’s (1999) critique of the notion of ‘women’ as subjects and the performative character of gender. Butler’s influential work challenged the implicit connection between biology and gender that according to her was reproduced by sociological approaches of doing gender. Butler (1999: 173) instead argued that the body itself is a produced effect, lacking “ontological status apart from the various acts which constitute its reality”. Gender in this sense is also a norm, a “performance with clearly punitive consequences” (ibid.: 178), which “ought not to be construed as a stable identity of locus of agency from which various acts follow; rather, gender is an identity tenuously constituted in time, instituted in an exterior space through a stylised repetition of acts” (ibid.: 179, italics in original). Consequently, there exists no prediscursive essence to

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which meaning is assigned or extracted from: gender is not an effect or expression of something true. Connell makes a slightly different case in Gender and Power, and one I find more convincing. The social practices constructing gender relations are not expressions of natural patterns, nor are they disconnected from such patterns. Connell acknowledges that practice deals with natural qualities, through transformative practice that “negates what it starts with in order to produce something new” (1987: 78, italics in original). While transformed in social practice, bodies are real – they are, in the words of Connell (1994), recalcitrant, potentially disruptive. Bodies, however, are organised in society not at random, but by structures of social relations. In attempting to formulate a theory of bodies as both objects and agents of practice, Connell introduced the concept of body-reflexive practice, a pattern of practices forming the very structures “within which bodies are appropriated and defined”: Body-reflexive practices are not internal to the individual. Particular versions of femininity and masculinity are constituted in their circuits as meaningful bodies and embodied meanings. … Through body-reflexive practices, bodies are addressed by social process and drawn into history, without ceasing to be bodies. They do not turn into symbols, signs or positions in discourse. Their materiality … is not erased; it continues to matter (Connell 1994: 14).

The set of the body-reflexive practices is the reproductive arena, which is constituted by the materiality of the body. The reproductive arena – which should not be understood as a biological base – is “a point of reference in gender processes”, but it is not stable; it can be and is being reshaped by social processes (by technology and political processes that are more contested in some contexts and times than in others: think of contraceptives or politics regarding IVF, et cetera; ­Connell 2009: 68f ). Linking the reproductive arena to gender processes in terms of a point of reference is a persuasive argument because it pays attention to the ways in which gender as social practice deals with or refers to bodies and their capabilities without reducing practice to bodily functions (Connell 2000: 464). It recognises bodies and their materiality, which takes on a deeper meaning as one enters a hospital in which some bodies move and labour to care for other bodies, whose recalcitrance is obvious and makes up a good deal of the emo-

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tional labour performed by care workers; no one expects the body to stop functioning, and yet it does. Like Smith, Connell recognises the body not as something outside of experience, but rather as “the site of consciousness, mind, thought, subjectivity and agency as particular people’s local doings” (Smith 2005: 25). Body-reflexive practices are formative of reality, Connell argues; they shape and are shaped by structures of social relations involving institutions and discourses. Actions are configured in larger units, and masculinity and femininity are defined as “complex configurations of gender practice” (Connell 1995: 72, 2000: 465). Femininities and masculinities are not essences, although they relate to experiences of male and female bodies. Rather they are “ways of living certain relationships”, in which the main foundation is men’s domination and women’s subordination; in the words of Demetriou, “the relationships within genders are centred on, and can be explained by, the relationships between genders” (2001: 343). Young (2005: 5) describes how the distinction between masculine/feminine often has been conceptualised as a relational position in a dichotomy … where the first is more highly valued than the second, and where the second is partly defined as a lack with respect to the first. This dichotomy lines up with others that have a homologous hierarchical logic, such as mind/body, reason/passion, public/private, hard science/soft science, and dozens of other value-laden dichotomies whose discursive application has practical effects in personal lives, workplaces, media imagery, and politics, to name only a few social fields.

This way of conceptualising masculinity and femininity, while useful in unlocking gendered stereotypes, risks asserting distinctions rather than challenge them. Connell contributed to expanding the analysis of varying forms of masculinities of femininities, not least through the concept of hegemonic masculinity, which refers to the dominant position within a given pattern of gender relations. Not many men can actually live up to the ideal of hegemonic masculinity. Most men are, however, complicit in the hegemonic project. Men benefit from the patriarchal dividend and thus from the subordination of women to men, and through complicity they can do so without actually having to directly and openly oppress women around them. Some

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­ asculinities are subordinated; not because they lack some “trans­ m histo­rical quality” but because “the configuration of practice they embody is inconsistent with the currently accepted strategy for the subordination of women”, as Demetriou (2001: 344) puts it. Here, Connell is mainly concerned with heterosexual dominance and the subordination, both cultural (status, prestige) and material (varying forms of discrimination) of homosexual men. Relations of class and race also lead to the marginalisation of working-class and racialised men, who can come to occupy hegemonic positions in some contexts through processes of authorisation. The concept of hegemonic masculinity has been employed and developed in several studies on masculinities in organisations such as the education system (Skelton 1997, Imms 2000); the military (Houl­ brooke 2003, Sasson-Levy 2002); and in management (­Collinson & Hearn 1996). There have, however, been fewer studies on the construction of varying forms of femininities within organisations and workplaces.

Relations of femininities Like Dahl (2012), I think Serrano’s (2007: 320) definition of femininity, as “the behaviors, mannerisms, interests, and ways of presenting oneself that are typically associated with those who are female” is useful because it avoids locking femininity to a female body. But I want to go further and understand the ways in which such behaviours, mannerisms, interests, and ways of presenting oneself vary across space and are enacted through processes of call and response in specific organisational contexts and labour processes. I am not arguing that only those who identify themselves or are clearly identified by others as women can be bearers of femininity. But in this study, it is those experiences of naturalised femininity that I am exploring. As Moi (1998: 8) has pointed out, though, “any given woman will transcend the category of femininity, however it is defined”. Analysing femininities does not imply that cultural ideals or demands on femininity correspond to actual personalities of women (Connell 1987: 184). It does, however, direct attention to the dialectic processes of the creation of active subjects and the organisation and mediation of texts produced by and coordinated with the global market and organisation of capital (Smith 1990: 121,

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Skeggs 1997: 98). Smith argues for a conceptualisation of femininity as textually mediated discourse, a “distinctive feature of contemporary society existing as socially organised communicative and interpretive practices intersecting with and structuring people’s everyday worlds”; this understanding of femininity would imply a “shift away from viewing it as a normative order, reproduced through socialisation, to which somehow women are subordinated” (ibid.: 122). For my part, I would argue that Smith’s suggestion of approaching femininity as “a complex of actual relations vested in texts” does not differ much from ­Connell’s conceptualisation of masculinities and femininities as configurations of practices referring to the reproductive arena and mediated by cultural ideals through symbols and discourses. Smith does, however, remind us of the power of the markets that exists to bolster, shape and articulate masculinities and femininities through commercial processes via print, film, et cetera (“clothes, makeup, shoes, accessories”, ibid.: 121 – what Bartky calls “the fashion-beauty complex”, a “major articulation of capitalist patriarchy” which has replaced the institutions of the family and the church as the central producers and regulators of femininity; Bartky 1990: 38f ). Where I disagree is on Smith’s focus on femininity “deployed as a descriptive category” (ibid.: 124), and her emphasis on femininity as a discourse “brought into being as actual practices (of writing, producing, reading texts, of interpretation, of shopping, of the deployment of skills in producing personal appearance as text, and so forth)” (ibid.: 123). I would argue instead that femininity is brought into being by historical processes of organising production and reproduction; that is femininity as configurations of gender practices is embedded in, shapes and is shaped by organisations and varying forms of labour in a dialectic process between structures of power (as explicated by Connell 2009). Not conflating the concept with the idea of a normative order, which was correctly criticised by Smith (she was, in my interpretation, referring to the conceptualisation of femininity as a sex role, which is a different approach altogether), I will employ the concept of normative femininity to discuss and analyse care workers’ experiences of occupying a contradictory but structurally subordinated position in the gender regime of the hospital and in the gender order of the state and the labour market in relation to the structural position of men. I

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will further illustrate the ways in which processes of identification and disidentification, as well as interpellation and the naming of the ideal worker by management, are central to sustain, negotiate and substantiate normative positions (Skeggs 1997). As care workers, the women in this study embody emphasised femininity, which was the concept proposed by Connell (1987) to match that of hegemonic masculinity, in that they perform the supportive and nurturant work that is linked to compliance and accommodation of hegemonic masculinity and men’s domination. In many other ways, the concept of emphasised femininity resonates poorly with the collective gender project of care workers in Swedish hospitals; emphasised femininity suggests an orientation towards accommodating the (erotic) desires of men and refers in my interpretation to practices and symbols of what Bartky (1990: 40) calls “a sense of successful adaptation to standards of feminine bodily presence”. I would rather work with the form of femininity that is conceptualised by Connell (1987: 184) only as ‘other’, and said to be defined “by complex strategic combinations of compliance, resistance and co-operation”. Looking at the history of care workers, and specifically the nursing profession, this definition corresponds to the strategies and negotiations carried out by women in both asserting, subjugating and professionalising traditions and knowledge of caring.

Thinking about femininities Rather than constructing several categories such as ‘hegemonic’, ‘subordinated’, ‘pariah’ and ‘oppositional’ femininities (such as proposed by Charlebois 2011 and Schippers 2006), I will work with one major dimension: normative femininity. I use the concept of normativity to illustrate the dominant cultural and ideological interpretations of gender and the ways in which women experience, live through, resist and negotiate them in a particular time and place.3 One aspect of this is the cultural emphasis on naturalness that is linked to motherhood and care, such as the pervasive idea that caring comes naturally to women 3.  Connell and Messerschmidt (2005: 832) describe hegemonic masculinity as “not assumed to be normal in the statistical sense … but it was certainly normative. It embodied the currently most honoured way of being a man, it required all other men to position themselves in relation to it, and it ideologically legitimated the global subordination of women to men.”

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and that care work is not an acquired but an inherent skill. The concept corresponds to Hearn’s notion of a “patriarchal feminine” which accords with the caring stereotype that works to reinforce female subordination (Hearn 1982, Porter 1992) and at the same time establish class boundaries and moral authority in relation to women performing other kinds of jobs that are structured differently vis-à-vis masculinities and femininities. Femininities are processes of configuring practice through time (Connell 1995: 72) and, with this as a starting point, there is enough analytical space for a dynamic view of how gender projects are shaped through structures of inequality and through inequality regimes of organisations. All women are involved in gender projects in one way or another and I would argue that all such gender projects relate to ideologies of varying forms of femininity and to forms of masculinity; specifically hegemonic masculinity. Instead of proposing a generalised schema of relationships within the gender category of woman, I would propose that research on femininities work from the experiences of women as they interact and coordinate their actions in particular contexts and fields of coordination such as occupations, social movements, families, neighbourhoods, workplaces, et cetera. Relating femininity to specific inequality regimes allows for analysis of strategies and embodiments of multiple femininities in specified historical junctures and spaces that avoid ending up in character types. This approach should not, however, imply collapsing all forms of gender projects into the same form of femininity; clearly there exist multiple ways of relating to and practising femininity. As Dahl (2012), ­Holland (2004) and Halberstam (1998) have argued, there are different ways of practising femininities and ways of embodying feminine masculinity. Halberstam explored practices that are commonly thought of as linked to cultures of masculinity embodied by subjects who are still identified (and identify themselves as) women (by, for instance, critically examining cultural constructions such as tomboys). The point of examining normative forms of femininity is to highlight the gender configuration that is asserted and privileged in this particular segment of society in which care work is performed. These notions of normative femininity can be transformed under particular historical instances and come to challenge the authority of hegemonic masculinity and men’s domination by, for instance, collective m ­ obilisation

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around pay equity, ­professional status and processes of women’s breaking into male-­dominated occupations (the concept of breaking into male occupations has been developed and employed in studies on male-dominated occupations: see Lindgren 1985 on factory workers, Gunnarsson 1994 on technical work, Bergman 2010 on steelworkers, also Selberg 2011 on leaders within academia). This approach should neither imply that relations of femininities exist disconnected from extralocal ruling relations; the concept of normative femininity should address the societal ideologies of gender to which people orient practice, in the words of Martin (1998: 472).

Why ‘normative’ femininity? I use the term ‘normative’ to suggest a privileged form of femininity that is organised around the moral authority that is culturally and ideo­logi­cally linked to motherhood and to the moral upbringing of the nation (Roberts 1997, Skeggs 1997). I view normative femininity in this context as a historically contested relationship, which embodies accommodation of men and masculinities as well as privileged positions in relation to other forms of femininities – while at the same time providing space for women to become economically independent and create boundaries of professional jurisdiction. According to Marso (2006: 30), “standards of femininity vary for women in terms of race, class, and historical and cultural location”. Whiteness is a privileged position that can embody many forms of femininities, as Mulinari (2010) argues in her study on Swedish midwives and their encounters with migrant women giving birth. While class shapes femininity, I do not suggest that normative femininity is a configuration of practice related to the most privileged class positions; in Sweden, it is linked to middle-class women and women within the labour aristocracy (Skeggs 1997: 46). This, in part, is why I choose not to talk about hegemonic femininity. I am unmoved by attempts at illustrating the employability of a concept referring to a feminine hegemonic position (such as Pyke & Johnson 2003, Schippers 2006). Hegemony refers to the domination and leadership position of a class (or group) that can establish and assert its power through control of institutions and discourses; in Connell’s words, “the cultural dynamic by which a group claims and sustains a leading position in social life” (Connell 1995: 77).

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Because women as a group are subordinated to men, even women who are able to embody and practise privileged forms of femininities do this in the context of domination and oppression in relation to masculinity as the gender order. Here, I refer to Connell’s (2000: 466) discussion of Young’s (1990) analysis of justice, in which domination signifies “the social conditions that prevent people from controlling their own actions, individually or collectively”, while oppression refers to “the social conditions that inhibit personal growth, self-expression or communication with others” (Connell 2000: 466f ). Why settle for one main concept in exploring the relations of femininities? Theoretical constructions of categories aiming to investigate such relations risk simplifying and fixing practices of gender, both as projects of individual life courses and collectivities. Even though Connell has been careful to avoid representing hegemonic masculinity and emphasised femininity as typologies, they have often come to be understood in this way (Martin 1998, Hearn 2004). Hearn (2004: 58) questions the concept of hegemonic masculinity by pointing to unclear ways in which it is to be applied and understood analytically: First, are we talking about cultural representations, everyday practices or institutional structures? Second, how exactly do the various dominant and dominating ways that men are – tough/aggressive/violent; respectable/corporate; controlling of resources; controlling of images; and so on – connect with each other? Third, why is it necessary to hang on to the concept of masculinity rather than, say, men’s practices?

While I agree with Hearn on the analytical difficulties of pinpointing what a specific relation of masculinity or femininity is (and is not), my counterargument is that by exploring the ways in which gender practices are maintained, challenged, transformed and called on in specific settings it is possible to illustrate the context-dependency of masculinities and femininities and their links to power structures, including cultural representations and connections to material resources. My argument is that empirical analysis of masculinities and femininities at the local level allows for more fruitful analyses of the ways in which actors become involved in processes of establishing, maintaining and changing men’s global ascendancy over women than the categorical concepts of men and women.

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Organising inequality: identity and work The aim of this part of the chapter is to explicate the role of women’s care work in relation to the ruling relations, and to locate historically the gendered position of care workers in the Western capitalist economies. In what ways does care work structure forms of femininities, and in what ways do notions of femininity shape care work? At the centre is the question of identity and consciousness. What are the connections between organisation of work, translocal structures of power, and social consciousness in new millennium welfare capitalism? I turn here to institutional ethnography, which aims to trace and explicate the distinctive translocal forms of social organisation and social relations – the ruling relations – defined by Smith as “forms of consciousness and organisation that are objectified in the sense that they are constituted externally to particular people and places” (Smith 2005: 13). Smith draws on Marxist theory and employs a historical materialist analysis as she lays the ground for relations of ruling in the twentyfirst century, noting specifically the new forms of social relations leading to differentiated and specialised forms of social consciousness, which became objectified in the sense of being “produced as independent of particular individuals and particularised relations” (ibid.: 14). Hers is an analysis of the ways in which divisions of labour and increasingly complex models of ownership and organisational control developed in the West in the early stages of capitalist expansion, leading to, among other things, “a radical division between spheres of action and of consciousness of middle-class men and women”; deemed by Smith as “peculiar out-of-body modes of consciousness of the nascent ruling relations” which required the specialisation of subject and agency. Smith traces the gendered organisation of the distinction between public (financial, political, bureaucratic) and private (reproductive, household) spheres of action and consciousness. The public sphere, including definitions of the economy and of labour, was defined by a gender order that excluded women (Smith 2005: 14). Capitalist development moved beyond Marx’s conception of capital in terms of individual ownership as such relations became increasingly complex and displaced by inventions of corporate control. Local organisation of economic functions and their coordination through

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networks of market relations were incorporated into large-scale corporations, and other institutional areas changed likewise as the governance of cities, schools and other institutions was transformed from “forms of patronage to bureaucratic administrations” (Smith 2005: 17). In this complex of social organisation, present-day ruling relations extend into almost all aspects of everyday lives, Smith argues, as we all … are ruled by people who are at work in corporations, government, professional settings and organisations, universities, public schools, hospitals and clinics, and so on and so on. Though they are, of course, individuals, their capacities to act derive from the organisations and social relations that they both produce and are produced by. The relations and organisation in which they are active are also those that organise our lives and in which we in various ways participate (Smith 2005: 18).

The argument here is that relations of ruling shape the everyday and experiences of the everyday, but these relations of ruling are bifurcated and extended. Going back to Marx and Engels and their concept of ideology (as formulated in The German Ideology), Smith argues that ideas and social forms of consciousness “may originate outside of experience, coming from an external source and becoming a forced set of categories into which we must stuff the awkward and resistant actualities of our worlds” (Smith 1987: 55). Here, Smith lays the ontological ground for institutional ethnography and its focus on ruling relations and experience as an entry point into knowing the social. The social in this context is understood as the coordination of people’s actions (this goes back to Marx and Engels and their definition in The German Ideology; see also Jónasdottir 2002: 22). Ruling relations are extralocal and mediated by texts. They are made invisible to those who are located outside of the extralocal relations of ruling, and who are instead located in work processes that sustain those social organisations of power and who are, in fact, the premise of its reproduction. Marx employed a similar view as he argued for “a knowledge based in the class whose labour produces the conditions of existence, indeed the very existence, of a ruling class” (Smith 1987: 79). The same argument, Smith asserts, can be made for a knowledge of the social from the standpoint of women.

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Experience and standpoint: understanding oppression The epistemic privilege attributed to women and Others (I use this term to refer to people who are subordinated by relations of class, race/ethnicity and by global relations of imperial and/or colonial rule – noting, of course, that women too are Others in this dual sense; ­Beauvoir 2002 [1949]) is based on this understanding of the type of knowledge made possible from the location outside the ruling relations. The abstracted conceptual mode of ruling needs to be articulated; the subsistence of a ruling class needs to be produced. Women and Others produce the means of this abstracted world. As women perform reproductive labour, they “mediate for men the relation between the conceptual mode of action and the actual concrete forms on which it depends”, according to Smith (1987: 83f, see also Smith 2004: 26). Smith exemplifies her argument by pointing to the work of nurses: In the health profession, for example, the routine practices that mediate the actualities of the immediately experienced world and work them up into forms corresponding to the abstracted conceptual forms under which they may be professionally (or ‘scientifically’) known are done largely by women. The psychiatric patient is indeed present to the psychiatrist as a ‘whole person’, but the routines that limit the psychiatrist’s relation to the patient, and hence define those aspects that come strictly within his professional focus, are performed in large part by women – nurses, laboratory technicians, social workers, clerks, and so on (Smith 1987: 84).

I am making an argument here about the ways in which institutional ethnography provides a radical perspective – in terms of an epistemological and methodological framework – on ruling relations, divisions of labour, consciousness and experience. The idea of beginning in the standpoint of women is formulated in the context of a historical materialistic analysis of how relations of ruling form complex structures of power that bifurcate experiences and shape the coordination of people. The role assigned to women in the social division of labour has generally been to work that mediates abstracted forms of action, and so the standpoint of women “directs us to an ‘embodied subject’ located in a particular actual local historical setting” (Smith 1987: 108). Experience refers to all those things that originate in bod-

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ily beings and actions. Butler and Scott (1992, Scott 1992: 24f ) have pointed out that experience is not fact; however, as Smith points out, it is spoken or written from the actualities of a person’s life (Smith 2005: 124). I agree with Moya (2002: 38) in that there exists no a priori link between “social location or identity and knowledge” – the link is rather “historically variable and mediated through the interpretation of experience”. Experience is conditioned by ideologies and analytical frameworks (“theories”, as Moya puts it), and experience is dialogic; it becomes data by means of collaboration between the ethnographer and the speaker (Smith 2005: 124ff). Thus experience in its mediated form, Moya asserts, contains “an epistemic component through which we can gain access to knowledge of the world” (Moya 2002: 39). Beginning in the experience of women and the varying forms of work women have been assigned to makes it possible to explicate the social organisation of their experienced world as it extends beyond what is directly known (Smith 1987: 89). Institutional ethnography, then, is not concerned with “formulations that will explain phenomena”, but rather to make the social visible through analysis of the ways in which the ruling relations extend from and shape experiences of people in diverse settings (ibid.: 106). Like Smith, Connell suggests that examination of social structures of gender should be done not in terms of structural models aiming for comparison, but rather in terms of structural inventories pushing “towards a more complete exploration of a given situation, addressing all its levels and dimensions” (Connell 1987: 98). She employs two concepts in order to separate between levels: the gender order, which refers to a “historically constructed pattern of power relations between men and women and definitions of femininity and masculinity”, and the gender regime, used to explore historically specific configurations of gender relations of particular institutions (ibid.; Acker 2006a: 109). Building on the work of both Smith and Connell, Acker (2006a, 2006b) has developed a model of thinking about the production of inequalities in the everyday that circumvents notions of separate structures of oppression and power. Rather than employing the concept of intersectionality, Acker (2006a: 30) takes up the focus on practice and the understanding of class and gender as “mutually constituting processes rather than as more or less static structures”, arguing

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that Connell’s work specifically opens up for analysis of such processes as “concrete practices that both reproduce and challenge oppressions and inequalities” (ibid.).4

Class questions, paid work: feminist sociological explorations Acker suggests focusing on organising processes that produce and maintain inequality. Specifically, she argues for a renewed focus on class as an essential relation of power; the concept of class, Acker argues, directs attention to differences between people in varying global situations, and points to “the economic realities which women and men of all racial and ethnic groups must contend with” in whatever contexts and conditions they make their life in (Acker 2006a: 2). Citing Smith and in line with the tradition of institutional ethnography, Acker proposes to begin the analysis of the ways in which these processes play out in the standpoint of women and Others to “look back at the relations of ruling to see how local class situations are being constructed” (Acker 2006a: 49). Acker defines class much in the same way as Smith, as a complex of social relations existing as active practices (Smith 1987: 135). By focusing on the economy and the practices that produce class within processes of accumulation and distribution, the analytical attention is not on effects of class but on class as a relation of power. I agree with Ebert and Zavarzadeh (2008: 92f ) in their (perhaps not too balanced) critique of the cultural turn in which class has been defined as discourse and the relation of labour and capital has been turned into a “hermeneutics of in-between-ness”. Through her focus on class as a relation of power within the realm of production and reproduction, accumulation and distribution, Acker employs a concept of power that acknowledges inequalities as relations of exploitation as well as issues of recognition (see also Fraser 1995). Thus capitalism comes into question as a system within which freedom, equality and collective human power are impossible; class is inequality, and capitalism presupposes class (see also Brown 2008: 163). This is why class is 4.  Going back to Smith (1990) and institutional ethnography, Acker defines practice as the “material and emotional production of human beings, and all the ordinary activities of daily living”; it is always infused with meaning, informed by thought – often in the form of tacit knowledge (Acker 2006a: 46).

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deemed legitimate: its relations are enforced both formally (through laws of ownership, corporate control, et cetera) and informally. But inequality and exploitation based on gender or race are not legitimated or regulated by law – however these relations of inequality are institutionalised. This contribution directs analytical attention to ongoing processes and practices of gendering and racialising that are integral to the production and reproduction of class. Class practices refer to activities that “organise and control production and distribution”; gendering and racialising processes shape these practices, the effects of which are varying forms of inequalities that are naturalised by means of ideo­ logies of natural differences. There are different points of entry into analysing gendered and racialised class practices, but as these relations are created in part by organising practices “that accomplish the practical goals of production and distribution”, one way to analyse their historical production is to focus on the organisations through which the capitalist economy functions (Acker 2006a: 105, 106). Class happens in organisations as some people work, others work by managing work, pay wages, perform ownership control, and/or bring home profit.5

Care work How can care work be theorised in terms of class? What is the place of care work in divisions of labour and ruling relations? This section of the chapter provides an overview of feminist conceptualisations of care work, and argues for the analytical inclusion of relations of femininities into studies of work and subjectivity. The aim is to map the historical topography (Gunaratnam 2003: 8) of research on labour processes in commodified care work and the meaning of work in the making of gender, and to define work as a central concept in feminist analysis. 5.  Much of Acker’s attention is on private sector firms; however, public sector organisations have “much of the same sorts of class-linked hierarchies and organising practices as private sector firms”, Acker asserts, noting that workplaces within the public sector may, however, be more open to examination and political pressures towards more democratic forms of management, recruitment and pay equality (Acker 2006a: 107).

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Conceptual frameworks of care work Duffy (2005: 68) identifies two dominating conceptual frameworks for analyses of care work: nurturance and reproductive labour. They overlap, but there are important differences, theoretically as well as empirically. Feminist understandings of care centre on relationality and interdependence, in which care is conceptualised as processes or practices with a “strong emotional dimension”, based on “human connection in relationship” (ibid.). As an example, Duffy mentions descriptions of care as a process with intertwining phases such as “caring about” (relational connections); “taking care of ” (being responsible for meeting needs); “caregiving” (practical tasks of care) and “care-receiving” (emphasising that care demands a two-way relationship instead of a “one-way dispersal of services”) (ibid.). Duffy labels such conceptualisations as the nurturance frame. One of the most influential contributions within the nurturance frame would be England’s et al (2002) study of the devaluation of caring labour. In their study, England et al included occupations that are often thought of as care work, such as nurses and childcare workers, but they also included higher-status, higher-paid (and in some cases male-dominated) occupations such as therapists and physicians. By analysing longitudinal data, the authors were able to prove a wage penalty for all care workers. The definition of care work that they use is “occupations in which workers are supposed to provide a face-to-face service that develops the human capabilities of the recipient”, i.e. “physical and mental health, skills, or proclivities that are useful to oneself and others” (England et al 2002: 455). Thus, this understanding of care work centres on the tasks involved, specifically noting the interactive and embodied character, and its aim to maintain or develop bodies and bodily functions. The other framework that feminist scholars have engaged in, according to Duffy, moves beyond the concept of nurturance and includes tasks that are not relational, such as cleaning, cooking, shopping, et cetera. This is the reproductive labour framework, which builds on feminist Marxist analyses of the division of labour and of women’s (often unpaid and unrecognised) work in the household: domestic work. By analysing such work in terms of reproductive labour, feminists have argued that women’s domestic responsibilities indeed play a major role in the economy at large by their specific relation to produc-

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tion (Duffy 2005: 70, Seccombe 1974). Here, the focus is not on the relational and emotional aspects of labour, but on the role of reproductive work in the economy as labour that is part of “the congealed mass of past labour embodied in labour power” (Secombe quoted in Duffy, ibid.). DeVault’s (1991) study of the work that it takes to feed a family is listed as one example of this, but there is a rich body of work in feminist studies examining this type of labour (such as O ­ akley 1974, O’Brien 1983). Gender scholar R.W. Connell places the division of labour at the core of women’s subordination. “Modern writers may neglect the point but it remains true”, she argues, because “labour is precisely a material, bodily practice: a practice in which bodies are deployed and consumed” (Connell 1994: 11). Likewise, Acker (2006a: 85) sees capitalism in its present form as organised in ways that are simultaneously “antithetical and necessary to the organisation of caring or reproduction”, and the resulting tensions contribute to maintain and reproduce gendered and racialised class inequalities. Building on Polanyi (2001 [1944]), Acker traces the separation between production and reproduction to the birth of industrial capitalism in which production provided the means for accumulation of capital, but not for subsistence or provisioning (Acker 2006a: 87). The public sector expanded as a way of ameliorating the destruction of the market. The separation between production and reproduction located women and their labour as outside of and less important than ‘the economy’, Acker contends (ibid.: 88), and the intrinsic connections between reproduction and the economy were obscured. Walby (2009), in her discussion on economy as a system of relations, institutions and processes of production, consumption, distribution and circulation of goods and services which are shaped by regimes of complex inequalities, points to the tremendous work that feminists have done in widening the definition of the economy so as to include activities performed outside of direct production. In the so-called ‘domestic labour debate’ (see Vogel 2008), feminists theorised domestic labour and its relationship to the reproduction of labour-power and so challenged Marxist theory and expanded the understanding of women’s subordination under capitalism. Feminist thinkers such as Dalla Costa and James (1972), Oakley (1974), Delphy (1984), and later Glucksmann (1990), Nelson (1996) and Gardiner (1997) have challenged the notion of the economy as

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confined to activities performed in circumstances where direct monetary value can be extracted, and argued that reproductive labour in fact plays a central role in production and accumulation by generating, among other things, accommodation and the maintenance of bodies (Walby 2008: 102f; see also Mulinari & Selberg 2011). Walby (2008: 106) addresses the separation between production and reproduction as it has developed in welfare states by noting how “the interpretation of activities of the welfare state as primarily redistributive can sometimes obscure the understanding of the simultaneously economically productive aspects of public services”. Education, for instance, is a major investment in the productive capacity of the economy, Walby asserts (ibid.). One example of feminist critique against Marxist conceptualisations of work is Bubeck’s (1995: 40f ) discussion on the dialectics of labour, wherein she identifies that historically there has been no dialectical development in women’s work. Women were and continue to be as slavishly bound to their work as artisans used to be. Their work seems to be, and is more often than not perceived to be, natural and ‘naturwüchsig’ in an even stronger sense than that of artisans: women’s work is considered appropriate and natural work for them in virtue of their sex – a characteristic which they are born with and stuck with for the whole of their lives. Women are supposedly ‘naturally’ caring and nurturing and therefore naturally suited to do women’s work. Women’s work, therefore, seems to be irredeemably women’s work.

However, the gendered division of labour has been explored empirically in a number of studies, such as Bradley’s (1989) case studies of processes of gendering work in agriculture, industries, medicine and education. In it, Bradley illustrates that gendering processes of labour are ongoing and negotiable but that some patterns are persistent, specifically women’s concentration in jobs that “can be linked to the association of women with ‘domestic’ activity” (1989: 9). The sexual division of labour, Bradley shows, is as dynamic as capitalism. As new work processes and technologies are introduced, new patterns of segregation and sex-typing “in line with the contemporary ideologies of masculinity and femininity” are formed (ibid.: 223). This has been examined empirically in studies such as Sommestad’s (1992) analysis of the masculinisation of dairy work and Ottosson’s (2005) study of the femini-

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sation of physiotherapy, both in Sweden. As researchers have pointed out, the divisions of labour are intricate and involve the gendering of professions as well as specialisations within occupations: the horizontal gender division of labour refers to the concentration of women and men in different professions, gendering as feminine nursing and social work, and as masculine business, educational administration, law and medicine (Charlebois 2011: 65, Lorber 1984). Much like Bradley, Connell (1987: 105) argues against Marxist conceptions of the gender division of labour as an “ideological addendum to a class-structured mode of production”, and sees them instead as core features of production itself. She draws attention to the gendered logic of accumulation, as the organisation of labour in capitalism under male domination “concentrates economic benefits in one direction, economic losses in another, and on a scale sufficient to produce a dynamic of accumulation in its own right”. Masculinity is mobilised as an economic resource in this respect, as men are in greater control of the division of labour, and the collective choice not to perform, for instance, domestic work serves to reinforce their dominance. Hegemonic patterns of masculinity become an economic as well as cultural force providing a base for solidarity among men. However, the sexual division of labour and the concentration of women in certain sectors also create “bases for solidarity among women” (Connell 1987: 106). Hartmann (1981) and Waerness (1984) pioneered this perspective by explicating the link between commodified care work and household labour, including care for children and other family. By pointing to the embodied practices, skills and experiences women acquired through such work, Hartmann argued that women hold a privileged view on human interdependence. Waerness suggested that there exists a specific rationality of caring that challenges scientific, abstract rationality and prioritises the quality of human relations and the practices of providing for another. Rationality and emotionality in this sense are not opposing qualities (Astvik 2003: 7). The care rationality correlates to and is derived from norms in the private sphere, dictating that a person in need should always be cared for. The separation of the two frameworks for theorising care thus acknowledges the overlaps and the effects of these overlaps on the empirical level (as explored by Waerness), but specifically points to

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the distinctions: a focus on what Duffy calls nurturant care engages in examinations of the relational activities of care work and the specific labour processes involved, while theorisation and analyses of reproductive labour emphasise the meaning of this work in terms of maintaining and reproducing the labour force across time and space. The concept of reproductive labour has thus been central for expanding the concept of work and in recognising its role in society. Because of this, it has also formed a major challenge against Marxism and materialist class analysis. As Acker (2006a) has illustrated, it still offers a powerful conceptual tool in explaining pervasive patterns of gender segregation as well as structures of recognition and redistribution, both culturally and economically. But as more relations and practices of care are commodified, as policymakers across Europe actively push for care (and domestic) work to be turned into commercial transactions – which is made possible through but also shapes new contracts of labour market participation, class hierarchies and migration patterns (Lutz 2011) – the concept of reproductive work does not sufficiently capture new discourses and practices of service work under post-Fordism. I argue that while the concept of reproductive work is still highly relevant in examining gendered and racialised class practices, the argument that these areas are represented as outside of the economy is being severely challenged. However, one of Duffy’s main points in separating the two frameworks is to pay attention to the work of researchers exploring racial divisions of work, most importantly Evelyn Nakano Glenn (1992, see also 1991, 2002) and Dorothy Roberts (1997). In her study of racial divisions within reproductive labour, Glenn illustrates how racial stratification specifically shapes the sphere of reproductive labour. White women tend to concentrate in public settings with high levels of interactional and emotional work, such as nursing, while racialised women tend to perform ‘dirty’ work in ‘back-rooms’, cleaning, doing kitchen or maid work. In Europe, researchers such as Anderson (2000), Platzer (2007) and Lutz (2011) have illustrated the ethnic divisions of labour in which migrants from certain areas within or outside the EU care for the children and homes of double-career households in the large economies of Western Europe.

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Body work: new understandings of re/productive labour Based on this topography of feminist conceptualisations of re/productive labour, there is conceptual room for several definitions of care work, as well as different theoretical and empirical entry points. While I’m not keen on the label ‘nurturant’ used by Duffy, I see care work as work that is specifically directed at human interaction. This work can be paid or unpaid and performed in different settings, but, as Waerness (1984) has illustrated, these practices will overlap, causing experiences, skills and approaches to overlap too. As well as opening up space for defining care work, here is also space for understanding the relationship between identity and work and, specifically, the ways in which care work is shaped by and in turn shapes femininities. By moving towards a conceptualisation of care work as body work, I will bring together my argument about work, organisation and femininities. As I have shown, care work is labour that historically has been interpreted as reproductive labour and thus outside of the economy. It is primarily in relation to Marxist labour value theory that the character of work outside of manufacturing has been debated: work whose results lack “enduring product” (Arendt 1958), or whose product is “immaterial” (Hardt & Negri 2005). However, what we are witnessing at this stage in post-Fordist Western capitalism is that this kind of labour is increasingly commodified and recognised as a source of profit (for some – but still undervalued, even stigmatised in relation to its providers) and consequently seen as an integral part of the service economy. I would argue, based on the push within the Swedish welfare state towards reshaping care work as a highly profitable sector, that with its actors being re-conceptualised as entrepreneurs and its enterprises agents of diversity, the feminist assessment that these forms of labour are not perceived as being inside the economy (Nelson 1996) needs to be rearticulated.6 6.  Publicly-financed private operators in education, healthcare and social services had a return on total equities of 15 percent in 2010, compared to 8 percent for all private enterprises in the country, according to Statistics Sweden 2012. While I am not arguing against the conceptualisation of this work as reproductive, in the sense Marxist and materialist theorists have suggested, which explains their undervalued position in the labor market, I do think it is time to reconceptualise reproductive work in ways that recognise the increasing economic interests in commoditizing these services within the welfare state.

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But regardless of the need for rethinking the distinction between re/productive work, care work is not easily subsumed under a selfexplanatory label. Feminist researchers have pointed out that, in part, this is because care is linked to emotions and to love. Graham (1983) captured this as she described care as both labour and love: “caring for and caring about, doing and feeling” (P. Smith 1992: 6). Care work is a process involving an array of different tasks and skills. Because it is mostly performed on and around responsive bodies, it involves transgression of boundaries in intimate spheres. It is also, and because of this, dependent on establishing new boundaries. These boundaries, between different actors within the organisation of work and, crucially, between care workers’ bodies and the bodies they work on, are set up within systems that regulate social relations within the workplace as well as the social constructions of work as appropriate for different categories of people (McDowell 2009: 56). Nursing is closely related to the history of middle-class women’s entry into the formal labour market, but it has its roots in practices established in the realm of the family. Commodified caring within the framework of employment is shaped by the gendered divisions of labour and structured by a specific pattern of femininity organised around themes of motherhood (Connell 1987: 187). It is within this context that possibilities and frameworks of embodied performances of acceptable workplace identities are laid out (McDowell 2009: 56). Wolkowitz explains how she started thinking about this connection as she realised that sociologists of work failed to recognise the role of bodies in organisations: It was true that we had courses in public sector unionism, but there seemed no explicit interest in considering its relation to the micropolitics of the intimate encounter between worker and customer. Sociologists could build on our understanding of gender relations, I thought, by considering not only the gender composition of the workforce in various kinds of work, but also by focusing on the connections between labour processes, gender ideologies and constructions of the bodies of workers and those with whom they interacted, including their patients, customers and clients (Wolkowitz 2006: 3f ).

The analytic framework of the body/work nexus links labour process analysis to types of work that have been placed outside of class analyses (Gustafsson 2002) and expands the sociology of work by drawing

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attention to social relations and practices associated with embodied work. By locating my study within this analytic framework, I am able to illustrate continuity and change in paid care work by focusing on the organisation of labour and the ways in which it is structured by hierarchies and divisions outside of the healthcare institution. It also enables analyses of the role of bodies and individual agency in care work. As has been illustrated before (Wolkowitz 2006: 5), the agency of care workers both challenges and reinforces gender stereotypes. Using this theoretical framework, the empirical sections of this book will illustrate some of the ways in which such processes are enacted in the everyday among nurses working the shopfloor of a surgical ward. The concept of body work refers to work that is performed on the bodies of others. Body work per se is not associated with femininity; doctors perform their work on bodies, but medicine is constructed as masculine and associated with technology and science rather than mothering, love and emotions (Pringle 1998). The difference is the type of body work performed. Doctors treat parts of bodies, and these body parts are often displayed in ways that seal off the rest of the body: Interactions between the patients, their relatives and the workers take place in the context of gendered understandings of care in which nurses are considered to provide care and empathy, as well as bodily maintenance, whereas doctors provide scientific or rational information and so are not relied on for emotional support in the same way as nurses are (McDowell 2009: 165).

In care work, the worker’s body is the primary vehicle for labour (McDowell 2009: 167). Divisions within this frame of work are often related to the kind of contact that body work involves: for instance, while nurses traditionally have performed skilled interventions (such as drawing blood, administering medication), assistant nurses and other auxiliaries have handled ‘dirty’ aspects, such as cleaning or feeding patients, changing diapers, et cetera. Thus class boundaries within this type of care have been established and negotiated through the control of different kinds of body work, wherein the ‘dirtier’ tasks traditionally have been delegated to working-class, often racialised women, while more privileged women have handled ‘cleaner’ tasks, often associated with the use of instruments or medication. This means that workers’ positioning as “classed, gendered and racialised subjects intersects with

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the differential status of forms of care that puts direct caregivers further down the hierarchy than those who identify the need for care or plan its provision” (Wolkowitz 2006: 153).

Body work, power of interaction, and class boundaries The concept of body work also draws attention to the bodies of patients and the relationship between bodies being worked on and bodies used to work. This relationship is marked by power, control and subjugation. While some forms of body work are performed mostly on clients who posit higher status than the workers, such as work revolving around the pampering of certain bodies (pedicure would be one example, discussed by Kang 2003), nursing is related rather to control of bodies who are positioned as weak (“through disability, old age or the humiliation of double incontinence … anaesthetised, supine or naked, or rendered immobile by gown …”, Wolkowitz 2006: 163f ) in a context where on the other hand nurses and doctors are empowered by their bodily positioning in interactions with the patients and, crucially, by their control of medical knowledge. Paid work is performed in tension between interests of employers, employees and patients. These interests may converge, but may also be opposed. For instance, patients and nurses alike may appreciate individualised care, which strives for increased recognition of patients’ needs and integrity. But as they assess their role as caregivers, nurses sometimes find the resources and labour processes of institutionalised care to constrain their possibilities of delivering this kind of service: empowering patients may involve deskilling, work intensification and lowered work satisfaction for care workers (Wolkowitz 2006: 163). However, while nurses hold empowered positions vis-à-vis patients, and historically have been positioned as privileged in relation to other women performing paid and unpaid reproductive work, nursing is consistently devalued (Davies 1995). Following Bartky (1990), Wolkowitz (2006: 166) argues that the experience of caring for another may lead to workers feeling more powerful than they are: Bartky (1990) argues that a woman responsible for ‘feeding egos and tending wounds’ in her personal relations, though ‘ethnically and epistemologically disempowered by the care she gives’, often experiences the outflowing of care she gives as a ‘mighty power’.

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Women who take positions within the formal labour market doing care work, and who accommodate men’s domination in this way, embody in these contexts forms of femininities that are normative; but they are not in a position to dominate over the organisation they work in. The privileged femininity is linked to the practices of caring, because care work has held a privileged position in the formation of the nation state and later in the organisation of the welfare state; women were made responsible for civilising the nation through their role as mothers and care workers (Holmdal 1994, Bashford 2000, Moberg 2007). Historically, going back to the formation of the modern Western European nation state in the seventeenth and eighteenth centuries, women who could claim success in their responsibility as mothers and carers could also claim the privileged position as bearers of respectability. Nursing has been created as a respectable profession for women, strongly linked to notions of purity and moral order embodied primarily by women in the middle class (see Gustafsson 1989 for a personal account of how such norms regulated access to the nursing profession in Sweden in the first half of the twentieth century). Nurses do, however, dominate other women’s work processes to a varying extent, such as assistant nurses. They further occupy dominant positions in relation to women performing service work within and outside the organisation. In a sense, then, they occupy a contradictory class location within the healthcare organisation (Wright 1997). This contradictory location reflects in a way the complex history of asserting women’s traditional caring and healing practices and the subjugation to the medical power held by men (Witz 1992). Nursing professionals continue to negotiate this semi-independent middle position in relation to the medical power in the everyday interactions in the healthcare organisation, in complex strategies of knowledge and authority claims and subordination/accommodation. Building on labour process analysis, Tankred-Sheriff (1989: 46f ) argues that women’s organisational location is increasingly characterised by an intermediate position between the labour process and the control system: “the defining characteristic of women’s work … is that it constitutes an adjunct to the control system”. Tankred-Sheriff is mainly concerned with the adjunct power exerted in the space between producers and employers/owners, but adds, “the extension of commodity

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production means that services (e.g. … health …) and products … which used to be delivered personally within the family are now delivered organisation-to-individual” (ibid.). In these spaces, women are concentrated in positions requiring the participation in management; through their personal dealings with clients, they “play an important role in channelling the ‘group-in-contact’ into appropriate behaviour” (ibid.). Tankred-Sheriff focuses on clerical work, but the mediating position in-between the medical power and the patient is a fitting conceptualisation of nurses’ labour. Assistant nurses lack in one regard the kind of adjunct power held by nurses, as they lack some aspects of control over the care process. They do, however, hold the privileged position of respectability and they too mediate the appropriate behaviour within the walls of the patient room.

Care: body and emotion Hochschild’s (1983) influential analysis of emotional labour has expanded the understanding of key aspects of nursing and care work. Emotional labour is defined as the management of feelings that “requires one to induce or suppress feeling in order to sustain the outward countenance that produces the proper state of mind in others” (Hochschild 1983: 7). Emotional labour in care work has been recognised as just as draining as the physical aspects of work (James 1992: 500). But it has also been pointed out that the separation of emotional labour from body work (such as James 1992) replicates Cartesian mindbody dualism (Wolkowitz 2006: 149, see also P. Smith 1992: 10): By identifying emotional work as a separate component of care, the understanding of physical care of the body is concomitantly narrowed … and identified with mindlessness or mechanical activity.

As I will show in later chapters, in nursing the separation between touch and emotion is not always easy to make. But the benefit of analytically separating emotional labour from physical labour is that the concept draws attention to the ways in which personality, demeanour and approach are implicated in the process of exchange within the framework of (in this case) paid work. Hochschild used this concept to explore how flight attendants were trained in smiling and dealing in certain ways with aircraft passengers. Not only did this play a

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role in keeping people calm; the flight attendants were called on to use emotion as a sales trick, in essence selling their emotions in the labour market as if they were a product (Theodosius 2008: 14). Thus emotional labour takes effort and is “sold for a wage and therefore has exchange value” (Hochschild 1983: 7). The context and conditions under which emotional labour is performed vary. Hochschild uses the term ‘feeling rules’ to conceptualise the standards “used in emotional conversations to determine what is rightly owed in the currency of feeling. Through them, we tell what is ‘due’ in each relation, each role” (ibid.: 118f ). Emotional labour has been a central concern in nursing (Mann & Cowburn 2005), not least because so much of what nurses are expected to perform in relation to patients is based on issues of emotions. As researchers have illustrated again and again, nurses use varying techniques to shield themselves from the anxieties involved in caring for sick people (Menzies Lyth 1960). P. Smith (1992: 9f ) argues that while the emotional labour on behalf of nurses has been assumed as natural qualities in women, feminist researchers have also questioned the reason why nurses distance themselves from intense emotional interactions and prefer technical aspects of work. On the other hand, research has illustrated that emotional labour carries with it options for workers to perform it on different levels and to give it as a gift, in which it is associated with pride and joy for the giver (Bolton 2000). But Hochs­ child’s (2003: 19) central contribution was the critical assessment of the ways in which emotions through processes of transmutation “fall under the sway of large organisations, social engineering and the profit motive”. Thus the imperative and condition to perform emotional labour in care work involves both agency and interpellation.

Constructing appropriate work identities In his study on factory work, Burawoy (1979) used the Althusserian concept of interpellation in order to illustrate how management constructs “idealised or stereotypical notions of idealised workers” (McDowell 2009: 60). Burawoy argued that as managers name workers, the workers begin to internalise these ideals and conform to or recognise themselves in this naming, thus embodying managerial assumptions or stereotypes (ibid.). However, as McDowell

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(ibid.) points out, feminist worksite ethnographies have challenged this conceptualisation of the construction of identity through labour. Researchers such as Salzinger (2003) have argued that workplace identities are multiple, may be contradictory, and characterised by both conformity and resistance to managerial naming. Crucially, research has illustrated that in interactive service employment (including care work), interpellation takes a dual form (Williams 2006) as workers not only conform to and are named by management but also by c­ lients/ patients. The concept of interpellation thus ties into emotional labour, and suggests a feature of gendered and racialised class practices that affect workers differently as they adapt to different ideals in different contexts. However, ­McDowell et al (2007: 6) argue that the concept of interpellation should not be conflated with Butler’s (1999) concept of performativity: While these recent reworkings of the construct of interpellation have obvious parallels to notions of performativity … they are based on a more grounded and more specific notion of identity, formed through particular and limited interactions within the workplace, rather than a broader discursive structure and forms of regulation, although the two forms of regulation are undoubtedly related.

Thus in talking about interpellation I locate this study between theoretical fields that have sought to explore the construction of identities within workplaces, and their connections to exterior categories. ‘Interpellation’ is a term specifically useful in understanding continuity and change in constructing ideal workers through the regulation of appropriate forms of femininities (and masculinities) in workplaces. This term specifically draws attention to the ways in which such constructions are made meaningful in relation to labour processes. In postmodern sociological contributions, the relationship between work and subjectivity instead has been explored through the framework of a ‘categorical shift’ in the relationship between individual and society (Crompton 1998: 128). Beck (1992: 131) has argued that destabilisation of “traditional commitments and support relationships” (family and local communities, disintegration of working-class communities, social movements, et cetera) along with transformations of globalisation and new forms of production and reproduction, includ-

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ing changes in the nature of work in industrialised societies, have lead to an increasing individualisation and expansion of individual responsibility. Together with sociologists such as Giddens (1991) and Lash and Urry (1994), Beck has argued that in contrast to the former industrial society, whose traditional constraints are now weakened (McDowell 2009: 68), late-modernity is characterised by self-reflexivity, an ability to “think and reflect on the social conditions” of existence and “to change them accordingly” (Beck 1994 cited in McDowell 2009: 68). Beck and Beck-Gernsheim (1996) consequently argued that the significance of structural constraints of class and gender are declining. Against this, Adkins (2003: 22) has argued that rather than being released from class and gender, reflexivity is “linked to a reworking or refashioning of gender”. By drawing on worksite ethnographies, she notes that while reflexivity, especially vis-à-vis gender, is increasing across different workplaces, studies show that “women’s performances of femininity at work are often defined as not concerning reflexive skills or competencies” but rather that they are seen as inherent capabilities in women and therefore not relevant to reward (ibid.: 33). Consequently, Adkins argues that reflexivity is linked not to the release from structural constraints but to gendered positions of privilege and exclusion, and classed processes of categorisation and classification. Rather than challenging gender, reflexive practices are part of the “very norms, rules and expectations that govern gender in late modernity, even as they may ostensibly appear to challenge these very notions”, Adkins (ibid.: 35) states. I see Adkins critical examination of postmodern interventions as a contribution to and continuation of the debate on interpellation and the construction of identity through labour. In the empirical chapters I will return to issues of interpellation and reflexivity and explore how these concepts can be employed to broaden the understanding of women’s roles and possibilities in the new millennium care workforce. Along with Acker (2006a), though, I argue that gendered and racialised class practices are still central principles of organising work and regulating workplace interactions and rewards. However, individualisation is part of new forms of interpellation, and my ethnographic data will place such calls and responses in relation to the question of reflexivity.

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Conditions of the care labour process Davies (1995) describes the differences between labour processes in nursing and medicine as a matter of boundaries. Physicians engage in ‘fleeting encounters’ with patients, and perform work that has “clear conceptual and practical boundaries”. Ward nurses, on the other hand, engage in a sustained relationship with patients in processes of work that are much more open-ended and unbounded, transcending dichotomies of public/private spheres and technical/manual divisions: At one end of the spectrum, nursing’s responsibilities shade off into the medical and technical and encompass procedures that were indeed formerly the province of doctors. At the other end of the spectrum, these responsibilities shade off into domestic work. The work involves both strenuous physical labour and the management of emotions and psychological well-being. There is a component, increasingly present in the hospital … setting, of health promotion and education (Davies 1995: 91).

The tension within the labour process of care work has been located in the attempts to organise work in linear models, which is a challenge when the needs of humans are what shape the actual processes. Davies (1989), in her study on women and social understandings of time, argued that ‘real care’ is beyond the boundaries of the job and male conceptions of linear time (so that nurses in her study would sit down for half an hour with a patient for the sheer joy of caring for another). This analysis was based on conceptions of nurturing or responsibility rationality, in which needs and the reality of others are taken into account in a way that disrupts techno-economic rationalities that prevail in institutional settings. Attempts to divide tasks and organise care work assembly lines means no one can “acquire a sense of overview of the whole care”, leading to frustration, alienation and power­ less­ness, Davies argued (1989: 119). I didn’t find this sense of frustration coming from a lack of overview of the care. However, nurses were frustrated with the fractured labour process. I use the term ‘fractured’ here in speaking of the labour process itself, beyond the spatial aspects, instead of circular or cyclical (Davies 1989), to indicate that constantly having to interrupt one task to tend to another is not an inherent feature of care work, I would argue, but an effect of the specific organisation of work and tasks.

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How, then, can the specificities of the nursing labour process be understood? In her discussion on labour process change within care work, Cohen (2011: 190) argues that there are three main constraints on the possibilities for (re)organisation in healthcare linked to the specificities of performing work on bodies. The first is based on the “rigidity in the ratio of workers to bodies-worked-upon”, the second is related to the “requirement for co-presence and temporal unpredictability”, and the third is based on the complex, unitary, responsive and recalcitrant nature of bodies as a material of production. Cohen’s examination of the challenges in organising and reorganising care work illustrates the conditions that structure labour processes in play on the shopfloor of a hospital ward. Care work is labour-­intensive, not easily subsumed under capitalist clock-time, and centres on material that is inherently unpredictable. It is important, however, to emphasise the presence of a structured, albeit changing, labour process in which workers produce the service of care. While public sector care work is different from the production of goods and services in the private market, it is increasingly performed in relation to pseudo-market mechanisms (ibid.). Labour process analysis brings attention to the ways in which the production of goods and services “shape (and are in turn shaped by) conflicts of interest between employers’ perceived interests (for instance, increasing profits, saving costs, controlling or monitoring workers’ input …) and by what workers define as theirs” (Wolkowitz 2006: 12). Because of the historical traditions of care work as feminine labour performed within the private realm and outside of monetary exchanges (England & Folbre 1999), the labour process in healthcare ties in to unpaid work outside of employment relations. But, as Cohen (2011: 190, references excluded) points out: Notwithstanding professional or compassionate commitment to patients, work and employment in health and social care settings are played out on the same territory as other work in capitalism. This territory is marked by persistent, albeit not always predictable, conflict and constraint and shaped by the imperative on capital to continually increase productivity and, to this end, engage in ongoing reorganisation and rationalisation of the labour process.

Thus care work is performed on territory that is gendered and tied to divisions of labour across the private/public divide, marked by conflict

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and constraint, shaped by capitalist logic, performed by both unskilled and professional workers with professional aspirations, and carried out within organisations whose current management regimes pose contradictory and divergent demands on the occupation claiming jurisdiction over care and its specific rationality.

Conclusions This chapter has laid out the theoretical foundation of my study by explicating my understanding of key concepts: work, femininities and structures of inequalities. It is, however, in the empirical chapters that I will put these concepts to work and illustrate their strengths. What this chapter has contributed to is bridging separate theoretical strands or traditions by creating a dialogue between different scholars that through the framework of work and/or organisation and gender develops the conceptual tools for understanding how interior and exterior categories are emulated and for what purpose. I have argued that woman, conceptualised here as seriality, is a necessary category to work with in research, because it reflects what Gunnarsson (2011: 30) has called “real groupings in the world”; it is a category that is necessary in order to identify and change structures of power. Rather than analysing gender in terms of a unified category though, I have argued for the concept of femininities as a powerful analytic tool in understanding different spaces for, possibilities of, and expectations on bodies and formations of subjectivities. I have linked this particularly to the ways in which organisations and work frame, regulate, and contribute to produce appropriate work identities. I suggest that identities are formed through a dialectic relationship between work, labour processes, power relations that frame work, and positions and experiences made outside of work. Work, then, is a central process through which identities are constituted in and through. Different kinds of femininities and masculinities are interpellated in different spheres of production and reproduction, and in this chapter I have proposed a definition of femininities that can be used to explore such variations empirically.

3. Researching from the standpoint of care workers

Institutional ethnography as a method of inquiry is an approach developed within and in relation to the women’s movement. Its aim is to begin in the experience of people in order to understand how those experiences are linked to complex structures of power that extend beyond the gaze of any one individual. In talking about women’s experiences of oppression, resistance and coping, feminists in the mid-twentieth century started naming practices that were common to most women – such as sexism, harassment and discrimination – and these terms, derived from the everyday world of women’s lives, gave “shared experiences a political presence” (Smith 2005: 7). Canadian sociologist Dorothy E. Smith developed this approach into an alternative sociology that would begin at the standpoint of women, not “as a given and finalised form of knowledge”, but as the entry point from which discoveries could be made (ibid.: 8). I too have had my earliest sociological schooling in social movements, specifically the Left and the feminist movement in Sweden. To me, the idea of a sociology that starts in the experiences of people and extends them to explicate and analyse extralocal structures of power resonates with how I’ve come to understand my own situation in varying contexts. Through political activism, which in the left was coupled with training in Marxist theory and historical materialism, I have come to view my own experiences of being a woman raised in a ­working-class, single-parent, all-female family as connected to structures of power and political processes beyond my immediate recognition. And so by engaging in a theoretical and methodological debate with the body of work developed within the tradition of institutional ethnography, I have found a set of analytical tools that relate to my

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own ­political perspectives (the personal is linked to the activity of work, which is linked to the theoretical, as Hearn 2008 has put it). This study is based on a little more than 29 hours of recorded and transcribed interviews, some 150 hours of observations, about 120 pages of transcribed field notes, about 200 pages of financial reports, and numerous texts ranging from work papers collected at Ward 96 to newspaper clippings and internet material, as well as books produced by the nursing trade union. The ethnographic data are described quantitatively in Appendix 1. In this chapter, I will discuss the epistemological as well as methodological issues and decisions involved in the processes of feminist ethnography. Inspired by Burawoy (1991: 271), I see methodology as the link between technique and theory. Consequently, the aim of this chapter is to explicate the “reciprocal relationship between data and theory”. In addition to exploring and reflecting on the techniques I have used during the course of this study, my ambition in this chapter is to contribute to the field of feminist qualitative methodology, particularly institutional ethnography, by critically reflecting upon and examining the means by which this study came to be. In the first section of the chapter, I introduce the feminist concept of standpoints and the principles of institutional ethnography, which have guided my fieldwork and the processes of generating and analysing data. I will then reflect on the micropolitics of the research process, and the decisions and deliberations involved in conducting interviews and doing fieldwork, including questions of research ethics. I examine these issues with the aim of highlighting critical aspects of knowledge production. In the last part of the chapter, I discuss how Acker’s (2006a, 2006b) concept of the inequality regime contributes to the tradition of institutional ethnography by providing analytical tools to examine gendered and racialised class practices and conflicts in organisations.

Feminist standpoints and institutional ethnography Standpoint theory, according to Harding (2004a), is “both explanatory and normative” in its ambition to expand “conventional horizons” of disciplines and methodologies. One of its main contributions

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is the critical examination of notions of objectivity and detachment within the social sciences. The epistemology of feminist research is normative in the sense that it begins, in the words of Skeggs (1994: 77; also quoted in Letherby 2003: 5), “from the premise that the nature of reality in Western society is unequal and hierarchical”. Drawing on Marxist historical materialism and critique of class domination, Hartsock (2004 [1983]) argued for a feminist historical materialism grounded in the everyday lives of women under patriarchal oppression and in the gendered divisions of labour. By beginning in practical activities of people, and by taking the perspectives of women, the structures of male domination and “the ways in which women both participate in and oppose their own subordination” would be exposed (Hartsock 2004 [1983]: 49). One of those arguing for a feminist epistemology that could develop into new ways of knowledge production was Dorothy E. Smith, who engaged in a dialogue with Marxist concepts such as ideo­ logy and state/ruling apparatuses in order to challenge and uncover “malestream” epistemology in the social sciences (Tanesini 1999). In the 1980s, Smith launched the project of a “sociology for women” by pointing out that “malestream” sociology did not only exclude women, it also took the standpoint of men, representing it as universal (Smith 1987). Taking up a standpoint of women, Smith argued, would not “imply a common viewpoint among women”; what women have in common, rather, is “the organisation of social relations that has accomplished our exclusion” (Smith 1987: 78). Smith’s critique of sociology aimed at defining an alternative way of producing knowledge, and what she suggested was a feminist research strategy that would begin in the experiences of people and explicate the social processes that organised these experiences in the everyday (ibid.: 151). The same argument was presented in an influential article by Acker, Barry and Esseveld (1991: 135), who argued that explanations in feminist research ought to centre on what actually happens in women’s everyday world and how these events are experienced. We begin, then, with the ordinary life of women, but neither stop there nor move into a search for psychological sources of feelings, actions and events. Although we view people as active agents in their own lives and as such constructors of their social worlds, we do not see that activity as isolated

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and subjective. Rather, we locate individual experience in society and history, embedded within a set of social relations which produce both the possibilities and limitations of that experience. What is at issue is not just everyday experience but the relations which underlie and the connections between the two.

Poststructuralist scholars have questioned the privilege of gender, as well as the unitary category of ‘woman’ and claims of epistemological advantage in this kind of theorising of experience (Eldén 2005: 66ff). Poststructuralist and postcolonial scholars have argued that feminist discourse “must be self-conscious in its production of notions of experience and difference” (Mohanty 1992: 87), otherwise it risks overriding diversity by representing experience as a unifying phenomenon (Scott 1992: 29). Scott points to the discursive and dialogical character of experience, refusing the separation between experience and language and instead insisting on “the productive quality of discourse” (ibid.: 34): When experience is taken as the origin of knowledge, the vision of the individual subject … becomes the bedrock of evidence upon which explanation is built. Questions about the constructed nature of experience, about how subjects are constituted as different in the first place, about how one’s vision is structured – about language (or discourse) and history – are left aside. The evidence of experience then becomes evidence for the fact of difference, rather than a way of exploring how difference is established, how it operates, how and in what ways it constitutes subjects who see and act in the world (ibid.: 25).

In this study, the question of how a specific form of femininity is established begins in the experience of nurses as I explore the interpellation of femininity in nursing and “the double context” (the relationship between interior and exterior categories) that form configurations of gender practices within a social milieu (Connell 1987: 179). I explore difference within this context in relation to ethnicity in chapter 11, where the focus of the study is somewhat altered and a multi­plicity of voices from within the hospital organisation are heard. However, while I agree with Scott that experience defies fixed orders of meaning, language being its site of enactment, ‘experience’ within institutional ethnography is not taken at face value and left untheorised. The strength of ethnography in this regard is the focus on the coordination of doings. As Smith (2006: 129) points out, it is not about extracting

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accounts of “what happened or what was really going on”. Rather, attention is directed at the informant’s knowledge, with the aim of producing a knowledge between informant and researcher in order to render visible the ways in which actions are coordinated with others. Thus it is the social organisation of people’s activities that is relevant. Smith (ibid.: 128) puts it elegantly: Experience always has a foot in two worlds: one remembered in the body as well as in the mind and the other in the actuality of speaking or writing it in the company of an interlocutor or the apprehension of a distant audience.

Scott insists on the discursive nature of experience and on the politics of its construction (1992: 37). I agree, and argue that institutional ethnography offers a powerful tool to historicise experience by connecting it to the social organisation through which the actor moves. What institutional ethnography offers in this regard is some insight into the actualities from which experience is spoken or written (Smith 2006: 124).

Mapping the local sites of people’s experience Institutional ethnography investigates practices, empirical linkages and coordinated work processes in an effort to identify and change the social relations that create inequalities (DeVault & McCoy 2006: 19). Starting with identifying an experience, and in order to recognise institutional processes that shape that experience, the researcher uses varying techniques of data collection, including individual interviews, group interviews, varying kinds of fieldwork such as observations, and textual analysis (ibid.: 20). The aim is to expose the relations of ruling from below. ‘The social’ as a focus for study in this regard is understood as the coordination of activities and practices as individual actors coordinate their doings with others (Smith 2005: 59). The social is not stable, in the sense of reified patterns or structures; it is an ongoing historical process, taking place as people act and speak and relate to each other. Language is coordinated through dialogue, in this sense, and language as a phenomenon is seen as “integral to the investigation of the social” (ibid.: 70). These ‘points of entry’ have been guiding me throughout my research project. I have employed core concepts developed within the

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framework of institutional ethnography as well as within broader discussions on feminist epistemology and feminist analysis of work and organisations in order to design a research project that could examine and unveil some of the practices and changing relations of power involved in paid care work and in the historical interplay between femininities and work (Connell & Messerschmidt 2005: 848). Whilst I locate my study within the tradition of institutional ethno­graphy, it is important to note that within sociology there is a vivid debate on ethnographic methods and ways of connecting local experience to extralocal relations of ruling. Burawoy’s (1991) extended case method is similar to the project of institutional ethnography; and whilst Smith (2006: 35f ) argues that there are central differences, I draw on both methods – specifically as I discuss the macro level, where I agree with Burawoy (1991: 284) that ethnography needs to be framed by the theory in order to “gain insights into the properties of the system world, which integrates the intended and unintended consequences of instrumental action into relatively autonomous institutions”. These can be understood only from the standpoint of the observer, Burawoy argues. But in starting out at the local level, I take up the standpoint of a specific group of people within the institutional setting. By letting that standpoint guide the research, my aim is to produce knowledge that can contribute to social justice and emancipation. The standpoint I take is that of people performing paid care work, and the experiences that guide me are the conditions and possibilities of this work in times of neoliberal changes within the welfare state. In the following sections of the chapter, I will discuss the ways in which I approached data collection and fieldwork.

Exploring the dynamics of fieldwork: the politics of hospitality Entering into a research field is often a tricky process. I was granted access via the personnel and research departments at City Hospital (this hospital and the county are described in the following chapters). I contacted them via telephone and also sent them a formal letter describing the issues I was interested in. I was then invited to present

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my research project to a manager and her colleague in the personnel department. They were both interested in ‘gender issues’, as they called them, and asked that I come to City Hospital’s celebration of the International Women’s Day about six months later, where I could present some preliminary results.1 When we met, I explained to them that I was interested in observing nurses, assistant nurses, doctors and physiotherapists. They forwarded my written description of my research project to some nurse managers and a physiotherapist, who they said were “interested in these issues and open to new things”. I was invited to ‘go along’ (shadow) nurses and assistant nurses at six wards: an emergency intake ward, a birth clinic, a psychiatric ward, a surgical day clinic and two surgical wards. I spent eight hours divided between two tours on each ward. At one ward, Ward 96, I spent a little over a hundred hours over the course of three years, a week or a few days at a time, observing nurses and assistant nurses covering all shifts including night shifts. I also went along a physiotherapist who worked in paediatrics; all in all seven wards or clinics.

Gatekeepers at the hospital The two ‘feminists’ (as I identified them) at the personnel department were my first gatekeepers (O’Reilly 2005: 91), and they communicated with another group of gatekeepers: nurse managers. The nurse managers decided which nurse or assistant nurse I would observe. Sometimes, they seemed to choose nurses whom they considered suitable for pairing with a researcher. Nela, the nurse in the psychiatric ward, said that she was happy when she was asked to guide me through her day: “I thought it means the manager thinks I’m a good nurse, she notices me and so on. It felt very nice to be chosen, actually,” she said when I interviewed her. Others seemed less amused to have been chosen, such as Marie at the birth clinic, who said, “Oh, so you’re back,” when I showed up the next day. Clearly, this method of getting access was not without tension or problems. I will discuss how I handled situations like that with Marie below. 1.  Unfortunately, the celebration – which was planned to consist of a seminar on gender and medicine and which would have been organised by the personnel department – was cancelled due to lack of interest among staff.

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The problem with consent One of the gatekeepers was Helena at Ward 96. The personnel department directed me to her and she was the one who greeted me the first time I visited Ward 96. She introduced me to Sara, the nurse she had decided I would ‘go along’. I asked Helena if I could interview her too, and she agreed. Her role in the research project would be significant: I interviewed her the first time in 2008, and then returned to interview her on other occasions between 2009 and 2011. Because of her, it became possible for me to keep returning to Ward 96 and do more extensive fieldwork. She also invited me to present my research at a ‘training day’ for the nurses. She let me in on meetings with other managers; she agreed I could be present during telephone conversations with doctors; she handed me texts, such as work descriptions; she gave me information on organisational changes and changes in the workgroup. We kept in touch via e-mail in between my visits. In a way, she became both a gatekeeper and an important gate-opener, as well as a key informant (O’Reilly 2005). Issues of power and control took a central part in this evolving arrangement. Helena was the person in charge, and there was an element of coercion involved in getting access to nurses and assistant nurses through her (and other managers). In the beginning, Helena decided which nurses I would shadow, and then later she agreed I could ask anyone I wanted if it would be okay for me to observe them during shifts. After a while, she took it upon herself to ask nurses who seemed less than enthusiastic to have me accompany them during shifts. This was the case with Danuta. I hadn’t really spoken to Danuta and I didn’t exactly get the sense she was interested in being a part of the research. One day, Helena and I were standing in the hallway talking about whom I could go along the next day. Danuta happened to show up and Helena turned to her and said: “Rebecca will go with you tomorrow!” Danuta said: “Not with me, it won’t be fun.” I thought it was an awkward situation. On the one hand, I didn’t want to impose on Danuta, and I didn’t want to force her to be a part of my research. On the other hand, I didn’t have the courage to object to Helena’s decision right there in the hallway. I also didn’t want Danuta to think that I did not want to shadow her: the reason she objected to letting me observe her was that she felt she wasn’t ‘interesting’, and

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I didn’t want to confirm such a notion. So I kept quiet, and Helena persuaded Danuta: “Yes, she can go with you, that’s the way we’ll have it.” I was thinking about how to get Danuta – and myself – out of this situation. When Helena left, I approached Danuta and I told her I would make an excuse and find someone else to shadow. Danuta then insisted it would be okay for me to accompany her. I made the choice to, as carefully as I could, explain my research project and the role she would play in it; explicitly ask if it would feel okay for her to participate; and try to convince her that it would not be a problem for either of us if she chose not to participate – even though, strictly speaking, I could not make such a promise, because I had no way of knowing for sure how Helena would react if she learned that I observed someone else (though I doubt she would have noticed). Danuta repeated that it was okay. She now wanted to participate, she said. She was just sure it would not be interesting to me. I asked her continually during the time we spent together if she wanted to withdraw from the process. I tried to establish that I was there with her permission, and I attempted to create openings for her to reconsider participating. She did not. Later during the observation I felt there was a developing connection between Danuta and me, and I ended up interviewing and talking to her on numerous occasions over a period of two years. She would ask about my son and I would ask about her daughter. She half-jokingly argued with me about my research (she was not a feminist and had strong opinions about biological differences between men and women), but she continued to affirm her consent to be part of the project. However, the story illustrates the different problems with consent in workplaces, which are regulated environments where people are, to a certain degree, stripped of their free will. When it came to the nurses I was observing directly, I continually asked them for permission. Towards the end of the shift I would again ask about their feelings of participating and being mentioned in the book. I frequently started this conversation by saying, “So, how did this feel, to have me follow you around and observe you?” All of them seemed to appreciate the research project towards the end of the observation and many offered direct quotes they wanted me to include in the book: “Write that we need …” et cetera (more on this below).

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As for the rest of the workers present during my observation, I would introduce my research and myself during the first ward meeting I would participate in (usually the nurse manager would introduce me first and then I would elaborate). Because there is a fixed timeframe to these meetings, I would be brief and say that I was there because I wanted to “understand what it’s like to work at a hospital in times of cutbacks, and how changing hierarchies such as more women doctors influence the work and the relationships in the ward”. If there was enough time, I would add that I was interested in issues of “equality from a number of perspectives, including ethnicity”. I explained that I would be taking notes and that, if they were talking and I was around, those quotes may end up in the research as long as it was interesting for the questions of my study, but that I would respect any wish not to participate. I also explained that the ward, the hospital, the county, and all of those working there, would remain confidential.2

Consent to a certain degree – patients and others There are ethical problems involved in this. First of all, not all of the care workers I would come to meet and observe during the day would be present during these meetings. I tried to introduce myself to all care workers I interacted with, but sometimes there was no opportunity for me properly to do so. Second, I could not make such careful presentation to the patients. As noted by Oakley (2000), establishing consent with patients is complicated, not least because of their dependent position in relation to healthcare professionals. When I entered patient rooms, the nurse was likely to introduce me first, and then I would elaborate. I would say that I was a researcher and my study involved gender relations and issues of equality among care workers. Then I would ask: “Is it okay if 2.  There is a level of manipulation involved in this. I would continue to introduce myself as I met more people during the day, and I think most researchers would agree there is a tendency among us to choose our words according to impressions we abstract from the person in front of us; in fact we are trained to present our research in different ways according to context. And so I left a number of versions as to what my research was about, varying my emphasis and terminology. I would not go into any depth in explaining research design, analytical framework or what my theoretical interest evolved around, partly because I was afraid that it would intrude on how people acted and spoke around me, but also because I didn’t want to provoke any deep reaction against my feminist framing (see also Thorne 2004: 164).

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I observe the nurses here while they help you?” Some patients would ask more questions about the study (one asked if I knew gender scholar Tiina Rosenberg); some would tell me how wonderful they thought the staff was; some would simply nod and continue to talk to the nurse instead. Some patients I could not get consent from at all. A number of patients were suffering from dementia and/or were hardly conscious because of their age or health status. I would still observe the nurse working with them as long as this work did not include situations where the patient was put in especially vulnerable or exposed positions, such as getting help with hygiene. What I was observing in these instances was the labour process of the nurse, not the patient per se (I am now talking about patients who were hardly responsive). I tried to make clear to all responsive patients (and kin, when they were present) that my focus was not on them as such but rather on the nurses’ work with and beyond patients. My presence did decrease patients’ integrity – observational methods do this to people. But I asked for their consent and I made sure my presence did not hinder the nurse – patient interaction. I acknowledge the difficulty in evaluating the quality of the sort of consent I could and did get from all responsive patients because of their dependency on the care workers. Lying in a hospital bed is to be in a vulnerable position, and it is difficult to separate out all of the people that enter the room and work on and monitor your body; this I know from personal experience as well. There were many times when I backed away in order to provide privacy, although I was never explicitly asked to do so by a patient or kin. People who were moving through the hallways – which was common because in any hospital there is a significant number of people visiting, delivering things, cleaning, et cetera – I would not ask their consent at all. As Thorne (2004) notes, in situations where there is a steady flow of people moving through the room in which research is being done, obtaining consent from everyone potentially being observed is simply impossible. Because I was dressed as any other nurse (complying with hygiene regulations of the hospital), I’m sure most people who saw me assumed I was one too. I was, however, wearing a badge with my name, the logo of my university, and the word ‘researcher’ printed in big letters.

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These are core issues because they involve the unequal power relation between researcher and participants. According to Thorne, “the universal principle of informed consent does not distinguish between the powerful and the powerless, but it offers some protection to the powerless simply by extending a right to be left alone which the power­ ful have always claimed for themselves” (ibid.: 171). As I’ve indicated, I was careful to communicate the right to be left alone. However, my experience and my feeling was that patients often wanted the opposite; they wanted company. Sometimes I had more time to talk to the patients than the nurse I was shadowing had, because she would go in and out of the room during a procedure to fetch things, for example. If a patient started talking to me, I would stay for a minute and chat. These conversations never made it into my field notes, though. I tried to pick up on signals where those I observed wanted to be left alone. I would always leave the room (or remain outside the curtain that nurses pulled around the bed) if a patient was having an invasive procedure done, or if the patient was getting help with hygiene. If a nurse said something indicating she was unusually tired, irritated or sad, I would also leave her alone, although there were exceptions to this. I did not participate in meetings between patients and care workers where they were discussing the patient’s course or future rehabilitation – except for one occasion, when a patient at the psychiatric ward was being discharged, and I asked his permission twice to sit in on this meeting before it started. I never asked for written consent. My practical decisions in relation to these issues have been guided by the Swedish Research C ­ ouncil’s Codex 3 and the American Anthropological Association’s Code of Ethics (AAA 2009). The latter argues that consent should be obtained from people who are being studied, who are providing information, who own or control access to material that is being studied, and who are “otherwise identified as having interests which might be impacted by the research” (AAA 2009). AAA further asserts that “the degree and breadth of informed consent required will depend on the nature of the project”, and I feel that the nature of this project is such that care workers were the ones whose interests were mainly impacted. Like AAA, I would argue that the quality and not the format of the consent 3.  Available in English at http://www.codex.vr.se/en/forskninghumsam.shtml.

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is what is important, and so I chose to communicate verbally with informants rather than handing out written statements and collecting signatures; I don’t believe such a procedure would have eliminated the ethical problems still present in all ethnographic research, including the study at hand.

Conversations, dialogues and questions Guided by what Smith has called a defining “commitment to discovering ‘how things are actually put together’, ‘how it works’” (2006: 1, italics in original; Smith 2005: 38), I have talked to people, walked with people, and located and read texts, only to go back and talk and walk with more people (and sometimes the same people over again). Whilst I locate my study within the tradition of institutional ethno­ graphy without always adhering to “definite principles of procedures” (Smith 2006: 1), I have been inspired by the idea of exploring society and relations of ruling from the perspective of people’s everyday life, work and coordination with others. I have focused on understanding practicalities and actions, in an attempt to move from local experiences to society as it “embeds, masters, organises, shapes and determines those actualities as we live them” (Smith 2006: 3). This is why data collection has been a non-linear, sometimes ad hoc, sometimes pendular effort lasting for several years and resulting in a study based on a large and rather unruly material. As I display it here, it may appear – for reasons of presentation – more organised than it has been in its compilation. One example of this is the interviews. This study builds on 25 formal interviews, each lasting between one and three hours: 10 with nurses, 2 with nurse managers, 5 with assistant nurses, 5 with physicians (one was conducted via e-mail) and 3 with physio­ therapists, conducted over a period of four years between 2007 and 2011. They each worked at one of five hospitals within the county: City Hospital, University Hospital, Lake Hospital, Bay Hospital and Middle Hospital (see Appendix 1 for an overview of these informants and their respective workplaces). The study also builds on fieldwork in the form of observations in one of these hospitals, City Hospital, where I spent just over 150 hours going along nurses and assistant nurses (plus one physiotherapist) on

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several wards and covering all shifts. During this time, I continued to talk to people I met, conducting informal interviews and engaged in what O’Reilly (2005: 79) calls opportunistic discussions, mostly with nurses and assistant nurses (in mixed groups). O’Reilly notes that during fieldwork, discussions between researcher and informants often take place in groups, and the researcher may engage in or even instigate discussions in order to test responses or subtly bring the topic around to something we are puzzling over in our ethnographic analysis. We might then consider this as becoming something in between a naturally occurring discussion and a focus group, and we could call it an opportunistic discussion. This acknowledges, reflexively, the ethnographer’s role in the discussion; that it was taken advantage of opportunistically but that she intentionally took part in with research goals in mind (ibid.).

I did instigate such discussions on a number of occasions. One time I started, without really meaning to, a major discussion on the word ‘pyssla’ (doing small chores) which nurses used from time to time to describe some parts of their work. The discussion ended when the nurse manager entered the room in which we were all sitting and said: “Anyway, I don’t want you to use this word because it demeans our work, especially in front of the doctors.” I took the episode as an example of how important conceptualisations of work were in varying contexts, a clue that would later lead me to investigate the distinction between ‘service’ and ‘care’, discussed in chapter 8. DeVault and McCoy describe the use of interviews in institutional ethnography as a “range of approaches” stretching from planned, formal interviews to talks that occur during field observations (DeVault & McCoy 2006: 22). They note too that researchers will often combine such informal talks that happen on the spot with formal interviews in which the interviewer can follow up on certain issues and add others. This was the approach I took during my fieldwork. But there were also interviews that belonged at neither end of the continuum. It could go like this: I was doing fieldwork at Ward 96, observing nurse Selma. I talked to her continually during her shift, but I wanted to know her background and there were some things I wanted to understand about the way she organised her work and how she related to

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her co-workers. So I asked her if we could set up an interview and she agreed. The next day, I was observing her again on the ward, and an opportunity opened up for the interview to take place during her shift. We moved into an exam room, where I interviewed her for close to an hour, roughly following my interview guide by memory.

The practice of interviewing and observing I also conducted planned interviews in which I asked questions based on an interview guide (Appendix 2). My research started out by conducting eight such interviews. I contacted the unions for nurses and assistant nurses (Vårdförbundet, The Swedish Association of Health Professionals, and Kommunal, The Swedish Municipal Workers’ Union) and, through them, I was able to meet with three assistant nurses and three nurses who were all union activists. I interviewed one physiotherapist, with whom I got in touch through a personal contact, and one physician, with whom I also got in touch through personal contacts. The rest of the planned interviews I did in parallel to or after I had worked with observations, and I got in contact with them mainly through fieldwork and in some instances by snowballing techniques (Letherby 2003: 104). These interviews focused on experiences of work and relations in the workplace, and explored issues of femininity, gender and equality. They lasted between one and three hours and took place at workplaces and in some cases in the informants’ homes.4 As explained by DeVault and McCoy (2006), within institutional ethnography, even planned interviews are not necessarily standardised. The purpose of the interview is to gain knowledge of the coordination of activity, so that each interview can be used as a base for the next one, providing “an opportunity for the researcher to learn about a particular piece of the extended relational chain, to check the developing picture of the coordinative process, and to become aware of additional questions that need attention” (ibid.: 23). The 25 formal interviews I did with healthcare workers were ­nonetheless 4.  I have presented the informants under pseudonyms in Appendix 1. However, in order for the nurses not to be able to pinpoint each other’s accounts, I have sometimes placed their words in the mouth of a different pseudonym. I have mostly done this when two or more nurses have been expressing the same type of experiences, feelings, or stories.

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semi-structured and included questions pertaining to views and attitudes toward specific areas of work, politics and relationships, in what cultural anthropologists would call issues of cosmology, which include questions as to what the informant was bored with at work and what she found exciting. I started these interviews by asking why the person chose her occupation, and how she ended up in her current position. I then asked questions pertaining to education, family background (including parents’ occupations, what kind of home the person grew up in, et cetera) and current living conditions, in order to get a sense of the person’s life history. The purpose of these interviews was to understand the institutional processes involved in changing relations of power and gender within the healthcare institution, but, because these are also matters of consciousness and political motivation, the interviews had a broader theme than usually suggested by institutional ethnographers.

Dealing with categories: deciding whom to talk to So I started out interviewing assistant nurses, nurses and physiothera­ pists, a few at a time and in no particular order. Soon, though, I decided to focus on nurses, because their position as an adjunct power with a semi-managing function in the labour processes of care work in hospital wards made them both vulnerable to and a force in changing hierarchies and neoliberal transformations within the organisation. The historic relationship between forms of privileged femininity and work within the public sector came together in this particular group of workers, whose contradictory positions and experiences seemed specifically relevant to explore in order to understand the production of femininities at work. This decision meant I had to decide how to think about categories and their meaning in sociological analysis. One way of understanding femininities is to compare different groups of people in order to illuminate differences in strategies, expressions, possibilities and restrictions in practising gender under different material conditions. This was essentially what Connell (1995) did in the ethnographic part of Masculinities, in which she asked questions about how men in different contexts and different strata of society relate to education and labour, to women and the institution of family, to violence and the state, to feelings, culture and consumption,

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et cetera. In doing this, Connell was able to construe categories that would explicate differences among men and their varying relationships to the gender structure, and contribute to the understanding of systematic inequalities between men and women. I decided not to pursue this particular path, which would have involved interviewing different groups of care workers in order to circle in on the differences between them in a more comparative fashion. Like Barry (2007), who studied a particular occupation (flight attendants) and the ways in which these workers came to resist embodying a particular form of femininity, my focus is on nurses and their individual and collective negotiations of normative femininity under neoliberal change. However, nurses work closely with other occupations and have often come to form their professional identities by disidentifying with other groups of women, mainly other groups of female healthcare workers. Holland (2004) in her study on alternative femininities (women who keep to a particular subculture through adulthood) studied femininities in much the same way, by exploring processes of identification and disidentification in a group of women who all shared the approach to fashioning the body in so-called alternative ways. In order to get at processes of identification and disidentification, I relate the informants’ strategies and experiences throughout the analysis to those of assistant nurses, doctors and physiotherapists, who work with nurses and whose professional and labour activism strategies have been formed in parallel to and in tension with the nurses’. The focus of my analysis, though, remains in most cases on nurses. I believe there is a lot to be gained from this type of concentrated analysis, which allows for a deeper exploration into historically situated conditions of a group of workers and the gender practices at play.

Where are the men? Hospital wards are predominantly female workplaces, and women dominate the nursing occupation. I interviewed two male nurses and one male doctor, but otherwise I have talked only to workers who identify themselves as women. While I agree with Connell (1995) that the structural relation of power between men and women shape the relationship among women and among men, I argue that gender practices forming in workplaces that are dominated by the one group

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(women) are not necessarily shaped in constant relation to the other group (men). That is to say, femininity at work is not necessarily or exclusively practised and maintained in the everyday vis-à-vis male co-workers, who are actually scarce. I believe the data analysed in the following chapters will illustrate this point further. During fieldwork, I had to think hard about my decision to study the ‘common’ (female nurses) rather than the ‘exception’ (male nurses). One of the strengths of institutional ethnography is the appreciation of the immense complexity involved in understanding what is deemed perfectly normal, and not taking it for granted. The near absence of male co-workers does not mean that men are not significant to the work performed. Patients are, of course, both male and female (although there are exceptions, such as in gynaecology), and so nurses deal with male bodies in this way. More significantly, the presence of men in the hospital ward is acute in terms of control, since most – but far from all! – doctors are men in this setting, as are higher-level managers. But doctors do not represent an embodied presence offering many actual or lasting interactions in ward routine. Their presence is of a different kind – they are the powers that be, so to speak. Rather, I would argue that femininity is reproduced and controlled through interaction among co-workers, who are predominantly women.

Observations: walking and talking After having conducted eight planned interviews, I started doing observations at City Hospital. One of the strengths of observation as a method is the way it provides an opportunity to move beyond individual experiences toward the coordination of people in an organisational setting (Diamond 2006: 61). The way that time and space shape work processes and movement of bodies is difficult to comprehend and accurately reflect in written dialogue. It is also during observations that the researcher can get a glimpse of the way that texts mediate and get activated. An excerpt from my field notes will serve to illustrate these points. These notes emanate from a situation experienced during one of two four-hour observations in the OB ward at City Hospital. I was going along Marie, an OB nurse (which is an assistant nurse), when things happened that made me write the following in my notepad:

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In the nursing reception. A midwife, Janet, is looking through some charts and she wants to show Marie something. They’re talking about one of the women who just gave birth and Janet tells Marie, “It all went so smoothly, it was just a perfect delivery. No screaming, just perfect calm.” Suddenly an alarm rings out; we all turn to look at a button flashing in red on the wall and a sign below that tells which room it is. Marie says: “Here we go!” and then she and another OB nurse – Britt-Louise – run out to the hallway. I follow behind. We run into a room, Marie goes first, and then Britt-Louise. Inside, the obstetrician, Elizabeth, is standing by the bed of the young woman, Mina. Beside Elizabeth is a midwife, who walks out of the room as we enter. Mina is crying. Marie goes up to Mina and takes her hand, strokes her forehead and says, “It’s okay, it’s okay.” The obstetrician is holding a printout in her hands and she is showing it to BrittLouise. They talk about it for what seems like a couple of seconds only, and then the obstetrician turns to Mina and says: “We are going to have to do a C-section.” Mina cries, “No, no, no!” and Marie is holding her hand and says to her: “But it’s okay, it’s not dangerous, it’s okay.” Mina is crying harder now and the obstetrician says, with a firm voice: “Yes, this is the only way and we have to do it now.” Marie leaves the bed, she is moving very quickly now, and she goes up to the closet in the corner of the room. She takes out some green clothes and gives them to a young man standing by the window. He hasn’t said a word since we came in. Marie takes him by the arm as she hands him the clothes and she says: “You go into the bathroom, you put these on, and then you’ll come with Mina and us to the operating room.” Then Marie runs out of the room, Britt-Louise is right behind her, and we run into the locker room, where they quickly find green clothes in their size and they put them on. I try to change as quickly as they and not be in their way but it is difficult; the room is very small. Marie says: “You’re a size S, right?” and she hands me some clothes. “You smell so good,” Britt-Louise tells Marie. “Have you been to the salon or something?” “No, it’s not me, it’s got be her,” Marie says, and looks at me. I am too nervous to respond. I am wearing sneakers and I feel it takes forever to untie the laces and then put them on again when I have put on my green trousers. Marie just sticks her feet in her sandals and I say: “Now I see the point in them.” “Yes,” she says, “they’re very practical.” Marie runs to the elevators, and I follow behind.

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I am going to make four points in relation to this excerpt from my field notes, arguing the strengths of observation as a way of exploring the social in motion, “as an ongoing concerting of activities” (­Diamond 2006: 60). Walking the floor during observations opened up new ways of talking about work, identity and experience in interviews. The four points I am making further serve to illustrate the direction and focus of my own vision during fieldwork. The first point is precisely that space, time and motion have effects on, and exist as effects of, coordination and processes of work. Bodies are moving between different spaces and at different paces: there is the lounge, in which two OB nurses can stand still to discuss a previous event, where harmony is suggested (“Let’s take time to look at this – it was peaceful, and special”); there are the hallways, in which people are sometimes running and somebody is going to be pushed through in a bed; there is the patient room, in which decisions are being made, mediated and effectuated (“This is what needs to be done: so we are now going to move out of this room and into another”); there is, not yet made physical but existing as an objective, the operating theatre, in which a C-section will be performed. The meaning of time has been shifted. The ringing-out of a red light means time has become a different issue: there is a medical intervention about to happen and it must happen quickly. This requires new kinds of motions. There is running between and towards spaces. Marie communicated via touching, and physically pushed the expectant father towards a bathroom and told him exactly what he was supposed to do in there. Everything had to happen fast, so people began moving distinctly and rapidly. The second point is that coordination of people’s activities operates on multiple levels, some of which exist outside of language and consciousness. Coordination, according to Smith (2005: 60), produces institutional processes “as they actually work”, but coordination of people’s doings is also set in motion and can be reshaped in distinct ways by those in power and by institutional procedures. The red light would set in motion a specific form of recognised coordination: “Go to this room – fast.” In the patient room, the physician’s decision, based on her interpretations of the status of the foetus and the mother, set another process of coordination in motion; relations of power frame all acts of coordination, including those carried out

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by equals coordinating with each other. Marie and Britt-Louise recognised the space for moving beyond the most common patterns of interaction set in motion by the physician’s interpretation of the medical status, and began touching and pushing Mina and her partner. However, these institutional processes did not shape the interaction between Marie and Britt-Louise completely; recognising a smell while changing clothes still merited comments. The third point is about the way that texts enter into the coordination of people’s activities and how they become activated in these processes. As I’ve pointed out in the previous chapter, texts are present in the everyday world, but they also connect people into trans­ local social relations. While texts carry this extended meaning and function, within institutional ethnography ‘text’ means quite simply material that is replicable, and does not refer to discourses or other immaterial presences as theorised within poststructuralist and postmodern traditions: Texts are key to institutional coordinating, regulating the concerting of people’s work in institutional settings in the ways they impose an accountability to the terms they establish (Smith 2006: 118).

Texts produce stability and replicability of organisations and institutions. Thus within institutional ethnography, texts are considered central because they connect the local with the translocal organisation of relations of ruling. Texts are mentioned twice in the excerpt from my field notes: first at the very beginning, when a midwife wanted to discuss a delivery that took place earlier. She talked about this by referring to the chart used to monitor and record the bodies involved in childbirth. Smith (2005: 170) recognises that texts produce “institutional observability of the work of those involved”. Documentation is key in care work and medicine, in which texts are produced to “ensure that what is done meets regulatory requirements”, and to secure work sequences (ibid.). Charts distil and reify interactions and medical interventions and it is in this form that care workers can return to them and evaluate them. The other instance in which text is mentioned is upon entering the patient room. The obstetrician referred to a similar chart, but one indicating a different process that would merit medical intervention.

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These texts connect the local with the extralocal because they are read and activated within a space of medical knowledge, which is supposed to produce standardised interpretations and reactions. During observation it is possible to “watch as texts get activated” in these contexts of coordination in motion (Diamond 2006: 61). The fourth and final point is about the way that the author actively enters into the production of data. Diamond (ibid.: 59) talks about processes involved in observations and the production of data through field notes in terms of a “corporeal, incarnate base with which to ground the author’s and others’ bodies in action and coordination”. If there are stories, Diamond concludes, there must be an author/ researcher behind them. I think the excerpt illustrates this point quite well, but it also highlights the strengths of observation as practice. I didn’t know the direction of where we were running or where I was supposed to get the green clothes in the right size, and I struggled to keep up and keep my nerves in control. I realised practical things such as the point of not having to untie laces. My being there and taking part in this process opened up new ways for me to understand, indeed feel, the work processes as they play out in the everyday at the birth clinic. But the data did not materialise out of thin air, and does not exist as facts or objective representations. The field notes were produced by me and reflect what I think I saw and experienced – there is a story and so there is an author who produced it. Smith talks about practices of inquiry, discovery and learning, and the inevitable presence of the researcher as a process that requires the researcher to recognise her own position: … recognising that you are always there, that what you discover is always seen, interpreted, heard, experienced by you as you are situated historically in the ongoing, never-stand-still of the social. It is the recognition that the social as your research phenomenon is to be found in that ongoing process of which you’re part (Smith 2006: 2).

This is the kind of methodological reflexivity with which I have tried to critically assess my data and the process of accumulating it.

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‘Going along’: a version of institutional capture O’Reilly (2005: 161) points out that observations take place on a continuum from total participation to non-participatory observation. Ethno­gra­phic studies on the healthcare field are often participatory (such as Porter 1992 and 1993, Franssén 1997, Diamond 2006; see Wind 2008 for a discussion on the concept of ‘participation’ in care work), and authors argue that participating in the work is one way of gaining knowledge about, for instance, the ways in which ruling relations are reflected and reinforced in the everyday work (­Diamond 2006: 60). I could not participate in the work to the full extent, because I have no education in and no experience of care work (and non-skilled workers are no longer employed in Swedish hospitals to perform care work). I participated in some chores. I would help make beds, clean rooms, carry things; I would help nurses sort and refill the medicine trolley; I would fetch things for patients, such as water or a clean shirt; I would sometimes mark down how much a patient had been drinking; I would be one of two people pushing a bed through hallways and into elevators heading for an x-ray; et cetera. In my mind, I was observing, and I conceptualise my fieldwork as direct observation or shadowing: “observation-on-the-move”, as Czarniawska calls it (2011: 95). I was in no way a part of the workforce, as has been the case in healthcare ethno­gra­phies produced by, for instance, sociologists who are also trained nurses (Irish sociologist and critical realist Sam P ­ orter is one example). On occasions where a patient indicated he or she wanted to chat with me, I sometimes sensed it was brought on by anxiety, stress or simply boredom. And while I could see that these small talks seemed to be appreciated both by the patients and by the staff, I never knowingly attempted to comfort patients. I never talked to them about their diagnosis or how they were feeling, for example.5 During observations, I continued to talk to people and ask them about their work. Kusenbach has described such practices as goalongs, “a hybrid between participant observation and interviewing” 5.  Those who talked to me usually had children my age or so, or even grandchildren my age, and patients would tell me about these family members that I seemingly reminded them of. Conversations also often centred on being a university student, what it was like to do research, whether it was difficult to write a dissertation, et cetera.

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(2003: 463). Anving (2012) used this technique in her study on class and gender in everyday family practices. The author went along parents while they were shopping for groceries, allowing her to study routine practices in a semi-intimate sphere in which decisions were made about how to feed and organise the everyday life of the family. Kusen­bach argues that this technique of walking and talking with infor­mants as they go about their everyday errands, et cetera, offers a way to observe informants’ “spatial practices in situ while accessing their experiences and interpretations at the same time” (ibid.). The technique of following informants into places where they would have gone anyway, like Anving did, is called “natural go-alongs”, but Kusen­bach asserts that even though they are “ideally rooted in informants’ everyday routines”, this method of collecting data is “obviously not a ‘naturally occurring social occasion’”; they are indeed “contrived social situations that disturb the unfolding of ordinary events” (ibid.: 464). Observing nurses at a teaching hospital complicates this disclaimer, however, because there, go-alongs are actually naturally occurring social occasions and do not really disturb ordinary events: in fact they are considered to be an ordinary event. Nursing students get a significant part of their training by going along senior nurses, and most nurses who have been working for some time have had a student follow her at some point. This meant that to all people working with care or medicine at the hospital, the concept of someone going along a nurse was a well-established practice, and a procedure that usually entailed a controlled process of knowledge production – “this is what you need to learn; remember this; I will explain what I’m doing now so that you can learn; I will not explain this because I assume you already know it; I decide what you need to focus on and what you should do.” There is a specific concept for this, which happens to be the same as the ethnographic method described by Kusenbach – “to go along” (‘gå bredvid ’, ‘walk beside’). And so, in a sense, there was a collapse between the ethnographic tool I was employing and the institutional practice employed by the hospital. Nurse managers would tell me: “I decided you will go along Selma.” The nurses I observed often commented on how “nice it is to have someone go along that I don’t need to teach or test,” thus referring to the familiar educational practice and labelling the difference as not having the responsibility of teaching me

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anything. I too came to talk about observations as go-alongs, in a manner that clouded the difference between the ethnographic practice and the hospital practice. In my field notes I would say: “I was going along Janet when …” In hindsight, I would say my research method was incorporated by work knowledges in place at the hospital, in a version of what Smith (2005: 155) calls “institutional capture”: … institutional discourse may enter into and, from the point of view of the ethnographer, pervert the dialogue that produces work knowledge. The researcher is up against the capacity of institutional discourse … to subsume or displace descriptions based in experience.

In this context, it was not descriptions of the work that were being subsumed or displaced by powerful institutional discourse, rather it was the understanding of why I was there and what I was doing. But the difference between what I was doing and ordinary go-alongs by nursing students was, of course, not primarily about nurses not having to teach me anything. My presence was not innocent, and I was not in a subordinated position like a student would have been. One of the risks of this type of institutional capture is that the actual unnaturalness of my presence, and my position of power as a producer of knowledge based on nurses’ experiences, might have been concealed. It took me a while to realise this, and at first I was quite happy about the effects of institutional capture: it is much easier to move and act within a space from a (albeit borrowed) position of normality. But, of course, when Kusenbach talks about go-alongs as contrived social occasions she is not presenting it as a problem: researchers ought not to conceal their presence, their aims or their methods. And so I recognise the problems involved in having research methods and my own presence partly subsumed under these powerful institutional discourses. But I also recognise the agency involved, and this process can be understood too as the informant’s desire to interpret and construct an unusual situation into something familiar, a process that also places her in more of an equal position in relation to the one observing her for highly abstract reasons.

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Whose side am I on? I never really had any problems getting access to the field of care work. It was easy enough to get nurses and assistant nurses to talk about their work, and it was not really a problem to get access to the wards. Once there, I felt welcomed. Informants would, as I mentioned before, often give me specific quotes that they wanted me to include in the book. These quotes tended to focus on their experience of a fundamental lack of recognition by society, often concretised as the politicians in charge of national and/or regional healthcare policy and funding. “Tell them we need more money,” a nurse said as soon as I had introduced myself and my research to her. “Write this down: we need a vacation to Hawaii. We need a pay rise,” another nurse said after we had shaken hands. When I was invited to present my research at the educational seminar for the nursing staff of Ward 96, the major qualm expressed regarding my research was that the people in charge of healthcare funding and salary settings, i.e. politicians, “would not listen because they never do, and I don’t think they will read your study anyhow” (I’m afraid they were right on that). Apart from processes of institutional capture, how could I understand the experience of feeling embraced by the institution and the informants I was observing? One avenue of analysis would be a critical examination of situated knowledge and “the politics of location”, in the words of bell hooks (2004: 153). Mulinari (2005) provides an overview of some of the major contributions towards expanding the dialogue on feminist and postcolonial epistemology and the role of the researcher and her social location. Mulinari argues, along with feminist theorists such as Collins (2004) and Bhavnani (1993), that one’s biography will influence not only the choice of research topic, but also “under which conditions we get access to the field, what will be said, and how our research will be understood” (Mulinari 2005: 116, my translation). She quotes McLaren, who asserts that: It is important to acknowledge that informants possess what I call reception formations: that is, different historically and culturally located subjectivities that will shape how the researcher’s presence in the field is both perceived and received. … This means that how a researcher ‘receives’ his or her informants and how informants might ‘receive’ a field researcher is contingent upon and to a certain extent determined by their situatedness in a complex network

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of gender, class and race relations (McLaren 1991: 153, quoted in Mulinari 2005: 116).

Mulinari discusses the “will to know”, privileged researchers’ notion of a will and a right to study and produce knowledge on subordinated groups. Mulinari examines the resistance to such claims within subordinated, marginalised groups who have often been at the centre of attention for policymakers and research projects seeking ways to regulate and resolve “social problems” (Mulinari 2005: 120f ). Resistance against the presence of researchers, and a scepticism towards ‘scientific truths’ which serve to legitimate processes of difference and subordination, can constitute an important type of knowledge, rendering visible the links between “the exercising of power by way of (scientific) knowledge and the biography of the individuals and the group,” according to Mulinari (ibid.). I never encountered any lasting resistance, which could be interpreted (first of all as an expression of my own ignorance: perhaps I didn’t pay attention to it, but I was always careful to try to be responsive and sensitive to any such indications) as reception formation based on perceived likeness between the informants and me: white, professional, respectable working-class or middleclass women, bearers of normative femininity, including heterosexual family formations. The embracing attitude could also be interpreted as the informants not viewing me as someone really outside or above them. Nurses are also trained in various research techniques, including qualitative methods, and the scholarly field of nursing studies is in some regards quite close to the field of sociology and anthropology. More importantly, I would argue that I was seen as an insider – really, as an advocate. The expectation was not that I would represent them, or the hospital, as ‘social problems’; there was instead a desire for my research to give voice to experiences of not being listened to, of being taken advantage of, and of being mistreated by those in power. There was a sense that the ‘social problem’ I was investigating should be addressed in terms of gender and inequality, and that the fields I represented (sociology and gender studies) would be the primary arena in which these issues could be explored. I will give one example of how this sense of advocacy would play out in communication between informants and me while in the field. I was walking through the main hallway of Ward 96 one day, and

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there was a discussion going on between a nurse and a patient (I analyse the situation in Selberg 2010). The patient was upset but could not communicate what he wanted to the nurse, and the situation was tense. When the patient, still angry, turned his back to the nurse, she quickly retreated to the staff restroom. I instantly knew she would cry in there. A part of me felt the right thing to do was to leave her alone, but another part – the cold and distanced sociologist – thought this would be interesting to follow up on. I knew nurses were crying more and more because of stress in the workplace, and, inspired by Foote Whyte (1949) and his assertion that crying in the workplace is a relevant entry point to understand breakdowns in the labour process, I decided to stick around outside the restroom. When the nurse came out, she looked teary-eyed and flushed, and I felt bad for having waited for her. But she saw me standing there and, rather than walk away, she stopped, tucked her hands into her pockets, and started explaining why she had reacted the way she did. She emphasised that it was not the patient’s behaviour that made her cry; it was the fact that she was so stressed-out because of the intensity of work in the ward these days. She knew why I was there, and I believe she took the time to explain these things to me because she hoped that I would help bring attention to the pressure that nurses experience after years of cutbacks. The nurse managers expressed such hopes, too. I talked to nurse managers during the course of fieldwork and I was also invited to sit in on a meeting with all the nurse managers at the surgical clinic, i.e. the nurse managers of all the surgical wards at the hospital. They were very welcoming and said things like, “Well, let’s hope your research can bring some attention to our situation,” and then they proceeded to discuss some of the problems of administrating care with not enough resources. So, whose side am I on? I was and I am on the nurses’ and assistant nurses’ side in terms of the level of exploitation they experience; in terms of the historical misrecognition of care work performed by women that is also visible in the low pay they receive; in terms of growing and increasingly complex workloads that they are made responsible for coping with without much institutional support or recognition; in terms of their efforts and dedication to performing beyond the boundaries of their employment contract (more on this in the

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empirical chapters, specifically chapter 7); in terms of their continued subordination to doctors and other more powerful groups within the hospital and healthcare system. I am however more ambivalent in relation to other issues. My view is that these women occupy privileged positions in relation to other women and many other groups of men, and that part of their acceptance of high levels of exploitation is that their position also grants them status as good women – and that care work itself is a source of pride, power, and control over others. Consequently, I take their side while also recognising that they in fact hold important privileges and are in positions of power wherein they are able to supress other groups of people, significantly other groups of women. This is also where my problem with institutional ethnography lies, as institutional ethnography rarely deals with such contradictory locations or experiences emanating from them. I hope to expand the project of institutional ethnography in this regard.

Making the case of an inequality regime So far, I have focused on institutional ethnography and how this feminist tradition has inspired my work and disciplined my ethnographic gaze. I will now shift the attention towards how I’ve treated the healthcare organisation analytically. I argue that Acker’s (2006a, 2006b) concept of the inequality regime offers a powerful tool to study the production and reproduction of class, gender and race/ethnicity in organisations. I have focused on the organising processes that produce inequality (general requirements of work; class hierarchies; recruitment and hiring; wage setting and supervision; informal interactions). The empirical chapters examine these practices and the thematic explored in each chapter has been identified and theorised from Acker’s conceptualisation. Thus I have treated the organisation as an inequality regime that I’ve studied from the standpoint of care workers, mainly nurses, and with institutional ethnographic principles as a methodological and epistemological base. One of the strengths of Acker’s analytical model is its understanding of conflicts of interest that emerge in organisations that are built on and reproduce gender, race and class inequalities. Poststructuralist critique of feminist standpoint theory rooted in historical materialism

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has focused on the risks of creating essentialised and fixed, homogenous groups; according to some critics, there has been a tendency in standpoint theory to render invisible varying and contradictory experiences (Hekman 2004; Mulinari 2007: 101). Acker’s intersectional model of the inequality regime can be seen as one example of how standpoint theory has developed through poststructuralist interventions and their call for approaches that would “examine critically pluralities of power relations” (Harding 2004b; also quoted in Mulinari 2007: 101). Within institutional ethnography employed as research practice, there is a lack of attention to conflicts and conflicting experiences among those (social locations and standpoints) to whom epistemic privilege is attributed. Working with the model of the inequality regime has opened up possibilities to explore such conflicts. For instance, I have been able to explore analytically how formations of femininity and experiences of work vary among care workers because of racism. I have also formed a standpoint based on experiences of care workers – both nurses and assistant nurses – recognising that they in fact do not share a common social location within relations of power. Nurses control the work of assistant nurses. What they share is a gendered location within the economy and division of labour; what separates them is, at the same time, class. At times, I have attempted to shift the angle of vision (Collins 2004: 249) from that of nurses to that of assistant nurses, in order to understand processes of femininity formation and the ways in which class location and experiences of work shape their variations, all the while keeping my focus on normative forms of femininity embodied historically by nurses.

Making the case of an embedded institution There are a number of ways to design a study on a particular organisation, just as there are a number of ways to represent the data afterwards. Lindgren (1992) visited wards and clinics at a university hospital, and stayed for a longer period of time at one of those wards. Because she didn’t want to reveal the identity of the staff, she constructed a typology of a ward, called the Type Clinic. She did not anonymise the university hospital or the county in which it was located. I have chosen not to create a typology of a ward, but instead focus to a great extent on the workers and actions of the ward I visited the

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most. I call it Ward 96 (and I describe it further in the next chapter), and, while it is not a type clinic, it functions much like a case study. My ambition has been to treat both Ward 96 and the hospital as embedded institutions – that is, I’ve tried to locate them analytically and empirically within a historical, political and economic space in which a case can never be sealed off even as it is represented and created through analysis. Using the term ‘embedded’ while collecting data has been a way for me to keep in mind the extended relations of ruling, the ways in which local practices are tied into extralocal structures that are rooted in history, politics and economy, but also to underscore the partiality of my view: [O]rganizations, and indeed actions within organizations, are always embodied in social contexts. This context-embeddedness means that it is necessary in conceptualizing, analysing and writing about organizations to bear in mind that attempts to characterize organizations are limited and provisional (Hearn & Parkin 2001: 2).

Thus I use the term embedded here to imply two things: the fact that an organization is embodied in a wider context, which also means it is, to a varying degree, in flux. Second, acknowledging organisations as embedded means recognizing them as reaching beyond the immediacy of a specific place and time (ibid.). The main challenge in recognizing and illustrating the embeddedness of the hospital is the issue of providing, at the same time, the space for its actors to speak freely. I have chosen to keep the hospital a secret, as well as the county it’s located in.6 The reason is that I want to avoid giving away the identity of those being interviewed and observed. It seemed to relax people I met in the field when I told them I wouldn’t reveal even what county they worked in, and that for me is reason enough. This has caused some problems, though. Each hospital is embedded in a regional and a national economic and political space. Politics, as Therborn (2006) notes, begins with place, and so getting 6.  There is a strong likelihood that people will be able to deduce to which county I’m referring, as Sweden is a small country with few regional clusters such as the one I describe. I’ve been as vague as I can without keeping central information about the political and economic context from the reader. It has been more important to me to keep the hospital and Ward 96 anonymous than it has been to keep the county itself a secret (although I have never talked openly as to which county I am referring).

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a sense of the place I’ve been studying has been key. City Hospital is part of a regional healthcare economy with significant logistical and varying forms of practical and knowledge-based exchanges and collaborations with other hospitals in the county. I have interviewed nurses, assistant nurses, doctors and physiotherapists working at different hospitals, but it is the county that formally employs them and they all work within this same regional public sector care economy. Because I have chosen to keep the identity of the county a secret, I am not able to cite directly the public material I have analysed in order to get a sense of the economical and political structures, discourses and rulings. However, the county does not deviate much from the course of other regional healthcare economies in Sweden, and the overall political agenda is the same as in other counties where the right forms the political majority, and has been for the last ten or so years.

Analysing the economy of an embedded institution Gorelick (1991), in her account of feminist debates on standpoint theory and methodology, refers to Marx’ concept of the “complex of many determinations” to underline the need for research with a wider scope that aims to locate actors and organisations in history, economy, policy and culture. Methodologically, this process involves patching together different kinds of data and the result can be described as a collage of information shedding light on some of the links between different sectors and markets in a specific time and space (­Glucksmann 2000: 22). As I described in the previous chapter, the ‘economy’ plays a major part in the lives of people, as bodies are located in the centre of economic activity within and beyond the accumulation of capital (Acker 2006a). From the standpoint of care workers, economy is relevant outside of paid labour but it is relevant also as they perform and experience paid work because work is organised within economic contexts that appear to be shrinking (see chapter 10). So how does one analyse the economy? I draw attention to the economy because methodological debates about empirical analysis of the economy of organisations within qualitative sociology are rare. Starting from the standpoint of care workers, I attempted to relate their experiences and situated knowledge of intensified work processes to concretised reports of the local economy. By local economy, I refer

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to the economy of the hospital, the county and the healthcare sector in Sweden. My aim here is to extend the workers’ knowledge of how the economy has operated in ways that sped up their labour process. As noted, I studied four years of financial reports (2008–2011) and the policy and funding recommendations and decisions by the county, along with statistical and financial reports produced and published by the unions and the employer party SKL (Sveriges Kommuner och Landsting, Swedish Association of Local Authorities and Regions). Additional data came from authorities involved in monitoring healthcare and public spending (such as the Institute for Labour Market ­Policy Evaluation and ESO, the government committee for studies on the economy of the public sector) on the economic status of all counties pertaining to the responsibility of providing care for citizens. Economic reports reflect only partial outcomes of global politics. Thus I focused on identifying and analysing texts that explicate local economic outcomes. Yet theory, specifically feminist theory challenging the notion of what constitutes economy and how divisions of labour can be understood, is involved in the process of linking such texts to the global relations of ruling. These texts are not “in motion”, nor do they “mediate the process of coordinating each stage of work with the next” (Smith 2005: 173). Rather, they work as distilled sites of the extended relations of ruling that have shaped (and continue to do so) the local organisation by affecting its resources. Because I have kept the identity of the organisations secret, I cannot share the actual financial reports but I can note that they are standard financial documents (that is, budgets, tax reports, reports to consumers and boards, and so on) and common procedures of analysis can be carried out on all similar texts (a list of the texts is found in Appendix 3). The financial documents included City Hospital’s annual report on the activities and results of the previous year, similar to data provided to shareholders and boards of directors in commercial companies. They disclosed the financial performance of the hospital for a specific year. Most of the report consisted of financial disclosures pertaining to, for example, the number of employees in relation to policy goals set by the county or the financial deficit of the hospital. There was always a deficit, thus the better part of the report focused on explaining financial results and the measures taken to reduce the

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annual deficit. I read the documents with the aim of understanding the financial ramifications of work performed within the hospital and critically examining the discourses that were in play including the policies being effectuated by the organisations.

Analysing from a perspective There is a part of research that is always difficult to describe: the part of interpretation, which involves filtering and selecting accounts and viewpoints. Because ‘femininity’ and ‘gender’ are not objects, not fixed identities, and because they are practised both reflexively and unreflexively, as Martin (2006) has pointed out, they are difficult to capture in text and in research. In the previous chapter, I outlined the theoretical foundations of this study and discussed how I employ the concepts of work and femininity, which indicate too how I have studied gender and work at the level of analysis. The theoretical definition of the inequality regime further describes what organisational practices I have been focusing on identifying through analysis. What a researcher interprets as gendered practice may not be seen as such by those whose actions are observed and examined, however. Even the most obviously gendered organisation, such as the hospital with its firmly gendered divisions of labour, can employ a powerful collective understanding of its internal structure as that of a gender-­neutral organisation and bureaucracy (Connell 2003). Researchers often encounter these types of responses. Skeggs, for example, describes how the women in her study refused the concept of class as something meaningful in their lives. The women’s rejection of class did not lead Skeggs to abandon it in her analysis, though; instead, she says, it “heightened my sensitivity to its ubiquity and made me construct theories to explain their responses” (Skeggs 1997: 30). My approach was similar. No matter how strongly some nurses argued that gender is a biological fact, or that ethnicity has no meaning whatsoever in their world, or that class is a concept of the past, I would pursue analysis that could explain these matters in line with the theoretical frameworks and the research context within which I conducted my study. Thus working with standpoint analysis does not imply echoing uncritically the words of a group of people. Experience as dialogue in sociological analysis is intellectualised and

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passes through theory (Pels 2004: 281). In order to describe the process of interpretation, I follow Widerberg’s (2002: 135ff) categorisation of analytical approaches in ethnography.

The process of interpretation The data of this study was collected using a range of techniques, from formal and conversational interviews to shadowing/go-alongs and textual analysis. Consequently, it is made up of a number of people’s memories, accounts, conversations, actions and written words. Glucksmann (2000: 49) uses the concept of knowledge interaction to reflect on the interpretative process involving multiple sources of experience: Producing new theory from these knowledges involves going beyond the rationality and reality of any one of them, and actively utilising the variety of disparate forms. If [the researcher] believed that each contained its own validity within itself there would be no point in consulting more than one, or interviewing more than one person, as all material would be radically incomparable, yet of equal validity. But each knowledge form is the product of particular knowledge interactions and of its particular location in time and outlook. These are features which can be known and used to inform how each form may now be interpreted and how different forms may be brought into connection with each other. By maximising the use of such disparate knowledges, and actively reinterpreting them, it becomes possible to give a wider frame of reference to the various sources and to produce a new analysis, a new social theory.

Glucksmann captures the strengths of ethnographic methodology and points to the logic of data accumulation and interpretation. But to actively reinterpret data requires a specific kind of labour of organising and connecting knowledges. Richardsson (2004: 473) argues that this process involves not only writing as a way of telling, but writing as a way of discovering. For me, describing is also discovering. Back’s (2007: 21) statement that sociological listening is tied to the art of description reflects this. Descriptions are interpretative, informed by theory. This relationship is captured in Back’s (2007: 21) metaphor of theoretical ideas and concepts hovering above the ethnographic ground “in order to provide a vocabulary for its explanation”. I love the notion of deep sociological listening and, while I am sure I

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have failed at it, this nonetheless has been my ambition during fieldwork and during the transference from fieldwork to text: This is a kind of description that is committed and dialogic but not just a matter of ‘letting the research subject speak’. It is informed by a commitment to patience, accuracy and critical judgment. Thick descriptions produced through deep sociological listening are ones that theorise as they describe and describe as they theorise (Back 2007: 21).

Writing up, discovering and describing is work. The labour process is hard to recount because this is not work performed linearly. Rereading and reorganising the data is also a collective process, which is often mentioned in the ‘Acknowledgement’ section of books like this but rarely in the Methods chapter. To discover and describe is a dynamic and dialectic process lacking the preconceived structure of a narrative. I began with organising the data thematically. Quotes, field notes and text excerpts were arranged under broad headings such as ‘education’, ‘family’, ‘hierarchies at work’; the themes were decided both by the questions of the study and by things I encountered in interviews or in other forms of interaction during fieldwork. The process of identifying and organising central themes can be described as a dialectic move between data and theory. The thematic organisation of the study was followed by an examination of possible patterns. I tried to identify recurring accounts and contexts. Looking for patterns also involved identifying things that stood out. Themes and patterns would often overlap. Silences and signs of distancing would signal to me an analytical theme that could connect with themes and/or patterns. Identification and disidentification played a significant role in getting at processes of gender formation. Widerberg (2002: 167) talks about clarifying different subject positions of informants by highlighting accounts such as “I am a modern woman,” “I am a good girl,” or “I am not modern.” When informants have taken such positions in interviews or during fieldwork, I have tried to map the context of the claim and relate it to similar statements, which I have later arranged in ‘clusters’ in order to identify predominant discourses (ibid.). In chapter 2 I addressed the concept of work, including the labour process. Burawoy (1979: 15) identifies two “distinct but concretely

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inseparable components” of the labour process, a relational and a practical aspect: I refer to the relational aspect of the labour process as the relations in production or production relations. They are, for example, the relations of the shop floor into which workers enter, both with one another and with management. In its practical aspect the labour process is a set of activities that transform the raw materials into useful objects or fractions of useful objects with the assistance of instruments of production.

While body work obviously is different from the factory work Burawoy examined in his study, I used his distinction to guide my ethnographic gaze during fieldwork in order to separate out the different modes of work that nurses entered. The theoretical frameworks conceptualising contents of care work, such as emotional labour and body work, were central in this regard as nurses’ labour contains many different tasks and requires the use of varying techniques and skills. During the move from the field to the text (Denzin 2004), I organised and developed my analysis according to Burawoy’s distinction in order to grapple with what kind of work mode I was describing.

Recognising positionality In this section, I have tried to disclose the steps I took during the interpretative process. But interpretation starts even at the beginning of a research project: deciding what questions to ask involves interpretation and decisions on what to look for and how. To use the words of Morgen et al (2010: 13), my social location as an individual and my theoretical perspective as a feminist sociologist has shaped my “vantage points, analytic strategies and conclusions.” This is a central point in what feminist theorists call reflexivity. In a critical intervention on knowledge production and feminist epistemology, Haraway (2004) argued that, far from relativism, feminist objectivity means situated knowledge, in which “only partial perspective promises objective vision” (Haraway 2004: 87). According to Bhavnani (1993), feminist theorising has acknowledged the need to examine practices, procedures and theories within scientific work in order to “bring into focus the ways in which knowledge production is a set of social, political, economic and ideological processes” (1993: 96). This is why Haraway’s

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contribution is central, Bhavnani argues, because the notion of situated knowledge and accountability poses questions that challenge the notion of feminist research as research of and on the unified category of ‘woman’: It is these three questions – Are the researched reinscribed into prevailing notions of powerlessness? Are the micropolitics of the research relationships discussed? and How are questions of difference engaged with? – which I suggest flow from Haraway’s discussion of feminist objectivity, and which provide reference points through which principles may be delineated and, thus, research projects evaluated (Bhavnani 1993: 98).

These are questions I have struggled with throughout the research process. Like Mulinari (2007: 103f ), I argue that it is important for gender studies and feminist sociologists to continually question not only the research practices and the representations we produce through our analysis, but our own notions of what the limits are for social change. I have tried to explore actions and practices of resistance in order not to reinscribe prevailing notions of powerlessness and feminine subjugation among those who care for a living, and in addition have endeavoured to take seriously issues of consciousness and constructions of a collective ‘we’. Following Skeggs (2007), I have viewed recognition as a means by which experience can be interpreted. “When experiences are recognised through naming and marking, positionality is understood and responded to. The same process applies to theoretical recognition when we recognise the explanatory power of particular theories,” Skeggs (2007: 29) asserts, and this has been guiding me through the interpretative and creative process involved in writing up a research project.

4. Places, spaces and contexts

This chapter will provide an outlook of the spaces that frame the social locations of the actors (Gorelick 1991: 473) and analyse the ways in which space structures work and social relations at City Hospital. It will further introduce the case study of Ward 96 by describing and analysing the organisation, including the spatial and temporal arrangements, of work. Gendered and racialised class practices take place in rooms that are fashioned by and provide the ground for the operations of inequa­lity regimes. These are actual places that can be experienced physically, but they are also political, economic and historic spaces in which activities relating to work, households, consumption and distribution are situated and flow through. Gender is practised reflexively and unreflexively, individually or collectively, somewhere. Work, too, happens somewhere. The ‘where’ will, to a degree, shape the ‘how’. Thinking about places (as physical realities1) and spaces (as socially constructed in relation to modes of production and reproduction, as well as dichotomies of private/public and visible/invisible, Lefebvre 1974: 33, Johansson & Molina 2002: 273) has helped me direct attention to the analytical importance of where and how people move, speak and act in the workplace, and to connect such activities (or silences, non-activities) to the workings and structure of the local inequality regime. Tracing the physical layout of a workplace and exploring the ways in which it is inhabited is, I argue, one step towards unlocking the “interface between embodied individuals and institutional relations” (McCoy 2006: 110). As suggested by Smith (2005: 68), I study the healthcare institution as a functional complex within the ruling relations, recognising that it can be viewed only in its partiality. It is explored not from an impartial, encompassing and ­objectified ­position, but rather from 1.  Or, in the words of Gieryn: “Places have finitude, but they nest logically because the boundaries are (analytically and phenomenologically) elastic” (2000: 464).

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the standpoint of some of the people involved in its multiple functions and work processes.

Describing places Description has been a powerful tool within ethnographic research to suggest distance, neutrality and notions of objectivity (cf. Haraway 2004: 86). While I do set out to give a valid representation of the places that I have entered into, it is important to view these descriptions as manufactured segments of the space that is County and City Hospital. This section is an outcome of theoretical and methodological deliberations, and the word ‘description’ should be understood in those terms. The questions that have guided me through the collection and analysis of ethnographic data are those posed by McDowell (2009: 14) in her argument as to why place matters in studies on work: “Are workers from the immediate locality? If not, why and where are they from? What difference does place make to workplace practices?” Many sociological workplace ethnographies have been forced to change the name of the workplace or move it to another city (­McDowell 2009, see also Glucksmann 2009 [1982]: xiv). I made the choice not to reveal which county or city it is I have studied, although, as Glucks­ mann realised upon the publication of her book, I’m sure there are people who will be able to tell at least which county it is I’m writing about. My number one concern has been not to give away the specific ward I’ve studied and the people I’ve interviewed. This decision nonetheless means that the specificities of local variations cannot be significantly addressed (McDowell 2009: 14). I argue that some local variations can be explored nevertheless, although in more general terms. I will begin by describing the national political and economic context of the healthcare system and the status of hospitals such as City Hospital in Sweden, focusing on recent developments that affect the occupations and the work processes. I will then move on to unfold some features of the county and the city itself, and briefly describe class, gender and racial relations in the communities surrounding City Hospital. I will then move on to City Hospital, exploring parts of the physical space and its effects on the organisation of work. The final parts of the chapter discuss the labour process and social interaction through and beyond work at Ward 96.

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New millennium healthcare in Sweden In 2012, Swedish healthcare employed about 300,000 people, the majority of whom were women. In order to answer the questions posed by McDowell that aim to situate the work and the workplace within a geographical and demographic context and make visible the places from which workers are recruited within the Swedish healthcare system, I have included a few graphs indicating gendered and racial/ethnic divisions of labour, wage differences and the localities from which workers are recruited. Swedish healthcare, as illustrated by graphs 1 and 2, is increasingly professionalised. Further, the gendered pay gap within the occupations is illustrated, showing the greatest gap between male and female doctors. 1,200 1,000 800 600 400 200

19

95 19 96 19 97 19 98 19 99 20 00 20 01 20 02 20 03 20 04 20 05 20 06 20 07 20 08 20 09

0

Nurses Doctors Figure 1: Number of nurses and doctors per 100,000 inhabitants 1995–2009 (The National Board of Health and Welfare 2012, Statistical Database on Healthcare employees). 40,000 30,000 20,000 10,000

Women Men

0 2005 2006 2007 2008 2009 2010 Figure 2: Number of assistant nurses employed in county healthcare sector 2005–2010 (­Statistics Sweden, The Swedish Occupational Register).

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70,000 60,000 50,000 40,000 30,000 20,000 10,000 0 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 Women Men Figure 3: Nurses employed within the healthcare sector 2001–2010 (Statistics Sweden, The Swedish Occupational Register). 25,000 20,000 15,000 10,000 5,000 0 2001 2002 2003 2004 2005

2006 2007 2008 2009 2010

Women Men Figure 4: Healthcare specialists (referring to doctors as well as specialised dentists) employed within the healthcare sector 2001–2010 (Statistics Sweden, The Swedish ­Occupational Register). Occupation

2004

2005

2006

2007

Doctors

23.7

24.3

25.3

26.2

Nurses

8.7

8.8

9.1

9.3

Assistant nurses

10.6

11.0

11.3

11.7

All employees

10.8

11.1

11.4

11.8

Figure 5: Percentage of foreign-born employees in municipalities and counties 2004–2007. ‘All employees’ refer to administrative personnel, EMS staff, paramedical occupations, engineers and technical support staff, counsellors, psychologists, service workers including cleaners and janitors, dentists employed by the Swedish Association of Local Authorities and Regions (Sveriges Kommuner och Landsting) (SKL 2007).

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No.

Nordic countries

EU

Doctors

7,348

17.4

42.4

19.4

23.0

9.8

30.5

Nurses

8,013

36.3

19.2

8.3

10.9

9.8

34.7

Assistant nurses 4,626

28.8

12.5

4.5

8.0

15.3

43.4

Occupation

Of which Of which Outside EU15 EU16–27 Europe Europe

Figure 6: Percentage of foreign-born employees in municipalities and counties 2007 according to region of birth. EU15: BeNeLux, France, Greece, Ireland, Italy, Portugal, Spain, UK, Germany, Austria. EU16–27: Bulgaria, Cyprus, Estonia, Lithuania, Latvia, Malta, Poland, Romania, Slovakia, Czech Republic, Hungary, Slovenia. ‘Europe’ refers to ­European countries outside of EU. ‘Outside Europe’ refers to all other countries (SKL 2007). 70,000 60,000 50,000 40,000 30,000

Women Men

20,000 10,000 0 Assistant nurses Nurses Doctors Figure 7: Average monthly income in SEK among county-employed healthcare workers 2012 (Statistics Sweden, The Swedish Occupational Register).

Changes in the healthcare system since the 1990s Up until the 1980s, the objective for resource distribution within the Swedish healthcare system focused on identifying and fulfilling needs within different sectors or segments. From then on, other objectives have been placed at the fore, especially cost control and productivity (Anell 2011: 181). While public sector resource depletion has affected the healthcare system throughout its divisions, this sector is continuing to increase its take of the GDP (representing 9.4 percent in 2008; Anell 2011). Two primary reasons for this are suggested to be advancements in medical technology and increased costs of pharmaceuticals,

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paralleled by an ageing population. New treatment methods mean that more patients can be treated, but also that the number of people who require treatment increases; “the number of people awaiting balloon expansion has not declined despite the increase in number of patients treated”, to take just one example of this contradictory development (Ds 2002:32: 111). In this context, then – increasing expenditure related to technological advancements and pharmaceutical costs, coupled with a political emphasis on general cost reductions within the public sector – there has been a number of significant changes within the healthcare sector. I outlined the political shift towards neoliberalism in chapter 1, and will therefore concentrate on noting some of the central factors that have marked the structural transformation since the 1990s (based largely on Ds 2002:32 and Anell 2011) and that have had profound effects on working conditions among care professionals: – The shift in distribution of labour between counties and municipalities means that counties now focus on emergency medical care and municipalities are responsible for long-term care. – The introduction of purchaser-provider models and performance-based remuneration systems, including the increasing numbers of private care providers, especially within the primary care system, marks a change towards a circumscribed neoliberal model of healthcare, affecting also the organisation of work and management responsibilities of clinics. Hospitals now have the responsibility of not running a deficit; this responsibility is usually placed also at clinic-level, redefining financial responsibility and opening up new career-paths for nurses, who now manage a great deal of first-line care. – The number of beds in institutional medical care was reduced by approximately 50 percent during the 1990s, beyond the takeover of geriatric care and nursing home care by the municipalities. The contradictory developments regarding reduced number of beds and increased number of doctors’ visits are related “in that the average periods of treatment were cut noticeably within insti-

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tutional care and also due to an increasing number of treatments within out-patient care” (Ds 2002:32: 11). – Staff reductions, primarily affecting assistant nurses and orderlies, have resulted in the disappearance of at least 60,000 jobs since the 1990s. – Meanwhile, Swedish healthcare is increasingly professionalised, with more physicians being employed throughout the sectors. This, however, does not mean that access to physicians has increased for the entire population: “Municipalities/primary healthcare clinics in socially exposed areas often have fewer general practitioners on staff” (Ds 2002:32: 110). – Households have been affected by increasing expenses of healthcare as well, mainly attributable to fees and pharmaceuticals: “The system of user fees related to the purchase of prescription pharmaceuticals has been fundamentally altered on a couple of occasions during the 1990s with the notable effect of increased costs for the individual” (Ds 2002:32: 109). – Further, introductions of versions of voucher systems (in elder care) and the so-called ‘health choice’ system in primary care, in addition to the deregulation of the pharmacy, have meant that care provision is progressively privatised in terms of the institutions patients and customers interact with (Anell 2011: 209). – Research and national statistics show structural changes in the wake of privatisations and New Public Management have transformed not only the composition of the healthcare personnel, but have also affected their work environment. According to a report from the Swedish Work Environment Authority (Arbetsmiljö­ verket), assistant nurses accounted for the highest number of reported work-related illnesses and accidents during the period in which I collected my data (Arbetsmiljöverket 2012). Assistant nurses and nurses reported more work-related illnesses than other occupations, mostly due to stress and high workloads; only 13 p ­ ercent

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of such injuries or illnesses were linked to allergies or medical/­ chemical/biological factors, suggesting that the main problem for these workers was not related to the sometimes hazardous materials they were using, but rather the outcome of intense labour processes and other organisational issues. These changes have taken place within and beyond the implementation of NPM regimes. Gustafsson (1994, 2000, Hasselbladh et al 2008) has followed these changes from the get-go, and his observations of the increasingly recognised and powerful discourse of public sector ‘slack’ in the 1990s provide a critical understanding of the ways in which the neoliberal transformation of the healthcare system, not least through NPM ideology, was legitimised through criticism of healthcare workers’ performances (Gustafsson 1994: 10f ): In … consultant- and economist-language, ‘restructuring pressure’ and ‘organisational slack’ is often debated. These concepts have bolstered the conflict between work environment and efficiency, rather than opened up for a debate on the conditions and role of care work in society. Patients and taxpayers have been placed against staff and ‘healthcare bureaucrats’. Pressure to restructure is a central concept in the official productivity report that was launched in 1989 on behalf of the Social Democratic government and aimed to “… both analyse the causes of the weak Swedish growth and propose ways to increase growth”. … Here one is told that the public sector has “an oldfashioned management system” and that “staff lacks incentives to preserve resources or increase productivity”. … The image conjured up is one of a conceited and ponderous staff, one which can’t be prompted to change with less than violent methods. No point in listening to what they have to say. (And certainly many of us have felt powerless in dealing with the healthcare system.) But there are other experiences to listen to, and other ways of making change. Or have we given up on democratic, thoughtful and perceptive approaches during these times of crisis? The concept of organisational slack is meant to fuel notions of distrust of what happens ‘inside healthcare’ and create hope for quick fixes, rather than to maintain interest in the ways in which the inner conditions of healthcare are related to effects on staff, patients and developments in society in general. … A leading consulting company … has in a brochure argued the following: “Slack exists in all organisations that have substantially expanded and practised without longstanding and efficient cost control. The slack is often difficult to point out directly. The resources escape, not through a few big holes, but through many, minor leaks. … In our studies we have seen many examples of first-line management not knowing exactly how staff spends their

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time or how much staff is actually needed for solving tasks at hand.’ In this brochure, one is told that it would probably be possible to save 50 million SEK in any average county if only the consultants were allowed to “stand by and observe” and point out all the slack. … What is promised is the possibility of saving money.

This is a lengthy quote, but I include it because it offers a critical examination directly of the discourse of the time, the crisis, the neoliberal transformation, and the implementation of NPM in the 1990s. It illustrates the ways in which the terminology favoured by politicians and private business placed the problem, perceived as growing costs and structural inefficiency in the public sector along with underperformance in relation to patients, directly among the healthcare employees on the floor. This explains the emphasis on performance management and contextualises discourses of individualised care and “customer orientation” (Du Gay & Salaman 1992). While it is evident that much of NPM ideology is linked to neoliberalism, especially the focus on market mechanisms as key principles of increased production and at the same time cost reduction, researchers have pointed out that main features within NPM are also products of modernism, such as emphasising measurable profit and management (Hasselbladh et al 2008: 61). This has long been a feature of the Swedish welfare state, Hasselbladh et al argue, noting that ­government-run programs of management have been interlocked with domestic corporate capitalism since the beginning of the twentieth century, leading organisations within different segments of the public sector to prioritise issues of management mechanisms and efficiency. Following Ferlie’s (2007;2 see also Hood 1991, 1995; Ferlie et al 1996) summary of NPM, central features of the change in healthcare management include: – New core values such as “value for money; efficiency; performance management; transparency; contestability” rather than “democratic control; public accountability; special status of the governmental sphere” 2. This summary is based on a lecture delivered by Ewan Ferlie at Copenhagen ­Business School in 2007. See reference list for further information.

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– Introduction of quasi markets; increasing flow of private money; contracting out – Rise of senior general management and diminishment of public sector trade unions; circumcision of traditional public sector professional groups; some attempt to empower consumers against producers – Emphasis on audit systems and contract management systems. This section has focused on describing some of the changes within the healthcare system since the 1990s, and has aimed to locate these changes in a political context of circumscribed neoliberalism and NPM regimes. Next, I will provide a local context for the ethnographic analysis of work and the construction of femininity among nurses on the shopfloor of City Hospital. I will begin with the regional economic and political space of which the hospital is part.

County Benner (2003), in his analysis of welfare state change in Scandinavia, argues that regions have become important factors in the rise of a knowledge-based Swedish economy. Acting as ‘clusters’, a core feature of the region is the interplay between institutions such as universities, financial sectors, public agencies and industries (Benner 2003: 134). Politically, one of the main ways of trying to push economic growth in Sweden during the last decades has been to focus on regions, including, as Benner notes, establishing regional growth agreements where “regional representatives from industry, organisations and unions jointly decide on the allocation of regional policy funds” (Benner 2003: 141). The county was located within one of the major Swedish ‘clusters’, and functioned as a key actor in this economic and political space. The discourse of facilitating economic growth and private sector development was prevalent within the county as a political entity, and public sector responsibilities such as transportation and healthcare were described in key documents as well as in public communication material as factors enabling industry, commerce and knowledge

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production. The county described its goals and visions in terms of facilitating “entrepreneurship”, “creativity” and “partnership between private business and public sector”. In terms of economy, the goal was “low levels of taxation … avoiding tax rises”. Despite the strong presence of neoliberal discourse, the main business of the county was the practical delivery of healthcare to its citizens. Within the Swedish welfare state, counties manage and control the primary healthcare system (local family clinics and dental care) as well as the specialised somatic and psychiatric care via hospitals. A regional assembly elected directly by the voters governed the county. The majority shifted every alternate four-year period or so, but during my fieldwork it was run by a rightwing majority. Social Democrats were the biggest party, but the biggest rightwing party, the Moderates, along with supporting parties, held a stable majority run by a number of governors (a majority of whom were women) in charge of the different sectors: healthcare, transportation, et cetera. The county constituted one of the strongholds of the rightwing, populist/racist party the Sweden Democrats. The Right3 was committed to privatisations. During the 1990s, they privatised a number of hospitals that were later made public again when Social Democrats in alliance with the Left party and the Green party gained the majority (the privatisations proved financially disastrous during that time; taxpayers effectively bailed out the corporation created to run the hospital as a private enterprise). In the election that was held during my fieldwork, Moderate politicians again said they would privatise entire hospitals, but seemed unable to live up to their promise; they did, however, privatise parts of care programs within different specialties. Municipalities within the county for their part privatised elder care during this whole period. Throughout the period of fieldwork, cutbacks were ordered by the political majority in the county, and thousands of care workers were let go despite a general surplus of several hundred million SEK. 3.  The Swedish political field is dominated by the Right (a conservative/liberal/center coalition of four parties all committed neoliberal financial politics) and the Center/ Left (dominated by Social democrats, and including a green party and a socialist party; the Social democratic party has also been an active force in the neoliberal shift). The racist and conservative party Swedish Democrats tends to passively support the Right.

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­ utbacks propelled recurring waves of media attention to the situaC tion at county hospitals, ranging from group interviews with overworked nurses and doctors to reports on patients being hurt and even dying because of lack of staff, space and resources in the emergency rooms. Petitions were signed and protests organised in other cities against the cutbacks and reorganisations of the hospital care in the county; the political response was bleak and no policy changes made. Cutbacks and reorganisations in order to cut costs were the main path for county politicians during the entire decade in which I did my fieldwork. In one especially memorable newspaper interview, a county politician said healthcare employees should work harder to cut costs by not wasting supplies and by preventing costly patient infections by keeping proper hygiene. In the article, the politician explained that every employee had to do their best to think of new ways of saving money. After the fourth saving plan was announced in the county, the unions stated that additional cutbacks would ‘affect’ quality of care, meaning patients and staff would be put at risk, but county politicians were steadfast.

City The city was one of a few cities with more than 100,000 inhabitants in the area. It was an old industrial town, with a socially and racially segregated urban centre. Politically, the city had a strong Social Democratic party but also a long tradition of rightwing and even extreme rightwing activism. During my fieldwork, the Right was in majority in the municipality. According to local statistics, women participated in the labour market to roughly the same extent as men. Overall labour market participation ranged from around 49 percent in the poorer and more ethnically diverse parts of town, to between 70 and 87 percent in most of the other parts. The division of labour was traditional: women were predominantly employed within the public sector, caring for children, the elderly or the ill; men tended to work in business, in the tech-sector, and in transportation. Local statistics were available in the form of colour maps indicating exactly how the unemployment rates varied across town, graphi-

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cally illustrating class and racial segregation and its social and economic effects on neighbourhoods. Some parts of town had less money, poorer health, higher unemployment rates, lower education, relied more on public transportation, and were disproportionately made up of people who had migrated to Sweden. About 20 percent of the city’s inhabitants were born abroad, mainly in the former Yugoslavia and Iraq, Scandinavia, Eastern Europe or Southwest Asia. Apart from the structural racism mapped by municipal statistics, there were also blatant racist sentiments shown in graffiti and stickers with xenophobic, sometimes even neo-Nazi, messages posted across town. I remember thinking about this as I took the elevator down from one of the wards where I had ‘followed’ a nurse born and raised in Bosnia, who came to Sweden as a refugee during the war in the 1990s. I had asked her if she ever faced racism, and she said “No, not really.” As I entered the elevator, pressed the button and turned towards the door, a graffiti-styled tag appeared: “MUSLIMS GO HOME”. When I exited the hospital, I saw a sticker placed on a traffic sign, citing some made-up statistic about immigrants and crime, clearly aimed at incensing non-immigrants. And then, when I approached the train station, another sticker with a similar message entered my field of vision. As I started to look closer at these little markers placed all over town, I noticed that a sticker-and-tag war seemed to be going on between racists and anti-racists. Evidently, even the hospital was claimed as turf.

City Hospital City Hospital was one of a handful of so-called ‘emergency hospitals’ in the county. Serving patients from nearby Lake City, Hills City and smaller towns and communities, the hospital was a large organisation employing close to 3,000 people. About 40 percent of all employees were nurses (about 94 percent of whom were women), 16 percent were doctors (a majority of whom were men) and 20 percent were assistant nurses (about 80 percent of whom were women; orderlies in the psychiatric care were included in this category, and they tended to be men). About 8 percent were so-called ‘medical secretaries’ and the rest was comprised of paramedical occupations such

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as physiotherapists and occupational therapists, as well as psychologists and counsellors, and administrative and tech-support staff.4 A majority of those I interviewed grew up near or around the hospital they worked in; those born abroad had migrated to Sweden under the status of asylum-­seekers. While the primary care system within the county was dependent to varying degrees on employment services which provided primarily doctors working on short-term contracts, City Hospital employed most of their physicians and recruited them locally and nationally.

Impressions of a place The first person I shadowed at City Hospital was Pia, a physiotherapist working on the children’s ward. I was supposed to meet her in the lobby on the first floor, but I misunderstood and waited for her in the main lobby on the ground floor. I sat down on a bench in the square lobby, surrounded by elevators leading up to different floors and wings. As I waited, a lady sat down next to me and struck up a conversation. “Isn’t this a dreadful place?” she said, and I agreed. It wasn’t just the reality of being in a hospital, where you normally only visit if something tragic has taken place (except if you’re there to give birth or greet a brand-new family member; those opposites were the drama of the place). The building itself was stark and imposing, a massive block of concrete and brick with interior decorating in yellow, beige, green and shades of blue and brown. There was a lot of movement in the lobby: staff walking purposefully and fast, visitors and patients walking more slowly, trying to orient themselves and find the right floor, turn or door. Janitors, cleaners, Red Cross volunteers and EMS staff could be seen standing or walking around doing their work or moving to and from it. As I would later learn, different floors had different flooring. The psychiatric wing had a dark-coloured plastic mat, surgical a brighter one, paediatrics something in-between. I had never really been on the inside of this hospital, in the corridors and wards. I hadn’t known 4.  A little over 80 percent of the women in care and medicine worked full-time. Almost all of the men worked full-time, although, towards the end of my fieldwork, the hospital reported that more men were working part-time than before, while there was a slight increase in full-time employment for women. I view this as one example of a shift towards more egalitarian gender relations (Stanfors 2007: 87ff).

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what to expect in terms of the physical layout, but as I sat there with the lady talking, I just assumed everybody who worked here found the aesthetic depressing, just as we did. I was wrong. When Pia found me, we took the elevator up to the paediatric floor and, as we entered the poorly-lit main hallway, I asked her what she thought about the building. She told me she loved it. “The view is amazing, isn’t it? And it’s so practical, the architecture is so clever – think about the way the elevators are located, and then there are separate elevator shafts for staff and for moving patients, so that you never have to walk around the public parts of the hospital with a patient in tow. It is well thought-out and functional, I really like it!” I had never thought about those things, and it shifted my perspective. From that day on I appreciated the building more and more, as I understood its functionality and saw the attempts at making the inside look interesting in all its sterility and public sector demeanour.

A partial view of a complex space Soon enough, I’d walk through the entrance, go straight for the ward I was supposed to visit (which was usually Ward 96), and almost never got lost. But the more I saw of City Hospital, the more I realised just how little I actually had accessed. I spent a good deal of time at the hospital, and yet I saw only a glimpse of its inner workings. There were entire wings I never entered. The real back rooms, in which laundry was handled and dishes cleaned, I saw very little of. Even a mid-sized hospital such as City offers most people, including those who work there, only partial views of its interior. Nurses would sometimes take patients for x-ray, fetch them from ER or take them to get tests at a clinic in a different part of the hospital. But mostly they worked on the floor of their own ward and saw little else (one study of Swedish hospital nurses found they spent 95 percent of their time within the confines of their respective wards, Furåker 2009: 271). Doctors moved around a bit more, depending on what specialty they were in, but mostly moved from their administrative quarters to the wards and operating, x-ray or examination rooms. Physiotherapists usually moved around even more, going from different wards and back to their own corridor and gym-like facilities.

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Still, an a­ naesthesiologist would have little to do in the psychiatric ward, an assistant nurse working in ER would have little business in the psychogeriatric ward, and midwives would seldom visit anything but the OB/GYN and the operating rooms in which Caesarian sections were performed. To me, the hospital comprised the wards that I visited during fieldwork, the main lobby, the cafeteria and the basement, where I collected suitable scrubs from large steel carriages on wheels. The wheels told me these carriages were sometimes taken to be restocked, but I had no idea where to. Such was the partiality of my view.

Shopfloor, back regions, front regions As Pia brought to my attention, the partial view was intentional. The architects had kept efficiency, both in terms of work and in terms of space, in mind when they designed the building. They were concerned with creating short distances, all in line with a Taylorist conception of how to promote productivity. But it was also clear that the architects had thought about the need for back- and front-stage spaces. Thus staff rarely used the central elevator shaft. Instead, there were backregion elevators used to move patients, and emergency elevators used to reach operating rooms quickly and without interruptions. Staff, I learned, preferred the stairs located next to each wing when they were moving between floors. The stairs were somewhat hidden, but I took to using them instead of the elevators, just to see who were running up and down them: it seemed to me that it was often male doctors, hands tucked into their white coat pockets despite the narrow spiralling of the stairway. I always seemed to get in their way. Concrete buildings have a limited flexibility. Over the years, City Hospital had undergone renovations and had annexes built onto it, but even though it was described by the county as “still comparatively well-functioning” in relation to other hospitals built at around the same time, there were problems with the facility itself.5 More people, changing technology, but also changing work cultures and standards of work environment meant the interior evolved over time and the capacity of the building was stretched to the fullest. During my field5.  See Prasad (2008) for a critical discussion on the tensions involved in designing and constructing hospital buildings for the public sector.

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work, plans were formulated to rebuild the entire hospital, but lack of funding put them on effective hold. Space itself had a major impact on the work performed. The layout would in varying degree dictate how work was organised and experienced. Older staff, such as assistant nurse Margareta, who had worked at City Hospital since 1962, remembered a much different layout. In a conversational interview over the coffee table in Ward 96 she told me: We used to have smoke rooms, where patients and staff would sit together and smoke. We had lounge rooms outside the wards, where everybody on the same floor could be on break together. We had much more lounge rooms where patients, and staff too, for that matter, could sit together. We used to smoke on the balconies.

Now, smoking was hardly allowed on hospital premises at all. Employees were not allowed to smoke during shifts, and were not allowed to smoke at all while wearing scrubs. There were essentially no lounges or rooms where patients and staff could sit down together; I saw this happen only in the psychiatric ward, where orderlies would sit down with patients in front of the TV and chat. But even then it wasn’t considered an off-stage practice, as it were, when doctors and nurses had a cigarette together with patients during breaks. So spaces where the front-stage/back-stage divide could be challenged did not really exist any more. The lack of these types of space that used to exist speaks to the changes in labour processes within the hospital and within the Swedish healthcare system. As research has shown (Blomgren 1999), time has become a commodity as austerity calls for intensification of the labour process. Sitting down midshift to pause is no longer a legitimate way of organising work. In The Presentation of Self in Everyday Life, Goffman analyses regions – “any place that is bounded to some degree by barriers to perception” (1959: 66) – and regional behaviour. Front regions refer to the space in which a performance is given – the interactional and public part of care work, as it were, in this particular context. Goffman (1959: 67ff) describes front-region actions as guarded by “an effort to give the appearance that [the actor’s] activity in the region maintains and embodies certain standards”. Some “aspects of activity” will

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be accentuated in the front regions, whilst some will rather be suppressed. In contrast, back regions (or back stages) represent areas that are closed off, and where the actor can “relax; he [sic] can drop his front, forgo speaking his lines, and step out of character”. Goffman, in his general description of back-region features, captures the way that front and back stages were connected yet separated both in terms of space and in terms of interaction at City Hospital: … the back region of a performance is located at one end of the place where the performance is presented, being cut off from it by a partition and guarded passageway. By having the front and back regions adjacent in this way, a performer out in front can receive backstage assistance while the performance is in progress and can interrupt his performance momentarily for brief periods of relaxation. In general, of course, the back region will be the place where the performer can reliably expect that no member of the audience will intrude (Goffman 1959: 70).

I use these same concepts to illustrate the way that work within the hospital was performed in two types of spaces: where interaction could and would take place with or in front of patients and/or visitors (front regions), or where interaction would take place only between staff (back regions). Access to back stages is linked to positions of power within the hospital organisation (Lindgren 1992). Consequently, there are degrees of back stages. At City Hospital, having a private office space was afforded only those in management positions. Chief physicians would have offices outside the wards, while frontline nurse managers would have their offices in close proximity to the nursing receptions on the floor of the ward. Doctors would have more rooms where they could perform administrative work behind closed doors, whereas nurses and assistants would share a number of computers in reception areas where telephones were constantly ringing and where patients could knock on the door at any time. Nurses working in these areas could in fact not reliably expect that no patients would intrude. Further, these rooms often had large windows facing main hallways in the wards. This was the case in the ER ward, for example. Each shift was divided into two groups who each took care of about half the patients. The reception was located in the main hallway and ran parallel to it. It

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was divided into two rooms by a thin wall with a door in it. The two rooms had desks, a couple of computers, big whiteboards, and bookshelves of binder-files. The main part of the wall facing the hallway consisted of windows, so that anybody who walked by could see inside (the room was closed off, in Goffman’s words, “aurally but not visually”, 1959: 66). At the end of the hallway was the doctor’s office, which had only a windowless door facing out and a simple sign that read: ‘Doctor’s reception’. Next to it was a small whiteboard where someone had written the names of the doctors working the shift. Front regions would be the public parts of the ‘shopfloor’ at the hospital, such as patients’ rooms and main hallways in the wards, the operating rooms, examination rooms, and the waiting rooms of the ER; all the spaces that patients and/or visitors would have access to and where they could interact with staff. I use the term ‘shopfloor’ to indicate the front-stage areas where most work was performed, but the term also includes areas that were usually off-limits to patients, such as medical supply rooms, rinse rooms, ward kitchens, et cetera. The concept of shopfloor has been used to describe industrial work, usually machine halls or production lines. But nurses and assistant nurses would often talk about their everyday experiences in terms of “us on the floor”, or “out on the floor” (‘vi på golvet, ute på golvet’). It’s an expression that echoes (Fordist) grass-root labour movements’ way of talking about themselves and their experiences. Talking about “us on the floor” often entails pointing out the distance to those “up there” (cf. Martinsson 2006, Mulinari 2007); thus there is a dimension of recognising power asymmetries – class – by using this phrase.

Continuity and change in spatial arrangements In several studies it has been pointed out that the division of labour between nurses and auxiliaries centres on the proximity to hightouch, intimate interactions with patients; specifically the level of involvement in ‘dirty’ tasks or intimate and ‘dirty’ parts of the body (McDowell 2009). In a Swedish context this has been explored by Lindgren (1992: 26f ), who linked this division of labour to the spaces controlled and inhabited by different occupational groups within the hospital. She distinguished between ‘in’ and ‘out’. ‘In’ refers to “the

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formal centre of power, that is the medical knowledge possessed by the doctors who are ‘inside the centre’”. Assistant nurses would be ‘out’ in this way of speaking: out on the ward, out on the floor. Nurses would be ‘in’, inside the reception area or administrative quarters. The innermost circle would be reserved for doctors as they managed the hospital based on their professional status. A more contemporary example is Wolkowitz (2006: 154 references excluded), who argues that within the nursing sectors, divisions of status reflect different relations to the body, sometimes conceptualised as the difference between ‘technical’ and ‘basic’ nursing, the first involving ‘cleaner’ tasks and the latter involving meeting the gross, even polluting, physical needs of the patient, including the ‘dirtier jobs’. This hierarchical distinction has been exacerbated by managerial cost-cutting strategies that seek to surround a ‘core’ of highly-paid ‘knowledge nurses’ with a periphery of cheaper care assistants.

This division of labour between nurses and assistants in terms of what space they inhabited during the workday and the level of touch their tasks included was – often – less strict than noted in Wolkowitz’ and Lindgren’s studies. Nurses in the wards I visited would spend a great deal of their workdays in the front-stage areas, performing high-touch work. At some wards, work was organised in teams, so that each nurse had an assistant nurse assigned to her, and they would decide how to organise their day, starting by going around to all their patients at the beginning of the shift and introducing themselves. In most wards, tasks related to the patients’ hygiene was allotted to assistants; however, this was not the case at Ward 96, where there were simply too few assistants to maintain this kind of division of labour. Thus at Ward 96 nurses performed the ‘dirty jobs’ alongside assistants. This shift in the organisation of nurses’ work is linked to two aspects of NPM: on the one hand the increased emphasis on production of core tasks, on the other hand on the process of professionalisation. In City Hospital, nurses were encouraged by management to “reduce time spent on administration” and “prioritise patient care”. What I observed at the wards of City Hospital was not a strategy to surround highly-paid nurses with a periphery of cheaper care assistants, but rather processes of expanding the jurisdiction and areas of

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responsibility of nurses and adding to their workloads. As there is only a minor wage differential between nurses and assistant nurses,6 it seems more practical for the employer to hire nurses, who can perform both skilled and ‘unskilled’ tasks. This matches the development in the service sector. Mulinari (2007: 231) argues that the expansion of tasks and responsibilities experienced by employees in her study can be seen as linked to degradation of work (the opposite of what Braverman 1974 found in his study on industrial work); at the same time, it makes employees more versatile. That on the other hand can render them more exchangeable. What Mulinari showed was that this also challenged the service workers’ sense of pride. Did this also match the development in hospital care work? The nurses in my study emphasised two things in terms of what gave them joy and what made them feel proud: the joy was in “meeting patients”, the pride was in technical skills. Ward nursing as organised at Ward 96 had both been degraded in terms of expansion of tasks and responsibilities, specifically in rendering nurses responsible for high-touch, “dirty” work. But it had also become more high tech, rendering high-touch work simultaneously more high tech. The closing strategies that nurse managers had put in effect towards assistant nurses, as nurse managers preferred to hire only nurses, had also the effect that registered nurses now controlled almost the entire work process around patients. Thus, ward nursing in this respect was signified by both deskilling and degradation and skilling coupled with increased control. In comparing observations from ethnographies conducted before the implementation of NPM regimes and austerity ideology, there is a marked difference in the availability and legitimacy of back regions and spaces for interactions between co-workers. One of the things many readers remember from Lindgren’s (1992) study is the off-stage spaces and practices available to and deployed by “the girls”, as she calls assistant nurses and auxiliaries. She describes how they would meet in the ward kitchens and rinse rooms: 6.  And sometimes, nurses make less money than assistant nurses; this was the case for Kadia, who was recently employed at Ward 96. As she moved up the ladder from assistant nurse in the municipality elder care to a position as registered nurse in specialised surgical care, she lost a good chunk of her monthly pay while at the same time experiencing a more stressful work situation where the stakes were considerably higher (as she was responsible for administering medication et cetera).

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The girls’ visits to more secluded areas such as the kitchen or the rinse rooms are not always motivated by work per se, but rather by the need to withdraw for a while. When a girl seeks out a space such as the rinse room, she is often accompanied by another girl and sometimes by all the girls. These meetings take place somewhat secretly, and most often the things they talk about have absolutely nothing to do with work (Lindgren 1992: 28).

I should begin by saying that the assistant nurses who had read Lindgren’s book disliked accounts like these. They took them as evidence of Lindgren stereotyping and sometimes being plain wrong. But what was striking in talking about such events with nurses and assistant nurses was the redefined notion of time. As one assistant nurse said: “When would we have time to hang around in the rinse rooms?” Nurses who were familiar with the book would find accounts like these pertaining to the practices of assistants more accurate, although oversimplified. While assistant nurses in some wards would use these spaces more often, and consequently have more opportunity to meet and interact in them, there were several factors restricting the possibilities of these rooms becoming social spaces. One obvious reason was the layout and function of the rinse rooms. No one would stand around for very long in those narrow spaces, filled with containers and sinks and trashcans for sorting biological and other waste material. In the rinse room at OB/GYN, Maria and the other assistant nurses would examine, weigh and dispose of placentas. In the rinse rooms at other wards, nurses would dispose of urine and faeces, diapers, syringes, empty cardboard boxes and plastics. They would throw dirty scrubs, dirty patient robes and dirty bedlinen into large bins. Assistant nurses would fill large, restaurant-kitchentype dishwashers with bedpans and instruments that didn’t have to be sterilised. Neither did I see much interaction in the ward kitchens. Most wards I visited had three kitchen areas: one patients’ lounge, with some kitchen facilities such as a fridge, stove, microwave, coffee-maker, tea-kettle and some basic utensils to cook or heat simple food. Then there would be a ward kitchen, which stored provisions such as energy drinks, ice cream, ready-made soups, bread, butter, cheese et cetera. Nurses and assistant nurses would use them to make sandwiches for patients who were hungry. It could go like this: Janet on Ward 96 had

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a patient with diabetes. After checking his blood sugar, she determined he needed to eat something. She told him: “I’ll go make a sandwich and then I think you need to drink some milk, okay? What would you like on your sandwich?” She would then go to the ward kitchen, prepare the sandwich and pour the milk, and return to the patient. The ward kitchens usually had windows and the doors were almost always open. Nurses were running in and out of them. Assistant nurses were usually scheduled to clean, refill and organise these kitchens. Lindgren’s description subtly resembles pop cultural depictions of maids convening in the back rooms of elite households, chitchatting and gossiping about their masters, leaving their blank faces at the green baize door to become real people once inside the warmth and relaxed space of the kitchen.7 Apart from the fact that the kitchens and rinse rooms were not big enough to convene in (despite the radically decreased numbers of assistant nurses since the 1980s), and not secluded enough to house secret meetings in, there was hardly any time for such practices at City Hospital. Further, as interactions did take place in the back regions, they did so as work happened. The strength of the concept of back regions is the notion that in these spaces work takes on another form, as it is removed from the service interaction with clients, customers or patients. It illustrates that front-stage work has dimensions beyond the practical, physical tasks. All front-stage labour has an emotional component in terms of management of facial expressions and bodily appearance. I would argue, though, that the distinction between front and back stage risks convoluting the work that goes on in back stages. It can create a notion that if work is not seen, it is not performed; or at least it isn’t as draining. There is need for a more complex understanding of different spaces of hospital work and the changes that have affected them during the last decades. The smoke room that Margareta talked about was not ‘back stage’, since smoking was an act performed alongside – in front of – patients. However, in this room, it was legitimate not to work. Thus it represented a space of somewhat levelled interaction between d ­ ifferent 7.  Some examples of pop cultural depictions of this kind: the book The Help (2011) by Katherine Stockett about black maids in 1960s Mississippi; the movie Maid in Manhattan (2002), where Jennifer López plays a maid in a fancy New York hotel; and Gosford Park (2001), a drama set in the 1930s about servants and masters at a British country house.

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occupational groups, but not a back area without an audience.8 In the back stages such as the rinse rooms, it was not legitimate not to work, and (dirty) work was what took place here. Further, these back stages was often entered and exited so quickly that there was no real spatial division that could settle and provide relaxation to nurses. As I will demonstrate in chapter 7, it was administration that provided nurses not only with professional legitimacy and visibility (Blomgren 1999), but also, crucially, with time to recuperate. It was in front of the computer that nurses would pause to think and find time to figure out how to plan their day. It was telling that when the experienced nurse Janet broke down in tears from stress, it was in front of the computer (see chapter 7).

Spaces to rest On the wards, care workers, frontline managers and administrative personnel would spend their breaks in the lounge room. The lounge rooms mostly looked the same throughout the hospital: a big conference table that would seat twenty-something people; a couple of fridges and microwave ovens; boards where information from the unions, the county, hospital management et cetera would be posted; a sink and one or two large dishwashers; a sofa or two; stacks of magazines (ranging from specialist periodicals such as Dagens Medicin to women’s magazines); some plants. They were crowded during breaks at around ten in the morning and during lunch at around noon. Alarms would sound and people would look up towards displays that indicated where there was a problem, so work was never shut out completely. At some wards, doctors used these rooms during breaks and they mixed 8.  In the Eighties and Nineties my mother was employed as a cleaner at a hospital. She remembers clearly the smoke rooms, where she and her best friend and co-worker sat down next to doctors and patients. “As smokers do,” they would lend matches and lighters to each other. Because of this, my mother knew the names of many of the doctors who smoked and they knew hers. This type of interaction would find no space to play out regularly at any Swedish hospital today. One reason for this is also that most hospitals no longer employ cleaners; instead, cleaning services are contracted out to transnational corporations such as Sodexo. I view this as a restructuring of social distance within the hierarchy of the hospital institution. While research indicates (Bejerot & Astvik 2009) that patients experience a decreasing social distance between themselves and doctors, my own research indicates that in some ways the distance between different groups of hospital workers has increased.

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with the nurses and assistant nurses. This was the case in the ER ward. On other wards, nurses, assistant nurses, sometimes physiotherapists or other paramedical occupations, but never doctors, would use the lounge rooms. Sometimes it shifted with the doctors; some doctors would join in on coffee at the ward, others would use administrative quarters outside the ward or go to the main restaurant in the basement of the hospital, where they would sit with other doctors. Assistant nurses could usually have a fixed coffee break at around ten, when their first round of work was finished. Nurses would have to be more flexible in this regard, and doctors even more so. These practices and habits seemed to reflect what Lindgren observed, although they were less temporally fixed than she describes it (Lindgren 1992: 28).

Lack of space There was always a lack of space.9 Nurses would bump into each other in the medicine supply room, where they had to squeeze by other nurses mixing antibiotics and preparing IVs. During morning reports and other meetings in the nurses’ reception, people would often have no place to sit. The lack of space affected patients as well. Patients’ rooms were small and, if families wanted to visit together, they would crowd the room and part of the hallway, which sometimes made it difficult for nurses and assistant nurses to move through the corridors with equipment. Having more patients than stipulated was common. During the period of fieldwork, from 2008 to 2011, City Hospital was criticised more than once by authorities for having placed patients in corridors and in areas not designated for medical treatment. Doctors experienced a lack of space as well, but more in terms of not having a private area to do administrative work close to where they would perform work on patients. I witnessed on several occasions conflicts arising from lack of space: for instance, when nurses who wanted to work in front of the computer had to wait for their turn, which stopped them from completing one task and moving on to another one; or a group of doctors and nurses with a patient and a relative in tow walking around looking for a room to hold a private conversation about treatment plans, frustration showing clearly 9.  The lack of space is mentioned in older hospital ethnographies as well, such as Lindgren (1992) and Franssén (1997).

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as they asked if the business taking place in the occupied rooms was as relevant and important as theirs. Usually when I came to a ward to do an interview, the informant would have trouble finding somewhere to sit down, and I once did an interview in a storage room of the hospital.

Conclusions In this chapter, I have introduced the political and economic context of Swedish healthcare and the county. I have analysed the spaces of work in City Hospital, with its complex and only partially accessible rooms. By employing Goffman’s (1959) concepts of regions, I have illustrated some of the ways in which the inequality regime operates concretely through spaces of work. The main contribution here is to illustrate the tension between the physical colossus, the extension of the building itself, and the regulated pathways of the employees. Spatial distinctions are a central feature of power relations in the workplace, and there is a connection between mobility and power (Lindgren 1992). Nurses and assistant nurses spend most of their time ‘on the floor’ of the wards: nurses have access to more back-stage spaces than assistant nurses because they control the areas where administrative tasks are performed, but both groups perform their work in front regions, with little opportunity to close any doors behind them. Doctors, however, perform most of their work in areas that are restricted. Surgeries are performed in rooms that are sealed off due to issues of hygiene. Clinics are constricted rooms where access is based on scheduled appointments. Doctors perform administrative work in closed quarters, not in rooms that are only audibly – not visibly – closed off, as is the case with nurses. Doctors control the work processes because they control the conceptualisation of patient needs: they are, as Lindgren (ibid.) put it, at the centre of power through their control of the science of medicine. What is notable here is the continuity of gendered spatial arrangements of workplaces across the productive/reproductive divide. As Wolkowitz (2012: 182) notes when revisiting Glucksmann’s (2009 [1982]) Women on the Line, women factory workers in the UK automobile industry of the 1970s were “bodily tied to their workstations, while men workers’ jobs meant they were free to walk about”. While

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doctors generally are increasingly female, the vast majority of the physicians at City Hospital were men, especially so in surgery. Thus four decades later the same spatial arrangements are visible within public sector organisations as Glucksmann noted in factory work. More than gender, though, this is an issue of class practices. Psychologists and counsellors within the hospital also tended to be female, and were less bodily tied to their workstations; the same went for physiotherapists, who would often move around the hospital and visit different wards. Spatial attachment is linked to hierarchies of power and knowledge, as pointed out by Lindgren (1992). But it is also crucially linked to high-touch body work: ward work demands co-presence because the labour process revolves around and is partly dictated by the temporal unpredictability of the bodies being worked on (Cohen 2011: 191). It is labour-intensive in a way that other forms of care work are not. This is another way of uncovering the link between divisions in care work which also speaks to its increasing variability, even within the nursing profession. It further illustrates one aspect of the changing working conditions among nurses: ward nursing is increasingly performed front stage; the time spent ‘in’ has been reduced over the last decades. In the next chapter, I will introduce Ward 96 and the organisation of labour performed within the confines of the shopfloor. I will outline the various components of the labour process, analyse the specific character of the body work performed, and discuss spaces and ways to pass time, recuperate and interact. I will begin by discussing the challenge posed by nursing at Ward 96 to the distinction of ‘hightouch’ and ‘high-tech’ work, and analyse the specificities of nursing in a surgical ward where skilled interventions can be the same thing as ‘dirty work’.

5. Ward 96: spaces, processes and cultures of work

Ward 96 was one of the specialised surgical wards at City Hospital. It cared for patients predominantly diagnosed with cancer, and was both ‘high-tech’ and ‘high-touch’ (Brush 2000: 162, McDowell 2009: 167) in the sense that patient treatment required technology-­intensive care as well as hands-on help with hygiene, nutrition and body mobility. The area of the body treated in this ward is connected to dirt and leaking when injured or hit by disease. Thus patients often felt sick and vomited; they would need help going to the bathroom, be in need of diapers, and struggle with complicated wounds from the operations that would be difficult to heal and which would also leak. The nurse manager, Helena, explained that some of the conditions related to surgeries performed were very demanding in this regard, as they involved dealing with leaking bodies and messy wounds: [These conditions] require an unbelievable level of technique and knowledge about how to take care of it, what equipment to use, what it is like for the patient – and all this is really, really hard. And it’s not that fun, either. But we’re really good at it.

This meant that high-tech work was often at the same time hightouch work. Consequently the distinction between high-tech and high-touch, while useful in explorations of divisions of labour, is less suitable for conceptualising the type of nursing performed at Ward 96. As Helena implied, medical interventions performed by the nurses also demanded emotional labour as the tech-part was often performed directly on the bodies of patients and pertained to the regulation of body fluids. The interrelation of technology, touch and emotion meant that the division of labour noted by scholars such as

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McDowell (2009: 167), in which assistants and auxiliaries are made responsible for high-touch dirty work while nurses focus on ‘cleaner’ skilled interventions, was an unpractical way of organising work at the ward. This affected hiring policies. For several years, management had prioritised recruiting registered nurses over assistant nurses, and during day shifts nurses would outnumber assistant nurses by something like eight to two. This produced a less strict division of labour between nurses and assistants than what I had observed at some other wards. Sometimes, if Ward 96 was short of an assistant nurse but was fully staffed on the nursing side, a registered nurse would ‘temp’ as assistant. The nurse manager explained the recruiting policy by referring to the high dependency of skilled interventions in the care of the patients, specifically in the aftercare of complicated surgery: We need nurses more than assistant nurses. That is because our patients are very sick and often in need of care that requires advanced technology, lots of different medical devices, tubes, pumps, IV injections, et cetera. So for us it’s more efficient to employ nurses, to put it bluntly.

The high ratio of nurses meant they performed many of the tasks usually assigned to assistant nurses. Nurse Danuta pointed out that it would surprise people to hear that registered nurses in charge of skilled interventions in high-tech surgical care also changed diapers: I was asked by someone, “Who washes the patients, who washes them when they crap themselves?” I do it. “Oh, nurses do it? You don’t have the assistants doing it?” No, we do it! All of us do it. So that’s why we should earn more.

Danuta pointed to the complex relationship between the wage penalty and the dirty tasks in care work. While Danuta felt that performing dirty as well as skilled tasks should merit higher wages, dirty work usually pays poorly. All the nurses I interviewed felt they were underpaid. But Danuta also pointed to the image of nursing as clean work, and the related association between assistant nurses and auxiliaries and dirt. As I have illustrated, this notion of registered nurses performing ‘clean’ care work is reproduced in the literature on body work (as seen in McDowell 2009), and is based on the organisation of care work in many hospitals and nursing homes throughout the

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globe. Thus what I am referring to here is an organisation of work that is atypical in terms of literature on divisions of labour in care, and speaks to the specificity of Ward 96. As I have illustrated, though, the specific organisation of tasks was based on the technical materiality of the work performed and the economic considerations and outcomes of hiring policies related to patient needs and use of medical technology. Much of what was considered basic care work around the patients at Ward 96 required interventions that only trained registered nurses are permitted to do. However, while I do want to point out that the relative predominance of nurses in relation to assistants at Ward 96 was not representative of all wards at City Hospital, one should note the structural reduction of assistants and auxiliaries in Swedish hospital care since the 1990s.

Expanded responsibilities As the development towards professionalisation of the care process commenced in the 1990s, some feminist sociologists of work warned against the consequences for patients. Waerness (1984) and ­Franssén (1997) both argued that care rationality based on private, non-waged care work would be rejected as scientific rationales increasingly dominated the nursing field, which would mean that the interest in and emphasis on care practices would decline among care workers in general. The picture they painted of the future of healthcare included a stronger division of labour in which nurses would distance themselves from high-touch body work and consequently lose touch with the ‘caring’ aspects of the work. Care workers without formal training would then adapt to such instrumental practices (Franssén 1997: 230ff). These researchers suggested that the healthcare institution ought to emphasise unskilled care work and have it gain more authority, at the cost of “the professional and administrative authority” (Franssén 1997: 234). What I will show in the analysis of the organisation of work at Ward 96 is that instead of increased dichotomisation of high-touch ‘dirty’ work and high-tech ‘clean’ work, these nurses’ labour has expanded and now encompasses a range of practices. The expanded responsibilities meant nurses’ spent their shifts performing what bordered on a variety of tasks. For instance, while on some other wards

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it was only assistant nurses who would take care of bringing patients food, at Ward 96 both nurses and assistant nurses would participate in this. As Danuta pointed out, nurses would change diapers, help wash patients, make beds, clean up vomit, serve coffee, help patients with transportation from the hospital, et cetera. Thus nurses performed all of the tasks that assistant nurses would perform, while the reverse was impossible because of the high level of medical technology required in the ward. In the next chapter, I will analyse some of the consequences of increasingly complex labour processes that followed from this type of organisation of work. In the following section of this chapter, I will outline the sequences of work and describe the labour process of ward nursing in the case of Ward 96.

Sequences of work Close to seven a.m., nurses and assistant nurses would start appearing in the hallways, clocking in at the electronic time clock by the staff elevator. At seven a.m., night staff would report to the day shift according to a checklist. Nurses, the nurse manager, assistant nurses, and maybe a student or two, would all cram into the reception area, trying to find a chair or a stool to sit on, otherwise using the desks to lean on. Night staff would go over each patient and their status, and the A-shift nurse assigned to the patient in question would perhaps get some specific points to remember or deal with during the shift. The nurse manager would sum up the status of the ward, inform staff of the number of doctors and which ones were working and thus doing rounds; if there were any sick nurses or assistant nurses; et cetera. The mood would range from relaxed, laughing at jokes (such as the nurse manager commenting on the doctors making rounds: “Today, ­Niklas and Markus are on call, so congratulations to all of you, you are going to have a nice day!”), to focused (the nurse manager again: “As you know, we are short one assistant nurse, and I know it’s starting to show that we had to let her go, it’s been tough, but the economy is what it is, we have to work together”), to downright tense. Tensions would arise if something had happened during earlier shifts, such as the time when two nurses had misunderstood each other and one of them had either failed to hang an IV, or failed to inform the next nurse that it

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was supposed to be set up. There was a minor discussion about it, and the two nurses would give each other some backhanded comments, causing other nurses to interrupt or let out irritated sighs. But, mostly, reports would be to the point and handled swiftly. There was a lot to do once the meeting was over. Night staff would leave after the morning report, and the day shift would start on the day’s tasks. Some nurses would begin by reading up on their patients in front of the computers in the reception area. Others would go out to their assigned patients immediately, depending on the information they got from the report. An hour or two later, when the doctors were ready, it was time for rounds. Nurses would go in individually to the doctors, who were seated in one of the small office spaces in the middle of the ward, and round their patients. Each patient was discussed briefly, normally not taking more than a few minutes. After the doctor and the nurse had gone over each of their patients, they would visit the patients together. Usually, the doctor would talk the most with the patient. Sometimes the nurses would make an extra round afterwards to make sure the patient had understood what the doctor had said. Thus one aspect of rounds for nurses was the mediating position in which nurses would elaborate or deal with practicalities of what the doctor had decided or reported to the patient. If a doctor came with news of a patient being thought medically prepared to be discharged, often the nurse would later talk to the patient to see to all the practicalities and explain about aftercare, et cetera. After rounds, nurses were primarily occupied with the administration of medication or high-touch body work. At around ten there would be a brief meeting again in the nursing reception to sum up any changes and to discuss discharges and intakes, and, before or after that, most nurses and assistant nurses would have coffee in the lounge. The aide employed to handle the ward kitchen (she was enrolled in an employment stimulus program) would set the table (a coffee mug each) and make coffee. The rest of the day was spent performing a range of tasks. Nurses would be on the telephone to municipalities trying to sort out home care after patient discharges, or arrange interpreter services for patients who could not speak Swedish; they would talk to kin, to doctors, update charts in front of the computer, and all the while they would walk up

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and down the hallway, crossing between supply rooms, rinse rooms and patient dorms. Administration of medication would follow time schedules, because some medications are supposed to be administered within fixed time intervals. If patients wanted anything, they rang, an alarm sounded, the nurse would check which patient was calling, and, if she could, she would go there (or else she would rely on someone else to do it) and talk to the patient. If possible, she would respond to his or her need. If the need could not be met instantly, then the nurse would write it down or otherwise try to remember to get it done later. At two p.m., the afternoon shift would start, and there would be two hours where the A-shift would report over to the next shift. At nine-thirty p.m., that shift would end and the midnight shift begin.1 The challenge in discussing a labour process in nursing is the fact that, although nursing is highly interrelated and dependent on interactions with patients, assistant nurses and doctors, it is labour performed semi-independently as far as the planning and execution of distinct work sequences goes. Other ethnographers have noted the difficulties of pinning down the labour process of nurses. Here is Franssén’s (1997: 149) description of seeing nurses from the outside, as she shadowed assistant nurses at a hospital ward in the 1990s: [Nurses] seemed to be under more stress than the assistant nurses. They did not interact socially with each other as much. … Because [the nurse] worked alone and was constantly on the move with a variety of tasks, I found it difficult to follow her in the ‘nursing work’. One minute she was on the phone in the nursing reception, the next she was on her way to a patient dorm and a moment later she was preparing medicine in the medicine room.

Just as Franssén noted, nurses’ work was not carried out in linear sequence; rather it was performed according to checklists and governed 1.  I shadowed a nurse during two full midnight shifts. The pace was slower; in the wee hours of the morning nurses and assistants sat down with some coffee and relaxed in front of the TV. While the midnight shift was less stressful because the patients were mostly asleep and there were less tasks to perform, working nights (especially during rotating shift work) is unhealthy and linked to increased risk of cancer, cardiovascular and gastrointestinal disease, disturbances in social functioning, and workplace accidents and errors (Kecklund et al 2010). I will not analyse the differences between the midnight and day shifts further; the analysis of the work at Ward 96 is based on the day and evening shifts.

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by impending needs and demands of those in need of care and those in charge of care: the patients (and sometimes their kin) and the doctors. Consequently, the process was partly unpredictable. In terms of space, it was not linear (as organised along an assembly line) but rather performed in circles, like layered pedals attached to a centre. The centre would be the medicine trolley and its laptop that functioned as the nurses’ mobile work station, often placed somewhere in the main hallway. The main business with the computer was checking what medication to administer to each patient. The trolley held drawers with boxes, one for each patient in the respective section. The nurses would make sure that the pills prescribed for each patient were placed in their allotted box on the trolley. In another sense, the centre would be the patients for whom the nurse was responsible on a given day, and their specific needs as determined by the doctors on rounds, by the patients themselves, and by the nurse’s assessments and decisions. The frame of work was set from a rough outline that started with the morning report, was updated by the rounds, and performed around specific instances such as lunchand dinnertime. Work was constantly interrupted, so that a task could be performed only step-by-step over several hours and in parallel to many other tasks. Furåker (2009), in her study of nurses’ everyday activities in hospital care, found this to be true in her study as well. Content analysis of diaries written by nurses illustrates some of the difficulties of organising work at hospital wards because of the temporal unpredictability of patient care. Constant interruptions mean there is little continuity in the work process no matter how work is formally organised (see also Cohen 2011). Different wards nonetheless have different systems of organising care work. In her study, Furåker (2009: 271) came upon an array of organising models: team-nursing, round-system, patient-responsible nursing model. All of these models are well-known organising principles within the nursing field, and hospitals employ different models in different wards and within different specialties (Segesten 1997). During my fieldwork, care work at Ward 96 was organised through a combination of functional and primary nursing models, which was then replaced by a round-system within a functional model. The dif-

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ference can be described as each nurse being responsible for “a set of patients, rather than there being a set of tasks for many” (Wolkowitz 2006: 165).2 Other wards organised care work through team nursing models or patient-responsible nursing models. It was the nurse managers who decided how care was supposed to be organised, but the number of staff, the tasks at hand and the work processes of the doctors framed and limited their choices.

A day at the workplace Because of the problem with defining and describing the labour process at the ward in general terms, I will use an excerpt from my field-notes from when I shadowed nurse Majken. The time period is between ten a.m. and three p.m. and although not all of the tasks are included, such as many of the in-between moments of checking the laptop placed on the medicine trolley, reading up on notes from reports, washing the hands and applying alcohol for hygiene, or chores such as cleaning up after procedures and sorting the waste material in different bins in the rinse room, all major and distinctive tasks are reported. It is however important to note that it was these minor chores, that were sort of remnants of a completed task, that would often cause nurses to move around a lot on the floor and create the feeling of a constant running around that many nurses talked about. I would say that this excerpt represents one of the least hectic days I experienced at Ward 96, but it nonetheless sheds light on the range of tasks performed during a day shift. Around noon, there were 2.  Swedish hospitals, according to Lundgren and Segesten (2002: 198), have a tradition of task-oriented nursing delivery systems, so-called ‘functional models of nursing’. Within the nursing field, these models are often contrasted with “patient-infocus philosophy”, which is associated with a variation of models and concepts such as ‘holistic care work’, ‘individualised care’, ‘primary nursing’ and ‘care teams’. These models are often based on team work (the team usually consisting of nurses and assistant nurses working alongside each other). Within primary nursing models patients are assigned a specific nurse who is supposed to have an overall responsibility for the entire care process (Segesten 1997). Research indicates that nurses prefer non-functional models of care delivery to functional models. After switching to a “patient in focus” model, nurses in one study stated that “their competence had been enhanced and that their knowledge and skills had moved towards a more reflective and creative attitude to their patients and work” (Lundgren & Segesten 2002; Segesten et al 1998).

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usually fewer relatives visiting (compared to the afternoon and evening), which reduced the number of interruptions and interactions, as reflected in the account below. Usually there was less ringing on the telephone and most of the administration required for discharges, which tended to involve (telephone) conversations with nurses in the municipalities, social workers, relatives, et cetera, was taken care of later in the day. Thus the excerpt provides a picture of relatively cohesive work sequences focused on body work, and excludes many of the other tasks that nurses would perform on the ward. It is time for the report meeting. Eight nurses, two assistant nurses, one physiotherapist and one dietician all squeeze into the nursing reception. Just before the meeting starts, Majken tells me that it’s been hectic because early in the morning before I arrived there was a patient who was extremely ill and there was a kind of emergency. … After the meeting, Majken needs to work on a patient. She heads for the computer station in the main hallway and looks at the patient’s chart. “I try to check everything before I go in, because it’s easier if you can concentrate on some of the tasks instead of running around. But that’s easier said than done. You’ll get interrupted anyway.” When she has looked at the chart and checked the box of the trolley to make sure all the patient’s medication is there, we go into the patient’s room. He is sitting up in his bed. Majken knows him, but I introduce myself and we talk a little bit about my research. Majken is going to dress his wound and draw some blood. There is a mobile worktable that she puts next to the bed. She asks how he’s doing and explains what she is going to do. She begins with checking his wound from the surgery. Then she asks to check his arm. “Do you know whether there is like a good vein on you, is there a good spot that you know of? Is one arm better than the other?” Majken asks. He says he doesn’t know. Majken excuses herself and we go out to a storage room where Majken picks up a pressure dressing and some other gear. We go back in to the patient. Majken puts on gloves and checks his other arm. Then she starts dealing with his wound, changing a few dressings. Then she moves on to the blood work. She talks a little with him: “This is usually tricky, right?” she says. She starts looking at his arm again. She is looking for a vein. It takes some time, so she talks a little about this with the patient as she struggles with the needle. The patient is not very responsive. He’s watching TV while she works on him. When she’s done,

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Majken cleans her mobile worktable and takes the blood work with her, and then she leaves it at the station for lab pick-ups. She talks about how much “heavy care work” nurses have to perform at the ward. “I personally would prefer if we could work in teams – you know, one nurse and one assistant – because then I could concentrate on this kind of work (she points to the blood sample) and the assistant could do the rest.” Next we’re on our way to another patient. Majken gets more equipment before we go into the room. She places her equipment on a small table. I’ve met this patient before and I know he is talkative; an older man, in his eighties, suffering from cancer. He starts chatting immediately. “Where is Janet?” he asks. “She’s on vacation, I think,” Majken says. “Oh, she already left? You know, we share a birthday and I thought maybe I would meet her before she left so I could congratulate her.” As Majken prepares to draw some blood, he says: “You know I’ve got blue blood, right? You’ll see, it’ll be bright blue when it comes out!” Majken responds politely and the patient laughs. He leans over the worktable and picks up a cone-shaped rubber object. “Are you gonna use this?” he asks and blows through it like a whistle. Majken laughs, I smile, and we exit the room. As soon as she’s out of the room she checks her notepad that she carries in her pocket. Then she opens some drawers and looks in the boxes of the trolley. She decides it’s a good time to head for the pharmacy room with the trolley. We’re going to restock it. Majken reads to me what should go into each box of the trolley and I take out the medication from the shelves. I have to make sure I take the right one with the correct potency. Several nurses, including nurses from other wards, accompany us, as this is a central supply room for the surgical division. Majken reads to me: Codeine, so-and-so many milligrams; Ibuprofen, so-and-so many milligrams. Later in the day we’ll do the same thing only in reverse, because one of the boxes in the trolley needs to be emptied as a patient is discharged. After about fifteen minutes we’re done. We literally bump into another nurse, Lisa, on our way back to the main hallway. She is in charge of a patient that Majken has worked with a lot and they discuss the patient’s current situation. Furthermore they both work in the same patient dorms today. Lisa says she can’t break for lunch just yet, so Majken says we we’ll go instead. This way, Lisa will cover the dorms while we’re on break. Majken goes down to the lobby to buy lunch. When we come back, there are only six people in the lounge, nurses and assistants. They are talking about time: what there is and is not time to do

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at home because of work. Majken and another nurse agree it’s best to be in bed before nine p.m. Another nurse says she is usually in bed by eight, or she’ll be too tired for work. We all laugh: eight is bedtime for kids! Majken tells us she usually gets up at five in the morning, because then she can have some peace and quiet around the breakfast table and read the entire paper. They discuss another nurse, who has just had her fourth child. “How on earth does she do it?” Majken says she must have extra-terrestrial energy levels. The conversation drifts to the subject of leisure activities. Majken asks about mushrooms: “Are they up yet? I didn’t find any when I was out last time …” One of the younger nurses, a recently hired woman in her twenties, tells us she owns a horse, a young stallion. They talk about her horse and about riding, and one of the assistants says: “It is so expensive with horses.” The nurse who owns the horse agrees and says she’s been thinking about moving to Norway so she could earn some more money. Her boyfriend doesn’t want to be involved with the horse riding business. One of the nurses’ husband is unemployed. “Oh my God, I hated it when my husband was unemployed! He was home all the time, it was such a pain to have him around constantly!” one of the nurses says. They all laugh, but Majken says that actually when her husband was unemployed he was “great around the house. He was washing and cleaning and cooking. When he got a job, I thought: what are we going to do now?” We sit down for 45 minutes and then we go back out to the hallway. We meet Lisa. She tells Majken to come with her because a patient needs help getting out of bed. We enter the dorm. The patient is sitting on the edge of the bed. Majken and the other nurse put their arms under the patient’s arms and slowly help him into a wheelchair. I try to direct the wheelchair so it will be easier. I’ve got the hang of this now, but I watched the physiotherapist nearly lose her grip around one of the elderly patients only yesterday. I know this is heavy work that requires some tricks so it will go smoothly and, even when you think you know what you’re doing, obviously things can still happen. It’s easier when you’re two. “You mustn’t try to go back to bed by yourself, now, like you did yesterday. You could fall and injure yourself. You must let us help you!” Majken says.“Yeah, yeah,” the patient says, “I will!” Majken gets his medication from the trolley and the other nurse asks him what he would like to drink. She goes out to make him some coffee. When Majken is done with this patient, she helps an assistant nurse wash and make a bed. After that, she goes to remove a central venous catheter. On her way

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to the medicine supply room, where she would go to get the necessary equipment, she opens the door to the room where the doctor is still working in front of the computer after rounds, and she tells him: “So now I’ll remove that CVC.” But the doctor has changed his mind. “No, could you hold off on that,” he says, and explains to her why he has changed the orders. Majken instead goes back to the patient and explains to him that they’re going to wait a bit before removing the line. The patient nods and says little in response. She returns to the hallway, where a doctor is waiting. “I’m looking for the nurse in charge of this patient.” he tells Majken and shows her a chart. “That would be Hanna,” Majken says. Doctor: What does she look like? Majken: She is young, one of the new nurses. Doctor: Where do you think she is? Majken: Well, probably having lunch. I’ll look for her. Majken goes into the lounge and says: “Hanna, a doctor is looking for you!” When they come out, the doctor says: “Oh, that young girl!” Hanna laughs. The doctor is in his forties. We head back to the trolley, when the nurse manager finds Majken and says: “I’m so sorry, but it looks like you’re going to have to come in tomorrow anyway.” Majken responds: “I thought so. It’s okay.” She tells me she had asked for tomorrow off so that she could arrange a birthday celebration for her daughter. She updates a few charts on the laptop. “Now it’s time to write a report,” she says next, and we head for the computer in the office where the doctor is still working. She sits down in front of one of the available computers and says, “Typing is not my thing.” She begins typing using her index fingers. “Ah, we never had to do this before, all the time we spend in front of the computer nowadays, writing …” But she’s soon interrupted. A nurse comes in and says a patient has been waiting an hour for an injection. “Really? There must have been a misunderstanding,” Majken says and heads out. She prepares the needle in the medicine room, walks at a quick pace to the dorm, and gives the patient an injection. She apologises for letting the patient, a woman in her sixties, wait so long, but the woman says: “Oh, don’t apologise! It’s all right. It’s just that I feel sick and uncomfortable, so that’s why I reminded that other nurse …” Majken chats with her for a bit and then sits back in front of the computer. But she is interrupted again. A patient is having difficulties with his CVC, an assistant nurse lets her know. Majken enters the dorm, greets the patient, explains what she is about to do, and

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starts w ­ orking to remove the catheter. “It’s an emergency, I need a massage quickly!” the patient says. He is in his sixties, I would guess. “Majken, get down here into my bed and give me a massage!” he insists, giggling. I interrupt him and introduce myself. “I’m a researcher …” I begin saying. He cuts me off and says: “That is all right. You can get into my bed and do all the research you want!” I force myself to continue to explain why I’m there and ask if it’s okay that I stay with Majken while she works with the CVC. Majken says nothing; she seems to be concentrating on the catheter. The patient says: “Yes, of course.” Majken still says nothing, and finishes quickly. Majken only says: “Yes, okay!” to the patient as we withdraw. “A lot of running right now,” she says as we come out into the hallway. She doesn’t comment on the patient’s behaviour. Using the excerpt from my hours shadowing Majken, I will discuss some of the different types of labour performed during a shift, and comment on the social interactions that take place through and beyond the different demands placed on nurses.

Conceptualising nursing tasks at Ward 96 administration: text-based coordination. I begin breaking down the period of work through which I shadowed Majken by focusing on the administrative parts. The excerpt started with a meeting, the follow-up report after rounds in which nurses and assistant nurses go through any changes pertaining to patient status. Usually the manager would lead the meeting, but this was not always the case and she is not mentioned in the field-notes. One of the tasks that nurses have claimed as jurisdiction is administration and documentation. Since 1985, nurses are required by law to document their work on patients. Formalised demands on documentation contribute to render nursing visible within the healthcare system. Through an analysis of the trade union publication Vårdfacket, Blomgren (1999: 169, references excluded) shows that during the implementation of NPM regimes in the 1990s an emphasis on documentation was seen as a professional strategy: In Vårdfacket there are, for example, statements saying nurses’ charts should not just be a copy of the doctor’s charts, but rather be a way of showing what nurses do: ‘It should be easy to show what nurses do.’ Another nurse says

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that while it is a legal requirement to document work, ‘through documentation we also strive to illustrate better what we do and that we’re worth higher wages.’ … Thus one can argue that the formalised demands on documentation are welcomed from the perspective of increased professionalisation. The explanation is the … problem nurses claim to struggle with, that is the invisibility of their work and [the union’s] members. There is a recurrent insistence on the oral tradition within nursing, the difficulties involved in defining nurses’ work in a precise way, and the lack of scientific concepts to describe their work.

Blomgren uncovers the way that the nurses’ trade union identified the link between documentation, administration and power within the work organisation and saw as their chance to make use of increased emphasis on audit control within NPM regimes. As Majken noted, nurses up until the 1980s and 1990s did not spend that much time typing, but typing is seen as a way of establishing a formal territory and making visible the efforts made by nurses. I would argue that nurses have been successful in making space for themselves to participate in the production of texts as coordinators of work (as Turner 2006: 139 argues, texts have the capacity to “produce and to organise people’s activities and extended and general relations in local and particular sites”). Most of the tasks Majken performed referred to written orders, and she constantly read up on charts in order to plan and execute her work. Further, she also had to document her own work, even though the documentation part had to take place after the administration of medications, for example, and was also interrupted because of such tasks. I conceptualise administration as time spent on text-based planning and documentation on other types of tasks. The meeting that began the work period represents the overlap between textual and oral practices of administration, since the point of the meeting was to update the work shift on changes in the status of patients. What was orally communicated between the nurses was also documented in charts. The same goes for the type of administration performed through telephone conversations with municipalities, social workers and the like: most such discussions and decisions made as a result of them would later be documented. I would like to clarify here that while some decisions were taken autonomously by nurses, doctors predetermined many if not most of their interventions.

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body work. While I view nursing as a type of body work, that is “employment that takes the body as its immediate site of labour, involving intimate, messy contact with the (frequently supine or naked) body, its orifices or products through touch or close proximity” (Wolkowtiz 2006: 147), it is important to note that far from all of the tasks nurses take on are performed directly on bodies. It is further central to recognise the different meanings applied to varying kinds of body work, including with what kind of joy, pride and interest different kinds of body work are associated among nurses (see also chapter 8). In this section, I view body work as a component of nurses’ work, as they deal explicitly with patients’ bodies. Majken pointed out that she would prefer to focus on skilled interventions such as drawing blood, and let assistant nurses do ‘the rest’. One way of reading her words is that Majken would like to concentrate on practices involving medical equipment or interventions aiming to change or regulate bodies, but would prefer not to participate in helping a man get out of bed and into his wheelchair. Both of these tasks are body work. The essential difference is that while the latter does involve tricks of the trade and “the transfer of domestic or maternal skills into the sphere of waged work” (McDowell 2009: 167; see also Waerness 1984, Glenn 1992), the former is based on recognised skills and requires formal training. Many nurses mentioned that they enjoyed the technical aspects of body work, like handling injections and catheters. They enjoyed being good at these things and were thoroughly proud of being able to, for instance, draw blood from a patient frail from cancer. That could be tricky and required competence of touch (fingers against the patient’s skin) and technique (inserting the needle at the right spot). Hitting a ‘rolling’ vein required concentration, but did not involve much heavy physical effort. The closeness to the patient would also be different in that it was hived off and limited (Wolkowitz 2006: 154), in contrast with situations such as when Majken and Lisa helped a patient into a wheelchair by moving in close to his body and physically lifting him. body work: tasks implicated. In contrast to the doctors’ organisation of work, the body work that nurses at Ward 96 performed included a lot of residual chores, such as preparing and cleaning up

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workstations and preparing and disposing of plastics, syringes, papers, pressure dressings, bandages, tubes et cetera. Sometimes it involved disposing of urine and other bodily outlets. Some of the body work entailed changing bedlinen and patients’ clothes. Actually changing clothes on a patient I would consider body work – work performed on the body – but it could also mean taking care of the patient’s stained clothes and bringing him/her new ones. During the day shift with Majken, there were eight nurses and two assistant nurses working with 22 patients. The assistants’ tasks were organised separately from the nurses’, and focused on helping patients with hygiene, on cleaning, and on responding to patients’ calls. At times nurses would perform tasks side by side with assistant nurses. This was the case when Majken helped an assistant nurse clean and make a bed after a patient had been discharged. Thus after the exit of bodies there were tasks remaining with cleaning up after them. At Ward 96, nurses did this type of labour too. Body work would often also result in residual administration, such as making sure blood samples were sent for analysis, contacting lab workers to get results, et cetera. I found it interesting that Majken knew to mention the imminent extraction of a catheter to the doctor, even though he had ordered the procedure only a few hours before. And right she was: by the time she was ready to do it, the doctor had changed his orders (which was communicated on the nurse’s initiative). Thus some of the body work performed was framed more clearly by the doctor’s assessments and decisions and consequently occasioned communication between nurses and doctors. To summarise, body work involved tasks that ranged from clearing workstations to clearing procedures with doctors. emotional labour and control. Much of the emotional labour performed by nurses at Ward 96 revolved around addressing the anxiety of patients as well as the anxiety and, very often, demands of patients’ relatives. In such interactions, nurses actively tried to induce and/or suppress feelings in others, or in themselves when, for instance, family members posed demands that were considered difficult or impossible. One such occasion (discussed further in chapter 7), was when a relative of an elderly patient implicitly asked a nurse at the ward to let the

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patient die, despite the fact that the patient was medically stable and socially forthcoming. The nurse, Danuta, was upset, but handled the situation by trying to defuse the relative’s demands without showing how strongly she disagreed. In such circumstances, it is fair to draw a distinction between physical labour and emotional labour, the two components emphasised by James (1992) in her conceptualisation of care work. However, as has been pointed out by Wolkowitz (2006: 148f; 158f ) and Knights and Thanem (2005: 32), it is problematic to represent these practices as ontologically separate. I would argue that in many cases emotional labour and the physical labour involved in different kinds of body work, including residual tasks, require some emotional labour. Emotional labour permeates much of nurses’ tasks, including administration – specifically telephone conversations. This can be conceptualised as a part of nurses’ display rules, that “shape employee emotional displays in ways that facilitate the attainment of the organisational objectives” (Diefendorff et al 2011: 170). What I would like to highlight in relation to Majken’s work is the ways in which touch can be both physical and emotional work: when she entered the room of the first patient mentioned in the excerpt, Majken knew it would be tricky to find a vein. She started talking with him and preparing him (and possibly herself ) for this. The patient in question seemed used to having blood drawn and paid Majken a minimum of attention. This, of course, was not always the case, so skilled interventions often involved emotional labour of calming down the patient in question. While drawing blood is definitely associated with physical activity, it is not performed mechanically. But emotional labour can also revolve around accepting or playing along with jokes. The man who said he had blue blood was not the first nor the last patient I heard tell that particular joke during my relatively short stint at Ward 96; I’m confident Majken had heard that joke a hundred times before. Her reaction made me think back to when I worked at Burger King and was asked by customers what felt like on a daily basis to serve them a Big Mac (that would be the hamburger sold at McDonalds). That particular joke grew old rapidly but mostly I answered politely in a way that did not actively challenge the emotional basis of the joke. I recognised, I thought, this strategy in Majken as well, although I would argue that these were two very dif-

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ferent contexts wherein the emotional labour of responding politely to the joke had different aims: behind the counter of a fast-food joint the point of the feeling rule is to entice the customer to come back and buy more; however, during the actual interaction, my experience was that it came down to keeping the line moving and making sure the transaction would go smoothly. Behind the needle in a hospital the point of the feeling rule is not only to perform the role of a good caregiver in a good welfare service institution, it is also to be responsive to and soothe nervousness or patients’ other ways of coping with a procedure performed on their bodies. Thus at the core of emotional labour is the issue of control (Hochs­ child 1983). But then control is also a significant part of nurses’ overall work, and sometimes it is difficult to distinguish between these aspects of labour. When Majken and Lisa helped a patient into a wheelchair, they not only controlled the patient’s movements in time and space, they also actively imposed on him the regulation of his movements. He was not to try to move from the wheelchair on his own like he had done on the previous day; there was the risk of injury. I know that many patients, as indeed I thought this patient did, tried to resist such regulations. Once I was seated in the lounge with a number of nurses during lunch and all of a sudden three of them ran out of the room, across the hallway, and into the room of an elderly, frail patient who was about to fall out of bed while trying to get up on her own. The nurses had been watching through the window of the lounge door how the patient had started to move and, just as she was about to lose control of her movements, they got up and ran towards her, and they managed to catch her before she hit the floor. Thus body work, emotional labour and control of patients would often overlap. The more serious form of emotional labour performed by Majken was her (lack of ) response to the overt sexism on behalf of the patient who begged us both for a massage. I thought what the patient said was disturbing, but Majken did not even comment on it. I never got the chance to interview Majken about it, and for some reason I did not ask her during the following hours of shadowing what she felt about the sexual harassment we encountered.3 But it seems possible to 3.  And I can’t explain why – as Majken said, we were running between different tasks all day and it is possible that I simply forgot the whole thing because I was busy concentrating on shadowing her in a smooth yet perceptive way.

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me that she simply waved it off, that she hardly noticed it, and that she forgot about it as soon as she left the room. There was nothing to indicate she was offended, apart from the fact that she spoke very little with the patient and exited in a manner quite atypical of her. Using Hochschild’s terminology (1983: 128), one could argue that Majken differentiated between deep and surface acting and displayed the latter to indicate disapproval. What was going on with the patient? I would conceptualise his behaviour as a form of sexual harassment, in terms of “verbal conduct, such as statements which are experienced as insults, jokes of a derogatory nature” (Hearn & Parkin 2001: 51). What he said pointed to the ambiguous position of nurses or other women care workers. While nurses hold a certain amount of power over their patients, patients can also choose to resist in various ways, and they can obviously also choose to call on hierarchies of “heterosexist masculinism”, in which femininities are “subordinated and derogated because they are seen to be linked to women and passive, receptive female sexuality, which is negatively connoted” (Hearn & Parker 2001: 85, references excluded). Majken was interpellated as a sexed body while being “immersed in a project” that in itself had noting to do with her sex, in the words of Moi (1999: 202). I stress the ambiguity of the power position of nurses in relation to patients because, as seen here, despite the fact that a patient crosses boundaries through uninvited and unwanted sexualised verbal conduct, a nurse is on most occasions still required to perform her work on the patient. What the patient challenged here, then, was the boundary of touch, in essence highlighting the requisite for such regulations. Sexual harassment is far from always recognised as such. According to Hearn and Parkin (2001: 149), it is often embedded in the everyday practices and interactions of organisations: … organisational violences recur in the everyday fabric of organisations. They include both obvious and dramatic violences: harassments, bullying and those physical violences that are becoming more fully recognised; structural oppression that may often be taken for granted; and mundane violations in organisations. This contradicts a ‘commonsense’ view of organisational worlds. An important, but as yet underdeveloped, area of politics and policy is the embeddedness of violation in the mundane practices of organisation and organisations, of doing organisation(s) and (re)producing organi-

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sations. What is often called organisational culture is often itself a site of and shorthand for mundane organisational violence.

What happened to Majken did not merit any particular response, and I would argue it was because it was thought of as a mundane violation; mundane in the sense of quite common, because it was not the first nor the last occasion on which I witnessed such behaviour from (male) patients. In the next section, I will use this incident to introduce a discussion on the role of sexuality and gender in social interactions in the workplace.

Through and beyond labour: interactions in the workplace It is interesting to note the ways in which the temporal arrangements of work were made central to the discussion Majken had with her colleagues during lunch. As I will show in the following chapter, nurses often felt that work spilled over into their ‘own’ time, so that work affected and constricted not only their physical but also their emotional presence in their homes. But beyond that, the discussion during lunch was illustrative of the focus of social interactions in the workplace: nurses and assistant nurses tended to discuss their kids, their husbands, their parents, and their pets. The wage difference would sometimes be illuminated here, as indeed it was when the assistant nurse commented on the costs of riding. Essentially, though, it was heterosexual family life that was at the centre of conversations during breaks.4 I learned, for instance, about the ongoing renovation projects of several of the nurses; what colour they were planning on using for 4.  I interviewed a physiotherapist (Mia) who lived with a woman with whom she had a child. Although she clearly did not identify as heterosexual, she refused the label of ‘lesbian’ or ‘homosexual’. She was open about her same-sex relationship to her co-workers but never to her patients, she explained, as “talking about yourself is unprofessional; the patient should be placed at the centre”. She had never experienced any harassment or unwanted behaviour, comments or the like from co-workers. “I’m treated just like everybody else, no problem, not ever,” she told me. The rest of my informants who were in relationships lived and identified themselves (to me) as heterosexuals. Going over all of the interviews, there is a strong orientation towards heterosexual relationships and heterosexual norms in speaking of patients, collaborations, myths about love at work, et cetera.

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which walls and where they were shopping for paint. I also got to know something of what these renovation projects required of the male partner, and was told about the various strengths and weaknesses of these men in terms of their ability to fix roofs, floors, walls and windows. Such experiences were drawn into the social world of the workplace, as nurses would update each other on the progress of their respective projects. But it was also the case that the home provided a dominant source for naming experiences across the work/family divide. I find the account below particularly telling in this context. A nurse had made a minor mistake in front of a doctor and now she was talking to the other nurses about it during a break in the lounge. After having told the story of how she apologised to the (male) doctor for her error, she brought up another situation in which she had made a mistake: “My husband never wants me to help out around the house, with renovations and such. This time he let me help paint a door. And there were two cans of paint there with the same colour, and I started painting the door, and I’m painting and it’s looking good. Then my husband appears and says: ‘Did you use this can? You’re not supposed to use that can! You have to use oil-based colour for the door because it’s the door in the bathroom.’ I say: ‘That can’t possibly make any difference.’ But he tells me that the paint will crumble from the humidity. I just dropped to the floor because he said there is no way we can coat it with the right paint once the water-based colour has dried. So I started scrubbing to get rid of it, but it had already dried. So finally I went to the hardware store and there were all these guys in line and I felt like they were all looking at me. But I told the guy behind the counter: ‘I used the wrong paint.’ He told me I could repaint it, no problem. I went home and started painting the door, and my husband came home and said: ‘What are you doing?’ And I told him: ‘You actually can repaint the damn door!’ And that felt good.” The other nurses laugh. An assistant nurse says: “My husband never lets me do anything like that around the house. He works in construction, so he does everything by himself. He says I can do the first layer of paint, but then he’ll be there to give directions anyway!” The nurse being reminded of another situation in which she had made a mistake, possibly within a realm outside of her immediate skills

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and confidence, could be interpreted as a recognition of the patriarchal relationships she was involved in both at work and at home. But mostly I find this excerpt telling because it shows how discussions about events at work would often be compared to experiences within the home. Thus there was an active linking of experiences made within these different spheres of life. Another aspect of this was the recurring discussions on care for parents or elderly relatives. On several occasions I overheard conversations such as this, which took place in the medicine room: Kerstin asks Lovisa how her grandmother is doing. “Not good. Now the doctors feel that maybe they should hold her a while longer, but, you know, all she wants to do is go home; she really does not want to be at the hospital. So now we’re trying to arrange that, and mom and me could give her all her medication – my mother is a nurse as well.” Kerstin agrees that that would be perfect, but wouldn’t it be hard too to take on that responsibility? “My mother works part-time already, so it could work out.” They talk some more about it while Kerstin prepares the IV. In this excerpt again there is the interconnection between care as paid work and care as unpaid work performed within the family, but here the sentiment is rather one of competence and confidence. In addition to family life, there was a strong discursive emphasis on practices and, importantly, joy of caring for patients. I contrast these findings with the image presented by Waerness (1984) and Franssén (1997) of professionalised care and nursing in particular as exempt from rationalities of care derived from the private sphere. On the contrary, the social interactions in Ward 96 were shaped by a discourse with strong emphasis on care for the patients, care for the home, care for relatives, and a concomitant regulation of socialising between co-workers, time spent on breaks, physical needs, and errors in work.

Responsibility and accommodation I would conceptualise much of the social interaction in Ward 96 as focused on responsibility and accommodation; practices linked to respectability (Skeggs 1997) and normative femininity. The strong focus on responsibility meant accommodating others was a central feature

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of social interaction and talk between co-workers. This was expressed through two dominating approaches in social interactions: emphasising care for others as the main responsibility and source of fulfilment, and (re)directing conflict towards issues of professionalism. These two approaches were shaped by a normative heterosexuality. In Westwood’s (1984) ethnographic study on women factory workers in the British hosiery industry, friendship was an essential and vital part of life on the shopfloor of StitchCo, and informants described the co-workers as the sole source of joy at work. In interviews with nurses in Ward 96, the patients were consistently said to be more important than the co-workers in this regard. When I asked about the best part of work, nurses would mention co-workers, but they would emphasise meeting patients and helping them back to a healthier life: “Meeting patients. Being able to help them. That is what is most important, that is what I like the most,” as one nurse explained to me, echoing the voices of all of the other nurses interviewed. Sharing a laugh with a patient would at least be presented as a greater joy and a greater achievement than sharing a laugh with a co-worker – which could, in some contexts, even be considered unprofessional: A while back there were some nurses here, I think one of them was temping or something, she came from another ward, and she was just laughing and making jokes with the other nurses. I mean it was a bit much. I don’t like it when it gets too loud around here. I think we need to be professional in the way of respecting that people who are here suffer from difficult disease and it’s not a place to joke around. It’s different if you share a laugh with a patient, that is a good thing. Then it’s different.

This quote from nurse Paula represented a common viewpoint on unprofessional behaviour on the part of (other) nurses. In a sense, then, what was recurrently represented as the joy and meaning of work reproduced the notion of nursing as a calling in terms of an altruistic approach that called for expressions of joy to be a form of emotional labour; otherwise it would risk being conceived of as unprofessional. This can be conceputalised as part of the local display rules that regulated not only the interaction with patients, but also between co-workers. As Diefendorff et al (2011) have illustrated, such display rules can be formed as shared, unit-level beliefs or norms about how

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to express positive or supress negative emotions. The central finding in their study was that display rule perceptions exhibited group-level properties; that is, collective perceptions of how to display emotions varied across units within hospitals. Paula’s understanding of boundaries of emotional expressions can thus be viewed as part of Ward 96’s locally established and negotiated display rules. What sometimes countered the emphasis on joy being centred on patient contact, though, were interactions with doctors. I found that even the slightest hint of a joke from a doctor would often make nurses laugh. Note, for instance, the “Oh, that girl” comment from the doctor in the excerpt under “A day at the workplace”. Here is another example, from an episode in the lounge during an afternoon break. A doctor who is associated with the ward but not a surgeon accompanies the nurses and assistant nurses: The doctor comes in and sits down. He starts chatting with the nurses and one of them asks him if he has replaced his broken glasses now. “Yes, I have! I have actually, don’t I look good?” The nurses laugh; the mood is upbeat. He says: “I’m so happy because all of you girls look so pretty now!” The nurses laugh more. One of them says: “Is that because you can see us more clearly or the other way around? I guess it must be the other way around?” The doctor says: “Oh no, it is because I can see you more clearly that I see how beautiful you look!” This makes some of the nurses laugh even harder. Lindgren (1992: 18) explored the practice of referring to nurses and particularly assistant nurses as ‘girls’. She conceptualised it as an expression of hospital hierarchy, in which some occupations are closed off to career advancement, forever stuck in the lower echelons of the organisation. I did not find this practice to be pervasive. However, young nurses and assistant nurses – and by ‘young’ I mean in their twenties, and new to the profession – were sometimes called ‘girls’, such as in the conversation between Majken and a doctor who was looking for a nurse he didn’t recognise. Beyond that, relaxed conversations between doctors and nurses would seemingly offer a space for the performance of heterosexuality, in which, drawing on Butler (1999: 194), gender and desire are stabilised and defined oppositionally and

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hierarchically. In these interactions, then, the performance of gender is naturalised and based on the process of constructing a “stable sex through a stable gender (masculine expresses male, feminine expresses female)” (ibid.). I want to underline that such relaxed exchanges were not the only forms that interaction took between nurses and doctors. The nurses were generally displeased with the doctors and described them as ‘messy’, ‘authoritarian’, ‘in their own worlds’, ‘elitist’ and even ‘crazy’; one nurse said: “The doctors here [in Ward 96] are dictators.” Thus at times there would be tension between nurses and doctors, and nurses would display their disapproval if they felt a doctor did not behave correctly. But such displays were ‘balanced’, as one nurse put it; a nurse would never raise her voice to a doctor. As Tabak and Koprak (2007: 322) illustrate through their literature review, nurses in conflict with other staffers – and particularly with doctors – “tend towards the tactics of avoidance and compromise”, which is a fitting description of how nurses described their strategies in dealing with the doctors in the everyday.5 So the relationship between these two groups was marked both by tension and the occasional re-enactment of heterosexual performance, which I often thought of as reproducing the gendered professional hierarchy. Nurses frequently explained the tension in terms of the doctors lacking respect and recognition of nurses and/ or patients. Nurses would be upset with doctors if they did not perform enough emotional labour for the sake of patients, or if they disregarded nurses’ work processes and hindered their work, for instance by delaying rounds. But even if nurses did not like a particular doctor, they would still laugh at his joke, as I witnessed on a few occasions. Once, the nurses laughed at a joke and then continued to criticise the 5.  I would like to stress here the social and the spatial distance between nurses and doctors in Ward 96. Nurses spent very little time with the doctors; they met them during rounds, during calls (when something happened with a patient, the nurse would call on the staff member responsible or on-call doctor to get clearance for administration of medication or physical assessment), and sometimes during meetings with patients (to discuss further treatment or course). But the doctors were largely absent from the wards, and many nurses commented that they doubted the doctors even knew their names. Further, the nurses claimed to have little knowledge as to how the doctors’ work was organised. Much related to the doctors’ organisation of work seemed to mystify the nurses, and often posed a problem because they could not predict changes in the doctors’ schedule et cetera, even though the nurses often would be on the receiving end of such reorganisations.

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doctor after he left the room. I interpret these exchanges as the practice of accommodating male power in a way that is reflective of women’s accommodation of men within heterosexual family life (Holmberg 1993). Laughing was an act of accommodating and seeking attention and through that recognition, I think, from the (mostly male) power. Hearn and Parkin (1995: 82) located the organisational construction of sexuality within internal divisions of labour of organisations. They described that gender divisions of labour “represent the organisational expression of broader social structures, of paid over unpaid labour, of public over private, of productive over reproductive” that create “blocks” and groups of workers differentiated by gender: Organisations are not neat, uniform asexual structures; they are more usually amalgamations of groups of women workers and groups of men workers, under the same control system of men. In mixed organisations where heterosexuality is dominant, this allocation in ‘blocks’ of women and men inevitably defines possible sex and love objects by means of job. Where one gender is in a minority, those few individuals are likely to receive greater attention in reality and/or fantasy as scarce, potential objects.

This has been explored in studies on nurses and doctors, and conceptualised as “the doctor-nurse game” (Game & Pringle 1984), wherein doctors expect nurses to be open to flirtation and erotic subtexts in interactions. I think that what I witnessed, nurses laughing and playing along with jokes, was a version of this game. However, it seemed to me that stories of flirtation and sexual contact, of colleagues falling in love, mainly involved women and men doctors. As Ylva put it, “It used to be maybe that doctors would flirt with the nurses, but nowadays we’re not interesting enough – they look at each other now, the doctors, I mean male and female doctors”. This statement was supported by many of the nurses, and in fact, not a single person I interviewed claimed to recognise flirtation between doctors and nurses as a widespread practice. “I’ve never seen it, never, a nurse might think a doctor is good looking but not really sexual language or jokes like that”, as Majken put it. On the other hand, Maria, a resident obstetrician at Lake hospital, said that it was “common knowledge that the older male doctors flirt with the female residents and that if you sleep with an older attending it can get you places”. In this aspect, the processes

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behind changing gender composition of the medical profession had affected the nurse-doctor game as well; I see this as both an increase in social and spatial distance between ward nurses and doctors, but also as a new understanding (informed by anti-discrimination legislation and the result of feminist struggle) of appropriate behaviour within the organisation that seems to especially regulate interactions between different categories of employees (see Tollin 2011).6

Friends and professionals Among the nurses, friendship structures did not work as an alliance against management. Westwood (1984) tells the story of three workers who set the buzzer off (indicating the end of the workday at the factory), and all the women on the shopfloor grabbed their coats and left work in a hurry, pretending to have been fooled by the alarm. When management started interrogating people about ‘the incident’, as they called it, no one gave the three co-workers away. This kind of ­sticking-up for friends was, I would argue, not a part of the social script in Ward 96. On several occasions, nurses approached the manager with complaints about each other. One such occasion was when two nurses thought they had discovered a manipulation of or omission to chart the use of narcotics. The number of pills in the cabinet did not match the information in the logbook, indicating that someone on the previous shift had either stolen pills or forgotten to register their administration. The nurses immediately took the information to the manager, who told them to recheck and recount. The nurses then discovered they had been mistaken about the whole thing. The hurry with which nurses would approach the manager with things like this irritated her, and she told me in interviews that she wished “they would sort things out amongst each other instead of come running to me – they are so afraid of conflict”. I view such instances rather as the enactment of normative femininity that called for loyalty and energy being directed towards patients and towards the work. The category of ‘professionalism’ was used to describe unwanted or disliked behaviour 6.  This is a subject that merits further research. A hypothesis could be that for professionals such as doctors, establishing a successful middleclass position involves forming a dual-career couple. This could also be part of the explanation as to the increased emphasis on and use of paid domestic workers in Sweden.

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and functioned as a way of legitimising criticism and control exerted between co-workers, and nurses and assistant nurses alike claimed in the interviews that they would not hesitate to interfere with co-workers if they discovered or saw something ‘unprofessional’. Sinclair (2011: 119) draws attention to the body of research on emotional labour, which has illustrated that “jobs – particularly those carried out by women at the lower ends of organisations – demand highly regulated emotional and physical performances”. Management of structures of feeling also regulate bodily performances, which was recognised by nurses in different ways. One nurse explained that it was unprofessional for nurses or assistant nurses to laugh, joke, talk loud or discuss personal matters with each other on the shopfloor: “I have told people to lower their voices, actually, because to me it’s just not professional, even if it can be nice to have fun with your co-workers, it’s not for the patients to see, it’s not the proper way.” The proper way was to be meticulous, serious, responsible, find joy in the interaction with patients, as well as go the extra mile for their kin. Agneta told me this story: I was very irritated one day – there was a booklet, it was called The Last Journey or something like that. Very beautiful, strong words. And the wife [of a patient] wanted to read it and she asked if she could have it, take it home. And the nurse said, ‘No, you can’t.’ I couldn’t stand that. It costs nearly nothing. So I said, ‘I’ll make a copy for you.’ Because those words meant something to her, she wanted to take it with her; maybe there is some dignity then to sit beside her dying husband if she can have that booklet with her. It was highly unprofessional, I thought. So I approached [the nurse who had said no] and I asked her if this really was correct, that they would save money on not giving these to the patients. Yes, she told me this was what she had heard. So I asked another nurse and she didn’t know, but I’m going to ask the manager because I can’t work here under those conditions. You can’t deny patients these things. We have to do these little extra things for people, to give them a sense of dignity. Then we are professional.

This account captures the emphasis on professionalism and how this concept took priority over friendship or alliances on the shopfloor. As soon as someone did not want to go the extra mile for a patient (such as making a copy of a brochure), there would be the risk of having the decision labelled ‘unprofessional’, at which point a co-worker may well turn to the manager.

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The focus on professionalism did not mean that everybody was professional all the time. Everybody would admit they sometimes did things that may not be exactly in line with their own standards of professionalism. But the examples they gave were mild, such as: “Once I cried a little in front of a patient, but I left the room quickly.” Yet, stories of grave unprofessionalism and dangerous behaviour were part of the local mythology, specifically involving repeated thefts of narcotics: “Someone has been stealing large amounts of [painkillers] for years”; the details of that story were repeated to me on several occasions. Ong (1987: 187), in her study on Malay women working in factories, notes that the first condition of introducing women into paid work was subjection to increased external control. In hospital work in general, external control exists in the form of regulations and authority supervisions forcing nurses to perform work according to standardised practices; they could lose their licence otherwise. There have been cases in Sweden were nurses have been tried and convicted in criminal courts for manslaughter after having administered wrong medication. This is a powerful form of external control that is at the same time a feature of the profession. But management could not exert too much control over day-to-day decisions; a hospital ward is not a panopticon-like factory floor such as the maquiladoras explored in Salzinger’s (2003) study, for instance. The control of the shopfloor was, as illustrated by the example of nurses reporting a suspected theft of drugs, in most cases internal and exerted within and between nurses themselves.

A workplace ‘culture’? I find it difficult to describe and analyse the pervasiveness of talk about the home, because as I try to convey the emphasis put on family life during breaks (where I was present), I risk fixating these women and their interests, even portraying them as narrow-minded in their focus on the intimate sphere; in the back of my head I hear the words of a feminist public intellectual calling dreams of a new kitchen “shitty dreams” (Dagens Nyheter 2007). I want to be able to explore the emphasis put on family life and consumption of and for the home (not just at Ward 96 but at all the wards I visited) without simplifying these women and their dreams, interests or micropolitical decisions

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of enacting appropriate subjectivity through social interactions in the workplace. Thus when I attempt to illustrate and analyse the content of social interactions in the workplace, I draw on researchers (McDowell 2009, Acker 2006b, Hearn & Parkin 2001) who have argued theoretically that social relations in the workplace are regulated through a hetero­ sexual matrix, Butler’s (1999: 194) concept referring to the “grid of cultural intelligibility through which bodies, genders and desires are naturalised”. It is, however, challenging to ethnographically capture the ways in which such interactions are regulated and played out through the heterosexual matrix in workplaces without representing them as facets of a specific ‘culture’, a contested concept within the social sciences. Feminist worksite ethnographies, such as Pollert (1981), Glucksmann (2009 [1982]), Ong (1987), Freeman (2000) and Salzinger (2003) have explored gendered shopfloor cultures of factory and tele­ com work, and have illustrated the ways in which celebrations, food, clothing and notions of fate and spirituality interlace with practices of resistance and control over time, space and body in the labour processes of different historical moments and spheres in the capitalist economy. Glucksmann (2009 [1982]: xxiiif, references excluded) reflects on the concept of ‘culture’ in this context: Culture has … assumed a greater centrality to the sociological enterprise since 1982, not only as a consequence of the ‘cultural turn’ and recognition of the existence of organisational culture, but also through greater attention to how actors make sense of their worlds and create identities. Long before this, however, it was common for workplace ethnographies to document the rituals and routines of factory and office life, but this aspect of workplace analysis has now attracted renewed interest. A risk of such narratives is that of objectifying or (horrible term) ‘othering’ the participants, making their coping strategies of ways of passing the time seem weird or outlandish in the manner of some nineteenth-century anthropology. Because of this I would feel uncomfortable re-presenting or dissecting my account of Smiths [the factory] in more formal terms as ‘work culture’. The customs, norms and ways of behaving emerged in direct response to the very particular circumstances of the Main Assembly, and were embedded in the totality of that experience, so that singling them out removes them from their context. Nevertheless, describing them also brings the shopfloor to life in a way that is otherwise impossible.

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While I agree with Glucksmann that the term ‘culture’ risks reifying and othering people whose practices are described and analysed, feminist workplace ethnographies have nonetheless convincingly argued that social relations on the shopfloor are central in the making of women’s lives and in the production and reproduction of power relations at work. Moreover, feminist workplace ethnographies have illustrated that femininity plays a central role in processes of interpellation, resistance and accommodation. One example of this is Salzinger’s (2003) study, which challenged Burawoy’s employment of interpellation to show that workplace identities are sites of both resistance and conformity (see also McDowell 2009: 60). An early example of a feminist workplace ethnography employing the concept of culture to study both resistance and accommodation is Westwood’s study of textile workers in the UK. The author analysed the shopfloor culture at StitchCo as based on the shared experiences of women factory workers. She writes that: The culture that [the women workers] created and sustained day by day, week by week, was a marvel of ingenuity and creativity. It was also a complex and contradictory whole: oppositional in terms of the demands of their employers; collusive in its emphasis upon women’s traditional roles in the home and the family. A culture of this type is undercut by the ideological constraints in which it is born because no culture is a spontaneous event divorced from its social and cultural landscape (Westwood 1984: 89).

Westwood defines culture in this context as “most simply a way of life, a set of shared meanings with specific symbols that signify membership of the cultural group, a language or its specific use, particular rituals and events in which all can share and thereby reaffirm as it is lived” (1984: 89). She draws on Gramsci to assert that cultures are “bound to a common-sense understanding of the world through what we now call practical ideologies” (1984: 89). Other researchers have located the concept in anthropological traditions. Kunda (2006: 8), in his examination of corporate culture and worker commitment in a high-tech firm, draws on Geertz (1973) to argue that when applied to organisational settings, culture is “generally viewed as the shared rules governing cognitive and affective aspects of membership in an organisation, and the means whereby they are shaped and expressed”. I use

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the term to describe shared rules that I view as formulated through ideologies and configurations of gender, most specifically the heterosexual matrix.

Constructing appropriate heteronormativity Examining my own impressions, memories, field-notes, and lingering feelings from the observations of City Hospital and Ward 96 in particular, I cannot describe a cohesive shopfloor culture, much less one fittingly described as a “marvel of ingenuity and creativity”. The resistance against demands of the employers (which I explore in chapter 7) and patients (chapter 8) was complex and contradictory, but on the whole it was more collusive than oppositional. Like Glucksmann, I would argue that social interactions were shaped by the experience of the shopfloor, but I also think they spoke to the specific kind of categorical matching of which nursing is the historical result. I interpret the strong emphasis on domestic issues as a central aspect of constructing and sustaining normative femininity, and I view the social interactions that took place mostly during breaks as characterised by the reproduction and regulation of this form of femininity. While it is a kind of femininity based on heterosexuality, it is constructed in relation to motherhood, not in relation to hyperfemininity that connotes access to the female body or even sexuality as related to specific variations of aestheticisation of the body. In chapter 8 I will discuss the ways in which notions of availability of bodies are produced discursively through conceptualisations of different forms of body work. Here I will simply argue that displays of dedication towards home and family were a way of performing heteronormativity scripted towards emotional labour and care, which holds a moral dimension – hence ‘normative’ femininity – that also hooks onto nursing. It further involves performing heteronormativity in a way that denies overt forms of aesthe­tici­sa­tion, and thus relies on a specific ‘natural’ and female-coded body. Nurses in Ward 96, for instance, rarely used makeup, and they all wore the same kind of scrubs for hygiene reasons. The same reason prohibited them from wearing nail polish, jewellery, or long hair. Here is Kadia talking about why nurses should not wear makeup:

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Rebecca: Your shoes look nice! Are they brand new? Kadia: Yes. So I can walk around here. Rebecca: Did you think about the way they look, too? Kadia: No, I didn’t care about that. I only wanted them to be comfortable. Rebecca: Do you think about your appearance when you’re at work? Kadia: Not much in general, there’s no time. You want to get a haircut, then you need a day when you’re off. And if you’ve got three kids, like me, and you’re a single mom, then you need to shop for groceries, wash clothes, you know. So I don’t think much about how I look. But I do think about what you’re supposed to look like at work. You need to look – you can’t have too much stuff, on your face and such. You shouldn’t wear makeup when you do care work. It’s not good, a lot of bacteria and all this. Rebecca: There are nurses who match their shoes with their nametags and stuff, have you seen it? Kadia: Yes. They’ve got pretty stuff. Some do that. I don’t care about it. To me, it’s important to be responsible, to act right, not do stupid things. That’s what’s important. What you look like or –, you know, I want my patients to be satisfied and happy about me based on what I do, not the way I look or smell.

Thus the emphasis on responsibility followed in nurses’ ideas of how to present their selves. On Ward 96, I saw hardly any nurses who would match their socks with their Crocs, their nametags and their watches as I did on some other wards (it was mostly noticeable in the paediatric unit). The older nurses in particular laughed at such behaviour. “I don’t get that – pink socks and pink stuff and pink everywhere – it’s not mature, for me it’s ridiculous,” as one nurse put it. I will follow Adkins and Lury’s (1999) discussion on the work involved in performing work identities in order to explain this further. In some service workplaces, the authors argue, “producing and maintaining a sexualised identity for women is ‘part of the job’” (1999: 206). However, for women such practices are rendered intrinsic and thus not recognised as a way of performing for the job; their workplace identities “are produced through the relations of production and are the subject of appropriation” (1999: 206). Men, on the other hand, are able to claim workplace identity as their own property, and make use of it as a labour market resource. They analyse this process in terms of naturalisation: We believe that both this requirement of the presentation of a naturalised identity and the ways in which such an identity cannot be contracted out

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and exchanged relate to the ways in which, for women, such an identity cannot be claimed as performance. Instead, such identity work is naturalised as part of women’s selves. Thus, within the airline industry women do not gain and retain jobs because of the particular occupational resources they possess, rather they are employed as ‘women’ with an assumed responsiveness (Adkins & Lury 1999: 605).

The term ‘naturalisation’ is specifically useful in relation to nurses, I would argue. Nurses’ performance of workplace identities are naturalised through the process of categorical matching that is linked to the construction of nursing as a respectable middle-class occupation for women. They are also employed as ‘women’ with an assumed responsiveness that is laced with notions of self-acclaimed professionalism and at the same time altruism. The focus on the home can be explained using this framework. Adkins and Lury turn to the work of Game and Pringle (1984) to analyse the failure to recognise women workers’ performance. According to Game and Pringle, housework became increasingly aestheticised during the shift from production to consumption, which took place at the beginning of the twentieth century. This was when middle- and, later on, working-class women were expected to furnish the home. The principle for doing this, according to the authors, was to create a home as unlike the husband’s workplace as possible, and further that expressed the personality of its occupants. “So close had the identification between woman and the house become in the late nineteenth century that a woman who failed to express her personality in this way was in danger of being thought lacking in femininity” (Game & Pringle 1984 referred to in Adkins & Lury 1999: 607). The increasing symbolic significance of shopping for the home and for the family means that, today, shopping is “not simply a straightforward technical or rational activity but involves selecting the ‘right’ goods to please and express love for husbands, boyfriends, children, even the dog, the cat” (Adkins & Lury 1999: 607). A successful presentation of identity required to be a wife/mother, Adkins and Lury (1999: 608) argue, involves a diminishment of self: At the very least, the self-monitoring required by women’s participation in the familial economy, while opening up to the aesthetic and emotional aspects of the self for work, does not make such aspects available as detachable resources.

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Applying this argument to the case of nurses, the construction of a work identity around themes of care, responsibility/accommodation, professionalism, and orientation towards the intimate sphere that is represented as an ongoing project with aesthetic dimensions, can be understood as the performance of an ideal worker in which the performativity (the work involved in constructing identity) is rendered invisible and thought of as intrinsic to women. The labour of identity is not determined by the division of labour but rather helps create the division of labour, according to Adkins and Lury (1999: 609), and this framework allows for a critical rethinking of the concept of culture at work. Thus workplace cultures are gendered, and “cultural identity practices form part of gender oppression in specific historical circumstances”. The concept of normative femininity in this context opens up further the category of gender and provides a tool for understanding specific gender regimes within organisations. There is however another feature of interactions in the workplace that could help explain the focus on the home, and specifically on the aesthetic aspects of creating a home. Josephine explained that one of the reasons that she enjoyed staying at home was the sense of being filled up with disease and dirt. Another nurse told me this story: You spend so much time around these sad things. You distance yourself from it of course but still, it’s all around you. These sorrowful destinies. We had a patient who was here [at Ward 96] for several months. She suffered from cancer and [there was a problem with her intestines]. She was leaking faeces, okay? She sat in her bed for weeks on end and she knew she would die, and it was painful and disgusting. Now if I go around town talking about faeces leaking out of orifices where it’s not supposed to be, people would be like: ‘what?’ So this is why my home is very important to me. I can’t explain it. But you do appreciate the home much more.

In light of stories like these, which were not unusual for the nurses at Ward 96, the focus on creating a beautiful home can be viewed as a way of coping with anxiety and dirt. Rather than “shitty dreams” then, it is the dream of life beyond the literal shit. I would argue that the strong emphasis on the home and the family is an outcome of several strategies and experiences: in addition to a way of performing work identity, it is a way of coping with the anxieties of nursing and the increasing workloads. This type of ritualised normality carries the risk of excluding those who cannot participate.

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Conclusions In this chapter I have discussed the complicated processes of organising and performing labour that is dictated by varying needs of patients, and that is constantly interrupted. I illustrated the way that these processes are shaped by the physical layout of the workplace, but also the ways in which the temporal unpredictability of bodies makes it difficult to construct and carry out cohesive sequences of work. I have placed the labour process in a context of power hierarchies, and illustrated the variability of tasks that nurses perform. One aim here is to challenge the notion of emotional labour as separated from body work, as I have pointed to the ways in which touch can also take the form of emotional labour and vice versa. One of the contributions of this chapter is to unlock the ways in which the heterosexual matrix operates on the shopfloor. I showed that whilst there is a social and spatial distance between doctors and nurses, their interaction is shaped by heterosexual norms in which nurses avoid conflict and accommodate the gendered professional hierarchies in social interactions, typically through laughing at jokes and recognising rather than challenging labels such as ‘girls’ or even ‘pretty girls’. My argument links such behaviour to the insistence on family life as the principal area for drawing examples and comparing experiences at work. While the concept of a workplace culture is problematic and risks reifying and stereotyping forms of social interaction and discourse at the workplace, the playing out of heterosexual accommodation and care for the family and the home can be understood as the performance of the ideal worker, but a performance in which the performativity is rendered invisible and thought of as inherently ‘female’. I argue that the specific normative form of femininity that nurses play out enhances this as they refuse overt aestheticisation of the body, thus channelling a notion of the “natural” female body. This is interconnected with coping strategies necessitated by the contents of work that involve dealing with intense emotions, death, dirt, and growing workloads. The emphasis on the home and the family can be seen as ritualised normality, which is both inclusive of those who can participate in the project and exclusive of those who can not. In the next chapter, I will illustrate how nurses relate to these structures on the level of the individual.

6. Dynamics of femininities: life histories and embodied careers

Who were my informants and what did the road to paid care work look like for them? This chapter introduces some of my informants in order to illustrate commonalities and differences in the path to paid care. Beyond that, the chapter seeks to contribute to an understanding of some of the ways in which femininities are formed in relation to institutions such as the education system and the labour market (Connell 1987: 229). Studies of dynamics of femininities and masculinities have focused on life histories as a way of understanding personality as practice and as sites of history and politics (Connell 1987: 223). Messerschmidt (2004), for instance, contributed to this end through his careful exploration of the life history of Tina, who embodied a ‘preppy’, dominant femininity at her school, until her circumstances changed and she embarked on a different gender project embodying a kind of oppositional femininity involving violent encounters. Through interviews and life history analysis, Messerschmidt unfolded the ways in which gender is accomplished in relation to gendered and racialised class practices and within specific inequality regimes, in this case a school. It is important to keep the structural bases of practice in view in life history analysis, Connell (1987: 221) argues, lest the analysis end up in empiricism; the logic of the life history must be combined with the logic of institutional analysis. The life history approach has been developed empirically and epistemologically by researchers (such as Bertaux 1981) who have collected, analysed and presented in-depth life histories as a means of exploring class and class mobility in varying contexts. The approach I’m employing here is inspired by life history analysis but is nowhere near the depth and scope of studies located entirely

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within this tradition. I am inspired by Bozkurt’s (2011) study on career paths in transnational corporations, in which she interviewed two women managers in order to understand what career paths were available to Japanese women in this context. Connell’s (1995) study of men and dynamics of masculinities is also a source of inspiration; in her influential book Masculinities, she explores crisis tendencies in masculinity by interviewing men about their lives and trajectories through education, work, relationships, and interactions with the state. Her aim is to grasp the “making and unmaking of masculinity”, in order to capture the gender project involved. A crucial point revealed by the interviews with working-class men in vulnerable positions on the labour market was that masculinity was shaped not in relation to a specific workplace but to the labour market as a whole (Connell 1995: 95). I will have a narrower focus and will instead explore the life histories presented here in relation to the paid care work these women have performed in the service of the Swedish public sector. In order to highlight certain aspects of these women’s approaches to their working lives, I will include quotes from informants within other occupations: doctors, assistant nurses and physiotherapists. I have chosen four cases to illustrate paths to and within care work: Josephine, Danuta, Sara and Helena. All of them were employed at City Hospital in Ward 96, but occupied somewhat different positions within the organisation. One of the reasons for this choice is that I want to illustrate commonalities as well as differences in ways of performing and asserting femininity as well as masculinity within the nursing occupation, in order also to relate increasing differentiation within the nursing profession in ways of embodying class practices. I work here with the notion of the lived body (Moi 1999), which is an understanding of the body as “enculturated by habits of comportment distinctive to interactional settings of business or pleasure” (Young 2005: 17). This is a perspective that brings together interpellation and performativity, as the individuality is lived out through a “unique body in a sociohistorical context of the behaviour and expectations of others” (Young 2005: 17). By employing this perspective I am able to combine a life history analysis that is sensitive to the ways in which bodies take their place in certain contexts with an understanding of how inequality regimes intercede in the situations of bodies. I refer here to Young’s

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(2005) and Moi’s (1999: 81) dialogue with de Beauvoir in which the body is thought of as a situation, “our grasp on the world and a sketch of our projects” (Beauvoir 2002 [1949] cited in Moi 1999: 62), in which subjectivity is formed through embodied relationships to the world: The idea of the lived body recognises that a person’s subjectivity is conditioned by sociocultural facts and the behaviour and expectations of others in ways that she has not chosen. At the same time, the theory of the lived body says that each person takes up and acts in relation to these unchosen facts in her own way (Young 2005: 18).

In discussing the life histories of these women, I connect their individual paths to structures and divisions of labour that position bodies in relation to “labour and production, power and subordination, desire and sexuality, prestige and status” (Young 2005: 181). When I talk about embodied careers I place this analysis within the context of a specific inequality regime in which gendered, racialised and classed assumptions about body differences and appropriate behaviour or forms of interaction regulate access to power, status and rewards (Acker 2006b).

Josephine I will begin with Josephine, a ward nurse born in the early 1970s. I interviewed her at Ward 96, where she had worked for ten years. She was in her mid-forties, born and raised near the city. She struck me as a happy and warm person, but she was also one to voice her complaints about cutbacks and increasing workloads. Josephine approached me on several occasions during my fieldwork to point things out that she thought I ought to write about. Mostly, it was about speed-ups and the ways growing workloads were affecting nurses. She was a person who read a lot, who took an interest in politics. Although she was not politically active, she always approached politicians when they were handing out flyers. She thought about her situation at work in terms of gender and value: women in care work were not valued by society, by politicians, by those in power. “We have to start thinking about what kind of healthcare we want to provide,” she told me. Josephine hoped for more collective action among nurses but felt bitter sometimes about the situation. The union didn’t do much,

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she said, and nurses were too overworked to take enough action to change things. She spoke about these things in a calm, almost gentle voice. Afterwards, when I read her transcribed answers, I saw that in fact she was forceful in her critique against the healthcare organisation and its treatment of nurses: The patients today are so much sicker. They are sicker and there’s more of them. They stay longer. Ten years ago, we would have maybe five patients here on some days. Empty beds – I can see why politicians would start looking at that, but today we have 22 patients all the time and sometimes more. One goes out, the next comes in, no pause between them. Multi-problem patients can be fun to work with, but not like this. Yesterday we were told that they might not increase staffing at night, which we were told they would because we had more beds here; and then they said because of that they will increase staffing, but now they won’t. They’re looking at schedules now to see how to arrange it, but what they’re doing is looking at the vacation schedules, so implicitly what they’re telling us is that they can’t increase staffing if we want our vacation time as well. That’s healthcare for you. No Hawaii for us.

The Hawaii-comment referred to something she told me the first time we met: “Write this down. We need a vacation to Hawaii.” When I interviewed her, she was disappointed, because the promise to add an extra nurse during night shift was now being withdrawn by management. While she loved her job, she was far from satisfied with the conditions of work, and she placed these conditions in an explanatory framework of gender, arguing that women were subordinated and her experiences an outcome of this structural relationship. Josephine, like many of the nurse informants, grew up in a workingclass/lower-middle-class family. Just as with many of the nurses I had interviewed, her mother was employed in care work, and Josephine had been working through high school as an aide at nursing homes. Unlike most of the nurses I interviewed, though, she was not married and she had no kids. She lived in an apartment in the city, and she rode her bike to work. She worked full-time, whereas most nurses with children worked part-time. She spent much time with her nieces and nephews. The fact that she was single was sometimes commented upon, she said: [A colleague] said, “You need to get out more, because you’re always working and this is the only place where you meet people.” So I should get out more, because I won’t meet anyone here. Maybe younger nurses can meet people at

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the hospital but not me! … Sometimes people ask me if I’m lesbian, which makes me sad. I don’t know if I give out those kinds of signals? Is it because my hair is short, do you think?

I asked her if she felt the reason people thought she was gay, was that there was a strong emphasis on heterosexual relationships among nurses. She agreed, and said that one of the reasons she thought she had leaned towards nursing was that she had had “trouble during my teens” with food and her body: “so all that – you know, it’s difficult for me.” Nursing, however, had not been a dream of hers during her school years. Rather, it had seemed like a practical and viable choice – especially compared to her initial dream, which had been to become something like an anthropologist: My family is working-class. My mom worked in childcare, and my father worked for the railroad company. He started at the bottom at the age of 14 and then climbed his way up to a management position. Mom was in the care business, you might say, so it was easy enough for me to start leaning towards that. Although I always wanted to travel. That was my dream: I was going to be an explorer. I would go to antique bookstores and look at these old, nineteenth-century adventure books about primitive societies. Look it up, they are dead fun! But I had been working as a cleaner since I was 16, and then as an aide at nursing homes. So it was easy enough to get my assistant nurse diploma. After I graduated, I travelled, and then I was going to study anthropology, but care work seemed like a natural – an easy choice. So I entered nursing school instead.

Josephine described her family as “typically working-class, no higher education but we took care of each other”: a “stable, safe” and loving home. She had a brother, a chef, and a sister, a preschool teacher, and they were all close. When I asked her if she had ever considered continuing as a cleaner or an aide, she said “absolutely not”. She entered the local nursing college as part of the last cohort before nursing was made into a university degree. Josephine’s choice to become a nurse was quite typical of this group of informants. Many had a mother who worked in the public sector, in health- or childcare, and many had started working as cleaners or aides in nursing homes. Up until a few decades ago, clean-

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ers were employed by the nursing homes and by the hospitals, not by transnational corporations. So it was possible to move from cleaning to being an aide. And a nurse position was a significant step upward in this hierarchy, but still very much within reach. Josephine did what her mother did and most other women in this country have done: cared for people within the realm of the public sector. She also did what her father did: started at the bottom and climbed her way up to a (semi-) management position. For nurses like Josephine, their career choices seemed natural, practical and feasible. Such a choice didn’t upset anyone, and the nursing degree commanded respect. For some, whose parents held middleclass jobs, it at least represented a horizontal move in the intergene­ ra­tio­nal social mobility of their families. This was a very different experience compared to that of the women doctors I interviewed. All four of them spoke of some kind of drama surrounding their choice to become doctors. Three of them had not even voiced their wish to become doctors; they had told friends that they were pursuing something else (psychology, economy) and then applied secretly. Once they were accepted, the reactions from families and friends varied. Anja decided rather late in life to pursue a career in medicine, and her decision was questioned by her highly educated family members: I didn’t know what to do with my life. After high school I studied at the university, then I tried to go to art school, and I studied art for one year. Then I had different jobs, nothing skilled. And then, much later – this must seem so strange; it seems strange even to me. … Approaching 30, I decided to study maths. Just to see: can I do this? And I could. So I studied science at the university. Then I applied for med school and was accepted. The thing was – I guess this explains it somewhat – I had had pneumonia during art school, and when I talked to the female physician who treated me, I learned that she had also gone to art school. So suddenly there was this connection between this unreachable profession and me! I was 36 when I entered med school. My family did not really react … Well, my sister was jealous. My parents didn’t react at all, I think. My father thought it was okay, at first. Yes. He thought it was okay and he supported me. But once I graduated my dad wasn’t there. It was like I had gone too far: like I was the artist; I wasn’t supposed to go that far.

Josephine’s entry into the labour market was marked rather by a steady trajectory, a seamless transition from school years and some extra cash

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into adulthood and a respectable career. In contrast to the doctors, the decision to become a nurse was a simple, even natural one. During the interviews, this was the biggest difference between the doctors and the nurses: whilst the issue of choosing medicine, entering med school, and identifying as a doctor was emotionally charged for all of the physicians, the nurses sometimes had trouble remembering how and if people had reacted to their career choice or even why they had decided to pursue this career in the first place. Josephine dreamed of mobility but was in fact strongly rooted in the places she had entered into. She had only ever worked as a nurse at Ward 96, abandoning her initial plan to move around and get experienced in different fields. “I had a plan: two years in surgery, two years in medicine, two years in the municipality. But it didn’t happen; I stayed on here, because I liked it,” she said. She had also lived her entire life around the city, although she had dreamed of “living with indigenous people”. She explained to me that although she travelled in her mind, her body stayed put. I asked her why this was, but she couldn’t tell; “It just happens like that,” she said, and added that seeing sickness all around her had made her less adventurous over the years. “I don’t want adventure any more. When you see people suffer all the time, you appreciate just staying home, being safe in your own home.” Seamlessly entering into care work was a common experience for assistant nurses as well. Like all of the assistants I interviewed and talked to during my fieldwork, Lisa had a working-class background. Her mother was a hairdresser and later had started working in elder care as an aide. Her father worked in a factory. It was a stable and loving home, she said, a close-knit family where grandparents and parents lived close to each other. Lisa had a brother who worked as a salesperson. Unlike Josephine, Lisa explained that she had always dreamed of caring for people, and she had fond memories of helping a relative: I always liked caring for people. My grandfather was quite ill. So already when I was a child I was playing around with Band-Aids and stuff, trying to help him. And then I’ve been sick myself. I have a kidney problem. So those two things, I think, was the reason that I became interested in working in care. I always wanted to work with kids, too. But after I got my own kids, I changed my mind. Just too sad to see sick kids, I think. And, you know, the idea was that I would be a nurse. But I procrastinated. I had my first child

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and then my second one. And now I feel like, well, they don’t make that much more money than we do. Sometimes, brand-new nurses, they make even less than assistants who have been working for some time. And then on top of that you’d have the student loan debt. At the same time, you get to do more for the patient as a nurse. I would like to be able to do the things that nurses do. There is more to it if you’re a nurse; it’s limiting sometimes to be an assistant nurse. So it’s not all about money. I still haven’t given that up, that I will become a nurse, maybe in the future … If they would start paying us to get the nursing degree I would do it right away.

Josephine also enjoyed caring for people, although what excited her was developing her technical skills. Nursing to her was not only caring for people, it was also about medical interventions in which she as a nurse could be more or less skilled; the emotional labour involved aimed at creating a good environment for her to treat patients. This was her best feature as a nurse, she said: I have developed an inner security in greeting patients with a sense of humour, and I have become much better at catheters because I understand that if you can do that and have the patient laugh, then you create this wonderfully rich interaction. I don’t know how the patients feel about it really, I only know that I laugh and then they laugh. They appreciate it. I don’t know what exactly it is that they appreciate but they do, because when I use humour then they do too.

Josephine had a different way of talking about her skills and what gave her satisfaction at work than Lisa and some of the other assistant nurses. While the assistant nurses tended to emphasise caring for the whole patient, nurses, including Josephine, tended to emphasise technical skills and reflexivity in emotional labour. They would recognise, like Josephine did in the quote above, that emotional labour was something that one could improve. But Josephine thought of herself as occupying a midrange position in the ward. She was “a three out of five points nurse” she told me, one that would “be a bit wasteful with supplies” but “on the other hand never call in sick”: I know that I waste supplies. Nobody told me, but I see it myself. I should be better at thinking stuff out before I do things, but generally I’m an okay nurse. The patients appreciate me. The bosses never see me, though. So I fill out the middle, so to speak. That’s where I am.

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Josephine was worried she wouldn’t be able to work until retirement age; she was worried she wouldn’t be able to work even for another ten years: “I buy Lotto tickets, hoping I will be able to retire prematurely, because I can’t imagine how I will be able to work here for another twenty years – that is impossible, absolutely impossible.” She felt fatigued when she came home after work, and, when talking about her life outside work, she concentrated on communicating the way work consumed her energy. “It’s difficult to let go of work when you’re stressed out all the time. The scheduling means we don’t have enough time to recuperate, and I feel in my bones that that’s so important now that I’m older,” she said. At the same time, she had no clear plans or ideas of what she would do if she quit her work at Ward 96. Instead, she talked about her ambitions to get more responsibility, perhaps by becoming a liaison between the Ward and the anaesthesiologists, or moving into a position at the clinic, which meant her schedule would follow office hours and the heavy care work would be reduced. However, being the kind of nurse who “filled out the middle” also meant she felt her career chances were restricted. She had tried to get a part-time position at the clinic, which would get her out of the heavy ward work. But management had chosen not to let nurses apply for the position that had just become vacant, and instead had asked another, recently hired nurse to fill it. This, Josephine felt, confirmed her feeling of not being seen, and she related this to her appearance and to the fact that she had been vocal about growing workloads: What happens is that if you look like me, then you’re not as appreciated. [There is another nurse who] is tall, blonde and kind, yet she gives this impression that she really knows what she is doing and she is straightforward. She is beautiful. Whenever I’m around women like that, I get self-conscious. I’m not thin; look at me! But I’ve been working here for a very long time and I’ve been working hard, too hard. It’s heavy work, and I can’t do it much longer. So I really wanted to work in the clinic; I know everything there is to know. Yet management went straight to [this other nurse] and gave her that position. So this to me is about the appearance or … I don’t know how to put it, but you don’t get as far if you look like me or if you are honest about how tough it is to work here. [The other nurse] wanted to work at the clinic because she can’t do this hard work at the ward – she told me that; but to management it was more like she has this attitude like she is the best nurse. She is a good nurse, but I’m also a very good nurse; I’m just very tired.

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Thus, for Josephine, mobility was hard to achieve, even though it was what she felt she needed in order to cope. She did not fit management’s image of an ideal worker, and her own interpretation was that this was so because she was open about being tired and because she did not display a successful femininity that coupled assertiveness with traditional, feminine beauty.

Danuta Almost ten years older than Josephine, Danuta was in her early fifties and a single mother. She was hesitant the first time I was supposed to shadow her on the ward. But once we finally got to know each other, she showed me her wonderfully dry sense of humour. I interviewed her in Ward 96 at the end of her morning shift, and I kept pushing the recorder closer to her, afraid that her low voice would not catch. But she was resolved and funny and we shared many laughs during the hour-long conversation. Like when I asked her if she was happy with her life, and she answered: “Yes, I have my daughter. We fight regularly.” The interview began with her complaining about my spending time with her instead of picking up my child at daycare. She clearly was family-oriented, I thought, as she told me I should play with my son instead of asking her the most obvious questions. But what does ‘family-oriented’ mean? Does it say anything about the ways in which people live family lives? Danuta was born and raised in Poland, just outside a larger city. Her parents had been farmers. She had siblings who were still in Poland. When she was in her teens, her father had a bad accident and spent a year at the local hospital. He had felt upset about the care he received there, and insisted on Danuta pursuing a career as a veterinarian. But Danuta resisted and instead became a nurse, which she thought would be a more rewarding occupation. When she talked about her relationship with her father, she revealed a lot about how her views on healthcare and her work ethics as a nurse had developed: The nurses in Poland were understaffed. Underpaid. It was a totally different system. We were all supposed to be alike, but yet different somehow … There was always waiting. People wait here, too. But if someone wants some-

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thing here, [we nurses] run down the hallway for it. Over there, it was more like ‘you can wait’. But we disappoint our patients here, too. There are big differences, of course, but still, things happen here that shouldn’t happen at a hospital. Patients lying in their beds, who are totally dependent on someone else, they experience things differently. It’s not as bad as what my father went through in Poland, but still, I hear the same kind of stories sometimes.

She explained that her experiences of caring for loved ones made her especially diligent. She understood, she said, that it was the little things that often mattered most to patients: not having to wait for a glass of water, not having to wait for someone to help them to the bathroom. She tried to teach nursing students this, directing their attention to the little things and not only to the complex technological stuff that mostly worried new nurses. “‘Don’t think so much about [the techstuff], think about what matters to the patient,’ I try to tell people.” Among the nurses and the assistant nurses, there were several who had experiences of caring within the realm of the family, and who explained their decision to care for a living as related to such experiences. This, however, was not the case among the physiotherapists or the doctors. All of them argued that it was, rather, a ‘private’ interest, as one of the doctors explained it, in the field of medicine itself; the physiotherapists were also dedicated to exercise and sports. The difference, then, was that, whilst many of the nurses and assistant nurses could relate their interest in care work to experiences within the family, the doctors and the physiotherapists focused rather on interests developed outside and irrespective of family life. Danuta’s experiences and ways of relating standards of care to her father’s history made her a hard worker and a good nurse, she thought. But beyond that, she had a work ethic that sometimes upset the rhythm of the nursing group. She would, for instance, have a hard time sitting down during lunch break. When I was shadowing her, I noticed that she kept coming up with things she had to do that made her delay or interrupt lunch. Other nurses commented on it, and I asked her about this: Rebecca: I remember when it was time for lunch, and the nurses said, “Danuta, sit down and eat!” Danuta: I worked twenty years in Poland. We ate at work, but only when there was time. When everything was finished, then you could eat. We had

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no regular breaks like here. And if someone was sitting down eating, and the manager showed up, it would be like “What the hell – you eat at home; now you’re at work,” things like that. So work first, food second. And I got that at home, too: work, then food. You eat to survive, quickly, quickly, quickly. So I’ll feel stressed about that. You know, I have so much to do and yet I’m supposed to go sit down and eat. I mean, what the hell is that, really?

There was some talk in the ward about Danuta not being able to sit down and eat. “I stress the others out, I know that, and I need to adjust to the others,” she told me in the interview. The reactions she got when she left her food to attend to something outside the lounge was equivalent, I imagined, to factory workers snickering about those speeding up the assembly line (such as the case with Nora in Glucksmann’s Women on the Line, 2009: 16). Nurses would shake their heads and sigh, and there would be some tension if Danuta left the table more than once without being specifically called upon. This was the exact opposite of what the doctors told me. They all spoke of a culture of over-achievement, where “you’re supposed to work till you drop, otherwise you’re not a good doctor, not a real doctor,” as Herta explained to me. Maria told me that she actively turned her back against “pressure, competition” and instead coped by “being satisfied with the fact that I’m good enough”. But they all agreed that doctors were “supposed to work, work, work, work overtime for free without complaining, so that we show that we are ambitious, that we love only medicine; family life doesn’t matter”, as Eva described it. This was different from what I witnessed among the nurses in Ward 96. Despite the fact that all of them experienced growing workloads that would often prohibit them from enjoying an hour-long lunch, there seemed to be a pressure at least to pretend to be able to sit down with the rest of the crowd. Showing stress was not appreciated, despite the fact that most of the nurses felt stressed out. In Poland, Danuta had worked as a nurse in a surgical ward. Her husband had moved to Sweden and to the city to work in a factory: “After school he came here and got a job in the factory, same job as all the other immigrants,” she explained. He was twenty years her senior, and they spent much of married life apart: We couldn’t decide where we should live. We were together for fifteen years, and we kept putting the decision off, we kept saying: next year we’ll decide,

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next year … We both had our jobs. My job – the salary they paid me didn’t last even for two weeks, but I had my husband. I had a position. I was doing well! I knew that if I moved to Sweden, I’d be an immigrant. My husband said: “You will like it here; you’ll be safe here.” … Now, the only place I feel at home is in my apartment. Otherwise I’m never home. Not here and not in Poland. You lose a part of yourself. And my husband had already gone through that, and he didn’t like to push me, but … Now I regret it. Now I think to myself that we could have lived together every day instead of just once a month. That’s life.

While this quote carries the grief associated with migration, including the cost of downward social mobility and loss of a stable position, it also speaks to the self-assertive, independent ways of Danuta. She had a position; she didn’t want to lose it, so she stayed behind. The nurses who had moved to the city from other places had often followed their husbands, despite the fact that they left jobs they enjoyed thoroughly. Not Danuta. She raised her child practically as a single mother while her husband earned a living in Sweden. It was not until he was diagnosed with cancer and underwent an operation at City Hospital that Danuta decided to move to Sweden with her then 14-year-old daughter. The husband died shortly after they had arrived in the city, and together Danuta and her daughter decided to start a new life there. Danuta began studying Swedish, and then started working as a cleaner. After a while she applied for a position as an assistant nurse and got a job temping at a nursing home. It was her boss there who encouraged her to look for a nursing position. After two years, he told Danuta: “I don’t want you here temping as an assistant nurse – out! Apply for a job at the hospital.” The manager knew a position in Ward 96 was open, Danuta said in the interview, and that, if things didn’t work out, he was going to hire a nurse six months later and that could be her back-up plan. She was scared to death when she started out, she told me, and for a full year she was hyper-concentrated at work. Starting to work in Ward 96 put her skills and her confidence to the test: I didn’t back down, even though I was so scared. I didn’t back down. But if I had felt like “I can’t do this” – I mean, then I wouldn’t have dared do it in the first place. I knew somehow that, yes, I can do this.

When she came home after her shifts during the first year she fell asleep immediately from complete exhaustion. But then she settled

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in, and now she quite enjoyed working in Ward 96. She struggled with the language, she said, and felt the loss of not being in complete control of communication. She said she had to work harder sometimes to gain the trust of patients and doctors because of it. She also pointed to something many other nurses talked about: the way that humour and laughter could both overcome and create a protective distance from patients: When patients hear my accent, some of them will worry a bit. You feel instantly that now I must prove I’m not stupid. “Okay, they can think whatever they want,” I say to myself. You have to show them that you know your stuff. And sometimes when I crack a joke they don’t get that I’m joking. But then I laugh and … I did that in Poland too, laughing and joking with the patients. Maybe it’s a way of coping, of not showing emotion, not getting too deep into it. A way of coping with work, with being a nurse, I guess.

This quote illustrates the multileveled emotion management involved in nursing, which is complicated in situations where the patients don’t trust the nurse. Danuta felt the worry of her patients and made an effort to prove them wrong. The strategy that Josephine could employ, of sharing a laugh with the patients, was not as easily accessible to Danuta, to whom joking implied learning how to master the nuances of a foreign language. And laughing is an important aspect of nursing, Danuta knew, because it is a part of emotional labour and emotion management: it is a way of relaxing the patient, but also a strategy for coping with the anxieties of work. Besides challenging her relationship to patients, her struggle with the new language meant that the coordination of tasks with co-workers would sometimes be put to the test. “I have these high standards, and I apply them to myself and to my co-workers equally, but sometimes if I remind them of things it comes out wrong because of my accent,” she said. Danuta lived in an apartment in the city with her daughter. She felt too tired to do much after her shifts. Working full-time consumed her energy, she explained, and confessed with a laugh that her only hobby was lying on the couch. “I’m lazy and boring after work,” she said. Her now almost-grown daughter studied literature at the university. “She’s not going to be a nurse, that’s for sure,” Danuta said. She thought it was too hard work for her, but she also felt her daughter

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may not have that sense of caring for others. “You see, you need something – you need to be very caring when you’re a nurse,” she explained to me; “not everybody’s got it.” Danuta had moved from a safe but hard position as a working mother in Poland to a position of settling into a new organisation, with a new language. While she emphasised her caring abilities, it is clear that Danuta also embodied strength, persistence and pride, which are celebrated as masculine features. However, being diligent evidently was a double-edged sword. While much indicated that Danuta had to work harder than some of her colleagues because she had to prove herself to patients, she was not allowed to let this stress show on her body or in her movements; she was not allowed to “stress others out” by actually revealing how difficult it was to take on a position of high-tech, high-touch, high-stress nursing in another language, and in another place.

Sara Sara was the first nurse at Ward 96 that I was introduced to. I was pregnant at the time, and Sara encouraged me to take up mommy-yoga. She came across as a pleasant, assertive person; tall and attractive with an immediate kind of demeanour. But like Danuta, Sara had struggled to fit in at Ward 96 and learn all the routines. Unlike Danuta, though, she felt she couldn’t stay on. She didn’t enjoy the work pace, the structure or the tasks. She bypassed this problem by opting for a career path that took her outside of ward nursing. When I first met her, she worked full-time at Ward 96, but shortly afterwards she started working part-time at the clinic as well. When I met up with her a few years after having shadowed her on the ward, she had left Ward 96 completely and worked full-time as a clinic nurse, a liaison to the surgical team who handled all patients recently diagnosed and commencing treatment and about to receive pre- and post-operative care at Ward 96. This work was different from ward nursing, as it contained much more administrative duties, closer contact with the surgeons, and involved little or no direct work on patients’ bodies. Sara had been a nurse at a hospital in another city, and moved to this city when her now ex-husband changed workplace. “He’s in the

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[sales business], and there you need to follow the jobs, the good agencies,” she explained. While she liked the city, she was not happy with work in Ward 96. At her former workplace, she had been a team nurse, which meant that she worked closer to doctors and other occupations in a smaller organisation specialising in a specific patient category. That work was more focused on administration and involved little high-touch body work. Team nursing was less spatially and temporally controlled, more flexible work than ward nursing: Wards are very structured. You know exactly what will happen during your shift. You can organise the tasks yourself to a degree, but then you have the fixed time schedules in terms of rounds and all this. On top of that it’s extremely heavy work, physically heavy, very stressful, sort of pushy; sometimes at Ward 96 there was no time to sit down to eat, even. Basic stuff didn’t work. It didn’t suit me. And besides, it’s fun to move forward.

Sara was raised in a family of academics. It was expected of the children – Sara had several siblings – to pursue higher education. But nursing was not Sara’s first choice. She had travelled to a Third World country after high school, and that had inspired her to become a psychologist or a midwife. “I was going to save all the children and all the women,” she explained. She studied psychology at the university, but finally opted for nursing, with the ambition to do work in developing countries. When I asked her why she didn’t want to become a doctor, she said: “Oh, like my father wanted? No. I wasn’t going to stay here; that was not the plan.” She had her mind set on children in developing countries. Then she had kids of her own. “You can’t save other people’s kids when you have your own to take care of, right?” she said. She continued with nursing, and temped as an assistant nurse in the meantime. With her grades in psychology, she advanced as a nurse and eventually moved into the position of team nurse. Then her husband needed to transfer. After having moved to the city and taken up a position as ward nurse at Ward 96, she said she asked management to be transferred to the clinic: I talked to the manager. My suggestion was that I could start out part-time. It was great because I met the patients both at the clinic and then at the ward. I knew [management was looking for someone to do part-time work at the clinic] and I had the experience from having worked in team care at

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the other hospital. So the bosses started thinking about it and then decided it would work out. In me they got someone with previous experience. Internal recruitment, you could call it. I suggested it, and it was a process, and then it happened. … Some people may not enjoy being in several places at the same time, but I like to be able to develop my skills and bring experiences from one place to another. I’m good at starting things. This is why I got to my position. It suits me; I’m like that in life too.

Sara knew how to attain mobility. She said that to her it was fairly easy: she just stated her goals and then management would respond to them, if they could. She explained that, unlike many other nurses, she actively pursued things for herself: Nothing happens automatically. Things don’t fall down into your lap. You have to say: “I would like to do this, and could we try this?” And then [management] will say yes or no or maybe. You can’t walk around thinking you’ll get an offer just because you’ve got blonde hair. You have to change something, and start changing stuff yourself. Of course, management wants people to take the initiative. It was all positive reactions from management when I approached them. The other nurses were not like that. The culture at the ward was more like, “If you’re at the ward, you’ll stay at the ward – if you’re at the clinic, you’ll stay at the clinic.”

Sara spoke of feeling noticed by management, and further of promoting herself towards management, which contrasted with Josephine’s feeling of “filling out the middle”. Sara was able to mobilise a force through communication in relation to management which could get her out of an uncomfortable work situation and up through the hierarchy. In her current position, she worked closely with the surgeons in planning care, but she also organised networks of other nurses in similar positions at other hospitals. Her move had definitely been a move up, which was recognised too by other nurses. The fact that Sara was visible to management was illustrated to me when I first started doing fieldwork there. The manager, Helena, immediately directed me to Sara, with the argument that I should “… meet someone who can deal in a nice way with a researcher, someone who is interesting to you and carries herself well in situations like these.” The manager explained to me that Sara had asked to get the position at the clinic and said of this process that she “recognised Sara’s abilities, I saw that she is capable and I was very glad to be able to facilitate her move into the clinic”.

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When I asked Sara why it was that she was able to get out and up from the ward, when so many others felt like they just ended up staying even though they all shared her notion of overbearing workloads, she gave several reasons. One of the things she related was a study she had conducted when she was a psychology student, about femininity and masculinity: If you picture like a scale of femininity and masculinity – which is not the same as being female or male – you will be most successful if you are sensitive to both these sides of your person. I reach high on both scales, of both masculinity and femininity, that is. I’m pragmatic. That is not a soft feature. I’m a “It’s like this, now we need to do this, and this is how it is” kind of person. Very pragmatic. I look for solutions, which I think is a masculine attribute. But then you need the other as well. Caring, that’s considered a feminine feature. So I’ve got both. … The problem then is that you tend to care too much for people, you take all the people into your arms, so to speak, and you tell them: “Come talk to me!” And then you tend to forget yourself, which is a problem that I have battled. Yoga is very good at helping this.

I think Sara was right in the assessment that she came across as a doer, a pragmatic and competent person. The manager’s assessment of Sara as a person who could carry herself well as she directed me to her confirmed this. Sara’s strategy of producing a solution that would emanate from herself I think was a key aspect of her ability to embody a kind of interactive performance that is valorised in neoliberal management discourse (McDowell 2009: 61). To problems that she identified she also presented a solution, and that solution centred on her own practices. She was unhappy at the ward but, rather than saying, “The workload is unacceptable,” she said, “I would like to try something else.” When she said that she cared too much, she also said that she would do yoga in order to cope. What Sara did, then, was present a self that was committed to “pragmatic” solutions, which she herself associated with masculinity. Of course, in relation to the workloads at Ward 96, these solutions related only to Sara, not to the structural problem of increasing patient loads and resource depletion. In this way, she could also distance herself from competing ways of responding to interpellations of care work associated with accommodation: Sometimes I find myself trying to smooth everything out, attending to everybody’s needs. Hello, why do I do that? We don’t have to do that. You can

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barely get fired as a nurse. In the [sales] business, you’ll lose your job if you’re not good enough. So really, there is no reason to stick around if you don’t feel like it. It’s interesting that we nurses are so afraid of change. Most people don’t appreciate change. I like change just for the sake of it. But most people will resist change.

Sara responded to management’s call for flexible workers with skills and training partly acquired outside of the organisation. She also employed an individualised strategy of mobility. But to say that management appreciated this is not to say that such approaches are desired of all workers. Acker (2006b: 451) argues that notions of appropriate behaviour vary “in relation to the situation, the organisational culture and history and the standpoints of the people judging appropriateness”. But it also varies for different workers: For example, managers may expect certain class deference or respect for authority that varies with the race and gender of the subordinate; subordinates may assume that their positions require deference and respect but also find these demands demeaning or oppressive.

I think Acker’s point is important, especially when considering the new career paths that are opening up to nurses. More privileged nursing occupations are developing in parallel to a restructuring of ward nursing in which nurses’ responsibilities are expanded to involve more high-touch, ‘dirty’ and physically heavy work. The increasing internal divergence of nursing positions accentuates the differing expectations put on different workers. I would argue, based on my interviews with managers (and especially with the manager at Ward 96), that, for the behaviour of posing demands on management to be accepted as a positive self-promoting strategy, the nurse needs to embody certain qualities and, further, needs to present solutions that are deemed ‘pragmatic’ rather than dealing with structural issues that are outside of first- and/or second-line management’s scope. Moreover, based on research that has explored the ways in which class advantages take on embodied character, Sara’s social background is key to understanding her successful claims to mobility within the organisation. Bodily conduct, as well as the ability to speak in ways that are appreciated by management, can be seen as the embodiment of class practices (Bourdieu 1990, Skeggs 2004). Sara was able

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to ground her requests to management in providing for her a way out of ward work in her middle-class background, and use her bodily disposition (what Bourdieu called hexis) to affirm or further such claims. It is reasonable to assume that Sara’s overall disposition fitted in with managerial notions of what bodies should be put in a position of representing the organisation and giving advice. McDowell (2009: 63) sums up the argument: As Young argues, ugly, fat, non-white, elderly bodies are inadmissible in societies that valorise an idealised white, slim, young, unwrinkled, typically hetero­sexualised body, and so such bodies are out of place in the interactive sales/advice-giving industries and occupations that increasingly dominate in advanced industrial societies. In these consumer societies, “dynamics of desire and the pulses of attraction and aversion” (Young 1990: 60) influence the scope and content of interactions between workers, their peers, superiors, clients and customers, a reaffirmation of the … argument about the significance of consumers in service economies in expecting to be served by desirable bodies.

Thus Sara thought of herself and was seen by management as someone who could live up to, embody, the position of advice-giver; the face of the clinic.

Helena I got to know Helena, who was in her mid-fifties, when I first contacted the ward in 2008. I had done some of my fieldwork at City Hospital already, and got Helena’s name from my contact at the Human Resources Department. We spoke on the phone a few times to figure out practical things before I came to the ward, and she agreed to be interviewed too. We met at the end of her shift, late in the day, on Ward 96. She had been a manager for only one year at that point. That interview created a bond between us; Helena was very optimistic about “having a researcher around” and she agreed to let me shadow more nurses on more shifts. We shared a common language, one might say, as Helena had an interest in social psychology, gender and organisations – although her interest was directed mostly on being able to manage the organisation properly. She was excited about developing her managerial skills and seemed to take an i­nterest

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in our conversations because of this. But she was not unaware of the harsh working conditions in the ward; in fact, she was one of the fiercest critics of the situation in Swedish healthcare. She was thoroughly upset about the lack of resources and identified strongly as a nurse in relation to the doctors, who she felt did not acknowledge the nurses’ work. Like Sara, Helena’s family story was quite different from the rest of the nurses I had interviewed. Her privileged class background was discernible through the ways she controlled space around her. If I were put in the unlikely position of having to guess her occupation as she moved through the hallway of Ward 96, I would have thought she was a surgeon. And I wouldn’t have been the first to think so: People will sometimes think – patients will think I’m a doctor. I enter the room and they assume I’m one of the surgeons. That has happened more than once. And then I have to tell them, “Oh, I’m not a doctor, I’m a nurse.” Maybe it’s the way I speak. I notice when people say the wrong things – you know, if someone uses the wrong word in a sentence. And I can feel that even with my own boss I have a kind of upper hand because of the way I speak and all this.

The fact was that both her parents were doctors; her mother was a surgeon. When I asked Helena why she didn’t become a doctor too – as it is one of those professions that tend to run in the family (Becker et al 1977) – she said her parents never pushed her: It’s a question of what kind of person you are. And whether or not you were pushed. I was never pushed to do anything. Which I think is too bad, because I think I could have achieved more and got things done more quickly if they had pushed me a bit, or if they could have managed things a little better. But they didn’t have time for that, or had no interest in it, and they didn’t think I possessed the right qualities. I don’t think I would have wanted to become a doctor – I never had that dream. Of course, it’s interesting that now I’m a nurse. But I do think it’s a coincidence that I work in this specialty and my mother was a surgeon in this specialty.

In a sense, then, Helena moved down the social ladder when she became a nurse. But, like two of her three younger siblings (none of whom worked in medicine or care work), she was now a boss. And her background gave her, she said, a stronger negotiating position in the

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hospital hierarchy. The doctors treated her with more respect once they learned that both her parents were doctors; some of the doctors knew about her mother. “The female surgeons know about her; in a way, she paved the way for them,” Helena said. She explained that, unlike many other nurses, she held the key to a successful communication with doctors, something she had learned by communicating with her parents: I know how to talk to doctors. I know the technique of talking to a surgeon [laughs] – how to be very fucking brief and get as much as possible out of the conversation – yeah.

Helena grew up with parents who both worked a lot. “I was raised on fish sticks and chocolate milk,” she told me, adding that her mother was very ambitious and one of only a few female surgeons during the 1960s and onwards. Her parents later divorced. On leaving school, Helena had modest grades. She started working as an aide after graduating from high school, and then she decided to get a nursing degree because she liked working at the hospital. She explained that nursing was not a “passion” of hers; she had just decided it would be a good job – and she never regretted it, she said. Her parents hardly reacted to her decision – “It was more like ‘Oh, okay’.” But once she became a manager, she gained some more respect from them, she thought, describing both her parents as dedicated career people who were “preoccupied with achievement”. Helena moved away from her hometown, one of the larger cities in Sweden, to pursue her degree in nursing in the city, “a town I had always adored”. She met her husband there, and they moved back to her hometown for a few years, where she worked at a small hospital at the forefront of nursing theory and practice. Once their first child was born, her husband wanted to move back to the city. “I was hesitant, but in the end it was the right choice, I think,” she said. Twenty years had passed since then. Her husband now worked as a director for the county, and the family lived in a house in a small town outside the city. Helena worked part-time while her two children were small but, once they were a bit older, she started to focus on her career. Unlike most of the other nurses I interviewed, she had had opportunities to do work outside the shopfloor as well:

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I’ve been working at City Hospital this whole time, I have. But I think I’ve used that time wisely. It was intense, of course, when the kids were little; I worked part-time then. Working at the ward for a long time meant I learned that job properly and then I could focus on doing other things. I got some extra training and participated in a couple of projects, and I always had more things that I was involved in around here. I’ve been able to grow through that.

She had first applied for a management position at another ward about ten years earlier, but was told she could not be considered unless she started working full-time, which she was not prepared to do. She left the ward to work as a ‘tutoring coordinator’ at another clinic for a few years, until she was finally promoted to manager at her old ward. Helena clocked in at 6.45 in the morning. She would participate in the morning report, and after that she would leave her office door open so that nurses could come to talk to her. After that she would do administrative work for the rest of the day, mainly to do with scheduling and oversight of patient influx, which often required meetings with other managers and hospital administrators. As a mid-level manager, she had the responsibility of juggling the quality of care with financial ramifications, which was what she thought was the hardest aspect of her work. She also recruited nurses and assistant nurses and handled all personnel issues. She was finished with being a ward nurse, she told me. “All these daily routines that you deal with as a nurse, working weekends and nights, mixing antibiotics, all that, I am so over that. But as I said, this group of patients and the way that we work with them, that’s what I enjoy doing,” she said. Unlike many of the other nurses, Helena did not emphasise her caring abilities. She was not “a caring persona”, she told me, but rather interested in nursing because the intense environment attracted her. Rather than caring, she spoke of her commitment to the patients in terms of advocacy, positioning herself at a distance from the immediate care transaction. There were many similarities between Sara and Helena, one being their parents’ class position, the other their determination to move up and out of ward nursing. Helena was reflexive about her embodied class practices and acknowledged her background as being a pivotal resource in interacting with superiors. She was torn when it came to managing, though. While she seemed ambitious about the project of learning management skills in her conversations with me, she was open about the difficulties of finding a place within the contradictory

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position of being a first-line manager at the same ward in which she herself used to work.

Dynamics of femininity These women, then, have all ventured into nursing from different positions, and have also turned nursing into different experiences. Josephine, Danuta, Sara and Helena have all entered into a functional complex with a distinct inequality regime through which they have made different paths. Here, I will discuss their life histories in relation to three institutions: education, family and the labour market.

Education For all of the women, education in some form was indisputable; none of them had considered not getting a formal education. J­ osephine’s and Danuta’s parents had little formal training but expected their daughters to enter into a respectable occupation. For Sara and Helena, higher education was expected and, although Helena was “never pushed”, a career was nonetheless valorised by her parents. None of the women spoke of any trouble in relation to their education. All had been more or less diligent students, and all had worked alongside school. They had not much to say about their paths through the education system. They were content with the nursing education they had received, and enjoyed furthering their training by partaking in whatever supplementary courses were offered by the hospital (and those were not much any more because of cutbacks). As opposed to the protest masculinity (Willis 1977, Connell 1995), “exemplified by the ‘rebel’ or the outlaw – the young man who is antischool, antiwork, despises ties, and wants his freedom to enjoy himself ” (McDowell 2002: 97), these women have entered into an education system to which they have been able to adapt seamlessly. They have been, as many more of them have stated, ‘good girls’ at school.

Family Both Josephine and Danuta spoke of a tightly-knit family, where the father’s occupation was the dominant one. But as Danuta migrated, she was removed from her parents and her siblings, who remained in Poland. For Helena, though, her parents were still very much in her

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life, as were her siblings, whose kids she spent much time with. In Helena’s case it was different. Her parents worked most of the time and she had to take care of herself a lot, and she told me in interviews that she had made an effort not to repeat the pattern with her own kids. She raised a tightly-knit family of her own. Sara was divorced, Danuta was a widow and Josephine was single. The latter was the only one who mentioned being questioned somehow for not having a family or, rather, for not being a mother. All of them chose to work parttime while their kids were small, and both Helena and Sara left jobs they liked to follow their husbands. Some of them now cared for their elderly or sick parents; a few of them had experienced caring for a sick partner as well. The heterosexual family pattern was strongly emphasised in these interviews, just as the family institution was valued and made important in the lives of these women.

Embodied careers These four women were all nurses, but had had different experiences and chosen – or were referred to – different career paths. All of them had experienced working as aides or assistant nurses, and all of them had pursued the nursing occupation. For two of them, ­Josephine and Danuta, nursing represented a move up, or at least a horizontal move, in relation to their parents’ class position. It could be argued that this goes for Sara, whose mother was a teacher, as well. For Helena, though, nursing was a step down. But both of these middleclass women moved up within the hospital hierarchy. Helena’s story is interesting as she identified strongly with the nursing profession, specifically in relation to the doctors, while at the same time having a kind of inside knowledge of the surgeons. She was also the only one of the informants who disidentified from the caring aspect, and rather spoke of a dedication in terms of advocacy for patients. According to Young (2005), a central aspect of social structure are the ways in which heterosexuality positions and constructs different bodies. The way a person is positioned in structures “is as much a function of how other people treat him or her within various institutional settings as of the attitude a person takes to him or herself ” (Young 2005: 21). One aspect of this is who it is that is rendered visible in the organisation. The two women who embodied middle-class

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dispositions, Sara and Helena, both had been able to move up from heavy, repetitive ward work. But Josephine, who wanted a way out of that kind of tough labour, experienced an invisibility, which she related to a sense of not fitting in with descriptions of beauty. “I’m not thin!” she said, and talked about the ways in which her body had been a source of self-doubt all her life. She was single, and this was also a source of some grief – not because she ever said that she longed for a family of her own, but because she referred to her body image while discussing her family status, and also because this status was marked as different. She pondered whether it was her short hair that made some people ask if she was a lesbian, which made her sad. So Josephine experienced the paradox of cultural imperialism, in Young’s (1990: 60) terminology, in which people who are excluded from dominant groups experience themselves as invisible at the same time that they are marked out as different. I want to stress the high levels of conformity within the nursing collective that creates Josephine’s sense of being different. Josephine did not ‘deviate’ in terms of body functionality, sexuality, looks or the like. She was a white, heterosexual female nurse. And yet because she was not a mother and not thin, she felt othered. I would argue that only in contexts where cohesive practices are assumed and strongly emphasised can people who by many standards are perfectly ‘normal’ be made to feel this way; unseen and othered at the same time. I think Josephine’s experience speaks to the strength in conceptualising the promoted forms of femininity within care work as normative. As ­Trethewey (1999) has illustrated, the space for bodily variation is narrow for women in management positions. The ideal is to be fit rather than fat, but not too fit, because that is associated with being competitive or lesbian. As Sinclair (2011: 119) puts it, the “corporate mould requires navigation along a trip wire: feminine movement and posture in organizations must physically embody professionalism, endurance and control”. In the hospital organisation, feminine movement and posture must also embody caring and dedication to family life. Even though there was a thin line between succeeding and feeling like a failure in embodying femininity, Josephine and the other nurses did live up to the norm. Unlike the women doctors, women nurses occupy an expected position within the division of labour. .

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What can the experiences of women doctors say about the situation of both these groups? More and more women enter medical schools, but there is an evident internal segregation and it is too early to tell if the increasing numbers of female medical students represent the reduction of gender segregation in medicine or its mere reconfiguration (Acker 2006b: 446). Women doctors are still marked as women and thus as others (see Lorber 1984, Holm 1995, Davies 2001, Pringle 1998). As Marso (2006: 190) points out, femininity “is a force with which women constantly must reckon”, even by those who choose to enact masculinity or forms of femininities that challenge dominating ideologies of categorial restraints, and so femininity “constrains and enables all women’s lives” in various ways (ibid.). Of course, there is nothing to say that entering into a place in the gender order that is marked as masculine should imply embodying masculinity. In her reply to Martin (1998), Connell (1998: 457) argues that the gender structure is a complex system of not only signs and meanings, but also practices involved in material labour and accumulation of wealth. Thus a man wearing a skirt may occupy “a feminine place in that segment of the structure of gender relations that defines semiotic oppositions in dress”, but does not necessarily occupy a feminine place in other parts of the structure, such as the division of labour. This kind of gender ambiguity and transgressions, Connell argues, are central aspects in understanding the gender order. Research on women in positions of power, such as women managers (Muhonen 1999), women members of parliament (Esseveld 2005), women within academia (Husu 2001, Selberg 2011), women judges (Martin 2002) and women physicians (Lorber 1984, Pringle 1998), show that women in such positions often experience continuing processes of othering and contestation because of the social meanings ascribed to them as women; their claim to authority will often continue to be questioned, and they are subject to varying demands of femininity (Marso 2006: 191). There is a difference between women and men in these positions because men in power, as individuals and collectively, are successful in their claims to authority in that they correspond to rather than challenge the cultural ideals that work to legitimate power. Female nurses correspond to cultural ideals of women’s caring abilities and place in the labour market. Their experiences are

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not of being ­othered; their positions are not contested. This explains their smooth transition into nursing, which for the most part lacks the drama evident in the female doctors’ stories. But women possess different capabilities of enacting the kinds of femininities that are expected within different positions. As the nursing field is expanded and diversified, so are the interpellations of femininity. In this chapter, I have illustrated that class practices inscribed and incorporated into the body (Skeggs 2004) can be used as a resource to move up within the nursing hierarchy. Deploying that kind of resource means moving away from physically draining and emotionally challenging high-touch body work and into ‘cleaner’ work associated with representative or managerial tasks. I argue that the analysis of the informants’ trajectories supports Adkins’ (2003) critical assessment of postmodern theories of reflexivity. It is not, as Beck (1992: 151) suggested, that some of these women “find it difficult to remove themselves from these social traditions and become individualized subjects”; rather it is a question of classed opportunities to embody the right kind of femininity in order to attain mobility, wherein what is deemed as the proper kind of reflexivity can be used as a resource to be seen and move up within the organisation. It is important to note, though, that while moving up in this context means getting out of physically and emotionally draining high-touch body work, it is still the case that women such as Sara and Helena are “excluded from the higher ends of the high-tech information and knowledge economy” (McDowell 2009: 69) even within this particular field of the hospital and the local healthcare economy. By that, I am referring to the fact that despite being successfully reflexive and embodying ideals of professionalism and career mobility, the career paths seem restricted to both Helena and Sara, whose proximity to ward nursing and whose distance to core structures or fields of power within the organisation is still evident.

Conclusions This chapter has introduced four informants, and analysed their career paths and approaches to work and private life in terms of dynamics of femininity. I have illustrated that these women, as opposed to ‘­protest

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masculinities’, have been ‘good girls’ in relation to the education system – but also in relation to the family institution, with some variation; Danuta prioritised her own work and her position in Poland and chose not to migrate to Sweden. Sara and Helena followed along in their husbands’ transitions. And Josephine was part of a big family and was highly involved in maintaining the family institution, but was nonetheless suspected of being a lesbian for not having her own kids and possibly for not living up to expectations of a feminine, attractive body. Contrary to the doctors interviewed, these women were uncontested in their positions as nurses, and the move into nursing was seamless and uneventful. However, as the nursing field is differentiated, embodied class practices can be employed as resources to move away from increasingly heavy, ‘dirty’ and controlled processes of work. This chapter has identified a contradiction within neoliberal working life regimes: ‘good’ employees are supposed to be mobile and supposed to strive for mobility. Thus ‘good’ employees should not express a will to stay within the same place, at the same ward. This complicates the notion of care work as the focus of nursing. Staying within the ward and performing high-touch body work, and not expressing a will to move forward, gives no status, but is rather associated with failure. This means there is tension between career mobility and care work, as career mobility often represents attaining distance from high-touch body work. This is one way in which work restructures normative femininity and vice versa; ideal nurses should be caring and family oriented, but also ambitious in their will to move out of care work and into administrative and/or management positions. Proper reflexivity about gender can be used as a resource in attaining mobility, however this mobility is restricted to the confines of what has been constructed as nurses’ territories within the organisation – still outside of the main avenues of high tech information and central power hubs. The next chapter will explore further the conditions of ward nursing that also affect the desire to attain mobility, and in part explains why achieving mobility can be understood as a reward.

7. Work intensification and interpellation of femininity

They take responsibility – but too much. They care – too much. They worry – too much. They take things upon themselves – too much. They want too much order and cleanliness. They want – too often – to get things done first. They are too energetic. There is just too much of all ‘the good’. ‘The problem’, as most of them across generations and professions express it, is that they are too much of a ‘good girl’. The traditional female qualities are therefore not looked upon as only positive or something to be proud of. They are also perceived as negative, due to their bodily costs; one does get tired and worn out living up to the standards of a traditional woman. Not to mention the ideological costs! (Widerberg 2005: 109).

This chapter explores issues of work intensification, resistance and accommodation mainly at Ward 96. Widerberg’s quote on teachers captures the tension in nurses’ experience of growing workloads. On the one hand, all agreed that the work pace was becoming unacceptable, or really that it had been for quite some time. All interviewed nurses, including the nurse manager Helena, felt that patients suffered because of the intense workloads, and all interviewed nurses felt that they suffered, too. Yet, most of these nurses went out of their way to cope; to provide care beyond the organisational means available. And many of them felt some sense of culpability for the state of affairs. They all seemed inhibited by being “too much of a good girl”, as nurse Azime put it. Contradictory accounts like these, wherein nurses complain about high levels of stress but then blame themselves for putting up with it, are not new and have been reported elsewhere (Mackay 1989). Davies (1995: 2) sums it up by stating that nurses will agree with negative assessments about them, and say that “their lack of assertiveness and unwillingness to engage in action at any level that seems ‘political’ is at the heart of the problem”. On the one hand,

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then, research indicates that being a ‘good girl’ is stressful and draining. On the other hand, the ability to embody the position of a ‘good girl’ is a privilege, based on the exclusion of other forms of femininities that are not constructed as ‘good’. In this chapter, my aim is to explore the effects of work intensification on nurses and their experience of labour at Ward 96, and contribute to an understanding of the ways in which interpellation of femininities work to increase exploitation and constrain nurses’ abilities to form collective and/or individual practices of resistance. My ambition is to shed light on changing conditions of work, but importantly to explore the role of normative femininity in the maintenance of exploitation in care work.

Work intensification at Ward 96 Ward 96 had struggled with a high turnover of nurses and was generally considered to be a ‘tough’ ward to work in because of its complex care program, but mostly because of its high workloads: It’s too much now. Ever since they closed the ward at [the nearby] hospital, it’s been hell here. All major surgery is performed here, even though the number of employees is the same as before.

In the quote above, nurse Selma sums up the situation for the nurses at Ward 96. Selma, who was in her late thirties, had been working at the ward for ten years. Although she used to like coming to work, she now described the situation at Ward 96 as “hell”. The explanation she offered was a restructuring process set in motion a few years back, which changed the volume and quality of patient intake. Helena, the nurse manager, explained what happened when the county hospital infrastructure changed in an effort to increase productivity: Everything changed for us with that. What happened was, we got all major surgery and [a ward at a nearby hospital] got all minor surgery. We got all surgery where there is risk of complications. We fight to keep at least some planned operations here. The influx of emergency cases is much greater now. This means increased workloads because the patients we treat are a lot sicker and suffer from more complications due to the operations. So yes, that was a major change for us.

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The new hospital infrastructure was a political project aimed at shaping the county healthcare sector along three lines of production in order to provide both patients and staff with a “more cohesive” care chain (Docu­ment 6). However, county representatives also explained the restructuring process by pointing to a mounting “discrepancy” between available resources and costs of care: i.e. the new care infrastructure was introduced in order to cut costs. Hospital management described the project as “not primarily” aimed at restructuring the organisation, but rather to adjust the “ways we work together”. What was actually being reorganised was the patient flow and type of care provided at specific hospitals. Before the project was launched, Ward 96 and a surgical ward at a nearby hospital performed matching operations covering the same, diverse groups of patients. After the reorga­ni­sa­tion, emergency and atrisk cases were directed to City Hospital, while its corresponding ward at the other hospital handled all minor cases and most planned surgeries. This effectively increased the workload at City Hospital, and made work more unpredictable and complex. The restructuring project fitted into NPM strategies in its focus on cost reductions and increased productivity through teamwork solutions, its emphasis on organisational as well as employee flexibility, and the implementation of task separations and more active management strategies (Ferlie et al 1996). Financial reports from City Hospital during this period (Documents 1–4) mention increased pressure to produce care within stricter fiscal restraints. For example, in a report from the Finance Division at City Hospital (Document 7), top management explained the plans to effectuate a saving requirement prompted by the new county budget. The plan was for City Hospital to let go of a couple of hundred people, mainly by not replacing personnel who would retire during the year; by effectively stopping wards from recruiting new personnel; by increasing practices of out- and insourcing and benchmarking towards other hospitals; by reducing the time spent by medical staff on administration and make them spend “more time with patients”; by considering plans to “improve efficiency” in both psychiatric and somatic care; by further restricting purchases of IT and telecom soft- and hard­ ware, furniture, medical equipment and technology; and by further restricting personnel from attending courses and conferences.

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In Ward 96, four nurses and two assistants were let go over a period of two years as a result of fiscal constraints. Further, there was no intake of temps when only one or two nurses or assistant nurses called in sick. There was one less nurse on night shift. The practice of taking in personnel from temp agencies on an hourly basis was severely restricted, which left management struggling over scheduling. The workload had grown, but the number of nurses and assistant nurses had not. As ­Ackroyd and Bolton (1999: 371) have stated, because of the labour intensity in public services, efficiency gains “almost invariably require increased working intensity”, which was the case at Ward 96 as well.

An increasingly dense and unpredictable labour process In addition to growing workloads, medical developments, advancements in nursing techniques and – ideology, and customer-oriented management principles meant work was becoming more complex. The shift in the way patients were treated and approached through notions of individualised care and customer orientation (Radwin & Alster 2002, Montin 2012) meant the job was more dense and more unpredictable than before, partly because the bar was raised from within the professions, but also because patients were more knowledgeable and demanding. Janet remembered when she, an assistant, and an aide took care of 22 patients during nightshifts in the 1970s, which she thought would be “unthinkable” today: Ten to fifteen years ago, if [the patients] had diabetes, heart failure and God knows what else, we wouldn’t operate on them. Today we do. And you try to do much more for them today, so no wonder it’s getting harder. And the patients know more, they demand more, as do their families. And we demand more of ourselves, because we learn how to treat them, with individualised care and everything, what they should drink and how they should move. It’s more complicated today; you don’t just go in and put in a catheter on a patient like you did before.

Cohen (2011: 198ff) gives several convincing examples indicating that under NPM austerity ideology, care is increasingly standardised. Standardisation is desired, Cohen argues, because “it enables the predictable allocation of resources” and facilitates a more constant work pace. What nurse Janet pointed out, however, was that increased demands on individualised care, both from within the professions and from

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patients, have rendered some features of care work less standardised. When Janet began working as a ward nurse, most patients, regardless of their status, had bladder catheters inserted. The Fordist-type organisation of care prioritised making bodies more “predictable materials of production” (Cohen 2011: 198) over decisions based on the individual patient’s ability. Today, the priority instead is attaining mobility and maintaining agency of patients, as well as preventing infections (Wald et al 2008) – which in turn is linked to an increased emphasis on high patient turnover rates (cf. Läkartidningen 2008). As one internet page puts it, “a catheter is not a substitute for good nursing care”.1 Thus as the organisation recognises bodies’ unpredictability while striving for continual cost reductions, nurses have to manoeuvre an increasingly complex labour process that both affirms nursing as a field and accelerates the pressure on nurses’ time and skills. From Janet’s point of view, then, there were several factors behind growing workloads and heightened temporal unpredictability – some of which were linked to advancements in medicine and nursing, and some that were linked to management developments. NPM attempts to achieve increased quality through an emphasis on customer orientation, which challenges the autonomy of the professions while attempting to strengthen the positions of clients (Nord­gren 2007, Caspersen 2007, Hasselbladh et al 2008). As DuGay and Salaman (1992) have illustrated, customer orientation increases the pressure on workers to perform, as the responsibility to orientate production towards serving the client is delegated to the shopfloor. However, as Bejerot and Astvik (2009: 6) note, power over resources remains centralised. But there has also been a cultural change regarding patients’ subordination within the healthcare system in general, and to doctors and nurses in particular, as scientific and specifically medical knowledge is democratized and more readily available (Turner 1995, Marshal 2003). For the most part, I found that nurses considered the discourse of customer-oriented care a productive and positive aspect of nursing, although they resented being treated like “mere service workers” (see next chapter; the same has been identified among doctors, see 1.  What is a Foley Catheter?, from http://surgery.about.com/od/questionsanswers/qt/ What-Is-A-Foley-Catheter.htm, 22 August 2012.

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Bejerot & Astvik 2009). Janet, like many of the interviewed nurses who had worked on hospital floors since the 1960s or 1970s, defended these changes and viewed them as strengthening the nursing profession. “When you put the patient at the centre and you view him [sic] as a customer, you somehow put care work – our work – at the centre too, not just the ‘cutting out the bad part’ [through surgery]”, nurse Kerstin said during a conversation at the ward. Josephine, however, pointed to the difficulties in living up to the ideal of patient-oriented care. The resources provided, according to Josephine, did not match the ambition set out by the county. Consequently, nurses on the shopfloor would experience a fracture between goals and means: In the county you’re supposed to work by ‘patient-in-focus’ philosophy. But at the same time, at the ward … it’s like – yesterday, Ulla said: “Josephine, I can’t take it much longer.” We were understaffed again yesterday because some nurses had called in sick. And the patients are extremely demanding in terms of the level of care required at this point. This has been going on for ten years; I know you’ve been told about the [restructuring project]. So yesterday – I mean, there is no chance for us to think about the patient’s perspective and all that. There is so much we need to do, you know, just to make sure the nurses from the municipalities don’t start calling us all desperate because they haven’t got all the paperwork and stuff. So looking back at how things were yesterday, which was a pretty normal day, we don’t have the chance to even start thinking about that philosophy. No way. Really. Because now it’s about pushing through the tasks, do what absolutely needs to be done: see to that wound, bring that patient to X-ray, call those people. Rebecca: But putting the patient in focus – is that your ideal still? Is that your ideal as a nurse: to put the patient’s perspective first, so to speak? Josephine: Well, yes. I mean, it is. But I feel like – okay, within the county, that’s what they want. And we want it too. But I was at this lecture that the Regional [Diagnosis] Care Organisation gave, and the last person to speak there mentioned something that no one else talked about. Not the politicians, not management. But this guy, he said: “In order to put the patient first, we also need to take care of our staff.” Yes. Because you have to! Otherwise we’ll never be able to sort of reach up to that standard of working from the perspective of the patient. I can be a patient too; of course you want to be at the centre of attention.

Josephine’s words illustrate the tension between the discourse of patient-centred care and the resources available to actually provide that kind of care. The intense workloads mean that in their daily routines, nurses at Ward 96 had little room for executing, organising or

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even emotionally committing to “putting patients first”. For them, it was still a question of task-oriented care in which things needed to be “pushed through”. Josephine’s concrete experience of day-to-day work at the ward thus illustrated the dissonance between discourses of service provision and the actual labour process. But she had also recently heard something that resonated with her: the fact that providing care is an interactive enterprise, and so the quality of care is dependent on the status of the person providing it. However, nurses’ work was organised partly in terms of patient orientation, specifically through increased demands on their accessibility. Demands on accessibility especially reduced nurses’ back-stage spaces and limited their ability to sequence their work according to their own planning. For example, while it was close to impossible for a patient or kin to contact the surgeons of Ward 96 without making due appointments and going through proper channels (meaning telephoning a clinic nurse who would screen callers), nurses were expected to be reachable as soon as they clocked in. The ward had no visiting hours or telephone hours. Nurse Majken thought that one of the biggest stressors of her work was the constant interruption caused by visitors: “We used to have visiting hours and telephone hours. The visitors, they always want to talk to us. It’s a good thing, but it’s also what’s making this job so difficult,” she told me during a morning shift. What follows is an excerpt from my field notes illustrating the unpredictability involved in being constantly accessible to families dealing with sickness: I’m shadowing Danuta. We have just left a patient’s dorm, and Danuta is on her way to get some painkillers for this one patient and a new shirt for another patient. She is talking to me about the type of surgery one of the patients has had, when suddenly a man stops her mid-step in the main corridor. I identify him as a visitor of the lady in room 20. The lady has been feeling better; she even got up to watch television today, which is quite an improvement. She and Danuta had been joking and talking about this and that just earlier. The man says to Danuta: “My grandmother is very old. This has been very tough on her. She doesn’t want to live any more.” Danuta says: “Well, she is doing fine right now, she is responding well to her medication, she is not in pain.” The man insists his grandmother

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wants to die. Danuta responds: “That is not something any of us can do anything about. That is up to nature.” Again the man insists. Danuta says, “I understand,” but explains to him again that there is nothing she can do except try to make the patient “feel as good as she can under these circumstances”. The man walks towards his grandmother’s room, and Danuta and I continue down the hallway. Danuta is walking very fast now; I feel like I have to run to keep up. When we get into the medicine supply room, she sighs heavily, and finally says: “There are people like that. You have to be nice to them, even though you think: ‘oh, no.’” She looks at the cabinet and says: “What was I doing? Oh, yes – the painkillers – things like that happen and you just don’t know what you were doing, always with the interruptions. I don’t get it – the lady’s doing just fine.” I use this excerpt to illustrate two things. Firstly, demands on accessibility are delegated to the lower echelons of the organisation and it is primarily up to nurses and assistant nurses to actually represent and provide access and time-flexible service to families. The cost of this on care workers, specifically nurses who are in charge of patients’ care plans in ways that assistant nurses are not, is heightened levels of stress. This was a small interruption that Danuta had to deal with. It could be argued that while it did bother her, she also chose not to address the potentially deeper issues underlying the man’s statement about his grandmother not wanting to live anymore. She did not try to understand or explore what the young man wanted to mediate to her. He was asking the wrong questions, and was hindering her in her work. But I think that what disturbed her was the sense that here was a potentially time-consuming effort of supporting family members during crisis; an effort she had no energy and little time to put in, because she had so many other things to take care of. The process of returning to a chore after having been interrupted would often demand the kind of ‘refocusing’ that Danuta performed in the medicine supply room when she asked, “What was I doing?” I came to understand these situations as especially draining for the nurses, but also ethnographically rich moments; the fractured work process seemed to create a space for recognising and naming some of the challenges in today’s nursing. In these instants, between two tasks in a broken-down work process, nurses would often mention how

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tired or frustrated they felt, and sometimes they would admit to being afraid of making mistakes. For instance, Janet had a similar experience to Danuta’s of being interrupted on her way to the medicine supply room. When she finally arrived there, she reached for the top shelf and carefully read the label on two boxes, and told me: “Did you hear about the nurse who was indicted for giving the wrong medication? These boxes look almost the same but the potency differs. I tell myself: don’t stress when you do this; I mean, even if I’m interrupted again, read the label! It’s my nightmare to get this wrong because I was interrupted – to come back in and grab the stuff and then get it wrong, because you want to get on track with what you were doing.” Thus, increased accessibility means increasingly fractured work processes. Being interrupted causes stress for several reasons, one being the fear of making a harmful mistake in the course of trying to repatch a work sequence. I would especially like to draw attention to the devastating consequences errors might have on patients and on nurses themselves, a responsibility of which nurses are acutely aware (see also McDowell 2009: 165). Ward nurses handle high-risk assignments such as administration of medication under increasingly stressful conditions in which their attention is more and more divided between multiple tasks at once.

Increased demands on emotional labour The second point I am making based on the story of Danuta and her interaction with the grandson in the hallway is that demands on accessibility are linked to increased demands on emotional labour, the management of feelings that “requires one to induce or suppress feeling in order to sustain the outward countenance that produces the proper state of mind in others” (Hochschild 1983: 7). Emotional labour in care work has been recognised as just as draining as the physical aspects of work (James 1992: 500). Danuta later told me that the encounter in the hallway was “upsetting”. The implication of what the grandson said provoked her, even though she claimed such reactions from families of dying, elderly patients were not uncommon, especially from “male kin who do not

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want to care for their elderly”. Handling such reactions required multi­ leveled management of feelings. The emotional labour of nurses in the public care setting is performed in tension to on the one hand notions of compassion and expressivity, on the other hand notions of professionalism which require the circumscription of emotions that pose “a threat to the abstract system of medicine” (Twigg et al 2011: 175), or to the relationship between the provider and client (Morris & Feldman 1996: 987). Thus Danuta was managing her own feelings, suppressing her reaction against what she felt was an attempt to get out of a care commitment, while also trying to neutralise the emotional state of the grandson without having to enter into a lengthy interaction which would require her to support him in his upset state. She balanced two types of demands: on the one hand demands on her compassion for both patients and kin, on the other hand demands on the ‘professional’ and customer-oriented interaction desired by the organisation. But she also guarded herself from becoming too involved because that would mean that her other duties, more easily quantified and deemed more necessary, risked being neglected. The discourse of ‘professional manners’ was frequently negotiated by nurses in conversations on the pressures of work. One of the main problems of feeling tired identified by the nurses was the effort it took to ‘keep up a professional appearance’. It was not primarily the technical aspects of work that would suffer in these situations, but the quality of the emotional labour performed. Danuta reflected on this by measuring her performance under stress: Danuta approaches the medicine trolley in the hallway, where Majken is working on the laptop. Danuta says: “Let me tell you. Majken is the best nurse here, because she is the kindest. Yes, she is, because she is never mad. I get mad. I try not to, but when people yell at me I explode. I don’t want to be mean but I am, it comes from inside me.” Majken responds: “Well, you have to get it out. I take long walks in the woods, that’s how I get it out. I work through it and I get it out, so I can come here and be happy.” The exchange illustrates some of the ways in which nurses negotiate and reproduce the historical link between nursing as a profession and embodiment of compassion, consequently maintaining the associa-

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tion between reproductive labour, mothering and normative forms of femininity (Waerness 1984, England et al 2002). What this excerpt also illustrates, however, is the time and effort that goes into emotional labour and the regulation of feeling rules and empathetic interactions. Majken’s response indicates that the management of emotions extends beyond the workday and takes efforts outside of the workplace (“I take long walks to rid myself of it all” was in fact a common response to questions of how they coped at work), while Danuta’s account illustrates that failure to sustain a compassionate demeanour calls for self-examination and self-doubt; at least that is how the nurses talked about it. But it was also the fact that nurses felt they received little training in emotional labour. One aspect of emotional labour in care work is the assumption that it comes naturally to women in care work. This is not assumed in the same way within the private service sector, as Hochschild’s (1983) and Barry’s (2007) studies on flight attendants illustrate. In private service businesses, employees are trained to deal with customers and their feelings for commercial purpose. Nurse Sara reflected on the lack of formal training in offering support or hand­ ling tense situations involving patients in crisis: Meeting the needs of patients is difficult, and this is where we fail sometimes. We need feedback and supervision I think, in learning how to deal with difficult conversations, handling aggressive patients. A counsellor or a psychologist, they get training in all that. But nurses are not really trained in this, not that much anyway. And I mean, you can agree with everything the patient says, but still, it’s difficult to know how to react to their –, and it doesn’t need to be a completely failed communication, it can just be the patient or a kin even that flips out emotionally. They have been sick before or they have this emotional baggage and all that will surface when there is a new crisis like a difficult diagnosis. And you just have to try to deal with it. My partner is in the [sales] business. The girls at his work, they are constantly trained in this, angry customers calling in, and they get support and training in how to deal with it. Nurses are just expected to know it. So you use your experience, “This worked, this didn’t”, and you go with that. My partner taught me some tricks. If it’s a telephone conversation, you can say: “Hang on a minute, I’m just going to close the door”. So you put the phone down and pretend to go close a door. And that’s all it takes, a few seconds, for the person on the other end to cool down.

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According to Sara one of the toughest aspects of dealing with difficult patients was that there was often little time to actually sort out what was bothering them (and I think that Danuta’s behaviour with the grandson was an example of this). But she also said that complaints from patients could be extremely difficult to handle because they stemmed from failures of the healthcare organisation that nurses had no influence over: Rebecca: When the patients are angry or frustrated, is because you fail? Are they right in being mad sometimes? Sara: Yes, many times they’re right. Those are the hardest ones. The palliative care – when you can’t operate cancer, for instance, the patients are sent to the oncology ward. There are supposed to be nine oncologists, but there are only four of them on staff. Of course that means that patients will have to wait for an appointment. It’s incredibly frustrating to have something grow in your body, and you’re supposed to receive palliative care because you do want to live as long as possible, but you are put on a wait list like that. So we’ve had cases where the patient had to wait for six weeks for an appointment. Six weeks just to meet with the oncologist. And then more waiting before treatment starts. Rebecca: What do you say to a patient when that happens? Sara: Yes, what do you say? It’s awful. Just awful. I think it would help at least if we could give them the date and time of the appointment right away, so at least they know from the beginning that this is when I have my appointment. So, we’re going to set up a meeting about this with the nurses at the oncology ward. We’ll see.

Twigg et al (2011: 176) point out that emotional labour “maps neatly on to the gendered occupational hierarchies of healthcare, with the privileged, predominantly male professions relegating the emotional work” to “those lower in the pecking order”. This is not a new aspect of nursing, however. Already in the 1950s ethnographic research showed that those working closest to patients were exposed to more emotional pressures than senior staff, for which the Fordist-type organisation created a distance from the patients in order to contain nurses’ anxiety (Menzies Lyth 1960). It used to fall to auxiliaries and even hospital cleaners to perform emotional labour linked to intimate and/or emotionally loaded interactions with patients and kin. Doctors and senior nursing staff would have access to distancing mechanisms, both in terms of training and professional ethics and in terms of organisational

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resources or practices that would create a buffer between them and the patients. When hospitals employed large numbers of assistants and aides, nurses were removed from high-touch “basic bodywork” and instead performed more of “high-tech, skilled interventions” (Twigg 2000: 390, also quoted in McDowell 2009: 167). For the nurses in Ward 96, this relationship was being restructured. Professionalisation and customer orientation have drawn registered nurses closer into the care of patients and their kin, and nurses’ work is increasingly performed front-stage. It is nurses who are required to perform emotional labour that complies with notions of time flexibility, because it is nurses who are given the responsibility to embody quality, accessibility and service at the hospital. It is also nurses who are at the receiving end of the complaints against the organisation. This is in line with research on gender and emotional labour in the public sector. Employees “most likely to be required to provide emotional labour in an organisation are women”, and specifically in public organisations, “female public servants are expected and required to engage in emotion work to a greater degree than men” (Meier et al 2006: 899). As Meier et al point out by referring to Hochschild (1983), earlier research has identified “both gender- and class-based association with on-thejob emotional labour expectations”. Thus there is both continuity and change in the demands on emotional labour in the public sector care setting: on the one hand, it is still women and female-dominated public servant occupations who are expected to provide emotional labour, and it is women who experience work intensification pertaining to heightened demands on the extent of emotional labour. However, the class-based association is being altered as registered nurses, who historically have been removed from some of the intimate interactions with patients as such tasks were allocated to auxiliaries, and who used to spend less time on the shopfloor (cf. Lindgren 1992), face increasing demands on accessibility, flexibility and expanding contents of work in the name of professionalisation of healthcare. But this development is not without contradictions. Growing workloads, including increased demands on accessibility and emotional labour, also reduced nurses’ ability to provide care as a gift (­Bolton 2000). Being stressed out meant that it was difficult to provide emotional support to the patients, and failing in this regard would add

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to the general stress among the nurses. Being able to make a patient feel better, to comfort a patient, was one of the things that nurses enjoyed most about work; this, in a sense, was the reason many nurses loved their job and could not imagine taking up something else. So not being able to actually provide this type of support to patients was experienced as a central part of work dissatisfaction. K ­ erstin told me this story, a quite typical one: Selma told me yesterday that she was sitting with a patient who was leaving for hospice. The patient started crying; this was in the morning. Selma said that she sat down because she could feel that the patient needed to talk, but at the same time Selma was going like this [drumming with her fingers, fidgeting]. The stress. She didn’t show it that clearly perhaps, but she felt it. Rebecca: You feel like you don’t have time to support the patients? Kerstin: Exactly. Rebecca: Have you experienced that, “I would like to sit down with a patient but there’s no time”? Kerstin: Yes. Oh yes. I remember one evening – I don’t remember exactly the patient or the diagnosis, but the cancer was inoperable at that stage. I was there for twenty minutes. Evening, single room, it was room 16. And he wanted to talk. And I was there; I gave my time, for twenty minutes. Then I had to leave, I had to go help the others. And, I mean, twenty minutes is a long time to give to each and every patient. But if you were just told about a diagnosis like that and you’re anxious, then twenty minutes is nothing.

Thus nurses felt an extra stress related to not being there for their patients in ways they felt were called for. They expressed a sense of being wrong in fidgeting or letting patients see their stress; but even if they managed to hide such feelings, they complained about not being able to be focused on the suffering person in front of them. This challenged the display rules, and it challenged their sense of “being human”, as one nurse put it. “You get cynical because you don’t have time,” Selma said at one point. The aspect of giving care as a gift has been underemphasised by researchers such as James (1992), who view nurses’ ability to induce or suppress feeling in patients as something exclusively exploitative and draining, according to Bolton (2000). She argues that … the deterministic stance of many … accounts of nursing gives little credit to nurses who, through their skilled performances of emotion manage-

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ment, obviously derive satisfaction from their ability to make a difference to patients’ well-being. Nurses, within the boundaries of professional feeling rules, retain a certain autonomy in the delivery of patient care and personal discretion in how they negotiate the patient/carer relationship. Nurses may work hard on their emotions but this is not always emotional labour; that is, emotion management regulated by the labour process (Bolton 2000: 581, references excluded).

Thus growing workloads meant that nurses both had to work harder in terms of performing emotional labour, but also that their ability to “add something extra to the patient/carer relationship” was restricted. Bolton (2000: 584) noted this in her study as well, and stated that On many occasions nurses allocate themselves the time to offer extra emotion work as a gift to patients. In an era of increasing patient numbers and decreasing staffing levels, as ‘creative altruism’ is rejected in favour of a ‘market mentality’, finding the time to do this is becoming more difficult.

Josephine shared a story that illustrated the loss of pride in not being able to provide enough emotional support to patients. A patient who had been admitted to Ward 96 for an entire summer had passed away. In the obituary, the relatives had thanked the hospice staff, but had not mentioned Ward 96. Josephine explained that she felt that was on purpose, that it was a message to the nurses, because the summer had been “awfully stressful”. The patient had been walking up and down the hallway, and Josephine said that she “could sense that he needed to talk, that he wanted something from us”, but she had avoided him because she was so busy. “It wasn’t my patient; I never cared for him directly, but still, I felt that he wanted to connect, but I didn’t have the time or the strength,” she said. When the obituary came out, she said it was right of his family not to thank the ward, although it made her feel sad and disappointed in herself. “It was right of them. We didn’t give him what he deserved from us,” she said. I want to point out in relation to this that emotional labour on the part of nurses is not always associated with compassion. Nursing historically has also had a civilising mission (Skeggs 1997: 42), rendering nurses a moral authority over patients. Nurses exert control of the care labour process as they manage, in various ways, the work of assistant nurses and auxiliaries. Research has illustrated the presence

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of conflicts among nurses, involving nurses who abuse younger generations of care workers (Rowe & Sherlock 2005), who manifest racism against co-workers (Porter 1993) and patients (Mulinari 2010) and discriminate against certain groups of patients who are consequently put at risk (Robertsson 2005). Researchers have also pointed out that while the nursing discourse emphasises ‘caring’, nursing practice has been shown to involve humiliation and abuse of patients (Jewkes et al 1998). The relationship between nursing and exertion of power and violence is under-theorised, although Holm (1995) has offered important insights in some of the socio-psychological mechanisms behind varying forms of unprofessional behaviour among care workers. I will point out, however, that work intensification and increased pressure on employees are likely to heighten the risk of such behaviour (as Rowe & Sherlock 2005 indicate in relation to intra-professional harassment among nurses).2

Shopfloor outcomes: extensive and intensive efforts The nurses experienced their working conditions in Ward 96 as highstress, high-risk, but they also described the care provided as high quality. This was linked to their work pride. While many of them complained about not being able to provide the best possible care because of fiscal restraints, most nurses thought the ward delivered “for the most part good enough, once in a while supreme” care, as one nurse 2.  I did not witness any overt violence, verbal or otherwise, against patients (and perhaps it is unlikely that such things would occur in front of a researcher). I did, however, witness nurses avoiding patients, just like Josephine talked about, and I witnessed nurses clearly indicating – mostly through body language – to patients that they did not have time (or did not want to take time) to talk or answer questions. Nurses rarely explained to the patients about parameters of work in terms of schedules et cetera, but simply made the patients or kin understand that for some reason at that moment she could not spend time with them. I view this as an aspect of guarding the back stage of the hospital and the organisation of nurses’ work. It was a way of not letting patients behind the scene – which could also be a way of avoiding accountability for prioritising in a certain way. Often, though, situations where a nurse signalled that she was too busy to talk seemed to be brought on by stress, such as when a nurse had to administer medication to another patient at an exact time. To share that kind of information with the patient being brushed off would be to disrespect the other’s integrity. However, on a few occasions I witnessed nurses acting busier than they really were, especially towards patients they felt were demanding too much service (see next chapter).

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put it. This meant that nurses performed under stressful conditions, but mostly without compromising professional or personal standards of nursing. In trying to understand whether and where compromises were being made in the processes of production, I talked to nurses about how they managed their workload, and focused my ethnographic gaze on trying to identify nurses’ efforts to finish different tasks. I found that nurses employed two strategies in order to provide care with which they themselves were satisfied: extensive and intensive efforts. Extensive efforts refer to the ways in which nurses prolonged their workday so as to be able to finish their tasks. Intensive efforts refer to the ways in which nurses instead chose to compromise their own time and their own needs so as to be able to finish their tasks. The context under which these efforts were made is central. Here is a quote from Josephine, in which she describes the challenges of managing multiple demands on nurses’ skills and time: What is tough is that patients who feel bad – emotionally they can be in a poor state – and then the telephone is ringing, and everybody wants something from you, and you’re supposed to be there for so many and for so much.

The first time I met Josephine, I was shadowing another nurse at Ward 96 who had just clocked in. I realised that when 45 minutes had passed into the night shift, Josephine from day shift was still there. I asked her about this when I interviewed her a few months later, and this is what she told me: Rebecca: You were working late that day [when we first met]. And I asked you: “Do you want to work late today?,” and you said: “No, I don’t, but I have to.” Josephine: I met Anna [a nurse] yesterday in the ER. She said the exact same thing: “I want to go home, but I can’t. I can’t leave!” We work late, yes. I think the county is using us. They steal the time in the flex-calendar. … They steal our time and our money. That is what they’re doing now. Rebecca: So you sometimes work for free. Josephine: Yes. Rebecca: Why do you do that? Josephine: Because – you can hardly ever leave at nine-thirty. It is very difficult to do that. Sometimes it’s simply because you wait for your turn to report [to the next shift], because you can’t talk when someone else is talking.

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So that’s twenty minutes that will be signed up in your flex-calendar. And then you can’t use it – it’s not approved or there is no time to take advantage of it, and then three times a year they take out everything over 25 hours [in the flex-calendar], so it’s gone. There is so much that goes on around the really heavy care work. And the patients are so much sicker since they closed down the other ward [at the nearby hospital]. So it just keeps adding up and you end up staying late, again.

This quote illustrates two things. Firstly, Josephine’s experience was that staying late was not an autonomous decision. She “ended up” extending her workday because there was no way of finishing the tasks within the allotted timeframe. The tasks, however, must be finished. Secondly, she did this without being fully remunerated. It was up to Josephine’s manager to make sure staff did not overuse the flex-system, meaning there was a limit to how much flextime one could use. If nurses did not finish within the timeframe on enough occasions, the flex-calendar would max out and the hours would be erased from the system. Josephine identified the high levels of exploitation involved as the employer expropriated her work without compensating her, but she saw no way out of this relationship. Selma explained that she too worked late, for free, and elaborated on the sense of not being able to let down the patients: I always work late, even though I know I don’t get paid for it. Because to me it’s about helping each other out. And also, we are not dealing with machines here: you don’t just leave; our responsibility is to human beings. By that I mean the patients.

Selma argued that nurses have a responsibility to human beings other than themselves and the organisation they work for, a responsibility exceeding the employment relationship between care worker and employer. Feminist research has linked this type of commitment to the gendered division of labour, which has maintained an ideological association between women’s care labour and unpaid work in the private realm. This relationship has shaped the conditions of professional care work, explaining its devaluation. For example, in their study on why care workers tend to experience a decline in wage when entering a care occupation, England et al (2002: 457) argue that the ideological association between care work and mothering is part of the explanation:

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While mothers are revered, there is a sense that they should provide care out of love, not for money. This is part of why they are revered! This notion may be extended to paid care work so that care workers are implicitly expected to prove their proper motivation by accepting a wage penalty.

In addition to the wage penalty, my data indicates that nurses face high levels of exploitation because the caring responsibility is assumed on their part regardless of whether they are actually paid in full for the hours they contribute to the organisation. Moreover, the nurses themselves are hesitant to compromise on the level and quality of care. They too feel that they should provide care, and so they do, even for free. Nurses at Ward 96 further employed the strategy of intensive efforts to manage their workloads. The intensive efforts heightened my attention to the corporeality of care workers. I initially discovered the corporeal aspects of intensive efforts by talking to a fellow sociologist who had done fieldwork at a hospital in the early 1990s. I asked her when was the best time to jot down notes, and she told me: “You take out your notebook whenever the nurse you’re shadowing goes to the restroom.” I thought it was good advice and planned to follow it, but discovered that the nurses I shadowed did not seem to visit restrooms, which from my perspective seemed like a nature-defying ability. I shared this experience at the ward staff education day and was met with laughter, as most nurses recognised how they failed to go to the toilet for entire shifts: Majken: It’s funny, because all we do here sometimes is check up on the patients’ urine: the amount, the colour, does it look all right? You give them drinks and think about their fluids. Then you come home, and your urine is dark brown because a) you haven’t been drinking all day except for some coffee, and b) you haven’t been going to the restroom all day. Paula: We say: “Pee we do at night and weekends, and the rest we save for holidays and special occasions!” [Laughter]

In Theodosius’ (2008: 3) ethnographic study of a British surgical ward, nurses reported the same thing: “… you have no time to go to the toilet. Yet maybe now when we say something like that, somebody can’t believe that something like that can happen, but it happens,” nurse Maria says in an interview with the author. Across borders, nurses regulate their bodies and the very same needs they monitor in their patients so as to be able to manage growing workloads.

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One reason nurses in Ward 96 felt they did not have time to go to the restroom was the absence of workload slackening. Cohen (2011: 197) argues that the temporal contrariness of bodies makes it difficult to “distribute work evenly across the working day”, meaning that care work (and other forms of work performed on live bodies) tends to contain work peaks but also slack time. In Ward 96, there was hardly any slack time during day and evening shifts, and nurses kept up a constant high pace in moving between tasks: We always run. You see these hallways? We run up and down in them to fetch things, do things quickly. Of course, we are always interrupted, so we forget things and then you run some more.

While I never saw Majken actually run in the way nurses and doctors run in hospital dramas on TV, she kept a steady, quick pace (in order to keep up with her, I on the other hand sometimes had to run). Some nurses tried to take advantage of the constant high pace by wearing special sneakers that were supposed to shape the figure during walks. It was a common strategy and an appreciated skill to be able to do several things at once. Nurse Paula, for instance, said she tried to learn from a senior nurse especially apt at this … how to do several things at once through planning, like: I am now going to get that thing for that patient and on my way there I can also do this and see to that – to always plan things like that so you don’t run so much in between; you try to be efficient in a clever way and take advantage of the running, so to speak.

While slack time had been eliminated, management seemed to have identified a need to reconceptualise the intensive efforts on the part of nurses. Here is the rest of what Majken told me about running in the hallways: [Hospital] management told us, and I thought it was clever, that “it’s not about running fast; it’s about running smart”. So I am trying to do that now – learn how to run a little smarter and maybe not so fast all the time.

Majken’s account illustrates the ways in which performance management aimed at defusing the effects of high workloads by renaming the

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costs and consequences for the nurses. Majken’s experience of being told to “run smart” instead of “fast” shows some of the new ways in which care work is being managed in times of “austerity”, “efficiency” and performance management, whereby nurses are expected to keep a high pace while at the same time take responsibility for the costs and manifestation of making the impossible possible, i.e. finishing the tasks at hand without enough time being allotted and without being fully remunerated. Many nurses linked the capacity to do several things at once to femininity. A recurring theme on the high workloads and low salaries was versions of the statement “men could never do this job”/“men would never do this job”. Men lacked the ability to juggle many things at once, and, perhaps more importantly, they would never accept having to be forced to do “a thousand things at once, while being paid nothing”, as nurse Kerstin explained to me. Her explanation as to how and why nurses managed their workloads thus referred to taken-forgranted expectations on women’s and female care workers’ efforts, and to stereotypical notions of women’s inherent abilities to cater to people in need.

Interpellation: constructing seamless nurses In her discussion on interactive service employment, McDowell (2009: 61) draws on the work of Goffman (1959) and Williams (2006) to argue that front-stage service workers have to conform to and handle both managerial imaginations of idealised embodiment of service work and the desires and fantasies of clients. In this section, I will focus on low-level management’s attempt to construct ideal workers and increase productivity through pressurising nurses to perform seamlessly despite high levels of exhaustion among staff. The first quote illustrates the ambition of the ward manager, Helena, to make the nurses perform seamlessly, that is without naming or acting on feelings of exhaustion: I’m going to actively – by some means work on making them feel proud of what we do. Because it’s like this: right now everybody’s pretty exhausted. We have too many patients and nobody has the strength, and the nurses don’t want to do it, and many start thinking about quitting and go somewhere else

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because it’s a tough ward to work in. So I feel like I have to – you know, they have to accept that it’s hard and stay anyway.

Helena could not describe in concrete terms what she meant by “actively by some means” make the nurses feel proud, but the statement speaks to the efforts to reconceptualise the working conditions and repress expressions of dissatisfaction. In interviews with Helena and with the nurses, there was a strong emphasis on individual performance, and many nurses recognised management’s attempts to unearth ways to make them perform better, more seamlessly, without adding resources. I use the word ‘seamless’ here to indicate management’s emphasis on defusing expressions of discontent and resistance through a kind of interpellation. Interpellation refers to the ways in which employers construct stereotypical notions of idealised workers in different class positions. This calling or naming in the workplace is in turn internalised by workers themselves so that they come to conform to or recognise themselves in the managerial naming (Batnitzky & ­McDowell 2011: 186).

I encountered numerous examples of the ways in which talk about how to handle growing workloads was redirected so that both the problem and the solution were placed among the ward nurses on the shopfloor. Majken’s insistence that she needed to “run smarter, not faster” was one such example. But there were formalised components, too. Nurse Selma identified how annual salary reviews were actually used to monitor and increase work output. Selma stated that she felt exploited because, despite taking on extra responsibilities (such as being made responsible for updating and supervising fire-rescue protocol and material), there never seemed to be any room for discussing a pay rise. Discussions with management centred on her performance, never the other way around: I’m worth more, I think. I have many extra duties, responsibilities. I’m not compensated for that. We never have salary reviews, it’s called ‘development dialogue’, and we only talk about how I can develop myself! We never talk about how I can be remunerated for taking on all these extra duties. And I’m a great nurse. I’m not lazy, I take care of my patients, and I give my heart and soul. I know everything there is to know about this place.

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Management actively repressed expressions such as these. One nurse shared a story of how she was called into the office of the nurse manager after having complained, in the nurse lounge, about the high workloads and feeling fatigued. The manager told the nurse that such behaviour “created a bad environment” and “affected the other nurses negatively”. The nurse started crying, and was thoroughly upset because she felt she couldn’t “… go out and keep a professional appearance to the patients when my eyes were red and puffy”. For that, the manager later apologised. Calling for positive thinking, and warning against the collective damage associated with ‘negative thinking’, is a form of powerful social control in the workplace that has emerged in the neoliberal era (Ehrenreich 2009). Interviews with the nurse manager illustrated some of the ways in which shopfloor-level performance management focused on reinforcing attributes, approaches and appearances that created the illusion of a seamless labour process and a workplace culture without conflicts; ‘positive behaviour’. Nurses shared stories of how management prioritised nurses who seemed (to management) unfazed by harsh working conditions and offered these nurses career paths outside of the ward, such as administrative clinic duties that were not as high-touch, high-pressure and unpredictable as ward nursing. The manager underscored differences within the nurse collective by representing younger nurses as a positive force within the workplace but also as a threat to older nurses who expressed dissatisfaction with the working conditions: There are some older nurses here who are just – they are not too easy to handle. They tend to whine a bit. But they’d better watch out now, because here come all these younger nurses – great girls, happy, positive, straightforward, they get things done.

From the manager’s perspective younger nurses posed less of a challenge in terms of performance management, while older nurses represented a problem because they did not adapt seamlessly to the changing working conditions and management regimes. The issue of age differences in relation to worker subjectivity and adaptation should be explored further. Do new generations of nurses more easily comply with and consent to neoliberal ruling mechanisms

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because their identities and subjectivities as workers have been shaped in relation to a neoliberal school system, higher education, labour market and welfare ideology (Fleming & Spicer 2003: 158)? Or is it more likely that the difference is related to time, and linked to the process of growing weary from years of high workloads? Widerberg (2005) argues that “the modern woman”, a normative form of femininity in a sense, is expected to embody four essential characteristics. She is supposed to be young (which implies being thin, athletic and beautiful), energetic (dynamic), rational and efficient, and individualistic. While these features can be linked to notions of masculinity, they are also associated with being young, which is what Widerberg (2005: 110) emphasises. All the other components, she says, are “connected to youth and a sign of it. Being young, bodily and mentally, is an imperative in modernity”. As I have illustrated earlier (chapter 6), not living up to notions of beauty and thinness can be experienced as othering. In this context, being young is also explicitly linked to constructions of ideal workers.

Performing beyond the boundaries In her discussion on the rationality of caring, Waerness (1984: 199) notes that care workers she had observed in a study would “break official job instructions” in order to perform work according to their competence of caring, which was derived from work in the private realm. Often, Waerness states, “they had to work for more hours than they were paid”. It is interesting to note the continuity of high levels of exploitation in care work, as women across borders and decades have been subsidising the Scandinavian public sector by working for free. What I wanted to emphasise here, though, is the way Waerness frames the phenomenon of working more hours than contractually agreed. By working longer in order to care for their patients, the women observed in Waerness’ study defied the boundaries set by the organisation. ­Waerness wrote in a context in which public care was questioned as impersonal and overly rationalistic (a discourse that contributed to pave the way for NPM), and she framed the employees’ actions as challenging the healthcare organisation and thus portrayed it as an – albeit contradictory – form of worker resistance. I was surprised when I found that management at Ward 96 viewed nurses’ unpaid overtime as a form of defiance as well. Staying late was represented not as a sign

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of dedication and good, thorough nursing, but rather of failing to keep up the pace and disrespecting the boundaries of labour: They have this need to finish, to complete their tasks. Which really is impossible in this ward. But that is their goal, and that is what’s making them feel stressed. They want more time; they want to do better for their patients. They work so hard for their patients, and then they stay late and do the final stuff like updating patient records or whatever. … I think they could be more proactive. We could probably benefit from a more – I guess continuous dialogue. I could tell them that, ‘This is not legitimate overtime; you should have understood hours before that this was going to happen’ – something like that.

Helena’s words echo Widerberg’s (2005: 109) summation of schoolteachers’ feelings of being tired, and caring too much. She points out that there are severe consequences of embodying “traditional female qualities”, both physical (it’s draining) and ideological: At women’s workplaces with an educated female workforce, such as the school we investigated, tiredness might even be a forbidden theme, since it is connected to a femininity one wants to move away from. Here there might also be a struggle to protect the identity of a profession, which often tends to be interpreted in gender terms. No wonder women want to distance themselves from tiredness and women who ‘whine’ and complain.

Widerberg thus points to the tensions involved in complaining about workloads while at the same time going the extra mile to finish up. It’s associated with the notion of ‘good girls’; many nurses thought so. They were convinced that their impulse to finish the job maintained the high workloads, so that they were in part to blame for the situation and for their exhaustion. This is a kind of double-punishment whereby women see themselves as carrying and reproducing the “female burdens” (Widerberg 2005: 111) of endurance. Thus nurses are first given an impossible workload and, when they endure it, they are guilty of reproducing traditional femininity. Another way of describing this is through the reconceptualisation of the paradox of care. Caring for others has been associated with essentialist notions of women’s innate capabilities of affection (Davies 1995: 2). Under NPM regimes, care work is subsumed under demands on efficiency and fiscal restraints. As research has illustrated, nurses on

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the floor experience such demands as at odds with the rationality of care (Blomgren 1999), and it restricts nurses’ ability to perform creative altruism (Bolton 2000). The paradox in commodified caring is that it is “both highly valorised (as more than a job, as a vocation) and devalued and correspondingly poorly remunerated” (McDowell 2009: 163). This paradox takes on a new shape under NPM regimes and welfare state retrenchment. Care work is still devalued and poorly remunerated, while at the same time care workers are required to produce more with fewer resources and with expanding demands on their individual performance. As care must be efficiently executed so as to keep the organisation cost-effective, low-level management challenges notions of specific caring rationales, vocational allegiances, and practices of creative altruism among nurses. While performing beyond the boundaries may make a good nurse, and further may provide nurses with a sense of control and meaning, it assumes resources and organisational conditions that are not available and risks slowing down the pace of work. However, performing beyond the boundaries compensates the organisation and conceals the discrepancy that exists between means available and emphasis put on quality of production. In this sense the notion of nursing as a calling is reproduced through individual acts of resisting new logics for providing care, and through the institutionalised expectation that nurses will perform beyond the boundaries. ‘­Caring too much’ provides a buffer between what the organisation proffers in terms of resources and what patients receive in terms of service. A paradox of nursing in times of neoliberal change is that care workers are called on to perform professionally, while at the same time being called on to assume women’s traditional caring responsibilities and, in essence, cover for the organisation.

The costs of work intensification In this section, I will describe some of the costs of labour speed-ups on the nurses. The most evident and dramatic effect of growing workloads was emotional breakdowns. Nurses would start crying from stress. I witnessed this on a few occasions, and, like Foote Whyte (1949) in his interviews with crying waitresses, I used these instances as analytic entry points to understand what kind of situations in the labour process would have such an impact on nurses’ feelings. It seemed like

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two types of feelings brought on tears: not being able to prioritise, and being yelled at. Nurse Janet, who had worked in the ward for a very long time and thought of herself as a skilled nurse and calm person, explained to me about feeling overwhelmed: [I cried] right before my vacation. … It was stress. I couldn’t manage. I take on too much responsibility. … [I’ve seen other nurses] cry. More and more they cry. They are overwhelmed because they don’t know how to prioritise. You always have to prioritise but sometimes it’s impossible because everything is equally important. That’s when it comes, the tears. The patients must be cared for.

Nurse Selma, who asked to be called “The Iron Nurse” in the book because she wanted me to represent her as a tough lady (which she was), explained that she too had experienced breaking down at work: I cried last Tuesday, and this Thursday. I had to leave everything and go and hide, to cry. I had a patient, she was so ill, and I really thought she would die. And then on top of that there was a patient who vomited all over the place and I had to take care of that and change her clothes and everything. Then another patient got ill and I thought that one was going to die too. So I called the doctor twice and he got irritated. Then he came up here and said: “Well, just give some morphine.” So I broke down in front of him and started crying. He said: “You can go now.” Then the boss came and said: “Just cry it out, it’s good for you.” And I said: “I don’t want to cry at work! It’s not normal to cry at work!” Why do people cry at work? The midwives in the birth clinic cry sometimes because of the beauty in a new child being born. Here, we cry from despair.

Such emotionally draining experiences clearly affected life outside of work. Selma, for instance, explained that she thought she could never have a child because she could not imagine having to care for another person in her own home: I see the nurses who have children – when I come home I just want to be alone. I want to sleep. I’m never there, it seems – I’m always here! That’s what it feels like, like I’m always at work. So how can there be time for a child as well?

Selma pointed to something many nurses felt: that work seemed to take over their time and their bodies, even outside of the workplace.

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Nurse Paula explained that she was usually too tired to see friends after work: In the evenings you’re almost anti-social. You can hardly bear to see your friends. It gets worse the older you get. It’s nice when you don’t have to talk to anyone. I didn’t feel that before, but now I’m glad when it’s just my husband and me. We’ll eat and we don’t say that much to each other. Then you regain some of your spirit during your days off. But it wears you down.

This brief and descriptive section aimed at illustrating some of the costs of work intensification on nurses. Many shared a fear of not lasting till retirement. “I’m hoping I win the lottery,” one nurse said jokingly, because she felt certain she wouldn’t be able to work as a nurse until 55 (yes – a decade before retirement age). Nurses in their early thirties complained of back pain, and considered career paths that would take them out of ward nursing. Many complained of feeling exhausted, emotionally and physically. Their experiences echoed the report issued by the Swedish Work Environment ­Authority (Arbetsmiljöverket 2012) that concluded that nurses and assistant nurses suffer disproportionately from work-related illnesses and injuries, with 60 percent of the cases being linked to “social and organisational factors” such as high workloads and stress. The manager added another dimension to increased volumes and decreased resources. She explained that the ward was “on the verge of not keeping up standards of care”: We have minimal staffing. It’s not good. It’s horrible, in fact. It’s horrible, because the workloads were extreme already, and now we’ve had to save even more, and we’re not going to be able to educate people the way we could before. When someone calls in sick, we’re not able to call in extra people. Maybe we’ll take in someone on an hourly basis, but not much. So the staffing issue is a major concern. And just quality- and competence-wise it’s a disaster. We have very good routines, especially when it comes to the care bit, but we won’t be able to maintain that and then we’ll just lose so much in other areas, but especially in the quality of care.

In this quote, the growing workloads were described in terms of risks: the risk of dismantling routines, the risk of subjecting the patients to danger. Beck (1999) has introduced the concept of risk society, and suggests that ‘risk’ is a modern concept that presumes decision-making

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and control. The point here is not increasing risks within the modern society, but rather the de-bounding of risks. One dimension of this is social risk, which involves the difficulty of determining who causes and who is responsible for disasters. In cases where disasters can be said to be “combined effects of the actions of many individuals (organised irresponsibility)”, there are liability issues (Beck 2005: 649). I read Helena’s emphasis on risks as a way of drawing attention to legitimate costs for the organisation, as simply stating that the nurses were stressed-out seemed to lack impact factor, according to her own statements of trying to “let them know how we’re struggling here”. She told me: “It’s good when we can speak about this in terms of patient risks, because that means that people tend to listen.” Thus referring to the risk of mistreating patients also implies drawing attention to the liability of the organisation, which seemed to be the best strategy to try to prevent further resource depletion of the ward.

Interpellation and resistance When I set out to do fieldwork in the surgical ward at the hospital, my focus was on understanding strategies to deal with new demands on care workers. While I was interested in strategies to adapt to such new demands, I was also interested in identifying and exploring strategies of workplace resistance. By workplace resistance, I refer to collective and/or individual discursive strategies and practices that aim to oppose and undermine control and exploitation (Knights & McCabe 2000, for an overview see also Fleming & Sewell 2002). Identifying practices of resistance proved to be a challenge, though. I am not talking about voicing dissent, which nurses did in the interviews with me but rarely in relation to management, according to their own accounts (this was corroborated by the manager, who said that the nurses “never oppose anything; this is part of the problem, nurses take too much shit, this goes for the nurses here as well” – however, as I have shown, complaining could also put employees at risk of being disciplined). There was a strong discourse of nurses being taken advantage of by the healthcare organisation. But it seemed difficult for nurses to form opposition against the growing workloads. This is Josephine on the topic of resisting speed-ups:

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Rebecca: Do you ever resist? I’m talking about – in factories, when they are dissatisfied, they will slow the pace down as a way of resisting, for example. Do you do something like that? Josephine: Well, already we are compromising on documentation. We don’t have time to do it properly. We’re supposed to write prevention plans for elderly patients, in order to prevent injuries from falls and pressure wounds. We don’t have time for that. You have to check for stuff like what kind of shoes do they wear, et cetera, so you don’t do it. I notice in the charts that my colleagues don’t do them either. So that is one way, I guess, of resisting; but any other way – I just don’t see what I could do without it affecting the patients. I mean my responsibility is to them. I can’t do anything that affects them. Rebecca: Sometimes the bosses say that nurses care too much and you spend too much time with the patients. So is it fair to say that taking more time with patients is a form of resisting that kind of approach that management wants? But you almost compensate the organisation then, so I don’t know. Josephine: Yes. Exactly. So we work late without getting paid for it because they demand sort of detailed accounts of why I had to stay late. They know we work for free and they’re okay with it – they must be, right? And there’s no use in protesting. Really. No use. They accept that we work for free. There are not enough resources for doing this type of care that they want us to deliver, so for us it’s a matter of sort of ‘chop chop’ and then: in with some extra humanity so that we can be at peace with ourselves.

It is interesting to note here that the strategy nurses were supposed to employ to render their work visible within the organisation (Blomgren 1999) is now being discarded by stressed-out nurses. This can hardly be seen as a strategic form of resistance aiming to undermine or oppose control or exploitation, since nurses themselves brought on the emphasis on documentation. But then the internal differentiation of the nursing profession has complicated notions of interests: management, to Josephine and the other nurses, are at the same time their colleagues. Further, management positions offer a way out of ward nursing. One nurse explained that this was one reason why there was no use in turning to the union: You go to them, they will tell you that the employer is right. By the way, the employer is a nurse and, I don’t know: is she not also in the same union? Or is that like another union, the bosses’ union? She’s a nurse, anyhow. So our union rep says: “Yes, the employer is right in doing this, they have the right to this and do that.” It’s meaningless.

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Consequently, what I observed were strategies to cope with and strategies to cover the discrepancy between standards of care and resources available. The notion of resisting seemed alien, although dissent was widespread. I had to explain what I meant by ‘resistance’ in the interviews, because the nurses had no way of relating to it. And on the times nurses actively challenged management, it was by staying late or taking extra time to finish their tasks. The resistance I identified could with merit be conceptualised as the opposite – as increased (self-) exploitation. While there has been mobilisation around demands for recognition and redistribution, such as the strike in 2008 and the ‘24,000-­kronor protest’ in the spring of 2012 when nursing students around the country attempted to raise entry-level salaries, nurses continue to face increasingly harsh working conditions and have yet to accomplish any major improvements through collective acts of resistance. Moreover, the ethnographic data in this study suggests that nurses on the floor have no means available to identify spaces and strategies to resist work intensification under neoliberal management regimes in ways that would challenge the organisation without also posing a threat to their professional standards and status. In the case of ward nurses working the floor of the Swedish public sector, work intensification is a multi-layered process propelled by three intersecting forces: 1) Work intensification is a result of austerity ideology linked to the neoliberal transformation of the welfare state and public sector resource depletion. 2) Work intensification is a result of explicit care rationales impelled by aspirations of the nursing profession to establish, render visible and expand the nursing field both in relation to the medical profession and in relation to so-called ‘unskilled’ care work performed by assistant nurses and auxiliaries. 3) Work intensification is a result of the progressive aspect of NPM, which challenges the power and authority of the professions and contributes to strengthening the positions of clients and patients.

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The latter point is important because it illustrates the ambiguous power relation between nurses and patients, and the continually ambiguous position of nursing within the healthcare institution. On the one hand, the holistic and individualised care that the nursing profession attempts to construct as their jurisdiction works to reinforce both nursing as a field and the position of the patient. As Erlöv and Petersson (1992: 185) argue, when holistic or individualised care (depending on how it is labelled) was introduced in Swedish healthcare by the end of the 1970s and beginning of the 1980s, “one had to look back to the days of Nightingale to find a corresponding attention directed at the care work performed by nurses”. On the other hand, this development expands the demands on service and emotional labour. Because all of these factors are interrelated, forming resistance gets complicated. Work intensification is in part an outcome of ideals put forth from within the nursing profession. It is also important to note that NPM implementation on the shopfloor is controlled, maintained and developed by nurses in management positions. New career paths for nurses open up for increased internal differentiation of the nursing collective, which also contributes to complicating the formation of resistance strategies. It is in this context of both continuity: in the misrecognition of care work and the insistence on women’s caring responsibilities, and change: in new developments, strategies and divisions within the nursing profession, that labour speed-ups and worker adaptation among ward nurses in the public sector should be understood. Further, I think it is necessary to include the empowering element in care as one tries to explain the lack of resistance on the ward shopfloor. As Bubeck (1995: 148) has argued, care is less alienating than a lot of other occupations and forms of labour that women are concentrated in: Helping others, looking after them and their welfare, meeting their needs, is one of the most important, if not the most important, sources of empower­ ment for many women. The power a carer feels, however, is subjective, a positive sense of ability and energy, and it is the sense of power that underlies the peculiar logic of care whereby the more one gives, the more one is given in return.

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Thus one way of explaining why nurses adapt rather than resist is to focus on the rewards of performing care work. These rewards are subjective, as Bubeck argues, but stimulates feelings of power and control as well as the positive sense of being a “good” and altruistic person. In this sense, it is also a question of affirming the gender project of normative femininity, which is associated with a privileged location in relation to other women and many groups of men. I suggest that this is one reason for why resistance is so fragile among the nurses (and among groups of professional women identified with being ‘good girls’, such as the teachers in Widerberg’s 2005 study).

Conclusions In this chapter, I illustrated that because of an NPM restructuring project, nurses have experienced growing workloads over the course of a decade. Work was intensified, both in terms of physical and in terms of emotional efforts. But increased demands on emotional labour were coupled with the restriction of creative altruism, which took some of the joy away from nursing. At the same time, there seemed to be little room for resistance, and what little resistance was acted upon would seem only to reverse some of the nursing profession’s ambition to render the contribution of nurses less visible. The demands put on nurses were contradictory. On the one hand, nurses were called on to perform normative femininity, specifically embodying ‘modern’ womanhood that emphasises youth and energy. Caring too much challenged in a sense the notion of ideal workers because it channelled nursing as a calling. However, because of the discrepancy between discourses promoted by the hospital and the county on “patient-centred” and high-quality care and the resources provided, nurses were also being called on to assume women’s traditional responsibilities of caring beyond the contractual agreement. Nurses were double-punished, and punished themselves for not coming up with ways of resolving this conflict without it affecting the patients or their own bodies and minds. In trying to call attention to the situation at the ward, the manager felt it better to actualise the discourse of risk, which pointed to the liability of the organisation in relation to patients and standards

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of care. Thus the interest that was promoted was that of the patients’ rather than the employees (see also Munro 1999). And the work pace constituted a situation of risk. Ackroyd and Bolton (1999: 384) has argued that as nurses are caught in a vicious crossfire of competing demands – from management to give care to more patients in increasingly adverse circumstances, and from patients themselves to respond more quickly and effectively to their individual needs – huge demands are placed on the nurses’ capacity to deliver the quality of care that their own professional training and professional practice suggest is necessary.

The demands put on nurses are contradictory, but are also contingent on nurses seizing the responsibility to deliver safe and quality care according to their training and capacity. While nurses reproduce the notion of a calling by coping and making due, the “levels of commitment that nurses traditionally exhibit do have practical and emotional limits”, as Ackroyd and Bolton (1999: 384) argue. The ward struggled with high turnover rates especially among younger nurses, and the older generation of nurses feared making fateful mistakes. I did not interview or survey the patients, as the issues pertaining to actual quality of care lies outside the scope of this study. In order to point out that patients are put in harms way when nurses are struggling with high workloads, I cite Weinberg’s (2003) study on the consequences of resource depletion and increased exploitation in the case of the merger between Boston’s Beth Israel Hospital and the New England Deaconess Hospital. Through a survey among the patients on their complaints about the levels of care, Weinberg showed that about 22 percent said they were unable to discuss anxieties with the nursing staff; 17 percent said they had trouble finding someone to help them to the restroom; 13 percent said they were not treated with respect or dignity. Some patients reported having to wait for an extended period of time before getting pain medication; others said nurses acted so stressed and harried that they made mistakes, such as missing medication time or offering a roommate’s medications. One patient said, “The doctors and nurses are overworked and always rushing around. Both in the ER and on the floors” (Weinberg 2003: 164). The author (2003: 165) concludes that

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For nurses, these complaints from dissatisfied patients were not trivial grumblings. Together, they provide a picture of patients, albeit a minority, who suffered feelings of being vulnerable, scared, and alone. Hurting, physically or mentally, they were dependent on a busy, harried nursing staff who did not provide them with either the medication or attention that they required and who could make mistakes in their treatment. While many of the patients’ complaints pertain to the ‘pleasantness’ of their hospital experience, they also have direct bearing on patients’ safety. These issues of physical and emotional comfort extend beyond smiles and handholding. Medication errors or delays, lapses in monitoring, and lack of information about one’s condition could all make patients’ experiences not only unpleasant but also unsafe.

The current neoliberal hegemony asserts that better results can be achieved without additional resources, and that equivalent outcomes can be reached with fewer resources (Hasselbladh et al 2008: 55). But as Cohen (2011: 189) has pointed out, “realising ‘efficiency savings’ [in healthcare] is comparatively difficult and unlikely to occur without degradation in the treatment accorded to both workers and the bodies they work upon”. I have illustrated that efficiency savings can be implemented and maintained because nurses, responding to women’s traditional caring responsibilities that historically have been and continue to be conflated with professional commitments, cover for the organisation. It can be concluded, however, that resource depletion is contingent upon increased exploitation and performance control of care workers on the shopfloor and their ability and willingness to sacrifice their own time and health for the sake of their patients. This situation is associated with risk – not only in terms of risks associated with the mental and physical well-being of the employees, but also risks associated with their ability of delivering quality of care.

8. Distinctions in care work

The concept of body work draws attention to the relation between experiences of employment and experiences of embodiment. It focuses on varying forms of interactive work that take bodies as the immediate site of labour, and wherein the primary tool is also the body of the employee (Wolkowitz 2006). However, the concept of body work risks concealing the hierarchical divisions within the different types of work and occupations that perform body work. As has been discussed by McDowell (2009) and Wolkowitz (2006: 154), status divisions within the nursing sector reflect ‘different relations’ to the bodies being worked on, whereby contact with ‘dirtier’ areas of the body or activities involving cleaning bodies have lower status than skilled interventions, particularly involving body parts deemed ‘clean’. Status divisions related to the type of bodies or body parts treated can be seen within the entire field of medicine, whereby dermatology and geriatrics have lower status than neurosurgery or cardiovascular specialties (Wolkowitz 2006: 154). Such status differences reflect and reproduce categorical matching within organisations, so that working-class and racialised women perform the dirtier tasks while white men tend to perform cleaner, more high-tech tasks. This is also related to experiences of work satisfaction, of getting to do interesting and high-­status work. Power and inequality within an organisation, according to Acker (2006b: 443), is not only about control over resources, but also about disparities between actors’ opportunities to perform work considered to be interesting or important. In this chapter I explore conceptualisations of tasks that are framed by the inequality regime of the hospital organisation, and I analyse how women occupying different positions within the hospital related to and recreated distinctions in labour, specifically the distinction between care and service. Hierarchical definitions of some types of tasks as ‘ser-

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vice’ and some as ‘care’ reproduced notions of varying forms of femininities as linked to the performance of certain tasks. These processes reproduced historical divisions of labour not only between classes and between women and men, but also more specifically between different groups of women workers. The theoretical contribution of the chapter thus lies in its exploration of how different tasks are defined, and how they fit into gendered, racialised and class-related hierarchies that involve “hidden assumptions about what is appropriate work for particular socially constructed categories of people” (Acker 2006a: 113), a process that divides gendered categories within specific class configurations. This serves to complicate the concept of body work and draws attention to the tensions involved in interactive work, but it also illustrates the boundaries of work that employees negotiate in their everyday. The chapter illustrates what the gendered and classed implications of such negotiations are, and specifically how they relate to and influence constructions of femininity. In order to do this, I will move beyond Ward 96 and include to a higher degree voices from other occupations. The reason for this is primarily analytical: in this way, I am able to better illustrate the ways in which all women doing body work within a care setting negotiate and maintain status-referred boundaries towards other types of work and, crucially, other groups of women workers. As a consequence, the malleable but central concept of ‘care’ will also be investigated.

Tensions and boundaries at work When I started doing interviews with hospital employees of different categories, I had no clue as to what the tensions at work would really be about. I was familiar with the notion of nurses treating female doctors less cordially than they would male doctors (Davies 2001), specifically by giving them less service, but I never thought about the role of definitions of such practices. As I started interviewing women involved in care work (and here I refer primarily to nurses and assistant nurses), I realised two things. First of all, which concepts I used to ask questions about their work seemed to matter. If I talked about care – which I thought was a general description of the work they performed on and in relation to patients on an everyday basis – they

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would start explaining to me that this concept was quite complex and had strict boundaries to it. Second, I found that in their explanations and reasoning about what care work was to them, the concept of service kept surfacing as a way of naming such boundaries. I found that many went out of their way to make me understand the distinction between service and care, and why they were so hesitant to perform what they understood as service work. The only true exception was in the high-tech wards in the ER or in surgery. In fact, at Ward 96, which has been my main case in the book, this distinction was not made out as important. Few assistant nurses, very sick patients and a lot of care issues involved in basic routines such as eating meant nurses had to use their skills even in unskilled tasks such as giving the patients nutrition. But mainly, at Ward 96, patients were so sick and often so disabled by their disease that they could not be asked to do even simple tasks for themselves. In this chapter, I am thus venturing out of Ward 96, focusing on the multiple accounts given by women working in different occupations and at different hospitals in the county. The distinction between service and care were created relationally and in two organisational spaces: on the one hand in relation to coworkers higher up in the hierarchy, such as nurses ‘serving’ doctors; I conceptualise this as ‘serving up’. On the other hand in relation to patients – ‘serving within’ – or outside actors such as municipalities, the social insurance agency or employment agencies – which I conceptualise as ‘serving out’. The same task could be conceptualised either as service or care, depending on context. How these variations were understood and experienced came up in interviews and discussions about the content of work. Nurse Malin, who worked at University Hospital, explained it to me: If a patient says, “Hey, get me some coffee” – well, then I’m serving that patient. If a patient hasn’t been drinking and I know they haven’t been drinking and I ask, “Would you like a cup of coffee?” and I go and get it, then I know that patient is getting fluid. Rebecca: So then it’s care. Malin: Yes, because then I’m doing something to make the patient better. If someone tells me to fetch that, do that, turn out the light when you can do

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it yourself, then it’s service. Then I feel like – it’s not my competence that is sought after but only my arm, or my legs.

Getting coffee for a patient could thus be described both as service and as care, depending on the context and on whose demand the task was performed. Care demanded ‘competence’ while service ‘only’ seemed to demand arms and legs – and service was performed on someone else’s initiative. Care was thus represented as of higher status because it presumed formal knowledge and the opportunity and professional space to take initiatives for someone else. The knowledge hierarchy, in which skills learned within the private realm (Waerness 1984) had lower status than formal training, was matched, unsurprisingly, with exterior hierarchies of status (reproducing, among other things, the Cartesian distinction between body and mind, which in the labour market has been a gendered and racialised configuration). ‘Service’, however, was not deemed problematic and unwanted by nurses just because it supposedly reduced the actor to arms and legs; there seemed to be something else, too, that sort of ‘stuck’ to service tasks historically performed by women. When I asked RosMarie whether she ever experienced sexual harassment at work, she said patients “and others” had grabbed her behind. When I asked how she reacted to that, she answered: When that happens, and it only happened once or twice, but I’ll get mad as hell. I’ll turn around and tell that person that I am not a waitress. Those were my exact words when a patient did it last. I turned around and eyeballed him and said, “Don’t ever do it again!”

By declaring that she was not a waitress, Ros-Marie felt she made clear to the patient that her behind was not his to touch. The account hints at a notion that there exist jobs and workers, located in the service sector, that may be touched this way. Ros-Marie spoke of a distinction between kinds of work that position employees’ bodies differently in relation to clients, and to clients’ fantasies and claims to the bodies of service employees. Ros-Marie’s account highlighted that, while workers across the service/care spectrum may be connected in that they share the experience of using their own bodies to perform work on other bodies, there exists a divide in terms of status which is linked to

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the accessibility of their bodies to the clients. While nursing historically has been constructed around motherhood, other forms of service work have been constructed rather around emphasised forms of femininities that are interpellated to accommodate men’s erotic desires. Consider, for instance, the embodied femininity of flight attendants in the early days of the occupation, whose labour was located in a space where “the point of production and the point of consumption were inseparable” (Barry 2007: 6). Their skills, Barry argues in her study on femininity and the history of flight attendants in the United States, were supposed to be concealed under the guise of glamour; even the fact that what they were doing was paid work was rendered invisible. Their bodies were made accessible to the customers through marketing strategies (“Fly Me!” or “Coffee, Tea, or Me?”) and the companies’ emphasis on things like conversational skills. Applicants were carefully screened so as to fit the fantasies and expectations of (male) passengers (ibid.). Historically, nurses too were supposed to be unmarried, respectable women who could handle high-touch work without transgressing boundaries (of sexuality, emotion, et cetera), but, just like flight attendants, nurses’ skills were rendered visible through collective efforts and strategies of professionalisation (Bohm 1961, Olsson 2002). I would argue, though, that one of the main differences between care work and service work lies exactly in the notion of the accessibility of employees’ bodies and their role in accommodating clients or patients: healthcare services historically were not sold as a commodity through references of nurses’ services (there is no equivalent of “Fly Me!” marketing pertaining to public service nursing). As Mulinari (2007) showed in her study on the service industry in Malmö, Sweden, different bodies were called on to provide different kinds of services: white women were hired to waitress in restaurants coded as ‘Swedish’, while racialised bodies were hired to waitress in restaurants that served ‘non-Swedish’ food. Their bodies were expected to be accessible to customers at customers’ demands. What Ros-Marie’s quote illustrated is that nurses’ bodies, while regulated and interpellated in different ways within healthcare organisations, are not accessible to the patients in the same way. Their labour shades off into control rather than accommodation towards patients, as Wolkowitz (2006) has argued. In this chapter, I will illustrate the

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tensions that arise as patients do claim to control or access care workers’ bodies. Further, I will discuss the tensions that arise as such claims to be served are raised within the organisation by co-workers, or from outside of the organisation by, for instance, other organisations within the public sector.

Complex divisions of labour Distinctions within body work and other forms of reproductive labour have been explored by scholars such as Roberts (1997) and Glenn (1992), who have illustrated that divisions within reproductive labour create and recreate differences between women. By using domestic work as an example, Roberts (1997: 51f ) detangles the class-based, gendered and racialised power relations among women involved in different types of body work and reproductive labour (including cooking, cleaning, et cetera): Domestic labour is divided into two aspects – the spiritual and the menial. Some work in the home is considered spiritual: it is valued highly because it is thought to be essential to the proper functioning of the household and the moral upbringing of children. Other domestic work is considered menial: it is devalued because it is strenuous and unpleasant and is thought to require little moral or intellectual skill. While the ideological opposition of home and work distinguishes men from women, the ideological distinction between spiritual and menial housework fosters inequality among women. Spiritual housework is associated with privileged white women; menial housework is associated with minority, immigrant and working-class women.

Indeed, I was surprised to see that the concepts of ‘care’ and ‘service’, to which I had paid no particular attention before I started interviewing, seemed to emulate the distinction Roberts points out in her article on ‘spiritual’ and ‘menial’ housework. The overlaps between different tasks within occupations on either side of the care/service divide were evident: making beds, for instance, is something that both hotel maids and assistant nurses (as well as nurses) do; taking out food and cleaning up afterwards is something that assistant nurses and nurses do – tasks that are also part of the job for waitresses. But the care workers I interviewed grappled to explain their conceptualisations of these tasks, specifically when they were dealing with patients who

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had a maintained mobility and thus were able to get coffee for themselves. I found that talking about the difference between service and care often provoked processes of disidentification, as service work was linked to subordinated groups of workers and forms of femininities that were represented as other, like in Ros-Marie’s quote. The need to distance oneself from work conceptualised as service speaks also to the professionalisation achieved by nurses and (to a lesser degree) assistant nurses during the last thirty years. Ros-Marie explained to me why she considered refusing to perform service work as a way of protecting nurses’ – in fact, women’s – position at the hospital. To illustrate the long way nurses had come since she began to train in the 1970s, she offered up this anecdote: In 1971, I was working at a hospital as a trainee; I was going to be an orderly in the psychiatric ward, which is how I started my nursing career. Training involved four months’ practice in somatic care as an aide. I spent two months at a surgical ward. My responsibility, as an aide, was to push the chart trolley and hold the ashtray for the doctor, because he smoked during rounds. If you didn’t keep up with him, he would put out his ash wherever. 1971, mind you. When I tell people this, they think I’m a hundred years old!

With nursing as a relatively autonomous field today, Ros-Marie used this story to illustrate the degradation younger nurses in training had to put up with only decades (and not a century, as Ros-Marie pointed out) ago. Even if nurses do act on doctors’ orders, the occupation is not viewed as ‘doctor’s aide’ any more, and is not associated with the type of servility expected of Ros-Marie by the smoking surgeon.1 This sort of work was considered to be of the service kind, and outside of nurses’ responsibilities. What is the difference between service and care in this context? Some of the tasks involved in nursing can obviously be conceptualised either way, but the difference seems to lie in how the work is defined and organised. The history of service work is different from the reproductive work performed in the public sector. Service sector jobs, in 1.  Ros-Marie hints that it wasn’t the doctor who expected her to pick up his ash; he would simply let it fall to the floor had there not been an aide to carry the ashtray for him. I suspect (I missed the opportunity to ask any follow-up questions, so I can’t say for sure) that it was the senior nurses who assigned Ros-Marie this task because otherwise the ward would get filthy.

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Roberts’ terminology ‘menial’ work that does not fit into the concept of care work as defined by Yeates (2004), are lower-status jobs: they are physically demanding, involve dirty work, they are unqualified and often ‘invisible’ (Glenn 1992). Workers in the service sector, in Sweden and globally, are often young, female and immigrants or racial minorities (Mulinari 2007). Service work and notions of servility have been linked historically to different subordinated groups; Glenn (2002) describes how Asian immigrants in the United States were considered specifically suited for service work at the beginning of the twentieth century, while Platzer (2007) illustrates how Swedish consumers of so-called ‘household services’ (‘hushållsnära tjänster’) at the beginning of the twenty-first century base their recruiting practices on ideas of the varying degrees of servility among different ethnic groups. The presence of the large public sector has meant that women in Sweden have not been drawn into the service sector to the same degree as in other countries, but research shows that as the public sector was diminished, women with low levels of education were likely to move on to jobs within the private service sector (Pettersson 2000). There exists an empirical proximity between public sector care jobs and private sector service jobs. This proximity now shows in different arenas. Due to the neoliberal shift in the welfare state, privatisations and practices such as outsourcing have meant that the service work inside the hospitals is operated by private companies, who often employ racialised groups of workers to clean hospital hallways (Kommunal­arbetaren 2008, EU-OSHA 2008). This means that the cleaners are no longer employed by the hospital, and their work situation is often described as impossible (one example is the multinational service company ISS that cleans many Swedish hospitals: at Lund University hospital, they demanded that workers cleaned an OB/GYN ward in 36 seconds, SVT 2006). Thus there is an ethnic division of labour in the hospitals, whereby white ‘Swedes’ are in the majority among those who perform care work, while racialised groups perform service work such as cleaning; during my fieldwork, I hardly ever saw a white person clean the hallways (Acker 2006: 107f ). It wasn’t just nurses who would worry about the distinction between service and care. Doctors talked about ‘serving’ patients (see

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also Bejerot & Astvik 2009). A physiotherapist talked about nurses wanting to care for the patient too much, so that they were actually ‘serving’ them, thereby somehow moving beyond professional approaches to care work. What these accounts all had in common was the image of service as less valued, less interesting, less productive in terms of providing care, and linked to ‘traditional’ femininity. Service would, in these accounts, connote old-fashioned, dependent, even subservient femininity; the same as Widerberg (2005) noted teachers disidentifying from as they related just how tired they were from ‘caring too much’. There was an ideological price, to use ­Widerberg’s words, of practising ‘traditional femininity’.

Serving up as linked to traditional femininity Assistant nurse Britta was 61 years old when I interviewed her at the local trade union office, where she worked part-time as a representative. She had worked for more than half her life as an assistant nurse in an oncology ward at University Hospital. “I am very proud of being an assistant nurse,” she told me at the beginning of the interview, and her pride was something she would mention several times during our conversation. She explained that she belonged to “an older generation of assistant nurses” who would feel joy and pride in being able to provide service, specifically “serving doctors”: Now, I belong to what we call the ‘old school’ [“den gamla stammens undersköterskor”] – you know, service. Many who graduate today feel like “Why in hell would you serve doctors?” – and then there is a conflict. Rebecca: They are not as good assistant nurses, then? Britta: No, no. I think they make better assistant nurses. They demand more from the employer.

I struggled to make sense of Britta’s account. She was proud of the fact that she, as part of an “old-school generation of assistant nurses”, could serve the doctors – in fact, this was a source of joy to her. Conflict would arise when younger assistant nurses, who were not trained to serve doctors and saw no point in doing so, started working alongside her. Yet they made better assistant nurses, staking their ground in a way Britta would not. She went on to tell me that nurses would

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perceive her as a threat because of her experience and competence, despite “just” being an assistant nurse. Sometimes, she explained to me, she would confront the nurse and call her out. But with the doctors it was a different story. “They come to me rather than to the nurses, maybe because they get better service from me, who knows?” she said. In trying to make analytical sense of Britta’s account, I thought about it as a story of the different strategies available to different women in different positions within the healthcare organisation. To Britta, who felt she lacked some of the ‘confidence’ that younger nurses – and younger women in general – portrayed, the ability to ‘serve’ was an alternative strategy. I would like again to draw on Widerberg’s (2005: 110) discussion of “how the modern woman is supposed to be”, which is focused on youth and what (supposedly) comes with it: beauty, energy, individualism. So while Britta had a hard time embodying that ‘modern woman’-femininity her younger colleagues performed, she was able to mobilise servility as an alternate resource. ‘Serving’ added to her work satisfaction, made her visible and brought recognition from authority, the doctors. At the same time, the will and ability to ‘serve’ was constructed as something belonging to the past, something that reproduced a function and position that care workers had tried to move beyond. When the ‘old-school’ assistant nurses were serving doctors, then, they reproduced a traditional feminine position in the inequality regime of the hospital that nurses and assistant nurses had sought to leave behind. As Davies (2003: 721) put it, nurses’ strategies of professionalisation, emphasising ‘independent duties’, means that the word ‘service’ and notions of nurses as ‘handmaidens’ appear antiquated in the hospital setting. Pringle (1998: 190) argues that this shift is linked to the women’s movement: The absolute authority of medicine has been challenged, the women’s movement has brought a redefinition of women’s roles, and a changed historical and cultural milieu has provided the space in which it was possible for nurses to develop new subjectivities which are more assertive than those usually presented in the sociological literature. A game [between nurses and doctors] based on medical omniscience now seems archaic.

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What makes Britta’s strategy contradictory is that serving doctors is productive to her as an individual actor, but not necessarily so as a part of a group of workers in the organisation. The recognition Britta got from deploying this doubled-edged strategy is one example of how “organisational hierarchies of power and reward are class hierarchies” (Acker 2006a: 107). The limited kind of reward was what Britta considered to be in her reach when it came to being recognised within the organisation; but she also saw that this type of recognition was not what she, as a labour activist and union representative, thought was productive in the long run. Britta felt her ability to earn recognition from doctors by serving them challenged some nurses. But in interviews with nurses, the story could be told differently. Nurse Agneta used to work as an assistant nurse but decided to study and become a registered nurse instead. In an interview together with her colleague Ros-Marie (who was quoted earlier), she talked about the “old-school assistant nurses” as “more traditional” in both their family orientation and at the workplace, which explained why they “kept up the service thing”. Just like Britta, Agneta described older assistant nurses as unwilling to stand up for themselves and as lacking in confidence and individual stamina: Agneta: I feel that it’s still a lot of collective thinking [among assistant nurses]. The Swedish Municipal Workers’ Union [Kommunal, the trade union that organises assistant nurses] stands for this collective thinking. And then it’s all about not standing out. At least with the women, that’s how I see it. … Here at the hospital, the assistant nurses are old, because there have been cutbacks and so younger assistant nurses [recently hired] have been let go. And the older ones have an old – older way of thinking: you don’t work independently, you don’t take initiative; even though the employer wants you to be participating, no one wants to stick their chin out. They are not brought up that way. Ros-Marie: Yes. And then it’s comfortable, when other people do all the talking. Telling them what to do, so they can take the easy way out all the time – that makes it simple, doesn’t it?

Agneta and Ros-Marie were able to identify the same notions of ideal workers and independent women that Sara in Ward 96 (previous chapter) did, and they placed their recognition of employer expectations in relation to their understanding of “traditional” and old assistant

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nurses, with “an older way of thinking”. In this conversation, then, they re-established modernity as a project that involves independence (specifically from work collectives) and the ability to “take initiative” and consequently be seen by management. Crucially, they positioned nurses in relation to assistant nurses as more able to embody a ‘modern’ femininity and ideal worker constructions. Agneta and Ros-Marie both worked part-time as representatives for the nursing trade union, The Swedish Association of Health ­Professionals (Vårdförbundet, SAHP in the quotation below). What may sound contradictory – the ambition to distance themselves from work collectivities and the emphasis on what the employer wants – can be explained by the ideological and strategic decisions by the union, to establish nursing as a white-collar trade. This organisation has moved away from what they perceive as ‘collectivist’ labour union strategies and rather to embrace ‘individual’ strategies, including individual salary-setting: During the last twenty years, Sweden has become a much more individualised society. Organisations that build on ideas of collective power and solidarity have struggled. Many within the trade union movement are frustrated and wonder where the solidarity has gone. Not SAHP.2 Since the mid-1980s the organisation has emphasised the mission to improve the conditions and possibilities for members’ professional development and wage trends. Former union leader Eva Fernvall put it like this: “As long as we fail to be judged as individuals we will continue to be discriminated against as a group.” The statement explains why SAHP never hesitated to embrace increased individualisation of the working life. The notion of a subordinated and self-sacrificing woman collective has been difficult to rid. … To SAHP, it has been important to break out of the abundant women’s collective and see each individual as a unique person with the right to be recognised for his/her own specific competence and capacity (Ryman 2007: 19). 2.  This statement is disputable. Apart from the union representatives, none of the nurses I interviewed were satisfied with the trade union. Many were considering leaving. The disappointment after the strike in 2008 was evident among the nurses I shadowed. One of them said: “It is so painful even to talk about how I feel about our union that you’ll have to excuse me; I’m just not going to comment on that. Let me put it this way: the leadership should be thrown out. They don’t care about us on the floor.” Like many other trade unions, The Swedish Association of Health ­Professionals has a decreasing membership base, but nonetheless organised more than 110,000 people in 2009, 92 percent of them being women (Vårdförbundet 2009).

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In this excerpt from a union booklet called Från strid till strategi (‘From battle to strategy’), The Swedish Association of Health Professionals explains their view as to why individualism is an embraced strategy even within the trade union: by disidentifying from the collective of women, the trade union feels it will be possible to reach higher salaries and render increased visibility and status for their members.3 But importantly this project, I would say, is about disidentifying from working-class women and working-class strategies of collective struggle; a way of distancing nurses from assistant nurses and their union, part of The Swedish Trade Union Confederation (LO, Landsorganisationen i Sverige). In Agneta’s account, assistant nurses’ union politics were turned into an aspect of what Britta is talking about: old-school care workers’ ways of deploying ‘traditional’, working-class-coded forms of femininities to succeed at the workplace. By linking the older assistant nurses’ strategies at the workplace to their union’s strategies, Agneta made a connection between the subordination of the working class and its historical strategies of resistance (Skeggs 1997). Assistant nurses thus were framed in her account as traditional women bound up with working-class strategies as a thing of the past; strategies that reproduced women’s subordination by acting like ‘a women’s collective’ rather than youthful, individualistic subjects.

Doctors and service: gendered conflicts One of the tensions surrounding notions of service was related to nurses’ and assistant nurses’ strategies of interaction in relation to the doctors. As Britta noted, doctors appreciated being served by nurses 3. This way of thinking corresponds to developments within gender theory, and could be seen as a political manifestation or a way of imagining the political consequences of refusing categories. As Moya (2002: 11) puts it: “Thinkers like Butler assume that the problem lies not in the way we have conceived of identity, but in the very existence of categories that are seen as logically prior to and constitutive of identity. Their critiques focus on these categories because access to sociopolitical power and material resources has historically been conditioned by our social identities and by how well we have been able to trade on them. Thus, identities have been central to the oppression of entire groups of people as well as to individual and group efforts to shift their status relative to others in the same society. The political force of arguments like Butler’s thus derives from the presumption that if we can do away with categories of identity – that is, if we can ‘subvert’ them – we will no longer benefit, or be denied benefits, on the basis of the identities we used to have.”

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and assistant nurses, but nurses tended to associate serving doctors with historical times during which nurses functioned as ‘handmaidens’. Anja worked as a doctor at University Hospital. In her interview, she talked about the conflicts that would appear on the shopfloor between doctors and nurses when it came to ‘serving’, noting specifically the generational difference in approach between the nursing staff: You’ll get irritated when the newer nurses, who’ve just come out of nursing school, try to hand over work to the doctors, because why should they? Oldschool nurses are more service-minded – that’s where service comes into the picture: serving doctors, I mean. That can be tough because it can lead to conflicts: if you are a young female doctor, maybe you do too much yourself, and there is conflict.

To Anja, the younger nurses posed a problem because they would not serve doctors in the way ‘old-school’ nurses would. Her account illustrated the tension between different groups of women within hospitals: by accepting the ‘newer’ nurses’ approach of not wanting to serve physicians as they distanced themselves from the notion of ‘traditional’ femininity; Anja herself risked embodying a traditional feminine position that was not easily matched with the role of the doctor. For her, then, it was a matter of getting the nurses to serve her, in the way male doctors had been served before (Pringle 1998: 186). Anja’s stake in the interactions between women doctors and nurses can be linked to what Pringle (1998: 186) has called “uncertainty of the shifting boundaries between medicine and nursing” that follows from the entry of women into medicine. Pringle showed in her study that women doctors have been able to appropriate “many of the caring demeanours previously attributed to nurses and so taken over some of the territory that nurses once securely occupied”, and that because of this, women doctors feel that they have “much to fear from the advance of midwives and nurse practitioners”. However, as noted too by Pringle, some women doctors found there was no problem in being accorded the right level of service from the nurses. Herta was in her mid-thirties and worked as a resident physician in psychiatry at City Hospital. Her account exemplified how everyday interactions in the workplace are governed by notions of gendered and classed bodies, as body differences “provide clues to the appropriate

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assumptions, followed by appropriate behaviours” (Acker 2006b: 451). Herta’s way of resolving the conflict between women nurses and women doctors that Anja talked about involved playing on such assumptions by taking advantage of features of masculinity. While Herta saw the same patterns at Anja, and recognised the tensions that would arise from different claims to providing and/or receiving service, her physique provided her with a resource that could be used in interactions with nurses: One thing that has helped me is that I don’t have an attitude that can be interpreted as me apologising for my presence. I’m pretty straight, very clear. People see me as very stable. More stable than I actually am, I might add. People comment on that, that I’m stable. And just physically I’m not small. I’m tall, which is positive in these situations. The classic thing that will happen to you as a female physician is nurses putting you down, not serving you the way they serve male doctors with tasks that are actually part of their job. If I’m three feet taller than the nurse in question, that is to my advantage.

To Herta, the appearance of her body and her general disposition facilitated the demand of receiving service from nurses. She incorporated certain features of masculinity and played them out in relation to nurses; that way she would get the same result in the claims to service as her male peers. This, however, did not mean that Herta came across as butch; as a psychiatrist, she was able to wear her private clothes at work, and she always wore skirts and dresses, often combined with colourful legwear and high heels (“I like being feminine and wearing nice clothes, and people often comment on my heels and pantyhose, that’s true!” she said with a smile during the interview). Herta was able to encompass features associated with both masculinity and femininity, much like Sara discussed in the previous chapter. Another doctor, Eva, had worked for over twenty years as a general physician, among other places at an ER in one of the county’s hospitals. She was older than Anja and Herta, in her sixties. She recognised no problems or tensions in relation to claims to service by nurses and assistant nurses. “Who else would serve me?” she said, and explained: “If the nurses don’t serve me, then we’ll have to hire someone else to do it! And why should we?” She took the stance of a kind of self-explanatory authority, and she had never met a nurse who had refused to give her service. “It has to be done,” she explained, and who would do it if

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not the nurses? Likewise, Ali, the only male doctor interviewed, had never come across nurses not wanting to serve him the way he felt was proper. Maria, another young resident physician, knew exactly what kind of tensions could arise from demanding service from nurses, and framed it as an issue specifically for women nurses – which is also how it is treated in research (Davies 2003, Pringle 1998). What was it, then, that the nurses did when they ‘served’ or did not serve doctors? Interviews and fieldwork showed that service was conceptualised differently at different wards and in different contexts. Often it seemed to be about tasks and assignments not regulated in work descriptions; things that were dealt with as they appeared and things that were not clearly assigned to any certain group of employees. It could be things that were perceived as beneath one’s competence, such as fetching things or cleaning up after a procedure. Serving sometimes appeared to be doing chores that were not organised by the technical division of labour, but were instead structured by the social division of labour. One assistant nurse said that cleaning out the dishwasher in the staff lounge was a typical example of serving within: “We’re all equals here until it comes to emptying the dishwasher, then suddenly the doctors when they’re there they are in such a hurry, of course they don’t have time to do it” she said: neither would the nurses, if they could help it. Mostly however the service that generated tensions was about chores that were linked to specific tasks, such as medical procedures. Here, there seemed to be grey areas of whose responsibility certain tasks were. Sometimes, tasks were expanded because doctors had specific preferences. One nurse gave an example of preparing rooms in a specific way according to certain doctors’ wishes; this could be a form of service that nurses generally disliked – especially if they felt that the doctor assumed nurses would do the special preparations without acknowledging the extra effort. Some doctors were known to demand more service than others. Kadia, a nurse at Ward 96, explained that some doctors wanted the reports during rounds to be presented in a certain way: You have to do it just so, and before you learn how this particular doctor prefers it to be done, you can get in tense situations; this is because they want us to serve them by us learning their preferences and we’re supposed to just remember that ‘this is the doctor who wants me to start with this and this’. They of course never ask us how we prefer to do it.

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In these spaces where the labour process did not exactly structure what category was suppose to perform each task, the concept of service would appear as a way of framing unwanted chores. Likewise, lack of acknowledgement for extra effort put into tasks that were expanded so as to fit doctors’ preferences were also conceptualised as service, and in these moments used to describe nurses’ subordination to doctors. And then it was the complex aspect of gender and femininity (and to some extent ethnicity) that seemed to frame notions of femininity: ideas about serving as linked to a subordinated position in the hospital, in the family, and in society at large. This was expressed in different ways. In the interview with Agneta and Ros-Marie, I asked them whether they felt as if assistant nurses would use service as a way of gaining recognition from doctors (in the way Britta claimed to do): Rebecca: I’ve heard about serving doctors. An assistant nurse told me: “We serve the doctors. The nurses don’t want to do it, but we do.” Agneta: [Laughing] That’s strange. How do they serve them? Ros-Marie: Yes, that sounds strange. Maybe at staff parties … Agneta: [Laughing] Rebecca: Do you feel like the doctors want service? Agneta: Oh, yes. Ros-Marie: Of course they do!

I will begin commenting on this quote by looking specifically at my last question: do the doctors want service? Of course, Ros-Marie said; and in these times of welfare state retrenchment and work intensifications in healthcare (Bejerot et al 2011), why would they not? Pringle (1998: 200) takes the example of cleaning worktables. Male doctors, it is suggested, simply leave the worktable to be cleaned by the nurses and the nurses will do it and “not make a fuss”. Women doctors, however, feel like they need to ask the nurses to do it and, either way, they will hear about it later. As Mackay (1993: 131) has illustrated, doctors prefer nurses to tidy up after procedures: it’s simply more convenient for them, and besides, doctors feel that keeping the wards clean falls on the nurses in any case. I think it’s important to note that, while this issue clearly is gendered, it is not strange or unusual for any employee to want to restrict their responsibilities or get out of certain tasks, specifically the dirty, boring ones. The nurses prefer not to do the tidy-

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ing up, as do the doctors. This in itself is not necessarily a question of asserting or resisting power, I would argue. It is, however, a relevant issue to understand why women doctors take it upon themselves to tidy up, and why nurses feel they can challenge women doctors to do it but not male doctors. While the doctors I interviewed recognised that it was “a classic” thing for women doctors to receive less support from nurses than their male counterparts, they all felt they were treated correctly in the end. I asked the nurses if they treated women doctors any differently, and whether they felt they could get out of certain tasks while working alongside a woman doctor, and none of the nurses recognised such a pattern. However, this is in line with earlier research indicating that women doctors’ experiences of struggling with nurse collaboration are not recognised by the nurses (Pringle 1998, Mackay 1993). And as I said, the doctors all had different levels of experiencing this troubled doctor-nurse relationship. The insistence, however, among women doctors (not just in my study but in virtually every study on the nurse-doctor relationship that discusses women doctors, from Gamarnikow 1978 to Davies 2003; for an overview see Gjerberg & Kjölsröd 2001) on this relationship suggests that the interaction between these two categories is contested. One reason for this can be found, I argue, in the differing interests among nurses to distance the profession from ‘handmaiden’-positions and women doctors who, in order not to re-establish themselves as below male doctors, have an interest in demanding service from subordinates. Both categories experience an increasingly stressful working life, and so for both there is an interest in avoiding residual chores. It is possible that normative femininity is exploited by nurses in trying to rid themselves of some tasks. I have not been able to explore the extent of this, since my study includes few interviews with doctors. I would suggest, though, that femininity is a central aspect here in terms of challenging women doctors and their position within the hospital hierarchy by drawing on notions of how ‘good’ women are supposed to serve and care for others, rather than demanding service for themselves. This is a relationship that is based on class and status. Nurses reject the notion of being in a position wherein they are supposed to serve others; they are not maids, they do not belong to the category of women workers who wait on others. However, it can also be argued that normative femininity is

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employed here in order to depict women doctors who demand service as un-feminine, as has been suggested by other studies (Davies 2001).

Affirming the status of nurses What could Ros-Marie and Agneta’s account say about the boundaries of care work in relation to assistant nurses? They questioned whether assistant nurses would be able to serve doctors at all, and argued that the organisational distance between doctors and assistant nurses made that kind of interaction improbable. But having observed a number of wards and clinics at City Hospital, I knew that different wards and clinics had different arrangements and so the patterns of interaction between different occupations varied. In the oncology ward at U ­ niversity Hospital, which also housed a clinic, Britta was working closer to doctors than many assistant nurses did in other wards. Agneta’s and Ros-Marie’s invoking of social distance between assistant nurses and doctors speaks to the status that is inferred by working close to the doctors. I found this to be true at Ward 96 as well, where the fact that Sara sat down with the surgeons once a week to plan the operations was mentioned several times as proof that she had ‘moved up’ the career ladder. It was also used as an example of the ways in which she was granted opportunities because management took to her. As one nurse put it, “How come Sara is the only nurse who gets to sit in on those meetings with the surgeons?” Despite the general resentment that nurses could express in relation to doctors, then, working closely with them did bring status. One way of refuting Britta’s account therefore was to affirm that nurses work closer to doctors than assistant nurses. What I also found to be the interesting part of the conversation with the two nurses was their joke about assistant nurses serving doctors at parties. It was implicit, but the subtext was clear to all of us in that room: Ros-Marie and Agneta gave service a sexualised meaning. One way of understanding this is to relate it to historical constructions of subordinated femininities. Working-class and racialised women have, Skeggs (1997) argues, been historically represented as non-respectable: promiscuous, collectivist, with low morals. These experiences and accounts by women working in hospitals, with their specific forms of inequality regimes, illustrate the com-

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plexity in strategies of compliance/accommodation and combination forms of resistance and co-operation (Connell 1987: 184). Too much compliance and accommodation was linked to service and to workingclass women, and to a ‘traditional’ form of femininity. Professionalisation to nurses was thus established as a process conflated with the rise of an historical awareness of gender not just in the home, but importantly in the workplace. This was illustrated by another reflection by Ros-Marie on changes in the hospital’s gender regime and its relation to the surrounding society: The old consultants, in the Seventies, they were served at home by a wife. Today both will be working. So some doctors need to get home, because they are picking up kids at preschool. So in time, I think, just naturally, you are no longer used to being served, neither in the house nor at work. The doctors’ wives used to stay at home. That was high-status. They’d be involved in a church group in the afternoons and whatnot.

Ros-Marie talks about the fact that, even though doctors may want service, they don’t expect it like they did in the 1970s when she was trained; the service is more limited and it’s restricted, for the most part, to things that actually need to be done. Ros-Marie’s argument connected feminine strategies at the workplace to women’s position in the labour market at large and in the home. Men, she felt, are no longer used to being served, and women – at least those who can be seen as bearers of a normative kind of femininity – are no longer satisfied with staying at home and joining a church group. Instead they work, and so male doctors need to get involved in the housework and in more facets of work within the hospital. However, considering the traditional arrangements most nurses had entered into when they formed a family (often performing most of the housework at home; working part time so as to be able to take care of the kids while the husband worked full time; being responsible for decorating the home et cetera), it is also possible that distancing themselves from service tasks at the workplace served a need to reaffirm their position as middle­class, professional and ‘modern’ women. One way of looking at the disidentification from serving positions is to view it then as the need to enter into formal positions of power wherein these women (nurses) have people below them who serve them; a strategy that works to reaffirm nurses’

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power over work processes in ways that also neutralise their involvement in subordinated positions in the home. It is possible that since the number of assistant nurses is declining, this need to decide over others is put in new light, as the semi-managing position of ward nursing is challenged. In this perspective, serving within and out becomes a bigger issue.

Serving within and out: neither maid nor waitress nor service machine Britta said she didn’t think there was a difference between the concepts of care and service, except for one thing: Well, care to me means that I take care of people, I help them. I help them to the bathroom maybe, or with hygiene, I dress them, I talk to them, I hold their hands. Sometimes I don’t have to say anything. Care and service is the same thing. But care sounds nicer. Service sounds like a maid.

Service didn’t sound as good to Britta as care did. Even though the maid would also perform the duties that the care worker would, the maid obviously had lower status. Before Britta got her diploma as an assistant nurse, she worked as an aide at the hospital and she thought that was a “maid’s job” because “you made the patients’ beds but you couldn’t care for them”. There were no maids working at the hospital any longer and, as an assistant nurse, Britta still performed the same tasks as she used to do as a maid, only she was also able to do some skilled interventions, and she worked more with technology. She could give insulin, which was more qualified work, she thought. Her education meant she had moved from a service position to a care position, which involved practices that were based on formal knowledge. This would constitute the other direction in which the distinction between care and service was made and reproduced. Serving up focused on strategies of serving doctors or doctors claiming service. But to all of the occupations, the same distinction was made in relation to claims made by patients. Malin, the nurse quoted at the beginning of the chapter, talked about how once the very same task could be conceptualised either as care or as service. Getting coffee could either be a way of caring for a patient, or being reduced to ‘just arms

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or legs’, from an intellectual to a manual function. For the doctors, the same situation would sometimes arise when patients were acting in ways that made the doctors suspect they were addressed like ‘service machines’, which was pointed out by Anja: I think the status [of doctors] has been lowered through the years. Especially considering the fact that people look on it as service, like you can order things. They surf the Internet and think a lot about things by themselves. And also because there are more women now; it used to be male-dominated.

To Anja, there is a link between the deprofessionalisation and the increasing numbers of women physicians, a theory explored and in part supported by research (Davies 2003: 722, building on Nordgren 2000, talks about it in terms of proletarianisation and disempowerment; see also Boulis & Jacobs 2008, Moore et al 2009, Bejerot et al 2011). But according to Anja, the status was also decreasing because patients were beginning to claim care the way consumers claim commodities and interactive services in the service economy. One reason was the access to information through the Internet, but it was also a question of gender, in which female general practitioners (a ‘female speciality’) wanted to be well liked by patients: Sometimes we talk about general practitioners being like kind of general service machines. Because we want the patients to like us, we want to be respected and deliver at all times, so maybe a few of us give too much service. It’s hard to say no sometimes. Serving with certificates and documents and things like that for employers, the Social Insurance Agency and all this, the patient comes in and orders from us. Rebecca: So what would be the difference between service and care? Anja: Service is like a waitress. Or like a cashier. The customer is always right. But in this case the patient can’t always be right. They can be right in their ways of describing a symptom, in how they experience their body. That can be true in a way. You know, their feelings are true. But sometimes even that’s not adequate if the patient has a poor sense of the body, for example.

As I discussed in the previous chapter, there is an increasing emphasis on viewing patients as customers, a discourse that has developed through NPM (Nordgren 2000, Hasselbladh et al 2008). Bejerot and Astvik (2009) have explored this issue in terms of new stressors in doctors’ everyday work situations. They conclude that while the

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“­customer discourse” has indeed strengthened the position of patients, it has also increased the stress among the doctors, specifically in posing new demands on the expansion of their jurisdiction and responsibility. Doctors in their study experienced pressure to send patients to X-ray even though they found it clinically unnecessary, or to write certificates for sick-leave because “on the one hand, you’re supposed to be the doctor, but the patients are also customers … and that involves: ‘I’m sick, I need to be put on sick-leave.’ ‘Well, then, I guess you do’” (Bejerot & Astvik 2009: 18). Thus patients demanding service posed a challenge to the professional status of the doctors, who found themselves not being able to assess and diagnose patients regardless of the patients’ own charges. In a sense, this means that there is an increase in demands on service within the organisation, as doctors and nurses are supposed to serve patients in their everyday interactions. This process can be resisted in different ways. At Ward 96, I found that acting on feelings of stress was a strategy sometimes employed to avoid demanding patients and to counter claims on service that challenged the nurses’ authority. One such example was when a pharmacist was being treated at the ward. The patient asked a lot of questions about the medication he was given, and also asked for specific painkillers that had not been prescribed, because he felt they were better (implicitly stating that he knew better than the doctors and nurses at the ward). I noted that nurses seemed to act extra-stressed around him, letting him know that they had very little time to help him or talk to him. I concluded that this was a strategy of avoidance, since it was not always the fact that the nurses had to rush to do something else right after having left his room, and because it went against their general ambition of concealing feelings of stress during interactions with patients. Some of the nurses talked about this patient as being “high-maintenance” and complained about his will to be “served with medication”. The fact that he had opinions about the medication, was considered as service claims that the nurses seemed uncomfortable with. Thus service in relation to patients can be a question of securing professional boundaries and emphasising jurisdiction and control: in essence, a question about reaffirming power positions. But there has also been an increased level of service claims from other parts of the welfare state, according to the interviews. Anja

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talked about this when she mentioned employers, the Social ­Insurance Agency, even travel agencies. Nurses would mention that there are increased demands on them from researchers, but also government agencies such as the Swedish Institute of Public Health (Folkhälso­ institutet): We’re supposed to think of so much when we talk to the patients. Risk analysis is one thing, and more and more we’re supposed to look at weight, smoking, drinking, exercise, whatever. Often now we’re given different assignments, like, for research, maybe a doctor here is doing research and we’re supposed to keep statistics or something; or they’re doing a report on something, an agency is measuring something and of course we’re supposed to help with all that. Fill out forms. I hate it! [Laughs]

In the quote, nurse Kerstin at Ward 96 talked about how outside actors claim increased levels of involvement in nurses’ work; or rather, the ways in which nurses become involved in efforts to quantify, measure and develop methods to prevent ill-health among the population. One could conceptualise this as ‘serving out’: the claims on nurses to participate in aspects of NPM that goes on both within and outside of hospitals. In relation to such tendencies, nurses would not specifically talk about added workloads as serving somebody. Rather, they would speak of this as “just loads and loads of new things that add on” to the workload, as nurse Ylva put it. While serving out was considered more and more of a nuisance, the problematic service aspect would be addressed more specifically in relation to claims made on behalf of patients, serving within. Like Anja, nurses would use the comparison with waitresses in this regard: “I’m not a waitress” was a statement that recurred in the interviews in discussions on the boundaries of care work and in relation to difficulties in nursing. Ros-Marie also made a comparison with a waitress, although in that context she was referring to not wanting to be touched inappropriately. I thought about what the waitress could represent in these accounts; I overheard other nurses on the shopfloor talking about, sometimes jokingly, and comparing themselves to waitresses when they relented and went above and beyond for a patient in a context where they did not take the initiative. It is important here, then, to

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note the difference between ‘serving too much’ and caring beyond the boundaries in the terms that were discussed in the previous chapter. Serving too much in this context was not something nurses did as part of creative altruism; this was about giving in to patients who demanded too much, as a way of avoiding conflict or simply getting out of a stressful interaction with patients considered demanding. Going over field notes and interviews referencing waitresses, I tried to find an analytical voice to enter into the dialogue in order to understand the role of the waitress as an image in the inequality regime of the hospital. I turned to an article using an interactionist framework to offer a ‘processual view’ as to why people stay in lowstatus occupations, analysing the everyday work and environment of cocktail waitresses: In a dimly lighted, escapist atmosphere (i.e. The Shangri-La Club) the function of the waitress is to sell drinks with as much ingenuity, speed and grace as possible. At the end of the evening she turns in money received from customers according to the reading on the cash register. Money over and above the reading is hers – her tips. The waitress is dependent on tips for her livelihood since in this city, as in many others, weak unionisation allows management to pay usually no more than one dollar per hour for her services. Since the waitresses feel they must make a total of at least thirty-five dollars to have had a ‘good’ night, it is imperative that the waitress please the customer, which shapes the interaction to the advantage of the customer. In addition, she must please the management or lose her job. A less than cordial relationship with her bartender can also lead to slow service and fewer tips, a situation which highlights her lack of control over the work setting (Hearn & Stoll 1975: 106f ).

According to the authors’ description, the waitress is dependent on the customer to earn a living, and so the interaction is to her disadvantage. She lacks control over her work situation and has to adapt her disposition to meet the expectations and hankerings of customers and management. Mulinari (2007) shows that the same processes are at play in the Swedish service industry. Waiters and waitresses belong to a sector of relatively low union density, and their working conditions are volatile and demanding. The expectations on their bodies and dispositions vary according to time, space and contextually framed notions of gender, race/ethnicity and sexuality (ibid.). These material conditions, along with the ideological constructions of what service

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work is and who it is that ought to perform it, turn service work in general and waitressing in particular into a discursive antipode to the practices and ideological constructions of care work. Mohanty (2003: 166) talks about this in terms of occupations and assignments as ideologically constructed in relation to notions of femininity, domesticity, (hetero)sexuality and racial and cultural stereotypes. I agree with her and would argue in this context that it is the material conditions and the ideological constructions of service work as linked to workingclass and often racialised women that both Anja, Ros-Marie and Britta relate to when they explain that they are not waitresses, not maids and not service machines. But the conditions in their own field are also relevant. I would argue that one of the aspects of the need among healthcare professionals for distancing themselves from service work is resisting processes of NPM.

Too much care means service It wasn’t just the concept of service that was filled with tension in the everyday world of the hospital. Even the concept that nurses and assistant nurses would embrace professionally, care, was interpreted differently in different contexts and by different workers. I asked Mia, who worked as a physiotherapist at Middle Hospital, whether care was an important part of her work. She said that in a way it was, but not in the way that nurses and assistant nurses would do care: It’s another way of thinking. As a physiotherapist or occupational therapist, you always have rehabilitation in mind, or habilitation. And I’ve heard and seen, like in nursing homes, you’ll meet people from other countries, like Southern Europe, and they are even more like that: taking care of the patient, caring for the patient. They think that it’s what’s best for the patient, but really it is not. I get mad as hell in a situation like that because the patient needs to do it [by his/herself ]. That’s what progress is about. Not being served all the time. So yes, it’s a caring kind of work but in terms of bringing out the abilities within the patient.

To Mia, too much care shaded off into ‘serving’ patients, which was further linked to notions of female migrant cultures of care that have been explored in research by Brodin (2006) and Gavanas (2001), in which immigrant women are located, by the majority, in a traditional, caring feminine position as an echo from the past; something ­Swedish women

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and Swedish society has moved beyond. Caring too much, made Mia “mad as hell”; it made her work more difficult if the patient could not get physical exercise and train her abilities in between Mia’s visits. But it also did not go with her idea of what care should be like and what it should strive for: it was a different outlook, in her way of understanding this; it may not even have been the ‘Swedish’ outlook. Again, service was linked to notions of ‘traditional’ femininities, and in Mia’s account this was associated explicitly with non-Swedishness. To the assistant nurses, it was well-known that physiotherapists would frown upon giving too much care. Monica, an assistant nurse in her early sixties working at University Hospital, explained that sometimes it was out of convenience that the nurses helped the patients ‘too much’. Older nurses, she stated, would be guilty of doing this far more than younger nurses. Sometimes, she said, “old-school assistant nurses” would run over to the patients in their eagerness to help them shower or dress. But Monica pointed to the material conditions that would frame such practices. She saw it not as a question of culture, but rather about what was convenient: “You have to stop yourself. But it’s faster if I do it. And sometimes, it’s just supposed to be quick,” she said. From her point of view, too much service or help was a necessary strategy in order to cope with work. She saw no real problems with serving patients or doctors. Monica, who identified with the “old-school assistant nurses”, thought of her work as fundamentally a service profession. “You cater to people when necessary,” she explained. However, she was sensitive to the fact that nurses would perceive the concept of service or of tasks defined as service as something problematic: Sometimes nurses will run around looking for me – this happened just a week ago or so – this nurse went around looking for me, and when she found me she told me a patient wanted a drink. She caught up with me in the ward kitchen. So I said, “Now that you’re here, you might as well bring him the drink.” But she said, “No, I don’t have time for that, I have so much to do!” That ticks me off enormously. Running around looking for me just to tell me that.

What irritated Monica was the fact that the nurse simply refused to carry out the specific task of getting the patient a drink. Monica would not protest at such behaviour, though, she said, and explained, “You

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sort of clench your fist behind their back instead.” But she did talk about it with her co-workers, the other assistant nurses in her ward, she said, and they all disliked it when nurses would shy away from ‘service work’ and make explicit efforts to have the assistant nurses do them instead. I thought about this story as an account of how some nurses, at some wards, would avoid service work. But that was not always the case. A recurring theme among all occupations was that ‘old-school’ nurses and assistant nurses showed less resistance to service work than younger nurses would. Older nurses whom I interviewed were slightly more relaxed about the subject than younger nurses, but almost all of the people I interviewed who worked at wards where patients were mobile talked about this and related to issues around the distinction between care and service, and between generational differences between nurses and assistant nurses in making sense of and practising these distinctions. Serving patients was generally less problematic to assistant nurses than it was to doctors, physiotherapists and nurses. But assistant nurses who worked in wards with a lot of technology seemed particularly relaxed about the difference between care and service work.

Service included Lisa was in her thirties and worked as an assistant nurse in an emergency intake ward at County Hospital. To her, it was obvious and unimportant that care and service work were overlapping. We take out breakfast and lunch, we serve coffee, and you can see that it is service. And then a lot of patients will ring the bell and ask for water too, even though they could get it themselves. So yes, that is service. Rebecca: So what does that mean to you? Lisa: It’s part of work. I don’t think about it. It’s included, so to speak.

Lisa said she had always been a caring person, but the things she really enjoyed were the technical aspects of her work. As an assistant nurse in the emergency intake ward, she would draw blood for testing, do cardiograms and take care of wounds. Assistant nurses rarely did those things in the other wards, so Lisa’s job was unusual in this regard. She worked in a team with a nurse and said she did mostly the same

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things the “sisters” would, the difference being that the nurses were responsible for the patients and their care, including charting et cetera. Lisa was unmoved by the distinction between care and service; it didn’t matter to her. There was not much point in using service work as an antipode to guarding boundaries of work. The ER and its intake wards were technologically advanced workplaces where patients never stayed longer than three days, at most. Veronica was 37 and worked in the ER at University Hospital. She said the same thing as Lisa did: service was simply a part of work, and not something she would think much about. If the patients demanded more than she wanted to serve them with, she would explain that they could do things themselves: People complain that we don’t offer enough help. We don’t offer them enough food and drink. But I feel that if you are in an ER, it’s not exactly like all your capabilities disappear. At home, if you need a drink, you go and pour yourself some water. Well, you can do the same in the ER, unless you are very sick, but then we actually will help you.

Veronica explained to me that care and service were basically the same thing, and she had no problem serving patients as long as she had time to do it. Work in the ER, which was organised somewhat differently to work in the wards, seemed to make the distinction between care and service less tangible, less important. The work itself was challenging yet tedious, dirty, and unskilled chores were always performed alongside high-tech work. The service work did not define the work of assistant nurses or nurses in these places; other things did.

Distinctions in care work Mulinari concludes that “women in the service industry are located within the framework of a sexualised femininity, while women in the public sector are located within the framework of a caring femininity” (2007: 133). She draws on work by feminist researchers such as Glenn (2002) and Roberts (1997), who highlight the distinctions between and social divisions within different kinds of reproductive labour. Even though they overlap, there are significant differences: most notably as to which groups of workers perform these jobs. What I have

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illustrated in this chapter is that these distinctions are important in the ongoing constructions of gender and labour at the hospital. Care work is distinguished from service work and thought of as the core task; it is valued as based on formal knowledge, and associated with a status that service workers are assumed to lack. The distinctions in care work are related to notions of varying forms of femininities. Waitressing and waitresses are discursively located in a subordinated and sometimes sexualised femininity. The idea of the waitress functions as a way to verbalise the menial aspects of work, and the increasing expectations and partial loss of power in the interaction with patients. But giving too much care is equally problematic. It is linked to classed, racialised and ‘traditional’ – old or antiquated – forms of femininity. Nurses occupying the organisationally delicate middle locus with a contradictory class position often had to be careful not to serve doctors too much, not to serve patients too much, and not to be too ‘collectivistic’. To the women doctors it seemed one strategy was to aim for the position traditionally occupied by male doctors: demanding service from assistant nurses and nurses, but not giving in to service demands from patients. And to physiotherapists, who sometimes encountered patients that “thought they could just order a massage”, as one of them told me in an interview, it seemed important to keep a distance from both service and care. But for assistant nurses, serving was a double-edged strategy. On the one hand, being cast as someone who would happily serve could lead to recognition. On the other hand, it risked reproducing notions of assistant nurses as docile, collectivistic and traditional. It also meant reviving the “antiquated” (Davies 2003) role of women at the hospital. The fact that care gives more status than service work is affirmed by research on racialised, male care workers. In her study on the experiences of male minority nurses in the United States, Harvey ­Wingfield (2009) shows that, while white men tend to distance themselves from femininity and associated characteristics such as “caring” and are often able to ride the glass escalators to advance within high-tech, masculine-coded fields, racialised men can instead identify with more typically feminine caring approaches as a way of combating racism and racial stereotypes. Thus either identifying with or attempting to create a distance from a caring, feminine approach can both be used as

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strategies to assert a position of status. However, it seems that identifying with a caring approach, specifically by doing it in terms of serving up, is associated with a ‘traditional’ form of femininity that is at odds with the project of professionalisation and embodiment of a ‘modern’ subjectivity.

Conclusions This chapter has illustrated how care workers give meaning to the distinction between what Roberts (1997) has called “menial” and “spiritual” reproductive work. These processes are classed and gendered, and even though I don’t have much data on it, I would also argue that they are in fact racialised even in this context, as Mia’s account suggested. The distinction is pointed out in relation to doctors, in relation to patients, and in relation to outside actors such as authorities and researchers. Changes in the welfare state, according to research (Nordgren 2003, Hasselbladh et al 2008, Bejerot & Astvik 2009), have partly transformed the relationship between care workers and patients as NPM regimes emphasise customer approaches in public sector service provisions. While research indicates that this somewhat strengthens the positions of patients, to the interviewed care workers, including doctors, this development challenged their authority and added to their workloads and was resisted. They experienced this development as being linked to, even degraded to, the structurally and symbolically/ culturally subordinated and, in their view, powerless position of service workers, such as waitresses. A major difference at the core of the distinction between care and service to these care workers was that they got to decide and take initiative in tasks that seemed meaningful in the labour process, while service chores were understood as something taking place on someone else’s initiative. In order to understand the relation between class, gender and body, and to capture the processes Acker (2006a, 2006b) talks about in terms of gendered class practices, the division of labour and the content of work are central features. To study complex divisions of labour and how these divisions are conceptualised is important in order to get at the core aspects of the inequality regimes of organisations, and how these shape masculinities and femininities within them.

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Women occupying different positions in the inequality regime of the hospitals in the county related differently to the ideological distinction between productive and reproductive work. I would argue that two strategies are made visible here: on the one hand strategies of dis­ identi­fi­ca­tion, on the other hand strategies of over-identification. Dis­ identi­fi­ca­tion means trying to distance oneself from notions of women’s historically (and still very much) subordinated place within the organisation, but also in the home and in the labour market at large. It also means disidentifying from the racialised working-class ‘dirty’, ‘backroom’ jobs. Over-identification has the positive effect of getting appreciation and recognition from the authority, but it also leads to conflicts with other women. Tension will arise out of the distinction between care and service, and, whatever the strategy, it seems clear from my empirical material that this is an issue, which leads to conflicts between women. Notions of gender and femininity are core issues in the creation and recreation of the boundaries regulating women’s positions and careers in organisations (Acker 2006a). As this chapter has indicated, conflicts among women in organisations, seemingly about how to cope with claims on their work, can be interpreted as the struggle over how to manage femininity and the historical and changing expectations concerning it. The next chapter will explore further an aspect of this issue, by looking specifically at processes of racialisation and experiences and resistance against racism within the hospital organisation.

9. Racism in the everyday and beyond

Patterns and experiences of racism were, without doubt, one of the most difficult issues to discuss during interviews and fieldwork at City Hospital, a subject that unlike any other would pause a conversation (see Bonilla-Silva 2010). And yet, some informants opened up about tensions surrounding notions of ‘cultural differences’, stereotypes, aversions against patients considered to be ‘immigrants’, as well as resistance against racism and challenges of racial slurs. I struggled for some time with understanding contradictory accounts of experiences, strategies and interpretations of the ethnic regime within City Hospital, the county and the healthcare sector in general. I noticed that acts of resistance against everyday racism (such as talking back at co-workers who made racial slurs, or pointing out ethnocentric preconceptions rendering significant parts of the healthcare staff invisible) could just as easily be followed by acts of racism (agreeing with parts of, or presenting alternate, racial stereotypes). And then, of course, there was the contradiction of policy dedication on the part of politicians and unions to equality (implemented in Sweden as an outcome of EU harmonisation and “with a strong affinity to US anti-discrimination law and practice”, Schierup & Ålund 2011), and the seemingly strong continuity of structural and everyday racism conveyed in national statistics on perceived and measured health (Socialstyrelsen 2009). I decided to write a chapter that would explore three aspects of race and ethnicity within City Hospital and Ward 96: first, recruiting processes that produce racial/ethnic inequality and those that aim to challenge it; second, discourses of respectability that shape processes of inclusion, exclusion and everyday racism; and third, experiences and strategies of everyday racism and anti-racism. The aim of this chapter is to examine processes of everyday racism and racialising practices within the hospital, and by extension within the welfare state and its labour market.

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This is a limited scope, excluding for instance the important issue of differences in accessibility of care depending on ethnic background. I will not be able to discuss in any meaningful way the experiences of City Hospital patients.

Everyday racism in the healthcare organisation Acker (2006b) points out that inequalities, including racial inequality, are produced in workplaces through a variety of organising processes such as establishing general requirements of work; in recruitment and hiring processes; in wage settings; in informal interactions (Acker 2006b: 448ff). This way of thinking about racism, and the ways in which inequalities are recreated in the everyday, is linked to the feminist understanding of the everyday as a problematic in which microlevel interactions and experiences are linked to ruling relations and ideologies (Smith 1987, Essed 1991: 288). Working within the post­ colonial feminist tradition, Essed developed the notion of the everyday world as an arena of “systemic, recurrent, familiar practices” of racism (Essed 1991: 3). Everyday racism, according to Essed, is defined by the recurrence of racist viewpoints and behaviour that is “infused into familiar practices”; these practices include “complex relations of acts and (attributed) attitudes” (1991: 288). While Acker focuses on racialised class practices within work organisations and the ways in which they are organised, Essed explores processes of everyday racism in terms of “ideologically saturated prejudice” (1991: 44), prejudice being understood in the sense Blumer asserted, as a cognitive component involving in- and out-group differentiations based on feelings of superiority, propriety, difference and fear (Essed 1991: 45, Blumer 1958). Such differentiations are not necessarily acknowledged as racist, and everyday racism is not about individuals being or not being racist. Acker points to the fact that, while class is considered more or less legitimate, overtly racist attitudes are often frowned upon. Prejudice and/or antipathy are rarely acknowledged as racism by the individual actor expressing it (Bonilla-Silva 2010). Essed (1991: 45) explains that because racism is morally rejected, reproducing prejudice “requires flexible use of rational arguments in defence of particular attitudes about an out-group”. Everyday racism is not about singular acts, but about repetition; just like everyday life, everyday racism is constantly

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repeated. However, its manifestations vary, so that it is impossible to know what expressions it may take in any given situation – even though it is the recurrence of racist practices that makes it into an everyday thing for both dominant and subordinated groups (Essed 1991: 288).

Conflicts and contradictions in managing ‘diversity’ During an interview with a nurse manager, Hanna, at City Hospital’s Ward 88, I asked about recruiting and whether or not ethnicity was an issue. All nurses were white and ‘Swedish’ in this ward, in contrast with the situation in Ward 96. Her response reminded me of the discourse of colour-blindness examined by Bonilla-Silva (2010), who argues that racism in the twenty-first century can be read through a “rhetorical maze” that develops in language when white people feel the need to voice concealed racist views or deny racism and discrimination. A feature of this rhetorical maze is heightened incoherence, “e.g. grammatical mistakes, lengthy pauses, or repetition” (Bonilla-Silva 2010: 68). In responding to my question, “In recruitment procedures, do you ever consider ethnicity, diversity?” the manager was hesitant at first, pausing before she answered, and then explained that ethnicity was not a factor. In a rather disjointed fashion, pausing and breaking up sentences, the manager told me that “ethnicity doesn’t matter; what matters is that this person fits into the group”; “I don’t see ethnicity as an issue; it’s more about that individual, like how can that person contribute to the workplace”; “the personality is …” and “yes – no, we’re supposed to welcome everybody and we do, so – we just look at who would fit this position. And then it’s a question of who applies for the position, too, and it’s all about that individual, so I don’t see that ethnicity is something that … yes.” I read the manager’s response as an indication of how difficult it can seem to address issues of ethnicity and racism in the workplace. There seemed to be no way for her to reflect about the fact that at this ward, all of the nurses were ‘Swedish’. The manager claimed she did not “see” and did not care about ethnicity or racial differences; she did not link the absence of non-white or ‘non-Swedish’ nurses to discrimination, racism or any kind of exclusion, despite the fact that about 20 percent (the number is even higher in the county) of the population have migrant background.

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During my interview with Selma, a nurse in the more diverse Ward 96, we talked about the fact that the neighbouring ward only had white, ‘Swedish’ nurses employed. “Why is that?” I asked her, and she said, in a dry manner: “I don’t know. I don’t hire people.” Her short answer was nonetheless delivered in an expressive fashion that was different from the incoherent stream of words let out by the manager in the other ward, who did not see ethnicity but also did not seem to hire nurses with any other ethnicity than Swedish. But Selma’s manager, Helena in Ward 96, was atypically open about these issues, and provided me with my first glimpse into the complexity of everyday racism within the public sector and its workplaces. In our very first interview in 2008, Helena talked about how proud she was that Ward 96 was a “multicultural ward”, in large part due to the fact that she had recruited nurses with “immigrant backgrounds”. Helena had an anti-racist strategy thought out: as a manager, she would use her position to break up the ethnic regime and include racialised women into the workforce. She explained that she thought of the city as provincial and ethnically segregated, a place where privileged people kept to themselves and shut out “anything that’s new and different”. I was quite impressed by her way of connecting political analysis and everyday practices, and I thought she was brave to use her own position as a tool of change. And then, later in the interview when I asked her about her thoughts in an ongoing recruiting process, she told me, “Well, it can’t be an immigrant this time.” Her reason for discriminating against non-ethnic Swedes was racism, but on account of the rest of the workforce, ‘the Swedes’: … sometimes I say to myself: “Okay, no more nationalities now” [laughs]. We need some order. [Multiculturalism] is a good thing; I see it as one of the strengths of this workplace. … But it causes trouble, too. And the problem is not these people, if you’ll excuse my phrasing. It’s the rest of the staff that won’t accept them. If you don’t speak perfect Swedish, there is a very low tolerance level when it comes to language. This girl from Poland, her Swedish is good but sometimes you have to tell her to speak a bit slower. We have a girl from Thailand and you need to listen carefully when she speaks, but you do understand her, if you want to. If you don’t want to understand her, then don’t criticise her, you know? But she’s been through a lot. I saw tendencies of bullying and I had to work with that. So now that I need to hire a new nurse, I just want someone who is energetic and happy and sort of grounded. So that’s what I’m looking for this time.

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In the process of recruiting a nurse, discrimination became a rational move to Helena, who considered herself an anti-racist, because of the conflicts that she felt arose from racialised notions of the conditions of cooperation, culture and communication primarily among the dominant, privileged group – ‘Swedish nurses’. As a manager, she saw the need for “order” in the workplace, not the kind of conflict that the presence of racialised others seemed to stimulate. This particular form of discrimination reveals some of the legitimating explanations behind racialised class practices in the welfare state, and it illuminates the way that racism as practised in the everyday goes beyond the issue of individuals being or not being racist. The situation that Helena accounted for has a formal term in neoclassical economics. ‘Statistical rational discrimination’ refers to practices of exclusion that are based supposedly not on ideological racist preconceptions of certain groups, but rather on assessments of effects of integration on productivity (Loury 2002, Bagenstos 2003). As ­Bagenstos concludes, discrimination may come down to “the costs employers believe they will incur in … managing the conflicts that inevitably arise in a diverse workforce” (Bagenstos 2003: 850). ­Mattsson (2004) discusses how this neoclassical economical perspective on discrimination was introduced in Swedish politics and research. Quoting the biggest rightwing party in Sweden, the Moderates, she identifies the links between discourses on ‘integration’ and ‘the new work life’: The rational element in this ethnic-cultural selection lies in the fundamental principle shaping today’s intensely communicative and collaborative business world, namely that culture – and the co-workers’ cultural-ethnic background – play a crucial role in the workings of an organisation (The Moderate Party, quoted in Mattsson 2004: 108).

Mattsson argues that one of the problems of the definition of rational discrimination is that it is based on the notion that there is no link to racism or racial stereotypes. Racism, in this way of presenting it, is ‘irrational’, it is incompatible with the good and innocent welfare state, and discrimination is represented as an outcome of the challenges in incorporating ‘other cultures’ into the new, highly communicative Swedish work life. One could argue that Helena’s account proves the Moderates right – there exists rational discrimination that

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is not based on racism on the part of the discriminator – but the issue is more complex than that. As Mattsson notes, the idea of rational discrimination as the Swedish Right has represented it is rooted in a specific narrative on migration, exclusion and structural changes of production in the welfare state. In this narrative, the loss of lowlevel jobs in factories and the simultaneous professionalisation has left migrants, whose lack of the right cultural competence renders them difficult to employ, without proper possibilities of attaining jobs that match their (in-)competencies (Mattsson 2004: 109ff). The notion of informal, cultural competencies that are deemed necessary in the new work life and that are not achievable or embodied by migrants, specifically those from ‘culturally distant’ countries, illustrates the inherent racial qualities of this model of explanation. In Helena’s account, the problem was not really lack of cultural competence on the part of the racialised care workers. It was racist, Swedish nurses who were instigating conflicts and bullying co-workers, yet the solution was to discriminate against those being harassed. The effect – ethnic discrimination – seems to be independent of the manager’s own emphasis on where the problem was located, but is part of a pervasive pattern of exclusion of migrant women in European countries and Sweden. Researchers have sought to explain the varying practices of discrimination in terms of different levels or categories: individual, institutional and structural, in which the first category relates to individual acts and the latter ones to institutional mechanisms, norms and routine actions (Kamali 2005: 32f ). The pervasiveness of discrimination and racialised divisions in the labour market, despite legal frameworks and policy dedication to equality and diversity, has led some researchers to emphasise the role of individual recruiters. Jenkins (1986) maintained that recruiters would circumvent anti-discrimination policies and employ strategies of racial exclusion by arguing that minority applicants wouldn’t ‘fit in’, a valid model of explanation considering Helena’s account. Other researchers have stressed the role of the individual, arguing that individuals are not abstract constructions; in organisations, some individuals are in positions of power and, as gatekeepers, they can choose to reproduce institutional discrimination actively. But the power of gatekeepers is based on institutional resources, norms, regulations and routines that shape the room for

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manoeuvring (Kamali 2005: 41). I think this last point is particularly relevant in relation to Helena’s choice of not wanting to hire “an immigrant” that time around. There were no institutional arrangements in place to support her strategies of inclusion, despite extensive policy production on equal opportunity and equality in the workplaces of the county and City Hospital. Her room for manoeuvring was restricted by forces beyond her power as a gatekeeper and manager. Conflicts added to her workload and she had not enough resources to be able to deal with them, or run the risk of having even more conflict once the new nurse was in place. This illustrates that there is a flipside to the argument: gatekeepers’ power both to reproduce and to counter institutional discrimination is restricted by organisational factors. Recruiting practices should be viewed in context and with some longitude. A while later, during another round of hiring, Helena employed a young woman of Palestinian descent who had just got her nursing degree from a nearby university. Helena’s earlier choice of excluding “immigrant nurses” was not a shift in policy on her part; it was a decision based on an assessment of the institutional resources and responses available at that particular time. In this light, people with migrant background also constituted a resource for the ward: One thing that is great about it is that we speak different languages. There is so little information – brochures and so on, in different languages – it’s terrible, really. So it’s great that we have people who speak different languages. [We have people from] Romania, Bosnia, Croatia, Russia, Vietnam, Poland, Estonia, some Scandinavians. One Albanian. Yes. We could use more people who speak Arabic [laughs]. It’s great.

What Helena referred to here was the practice of using nurses as interpreters. It would be convenient to have people around at all times who could speak to patients in their own language. Things like getting an interpreter in place for a patient could involve quite complicated logistics, specifically since it was a matter of a service being contracted out. Here is one example, which took place in Ward 96 during my fieldwork: a patient was scheduled for an examination some time during the next day. Because the examination had to be done before the surgery, but was not an emergency and thus not a top priority to the clinic that was going to perform the examination, there was no way of saying

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exactly when it would be done. The clinic was supposed to telephone Ward 96 some time in the morning or before lunch to let the nurse know when the patient could be taken to the clinic for the examination. On the day before, the nurse had to schedule for an interpreter to accompany the patient to the clinic. She took the matter to the nursing manager: “So, at what time should I tell the interpreter to be in place? Can we afford to have her here all day, or at least on standby? Is that even possible?” Janet asked Helena. She continued, “And by the way, which company [for interpretation] are we now contracting?” Janet and Helena talked about it some more, they looked at some papers and took out a manual with phone listings, and it turned out that the nurse had phoned the wrong company because their phone number was still listed in the manual by the nursing reception. “Well, I guess that made them happy, at least. I just hope they don’t think we’re still using them, because we have another company on contract now – that’s the number you should use. And I’m not sure how we’re supposed to resolve it for the exam tomorrow; talk to the company about it,” Helena said, and added that she was going to change the manuals and update the information about phone numbers for interpreters. In cases where nurses could also interpret, the labour process was simplified. However, this also meant that some nurses were given extra responsibilities that added to their workload. In a study on inequality regimes within the British public sector, Healy et al (2011: 472) illustrated that lack of English skills was used as an explanation for lack of advancement among hospital employees with migrant background, while at the same time, being able to speak more than one language was “seen as a taken-for-granted free resource extracted according to organisational need”. Some of my informants reported the same thing. Here is Nela, a nurse at City Hospital’s Ward 70, a locked psychiatric ward: Sometimes we have patients who are also from the former Yugoslavia, and so then we speak the same language. At first the managers thought it was great. They asked me, could I interpret? And I usually did because you want to help out – if I can help out I will. But then there would often be – it would be sensitive. You see, in my own language, when we are here [in the ward] and we

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speak the other language, there can often be issues that come up. It gets too close somehow. Patients would say, “Where were you during the war – did you come here and escape everything? Do you know what I’ve been through? You failed your countrymen” – all this. And the doctors will ask, “What is he saying?” and – it gets too close, too personal. So now when there is someone who comes to the ward I tell them [in Bosnian]: “Now I will show you where the restroom is and where you can smoke, but after that we will communicate in Swedish.” It’s difficult also because patients who come here, naturally they don’t feel good emotionally. I stopped interpreting after one specific event. I sat in on a meeting with – I was not supposed to be there; I was asked to interpret during a meeting between a patient, her doctors and the M ­ igration Board. The lady was [told she was] being sent back to Bosnia. Suddenly she pulls out a knife, from out of nowhere there is a knife, and she points it at me, and I was scared to death. I was so, so scared! Nothing happened, but after that I said “Never again.” And the manager here on my ward, she let the rest of the people within the [psychiatry] division know that – she said: “Nela is not an interpreter, she’s a nurse, and that’s her job, nothing else.” So that was good, it felt good the manager supported me in this. I am a nurse!

Nela’s account illustrates how language skills can be used as a resource without much consideration of how it affects the employee’s workload, feelings and position within the work organisation. But it also highlights how actualisation of non-Swedishness can challenge the professional position of the nurse and turn a professional location into an embodied being with a personal history that is shared with the patient, thus blurring the distance between caregiver and care-receiver. Sometimes, this was appreciated, as when a nurse in Ward 96 told her colleagues how “wonderful this patient is when she speaks our language – the cutest person, she tells these stories that I recognise from my childhood. I wish you all could hear her like that.” In that situation, language created a bond that seemed to bring both patient and nurse joy, and it was not considered a problematic blurring of boundaries. But in the psychiatric ward, the context of care was different and the boundaries between patients and care workers more emphasised, and also often more challenged, because it was more common for patients to transgress social boundaries in all kinds of situations. Thus in this context, interpretation was a difficult task. But the resistance towards being used as an interpreter was present among nurses involved in somatic care as well. When Nela said, “I am a nurse!” she captured what some of the other nurses told me as well about feelings

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of being treated differently from other nurses. “Sometimes Swedish nurses speak English, I guess, but I don’t know, it’s about that I want to be seen as a nurse like any other nurse,” one of my informants told me, indicating that this added task which did not fit into the actual job description of nurses at the hospital was sometimes experienced as being othered. I would argue that it challenged the professional identity by questioning its boundaries. But the story of how Nela’s boss supported her also points to the ability of professions and collective identities of professionalism to defend in-group members and protect them from such challenges.

Language and tolerance In Sweden, nursing has traditionally been the domain of white, ethnically Swedish women. While the ethnic regime of the nursing profession is beginning to change, less than ten percent of all nurses in Sweden are born abroad, marking the profession as ethnically homogenous compared to assistant nurses and physicians, a fact that challenges Essed’s and Goldberg’s (2002) assertion that ‘cultural cloning’ is perpetuated more deeply the higher the status of the profession. The nursing profession embodies the maternal aspect of the representation of the welfare state, a contradictory position of both privilege and subordination in which discourses of responsibility/regulation and respectability are pervasive. Communication is key within the nursing profession, a feature of professionalisation in which nurses are made responsible for the front stages of care work and for intermediating medical knowledge and regulatory practices. Helena talked about the upset that the presence of racialised others would cause among the nursing staff, conflicts based on notions of racialised workers as ‘not fitting in’ – primarily expressed through notions of the importance of language. There was much talk about the role of language and communication among the nurses at City Hospital. Communication was seen as a skill, and was conceptualised as one of the main responsibilities of professional nursing. Josephine explained that one aspect of the focus on language skill was that sometimes nurses were simply too tired to be able to make an effort during interactions with each other:

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Rebecca: I heard this is a multicultural ward. Josephine: Yes. So we asked them about these hats,1 but actually the most important thing is that they learn Swedish. Because it is unbelievably tiresome to listen to accents. I mean too thick accents. And I understand that it is damn hard. It is wonderful with different cultures and immigrant backgrounds, but I notice that between the immigrants there is much more friction. And I wonder: has that got to do with language? Actually, I find more friction between immigrants than between us Swedes and the immigrants. Rebecca: You mean, between patients and – Josephine: No, I am talking about staff. More irritation there, perhaps because they understand each other less. Anyway, it is terribly tiresome to listen to this during morning report. You just want to get it over with because when they are tired, coming off the night shift for instance, it’s extremely hard to hear what they’re saying, and it takes too long.

If I were to assess Josephine’s quote based on what I witnessed in terms of friction among staff, I would say she was generalising the situation based on the friction evident and known to many between two specific nurses. It made it possible for her to say that she identified problems related to heterogeneity in the workplace only as problems external to her and not at all involving her own sentiments towards diversity. However, what I found interesting was that her hesitant attitude towards the heterogeneity of the ward was framed by her assessment of the impossible workloads, and her sense of feeling tired and stressed. Reports given by people with an accent slowed down the work pace and took effort and energy that Josephine felt she did not have. Studies within the medical field have illustrated that having to communicate with effort can lead care workers to avoid interaction with migrants who are not in total command of the Swedish language; such strategies will sometimes result in migrant patients receiving less attention and care than the dominant group (Pergert et al 2007). But Helena also suggested that avoiding or exaggerating the effort of communicating with co-workers not fully in command of the Swedish language worked as an excuse for racism. Helena returned to this issue on a number of occasions during interviews, and she explained to me that she would sometimes intervene by telling nurses either to speak slowly and clearly, if they had an accent, or to listen up and make the 1.  I didn’t pick up on this during the interview, but I am assuming she is talking about the hijab, which the hospital provided and a few nurses at the ward wore.

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effort. Research indicates that low levels of tolerance towards ‘nonSwedish’ accents constitute an important aspect of everyday racism. Most people will accept ‘Swedish’ dialects, de los Reyes and ­Wingborg (2002: 23) conclude in an official report on ethnic discrimination in the labour market, but are far less accepting when it comes to accents stemming from having another native tongue. The focus on language has been prevalent in the political debate as well. The Liberal Party first demanded in 2002 that (an unspecified level of ) command of ­Swedish should be a condition of being granted citizenship, supposedly as a way of increasing integration of migrant populations who, according to popular and media representations, did not bother to learn ­Swedish and thus could not partake in Swedish society (Folkpartiet 2006). Such demands were not considered necessary during the 1960s and 1970s when migrants were an essential part of capitalist expansion. Postcolonial researchers view new demands regarding language skills as an example of the ways in which racial discourse varies over time and relates to material conditions in the labour market and the welfare state. For example, these new demands can be seen as one aspect of the redefinition of ‘full employment’ to ‘full employability’ (Schierup 2006: 49). Willingness to show tolerance towards accents will not only vary over time and in different political and economical contexts. It is also a matter of sensitivity to hierarchical relations and divisions of labour. At City Hospital, being able to communicate was a responsibility primarily for nurses, not for doctors, as Helena illustrated in a follow-up interview: But there are still people saying [about nurses who have migrated to Sweden] that she doesn’t understand, she’s like this and she’s like that. It’s terrible. Rebecca: And how about the doctors? Helena: With the doctors it’s different, of course. If there is a doctor here and the nurses don’t understand shit of what he’s saying, we don’t stand a chance. But if there is a nurse that the doctors can’t understand, then that’s a catastrophe right there. They will come to me, call me, have opinions about it; I have to sit in during rounds, I have to get this person in order and make sure she speaks clearly and [not put her hand in front of her mouth] – and, you know, that would not happen with the doctors, never ever. Never. Not here, at least. So it’s very unequal. I assume that if I do what I expect them to do – if there is a doctor that the nurses can’t understand, then I’ll expect the doctors to help that person and to help the nurses with that.

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Rebecca: Will they? Helena: No, they won’t. No, no, no. No way. There’s a huge difference. Rebecca: Do [the other doctors] defend that doctor, or what happens? Helena: Well … Rebecca: They don’t care? Helena: I don’t know. That’s what it looks like to me. But I don’t know what they do or feel or – it’s like it has nothing to do with me. But if someone complains about [a nurse with an accent], I feel responsible for her, but also for the work: it has to function, they have to be able to communicate; and if they don’t know how, I’ll show them how. You listen and you make an effort, and sometimes you ask and sometimes you just make sure that person really has understood; if you’re not certain she understood, you make sure. It’s hard. This is really hard.

This is a lengthy quote, but I included it in this form because it captures the complexities in expectations of and demands on different groups within the healthcare organisation, and it also shows the restricted but nonetheless existing room for manoeuvre by managers within organisations. At the very beginning of the quote, Helena revealed the durability of everyday racism. Despite having worked in Ward 96 for years, nurses who spoke with an accent were still being complained about and were not fully accepted by their co-workers. Helena related that some of the harassments of these nurses centred on notions of their lack of skill: “she doesn’t understand.” There was the sense that these nurses still did not ‘fit in’, even though the manager had received no formal complaints about them. I then asked an open question about the doctors, and Helena answered by reflecting on the differences in power between the two groups and how this was played out in conflicts regarding communicative skills. There was no room for nurses, according to Helena, to put forth demands on communication from doctors. There would be no collective body and no one responsible to put forth such demands or complaints to. There was no room to ask an individual doctor to make an effort in communicating with nurses, or with patients; nurses were the liaisons in those instances, and it was solely their responsibility to understand what the doctor wanted to communicate. Nurses, represented by the nurse manager, had “nothing to do with” what doctors did or how they acted; they would evaporate as a collective body in front of Helena’s eyes. However, doctors

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would turn into a collective if the ‘problems’ with communication were located among the nurses. There would be someone to claim responsibility from: the nurse manager. Doctors not understanding nurses, or doubting whether nurses understood them, was deemed an organisational “catastrophe”, according to Helena, and she was told to discipline the nurse in question, “get her in order”, even have her adjust her body language. Helena, by her account, argued for pragmatism: in order to ensure a functioning labour process, there was a need for certain efforts in the process of communication, an effort she felt needed to be made by all involved in the conversation: “You listen to her – then you make sure she understands you.” She had, by her own account, little resources or support from within the organisation to back her up in that approach. Helena’s way of promoting diversity in the workforce was successful, but not without tension. Her account illustrates the ways in which individual actors do matter in organisations when it comes to racialised class practices, but it also highlights the durability of everyday racism – it is not easily quenched by contact between racialised minorities and dominant groups. Racialised conflicts can endure over time, even when they are not granted legitimacy by gatekeepers. Helena’s account also illustrates the ways in which everyday racism represented as demands on or tolerance towards language skills vary with position and status. Finally, her reflection on the differences between nurses’ and doctors’ needs and privileges shows that class regulates the ability of collective mobilisation of everyday racism within the organisation.

Processes of racialisation One of the most confusing exchanges I ever had with a nurse took place in a small surgical day clinic at City Hospital. Being a clinic, it only operated during office hours. Patients would come in for surgeries that normally could be performed under local anaesthesia. The clinic employed a few surgical nurses and less than ten assistant nurses. One of them was Henny, whom I observed for two half-shifts. The pace at the clinic was relaxed compared to wards, because patients would come in for scheduled appointments and the labour process was much more linear. Henny and a co-worker would prepare the

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operating room, bring in the patient, and the surgeon would get to work. Because of the relaxed tempo, I was able to ask Henny questions and the fieldwork turned into a prolonged interview situation (these exchanges were written down as the conversation took place). One of the issues I wanted to discuss with her was gendered hierarchies within the healthcare organisation; she was one of very few assistant nurses I interviewed and observed who had a continuous cooperation and interchange with doctors, and I was interested in her opinions and experiences of that. My field notes reveal the surprising turn the conversation took: During the second shift, she told me I was going to meet Babak, one of the best surgeons around. “You’ll see how fast he is! He’ll do it in twenty minutes. He is so fast; sometimes he will take in an extra patient before lunch. It’s unbelievable!” When Babak came to the clinic, I shook his hand and explained why I was there. Henny, who was standing beside me, cut in and said that she had explained to me that I was about to see something special. Babak laughed and showed me to a computer. “Look at this, I have a presentation that explains the procedures I will be performing today.” Then he talked me through a PowerPoint presentation that explained in detail where and how to cut, what instruments to use, et cetera. When the presentation was over, I walked over to Henny, who was looking at a schedule, and she said: “Wasn’t that exciting! He cares about everybody here.” Henny, Babak and I walked into the operating room, where Henny had prepared a table with sterile instruments. This time she had also taken out a CD-player. She turned to Babak and said: “So, you’ve got the records, right?” He walked over to the window where the CD-player was and looked through some discs he had in a bag. He put one on. During the procedure, Babak described in detail what he was doing. He was talking to me. At first, the patient thought Babak was talking to him, so Babak said: “I’m just explaining to our guest here how the procedure is done.” “I see!” the patient said, who continued to communicate only sparsely with Henny, who stood on the other side of the room. This embarrassed me, surprised me. After the surgery, when it was time for a break, Henny and another assistant nurse pointed out to me how fast Babak was and how good he was, “absolutely one of the best we’ve got!” A

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moment later, I returned to some questions I had been asking Henny earlier. I asked about equality, and I thought it was interesting to hear what she had to say because she was one of the very few assistant nurses I had met that had so much interaction with doctors. She interrupted me before I had asked the question: Rebecca: “So how do you feel about equality, I mean hierarchies and …” Henny: “Yes, it’s important. But I feel that you have to make an effort, too. A big problem for us is when there are patients who come here and whom we can’t communicate with. I think that if you come here, then you should learn the language. You can’t stay here and then not speak the language. You have to learn Swedish. We get them here to the clinic, and we have to bring in an interpreter just to get them into the chair. And we can’t have that; you have to demand more. I think that learning Swedish, that is basic, actually.” Her response was not at all what I had expected. I thought she would reflect on the gender regime of the hospital, professional hierarchies, perhaps talk about the fact that the clinic was special in that assistant nurses and doctors sat down in a small lounge during breaks, laughing and talking. It was very different, and I wanted to know more about that. Instead, she raised the issue of language. This took place in 2007, when the proposition to test the language skills of those seeking citizenship was much debated. I thought it was misplaced to talk about language skills in this context; it was not something we had talked about before, and the connection between ‘equality’ and ‘hierarchy’ that was in my question to issues broadly labelled under ‘integration’ in the Swedish public debate seemed far-fetched, or really non-existent. I was baffled and didn’t know how to respond, so I moved on and asked another question. It was only afterwards, as I was going over my field notes, that I thought of this episode as a comment on the presence of Babak, and his position in the clinic. I met four surgeons at this clinic: one was a woman (‘Swedish’), two were ‘Swedish’ men and then Babak, with a foreign-sounding name, a dark complexion and an accent. Babak seemed to elicit joy, servility and pride from the assistant nurses. It was clear to me that they wanted me – and him, via me – to understand how skilled and special they thought he was. But I also understood

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Henny’s interest in relating to me her views on ‘other’ immigrants – who were not like Babak, and who constituted a category from which Babak was exempt – as an expression of racialising processes. In her study on midwives and migrant women giving birth, Mulinari (2010) examined processes of categorisation and de-racialisation in a birth clinic. Some parents moving through the clinic passed through a deracialisation process as the midwife felt comfortable to conceptualise them as “part of her shared local community” (Mulinari 2010: 169). I read Henny’s inapt response to my question as a way of establishing a process of de-racialising Babak, and racialising ‘other’ immigrants: her quick change of subject served to assert the distinction between ‘good’ (de-racialised) and ‘bad’ (racialised) immigrants, which accentuated Babak’s position as an exception. Babak made an impression on me, too. The fact that he took the time to explain the procedure impressed me. He was swift, and kind to the nurses (in fact he was kind to everybody except, I thought, to the patients, whom he treated matter-of-factly and communicated little with). It made me think of the vast body of research indicating that female doctors feel pressure to perform better than male doctors, and to negotiate their professional relationships more carefully (Davies 2003, Lindgren 1999, Lichtenstein 1998, Pringle 1998). Could this be the case of (male and female) doctors with migrant backgrounds, too? I never had the chance to interview Babak, so instead I started to include questions pertaining to this in interviews with nurses and doctors. There was nothing in the interview data directly suggesting that doctors with migrant background shared the experiences of female doctors, such as feeling pressure to perform better and to be more diplomatic towards co-workers. I only interviewed one doctor with socalled ‘migrant background’. However, the nurses I interviewed supported this idea: Danuta, for instance, said that because of her accent, she “needed to work harder than Swedish nurses”. Furthermore notions of ‘good’ and ‘bad’ ‘immigrants’ kept recurring, and not exclusively among white, ‘Swedish’ care workers. Selma, who came to Sweden as a teenager from the former Yugoslavia in the 1990s, asserted that working in a “multicultural ward” such as Ward 96 was not always “a good thing”. Mostly this was because of the everyday racism she had to deal with from white, Swedish people, but also because “some immigrants”

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were not good co-workers and should not have been hired in the first place. Selma was specifically upset that she had to work with people with foreign nursing degrees: “I can’t believe some of the people they let in here with their foreign educations,” she explained, and pointed out that she had earned her degree from a Swedish university. Ali,2 a resident orthopaedic surgeon born in Iran, also made a distinction between himself and “other immigrants” who would not “integrate themselves” the way he had managed to do. Because we never got the chance to set up an interview in person, I interviewed Ali via e-mail. He wrote to me saying that, while he thought having migrated made people work harder, he didn’t think the pressure came from the outside. Rather, it was about wanting to perform well so that one would not have to go back: I don’t see ethnicity as an issue in Swedish healthcare. … I feel like colleagues who have immigrated actually work harder because they don’t take things for granted; they are familiar with situations where you don’t have that much money. I think about my Greek colleagues, who are working and performing extremely well right now because of the catastrophic financial situation there, and their friends and colleagues in Greece are unemployed. So they care more about the work and perform better. If you’re a stranger, then you need to prove yourself, not because you have black hair and dark skin but because you want to stay and work here and you don’t want to have to go back. Swedish doctors don’t have this in their collective memory, so they can perform their work under less pressure.

Ali asserted that, from his experience, “ethnicity” was not an issue in Swedish healthcare. I gathered he was suggesting that there was no racism within the healthcare organisation. He went on to tell me that, while he knew of some cases of discrimination against doctors who had migrated to Sweden, he did not view this as a matter of power, domination or inequality. Rather, processes of discrimination were the outcome of failed communication between two parties. He suggested 2.  The reason I suddenly turn to a male informant is that this chapter focuses on the ethnic regime and practices and experiences of racism. Only a few of my informants experienced being thought of as ethnically or racially othered, and Ali was one of them. While I argue that this chapter contributes directly and indirectly to the understanding of racialised aspects of constructions of femininity (and by extension masculinity), the primary ambition is to explore the racialised aspects of the inequality regime, and it is in this context Ali’s position is relevant.

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there are two different strategies among people who have migrated – the choice to integrate or not to integrate. Ali felt he belonged to the first category: I was born in Iran and came to Sweden [as a toddler]. I was always fluent in Swedish and integrated myself as much as I could. I consider myself ­Swedish and, having that mentality, as of today I have never encountered any kind of discrimination. It’s quite the opposite, actually: I’ve been offered jobs because of my background, because of my ability to speak several languages and because of my knowledge of different cultures. But I am aware of the problem of discrimination and it depends both on the person discriminating and on the person being discriminated against. I’ve got immigrant colleagues who don’t want to be integrated; they have an accent, and they feel discriminated against and sometimes they are in fact discriminated against. I’ve never had that problem. Maybe it’s because I’m not that sensitive about these things.

Killian and Johnson (2006) discuss identity work and processes of disidentification among Muslim, migrant women in France. They claim, based on earlier research in the field of social psychology, that identity work entails creating, presenting and sustaining identity that is congruent with a positive self-image, and involves creating positive group identities (Killian & Johnson 2006: 64). Based on the work of McCall (2003), and inspired by postcolonial scholars such as Hall (1996), ­Killian and Johnson argue that disidentifying from the stigmatised and subordinated category of ‘immigrants’, like the women in their study did, involves identity work aimed at reasserting a positive selfimage and resisting racist perceptions and associations, since individuals “negotiate with others in interaction about their respective identities” (ibid.: 65). What I found particularly interesting in ­Killian’s and Johnson’s article were the similarities between some of the accounts of their respondents and those of Ali and Selma. Souad, a woman who migrated to France from the Maghreb, explained that while there is racism in France, she was never the victim of it because her family had “never done anything to be reproached”: “When you respect yourself, everyone respects you. Where I’ve lived, I’ve always been neat, always honest, always. I know they won’t talk [behind my back]. I haven’t felt that. [It’s always been] the opposite. I only hear compliments,” she told the researchers (Killian & Johnson

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2006: 69). Another respondent, Lina – who had also migrated from the Maghreb – explained that she did not consider herself to be an immigrant because she did not have “the same mentality as them”, meaning other immigrants who had not “integrated well” the way she had (Killian & Johnson 2006: 76). Respondents distinguished themselves from immigrants who had not properly learned French, who were poor, who suffered from “identity problems” of living in another country and cultural context. I see some of the same notions in Ali’s account, and I kept running into distinctions between “well-adjusted” (‘integrated’) and “other” immigrants as I carried out my fieldwork and interviewed nurses. I overheard racist comments on a number of occasions, and they were uttered by white, ‘Swedish’ nurses as well as by nurses who themselves had migrated to Sweden (or had parents who had migrated). The notion of ‘good’ and ‘bad’ immigrants was reproduced not only by the likes of Henny, but by Ali as well. In the study on migrant women in France, one respondent, Souad, said “there is racism”; Ali said he was “aware of discrimination”. Souad suggested that those who experienced everyday racism were very different from her, and went on to describe herself as a good person (honest, neat, et cetera); Ali suggested that doctors who were discriminated against were partly to blame for this because they would not integrate themselves. Souad said that because of the way she acted and respected herself, she was never reproached: on the contrary – she only ever heard compliments; Ali said because of his “mentality” and effort to integrate, employers found his multicultural abilities attractive. Like Lina, Ali talked about having a specific “mentality” that separated him from other immigrants: like the women in Killian’s and Johnson’s study, he refused the identity of ‘immigrant’ or ‘other’. The authors conclude that the women’s experiences “illustrate how the self can affect, or at least stand up to, society”, and argue that dis­ identification with the category ‘immigrant’ helps in constructing a positive identification as someone who is well-adjusted and successful (Killian & Johnson 2006: 75, see also Skeggs 1997). However, they also point to the fact that, while refusing to be an immigrant could be viewed as a “powerful act of resistance” and may bring “psychological benefits to a particular individual”, it is also a strategy that works to

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reinforce hegemonic definitions of some people as inferior and is based on the internalised conception of ‘immigrant’ as a negative. Ali’s response indicates that the concept of ‘immigrant’ is fluid; it is not always related to experiences of racism and discrimination. Some people deemed ‘immigrant’ will, as Mulinari (2010) illustrated, pass through the process of de-racialisation in which they are perceived not as a problem and not as an ‘other’. Other ‘immigrants’ will rather be blamed for causing racism and discrimination because of their ‘mentality’, or lack of will to ‘integrate’. Identity work plays a part in reproducing and resisting the category of ‘immigrant’.

The role of space in experiences of racism Another way of thinking about Ali’s experience is the means by which the hospital and inclusion into professional categories offer protection from racism. This was something that was emphasised by some of the nurses I interviewed, who had worked as assistant nurses in homehelp while they were studying at the university. Several who had experienced sexist or racist verbal and/or physical violence from patients explained that such episodes had occurred while they were working extra hours within municipally provided home-help. Kadia, who was a nurse in Ward 96, was one of them. By reflecting on her accounts of experiencing racism in these two different contexts, I will illustrate my point about the role of space in experiences of racism: I do think people think about it [the hijab]. I’m sure they do. The other day a patient came up to me in the hallway [laughs]. And she said, “You’re going to get tough reactions because of your hijab, because where I work, a preschool, I had to stop wearing my veil,” you know, because they didn’t treat her right. She was a patient, and it was strange the way she approached me, so I just left. My colleague said, “Don’t pay her any attention, she is always up in people’s business.” Then [the patient] came back and apologised and said she hoped I wasn’t offended by what she said. I said: “I’m used to it. I’ve been living in Sweden for so long that I don’t care any more what people say about the hijab. I’ve heard so many people say I look stupid in it. That’s old news to me’ [laughs]. Rebecca: Have you ever been treated badly because of it at work? Kadia: By staff – never. Never ever. Rebecca: When you were a student? Kadia: No. Never. Really, nobody ever said anything like that. Rebecca: And patients, I mean racism in general from patients?

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Kadia: Yes, lots of it, when I worked as an assistant nurse, because then you go to the patients’ homes. It’s not like the hospital. When you’re in their house, you’re forced to listen to stuff – I don’t know, I can’t answer what they’re saying, but you have to respond somehow. Many times I heard strange comments. Why do I come to their house wearing a hijab, they don’t want me in their homes if I wear a veil, all this. I talked to my boss about it. If they don’t want me there, they’re not getting any help, okay. My boss supported me, it was fine. Rebecca: So you went [into their homes] anyway? Kadia: I kept going. If they don’t let me in, fine. I remember one thing – a patient with a wound, we were supposed to dress it. He absolutely did not want me in his home because of my veil. He didn’t want me to see him exposed with his wounds, he said. My boss called him up and said, “Here we have no racism – we don’t talk like that. You can’t behave like that. If you want help, you will take the help you’re offered, or decline, and be without.” She was very clear on this: you don’t offend people or their religion. So I went, because he was tremendously dependent on us. He needed to be lifted up, and you have to be two people when doing it; that’s the law. He didn’t want me to touch him, so I handled the [mechanical] lift while the other nurse held him, and he had to carry what stuff he needed because I was not allowed to touch any of his things. Over time, he changed a bit, but he was a difficult one. … It made me sad. Then I thought, he is sick. This is why he behaves like this. I focused on his disease, his problems that I was there to help him with. I didn’t dwell on it; if I did, I would have started feeling sick too.

I included this lengthy quote in order to illustrate two things: that experiences of racism in care work are shaped by the organisational context, in which the hospital provides a more protected space than municipal home-help; and that inclusion into a professional category offers strategies to deal with racism within the framework of caregiver/ receiver hierarchies. Kadia discussed how the situation of caring for someone in the home was quite different from caring for someone within the hospital in terms of the level of violence directed at her and strategies available to deal with it. In a patient’s home, she felt she had to respond to his or her claims, while in the hospital hallway, she simply walked away if someone approached her about an issue she had no interest in discussing. Anderson (2000) and others (such as Salzinger 1991) have illustrated through interviews with domestic workers that working in the homes of clients is an extremely vulnerable position. Anderson (2000: 121ff) has argued that domestic work in the home is highly individualised and based on the manipulation

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by employers of the relationship with the employee and the fiction of labour power, in which the employer wants to buy not command of the labour power but command of the whole person, as this person is to care for the employer’s home, possessions, even children or the elderly, in an intimate context. The relationship between employer and employee in this context is saturated with asymmetrical relations of power that are entwined with notions and feelings of love and intimacy. In the hospital, work is performed in a more neutral space in which the employee is in control of the work, and in which the professional categories function as collectivities with intra-professional loyalties. The employer is not the person being cared for. The caregiver/receiver hierarchy further means that the caregiver category is supposed to diagnose and decide treatment; this is where there is power. And this is what Kadia used as a strategy to cope with being forced to work in the home of a racist. She focused on his disease and subsumed his racism under his sickness, which turned caring for him into part of her general commitment and responsibility to care for everybody regardless of their position. Was there a flipside to this argument? I would say that while the professional role offered racialised nurses some protection from racist verbal violence, the professional role could also be used to adapt racist sentiment into seemingly professional judgements. The example that stuck with me was an episode at the birth clinic, when I shadowed assistant nurse Marie. There was a young woman giving birth, and she needed an emergency caesarean section (this episode is mentioned in chapter 3). After the baby was delivered, the patient, Mina, complained about being in pain. She moaned and cried and asked Marie, who was in the room to weigh the baby, for some painkillers. Marie hardly responded. One thing I found strange about the situation was that while Marie had showed me little interest during the day, she suddenly started to include me in every little thing she did. She offered me to hold the baby and in fact handed him to me, without asking the mother or father for permission (I had never held such a small baby in my arms before and was utterly confused by the situation). She atypically explained to me the procedures of care, such as why she took the baby’s temperature, and described all the routines after delivery. At the same time, Mina was crying:

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Marie walked up to the bed, finally, and said: “It’s normal to be in pain, it’s not that serious, come on, it’s okay”. She touched Mina gently but did not respond to her request of painkillers. Mina’s family was standing around, mostly quiet. When they spoke it was in another language. A woman I assume was Mina’s mother kept speaking to her quietly while stroking Mina’s arm. Mina kept crying. Marie turned to me again and continued to fill me in on the routines. It felt strange, that I was offered to hold the baby as if the mother was not even there, as if it was Marie’s baby. I stood there with the baby in my arms, glancing at Mina who was crying and complaining about stomachache. Marie kept busy with the scale and some equipment. She then took the baby and said that he was cold, that he needed to be kept warm: “A newborn needs a lot of heat, you see, they get cold very quickly”. I nodded. Marie went over to Mina and explained that she needed to keep the baby warm. She then placed the baby in a cot, which she positioned under a special heating lamp. After we had left the room, Marie said, “These foreign women they always complain about the pain. Now, I had a C-section my self and I know it’s not that painful, I mean it’s painful, but not like that. It’s quite typical behaviour and it’s about culture. Also you could see that the whole family was there, these people will fill up the hallway sometimes and it’s drama, drama”. This was one of the most racist episodes I ever witnessed during my fieldwork at City Hospital, but I find it hard to capture in writing. I watched as the assistant nurse transformed into a teacher, and used the teaching position to distance herself from Mina and the family and to deny Mina the level of care she asked for – and to deny her the level of care I had seen Marie give to other new mothers. Marie handled the baby not as a member of the family in the room, but as a nurse’s responsibility, as part of her jurisdiction and as part of her teaching material. She denied Mina pain relief, and for no apparent reason it seemed. She simply concluded that Mina did not need any help. In that room, Marie appeared professional in an instrumental kind of way, and at the same time, the instrumentality of her demeanour made her seem anything but professional to me. Her over-inclusion of me was in fact an over-emphasis of the professional role and a way of excluding Mina and Mina’s family. I knew instinctively that as soon as we got out of the room, she would talk about the family in a racist

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way, and she did. I imagine, though, that it would have been hard for Mina and her family to level any concrete criticism at Marie’s behaviour. To say that she acted in a racist way when in fact Marie never uttered a critical word against Mina would have been easy to brush off as paranoia (see Sohl 2012 for a discussion on the label of “paranoia” in debates on racism in Swedish). I view this episode as an example of the ways in which everyday racism within the hospital could take on the form of distance and denial camouflaged (as in difficult to formally criticise) by instrumental professionalism. I use the concept of instrumental professionalism to refer to intentional and manifest surface acting (Hochschild 1983: 33ff) practiced in interchanges where the nurse harbours feelings of contempt for the patient and is not interested in disguising it beyond what would subvert claims of unprofessional and/or racist attitudes and behaviour.

Challenging everyday racism An episode in Ward 96 illustrated the way that the category ‘immigrant’ is both called on and made unstable in everyday exchanges. A nurse, Liselott, was about to visit a co-worker, who had a “migrant background”, and who lived in an ethnically diverse neighbourhood in the city. The way Liselott talked about the impending visit irritated some of the other nurses present, who called her out on her racist language: Lounge, at night. Five nurses were sitting around the table talking about the summer party being held in a few days’ time. On the wall behind them was a note with information about the party. It said which nurses were responsible for organising it, and below it a list was posted where nurses had signed up to attend. The nurses looked at the note and the list and were now talking about how to get to the party: should they go straight from work? Should they meet up first and have a drink somewhere? Liselott said, “I’m going to Hanin’s place first to party [‘for a preparty’]. We’ll be drinking and listening to music. The only thing is, I have to get out all the way to Ali Baba-land.” There was laughter, but Linda said, “What do you mean, Ali Baba-land?” and Liselott responded, “You know, I have to go all the way to [Neighbourhood]. Damn, having to go

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all the way out there, and in the middle of Ali Baba-land – I can’t believe she lives there. I don’t like that place.” Christel responded, “Why do you say that – do you think she’d appreciate that, when she has invited you to her home and all?” and Liselott answered, “She knows what I think about that place. I can say it; she thinks it’s okay. I call her ‘blatte’ too, and it’s okay. Anyway, I’ll be riding the bus all the way out there, but it’s going to be fun. I think it’ll be a fun party this year.” Another nurse walked in, and Linda asked her about a patient. The subject was changed. It would have been interesting to know whether or not Hanin ‘was okay’ with being called ‘blatte’, which is a derogatory word comparable to ‘spick’ but referring to migrants in general. I never had the chance to interview Hanin, and either way it would have been ethically problematic to relate to her what Liselott said in the lounge. Linda questioned the fact that Hanin lived in a neighbourhood Liselott called ‘Ali Baba-land’. The term ‘Ali Baba-land’ was new to me. I have since asked people who live in the city if they are familiar with it; none have heard this expression before. However, there are other well-known nicknames for different parts of the city that suggest a connection to Arabic culture and Arabic countries. Those neighbourhoods are ethnically diverse; for instance, there is one street sometimes referred to as a known area in the Middle East, and around this street about 41 percent of the population are born abroad, the majority in the former Yugoslavia, Iraq or Lebanon. Liselott found it strange or misplaced for Hanin to live in a neighbourhood categorised as Ali Baba-land. Hanin, it seemed, according to Liselott, was not the right type of Arab to live in a neighbourhood perceived as so full of Arabs it could be called Ali Baba-land. And still, Liselott made the location of Hanin’s home her main point, passively reminding everybody about the difference between her and Hanin. Although Liselott assured the rest of us that Hanin accepted that kind of language, it was clear that not all of the nurses present did. So Liselott changed the subject back to the party itself. But there was a sense, I felt, that the moment had passed: no one spoke more about the party after that. There was a void created in the conversation as no one supported Liselott in her description, and no one followed the path she took in racialising Hanin and her neighbourhood. I would

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argue that this exchange serves as an illustration of Porter’s (1993) argument that racist attitudes can work as ideological rationalisations for benefiting from structural inequalities. Liselott and Hanin were friends and co-workers, yet Hanin lived in a poorer neighbourhood that Liselott wanted to keep her distance from. Liselott’s talk about the trouble of getting to Hanin can be interpreted as dealing with the fact that Liselott resided in “the empowered camp of a racist divide” (Porter 1993: 597). As the situation with Liselott and the party illustrated, racist remarks were often challenged. On some occasions I debated whether or not they were challenged because I was there, and of course I have no way of knowing if this was the case. One example was when an assistant nurse, Lillian, found a pair of boots left in a room at the birth clinic. The episode illustrated how common3 and random acts could be used to call on racist stereotypes: One of the women who had given birth had forgotten her shoes, and an assistant nurse came in with them [to the nursing reception] … Lillian looked underneath the soles and said, “They’re my size, and they are goodlooking boots, maybe I should take them home!” and she laughed. A midwife said, “How can you forget your shoes?” Another midwife responded, “Well, they were immigrants, from – where was it?” and Lillian said, “Was it Morocco or something? They spoke Arabic, I think.” “Well, those people are strange,” one of the midwives said. “There is no order around them; it’s always a little chaos.” … When she said it, I felt like the other midwife, who was standing close to us, looked at me and I looked at her, and then she said: “Well, one shouldn’t lump them together; some are like that and some are not.” While she said this, she picked up some papers, looked at them, tore them apart, and threw them in the bin. Then she said: “Oh well,” and left the room. The midwife being corrected said: “No, of course, that’s right.” In this instance, the discourse of chaotic Middle Easterners was reproduced because a mother forgot her boots on her way to another ward. Processes of racialisation could be challenged in different ways and 3.  It was fairly common for patients to forget things in the wards. I helped store leftbehind items on several occasions.

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possibly for different reasons. I got the sense that the midwife protested at the statements only after having recognised my presence; it was a feeling of mine, and I can’t be sure of it. This whole interaction nonetheless illustrates how racist statements can be made part of every­ day interactions at work. In interviews, those acknowledging racism in the workplace said they would often try to confront it. Maria was a resident obstetrician at a smaller hospital in the county, and she claimed racism was common there, especially among nurses and midwives. She described herself as “afraid of conflicts”, but would nonetheless and atypically challenge racist comments or actions. She had a number of concrete examples of how racism could be played out. In the first part of this quote, she talked about how midwives or assistant nurses would describe migrant women’s status during labour. One stereotype involved the idea that migrant women, particularly Arab women, were overdramatic: Rebecca: Have you ever experienced racism? Maria: Yes, I think that I have. My workplace is frightening. I mean, it’s frightening how common it is. I will react, actually, even question people in the lounge. And I am afraid of conflicts, so it’s surprising that I do that, but I do. Because I get mad. Rebecca: So what do people say? Maria: You know, any professional category really, but often when you’re in the lounge it’s nurses rather than doctors; doctors don’t sit there that often. It can be like, oh, you know, “She was screaming like a pig, but they always do that, those Iraqis,” or, “She’s not moving, but it could just mean that she’s like any other Arab.” Things like that. “People from Poland are thieves, you can’t trust them.” That’s the way they’ll talk. Rebecca: What do you say? Are you the only one to react? Maria: Sometimes other people will react, but not too often. I say, “What do you mean, she’s not in pain?” I may not confront it as, “What a racist thing to say”; more like, “What do you mean, why shouldn’t I trust her? I don’t know what you’re saying.” There is a lot of it, I think. It’s hard to give you an – it’s more innuendo, if someone is not Swedish, like: “You know what they’re like, I’m sure it doesn’t hurt that much. She can go home.”

Maria worked at one of the smaller hospitals in the county, but one that also served large groups of patients with migrant backgrounds. She explained that certain groups would be singled out, and it seemed like ‘Arabs’ were the most common target. Processes of de-racialisation were in play at this hospital too: not all ‘immigrants’ were treated

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badly; not all ‘immigrants’ were considered problematic. Maria considered herself Swedish, but one of her parents was a migrant to Sweden from Peru. Although Maria had dark hair and brown eyes and talked to people on occasion about her background, she was never considered anything other than Swedish, and colleagues would display their racist attitudes in front of her seemingly without hesitation. Racism would sometimes involve challenging her orders regarding patient care. Rebecca: [Your parent] has this [migrant] background. Do [nurses] think like this of you? Maria: No. I tell people, and if it comes up I’ll talk about it. But they don’t think about it because I still look pretty Swedish and my name is S­ wedish. They forget after a while. … I don’t use Facebook that much, but sometimes I read it and I am friends with some co-workers there. And they post racist things. You know, people that I work with, these are people who work with patients, and they post things like: “Do we have too many immigrants in Sweden? 10 % says no, 20 % says yes and 70 % says” – and then Arabic letters.4 Rebecca: Mm. Maria: That is racist to me. And they post that and we can see it. And people ‘liked’ it – you know, you can ‘like’ stuff on Facebook. And I used to enjoy this person and I thought: who is this person, she can’t do care work; she should not work with people at all! [Laughter] I get upset because we have patients who are Arabs and then I know what these nurses think about them. Rebecca: Have you ever seen – have you ever been in a situation with a patient – can you tell from how they act or are they professional [towards patients]? Maria: Sometimes they will treat patients differently. I confronted one nurse – there was a foreign woman who came to us, and she couldn’t speak Swedish. And when we do a pelvic exam, we use an interpreter on the phone, on a loudspeaker, and it works very well. So I told the nurse to get an interpreter on the phone for the exam, but it’s better if the interpreter is there, at the hospital, in case something happens. Maybe I need to follow up and talk to [the patient] about the results. The nurse said, “Yeah, yeah.” When the exam was about to start on the day we had agreed on, there was no interpreter. The nurse explained that no, it wasn’t necessary. So I said, “I told you to get one. Now, if something happens, something I need to inform the 4.  I have gathered this ‘joke’ is difficult to understand in this context. The sentiment is that it is beyond debating whether or not there are “too many immigrants” in S­ weden: there are already so many people speaking Arabic, there obviously are too many (hence the “70 percent responded in Arabic”).

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patient about, we need an interpreter.” The nurse just said: “No.” I thought that was racist. She was not lazy, it wasn’t about that – it was about her not thinking this woman deserved an interpreter. She didn’t give a shit. It was like, “If she can’t speak the language, she’s got herself to blame.” Awful. I was mad. I had told her to arrange an interpreter and she did not do it. So I confronted her about that.

Maria gave a number of examples of how she would challenge everyday racism at work. She would rarely call it out explicitly; that is, she would not say, “that’s racist” or “you’re racist”. Instead, she would use her position as a doctor, bearing the medical responsibility, knowledge and power, to question accounts such as doubts of whether a patient really was in pain or was just “behaving like any other Arab”. “Should I not give her pain medication, is that what you’re saying?” she would ask, and more often than not the midwife or nurse would step back. But it seems Maria’s resistance did not leave any permanent marks; the racist comments kept coming, even in front of her. Porter (1993) discusses the varying conclusions researchers have drawn when it comes to professional hierarchies and racialised relations of power. This involves two “contradictory social mechanisms”, Porter says, wherein “racism tends to reduce social status, while professional power enhances it” (Porter 1993: 604). Some researchers, drawing on E.C. Hughes’ (1945) notions of status (such as the professional status of doctors) and auxiliary characteristics (such as whiteness), have argued that racialised identities interfere with status positions, causing “some departure from expected role relationships” between, for instance, white nurses and black physicians (D. Hughes 1988 cited in Porter 1993: 603). Like Porter, there is nothing in my data to suggest such departures from expected role relationships when it comes to exchanges between racialised doctors and white nurses. However, one could view Maria’s account, in which she keeps encountering racist attitudes and actions despite calling on her professional status to counter them, as an example of racial stereotypes and racism as an arena where lower-status groups can challenge professional status. ­Porter, drawing on critical ethnography, argues that attitudes and actions exist and play out with some independence of social structures. Individuals engage in practices that are influenced but not determined by “the social position they occupy, in that that social position provides the

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means, media, rules and resources available to enable or coerce action” (Porter 1993: 597). In this respect, the nurses express racist attitudes and act in a racist way, and the doctor tries to counter it. Their relationship is not necessarily disturbed (in the sense of Davies 2001) by processes of racialisation, but rather by politics (views, actions) of racism and anti-racism. Considering Porter’s assertion that people living in racist societies will experience some pressure to display racist behaviour and possess racist attitudes because of the ideological rationalisation it provides for their benefiting from structural inequalities, there is enough weight behind the nurses’ actions to keep defying the doctor. The doctor in this particular case is also young, still in training, and embodies a kind of emphasised femininity in which she shies away from conflict, according to her own account; notice, too, the way she laughed and smoothed over her harsh criticism of racial attitudes and actions at her workplace.

Solidarity and consciousness In their article on the network of union activist migrants in Sweden (FAI, Fackligt aktiva invandrare), Mulinari and Neergaard (2005) discuss a form of pan-ethnicity forming in Sweden. Migrant union activists would talk about themselves in terms of ‘black skulls’ (‘svartskallar’), in an attempt to appropriate its meaning (the term was originally and is still often used by racists as a derogatory label for immigrants). The insult, Mulinari and Neergaard argue, was becoming “a symbol for belonging and struggle” (2005: 64). It was a word that marked class boundaries too, a political concept that was also “gaining wider exposure in the public arena, in part because the so-called second generation uses it continually in oppositional ways” (2005: 64). The term ‘black skull’, according to Mulinari and Neergaard, could be seen to grasp and name “an emerging Swedish immigrant and panethnic working-class identity” (2005: 64). In an interview with Helena, the term ‘black skull’ was brought up by her in a way that mirrored Mulinari’s and Neergaard’s conceptualisation. Helena explained that “some of the immigrant nurses” would sometimes talk about their status as immigrants in a way she felt was inappropriate: [One nurse] will say: “I’m just a black skull,” “us black skulls,” – you know, she will talk this way … I mean, she can say other things too that are per-

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haps just a matter of language: she can call her daughter a little donkey or something, which to us Swedes, it just doesn’t sound right – maybe in her language it’s an affectionate term, I don’t know. But mostly when she talks about black skulls and all this I will react and tell her not to talk like that because this is not the place for it … I don’t know what she means by that, so it’s just unnecessary.

I think Helena picked up on and reacted to the political effort in employing the term in this fashion. It addressed a kind of collectivity and consciousness that made the manager uncomfortable, because it highlighted some of the experiences lived by racialised nurses that connected them to patients and people on the other side of the racial divide. Helena was anti-racist, the one working to counter some of the effects of discrimination and cultural cloning, but still: the discourse of a pan-ethnicity, shared experiences, struggle, and resistance, proved too much to be deemed appropriate within the workplace. Azime, who worked as a nurse in an Internal Medicine Ward at University Hospital, talked about a certain kind of solidarity she felt towards other racialised nurses. She would challenge racist comments even though it made her feel especially uncomfortable – more uncomfortable, she explained, than issues of gender inequality. It was her position as a member of a minority group within the subordinated group of women and care workers that made her feel this way: One of the other nurses was going to order pastries for the afternoon coffee. I asked what I could choose from. She said, “Cinnamon buns and Danish and Negro balls5.” I said, “Come on, what the hell, no one says ‘Negro ball’ any more, do they?” She said, “No, no, I mean, oh, blah blah …” It makes me uncomfortable to confront people like that. It’s especially hard to confront people on racism. If it’s a matter of sexism, everybody agrees you should not have to be harassed in the workplace. If there was a doctor or a male nurse who said something stupid about women, in a workplace full of women, then more than one person would have protested. He would have been outnumbered. But when it comes to racist comments – or comments that perhaps are not perceived as racist by some, but others feel they are racist – it’s so much harder. Because, I mean, I personally don’t feel offended if someone says ‘Negro’. As a Turk – I have lived in Sweden for 25 years, but anyway, as 5.  The nurse was referring to a Swedish chocolate pastry in the shape of a ball, and covered in desiccated coconut. It used to be called ‘Negro ball’, and racists have insisted on that name instead of the more accurate and innocuous term ‘chocolate ball’ (Wirfält 2009).

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an ethnic Turk, you know – but I have colleagues who are black. I feel like I have to say something in order for them not to feel completely alone in this. The one at work who is black, she’s from Ethiopia, she wasn’t there at the time, but it doesn’t matter. So … yes. And then I worked at this other place where people had some really strange ideas about immigrants, but you have to choose your battles.

Sexism was not accepted by any of the women at her workplace, she felt: there was a strong collectivity around being women working within the public sector. Racism was a much more sensitive issue, and one in which Azime had to assert both herself and another kind of collectivity that went outside the women care worker collective. But she would protest, even if she knew that those around her would not acknowledge some things as racism. The ‘Negro ball’ discussion showed the sensitive work that can be involved in challenging racism without upsetting the relationships at the workplace. She didn’t say: “that is racist” or “you’re a racist”, just like Maria did not call nurses racists. Another aspect of the work involved in challenging without disrupting was choosing when to confront racist stereotypes, and when not to. In this particular instance, she did confront racist language, but she defused the situation by suggesting the nurse had simply used an outdated expression. Azime did it so that another nurse would not feel ‘alone’: it was an act of solidarity, too.

Conclusions This chapter contributes to the understanding of the processes of reproducing sameness by partly challenging some key presumptions in Essed’s and Goldberg’s (2005) work. Contrary to what they claim, it is not always true that “the higher the status and power, the stronger the preference for the (embodied) profile as white, masculine, heterosexual, middle-class, married” (Essed & Goldberg 2002: 1079). When it comes to healthcare professions working within the public sector, it is rather the middle position – the nursing profession – that has shown the strongest ability to reproduce in-group sameness. The medical profession is ethnically heterogeneous in Sweden at the beginning of the twenty-first century; the nursing profession, however, is still relatively homogenous. I argue that the highly interrelated labour process, the

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care-managing position, the focus on communication and the notion of a functional liaison, in combination with a strong ideological link to the embodiment of the Swedish welfare state in its encompassing capacity, make it more important for the nursing profession to reproduce a specific kind of sameness: nurses are expected to be white, ‘Swedish’ and female. Interviews and field notes indicate there is less tolerance for varying accents when it comes to nurses compared to doctors, and I see this as an outcome of the division of labour and the specific role ascribed to nurses within the hospital: they are the frontline service workers in the hospital wards and, as such, they are the ones interacting with patients and representing the hospital. Doctors are more protected, because they are not as accessible, and because they occupy a position more powerful than that of nurses. But nurses are still not as subordinated as cleaners, for instance, who very often are racialised; the difference is the position of liaisons of the power – and this is what makes communication and notions of what communications should look or, rather, sound like. I would also suggest that the scientific language of medicine negates doctors’ lack of language skills and provides a powerful resource for de-racialisation. The doctors’ skills are framed as technical, and their labour processes less interrelated and less dependent on horizontal communication. Their work processes are also less likely to lead to conflicts that need to be addressed on the shopfloor. One of the findings of this chapter is that race/ethnicity, played out as cultural and communicative differences, is called on and becomes an issue when there is conflict. But everyday racism is also a cause for conflict, in some contexts and instances. Discrimination can be used as a tool purportedly to avoid conflict. In this chapter, I suggest that racism and discrimination occur both as everyday phenomena through interactions, but also through practices that move beyond the everyday, such as recruitment. These practices, however, are interrelated. It is interesting to note that, while there is an increasing political emphasis on the importance of diversity within the public sector workforce (Tahvilzadeh 2011), resource depletion seems to increase the demand on seamless workers and instigate processes of what has been called ‘statistical discrimination’. And despite the discursive emphasis on individualist perspectives on employees and their abilities within

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NPM and related managerial approaches, growing workloads narrow the space for diversity and increase the (perceived) need for homogeneity in the work collective. This is one way of understanding Helena’s decision not to hire “an immigrant” at one point. However, in this chapter I have also shown that employees are represented as problems because they are not in total command of the Swedish language, while at the same time being taken advantage of by the organisation that uses their skills in other languages so as to simplify the labour process. Another important contribution in this chapter is the role of the hospital and giver/receiver hierarchies in offering employees protection from racism on the part of patients; as has been illustrated before (Anderson 2000), work in the home of others is a precarious situation in which the employee is put in a vulnerable position vis-à-vis the client. The results of such research are underscored by this study as I illustrate how healthcare employees experience the hospital as a space in which they are rendered more powerful through their professional role, which places them in a more secure position and more firmly associated with control over space and work processes.

10. Femininity at work: conclusions

It’s Friday morning and I’m about to head for work where I’m in the final stage of writing up my thesis. In the local newspaper, 59 gynaecologists and obstetricians in Sweden’s third largest city have published an article warning against further privatisations and cutbacks that, according to them, would cripple the reproductive healthcare in the county and restrict women’s access to safe and qualified care.1 In the article, the doctors say that county politicians have shown blatant disregard for experienced doctors’ positions on issues regarding reorganisations of the hospital, and have ignored warnings against the effects of further privatisations. They assert that the proposed expansion of privatisations within the field of women’s health will quench doctors’ ability to adequately develop, lead, research, teach and perform their jobs. News about crisis – crisis in the industrial sectors, crisis in the public sector – has made headlines in Swedish media during the last twenty years. The fact that public services (trains, schools, hospitals) do not function has been a common and recurring topic both in national and local press. But the intervention by 59 doctors declaring that their working conditions in one of Sweden’s central regional clusters are now posing a potential risk to the lives and health of patients provided the notion of a crisis of a different form and content. Together with the story of a toddler who died from sepsis due to lack of attention in an overcrowded paediatric clinic at the neighbouring university hospital in Lund (Sydsvenskan 2011), the doctors’ appeal gave the crisis a new face and a much more alarming tone. There is increasing consensus among scholars studying healthcare that processes of privatisation, deregulation (and re-regulation), 1.  Sydsvenskan (2012), the heading read “County politicians are destroying reproductive care in Skåne”.

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subcontracting and resource depletion have had negative impacts on what, up until the neoliberal shift in the 1990s, was one of the most well-functioning healthcare institutions in the world. Research has identified that NPM and other neoliberal policy and management regimes lead to work intensification and decreasing job satisfaction, including work-related ill-health, among healthcare employees. To assert, then, that the Swedish healthcare system is in a state of crisis, that this crisis to a certain extent is provoked by neoliberal reorganisations, and that it strongly and negatively affects the working conditions of the employees – most of them women – is not original, or new. My contribution to this scholarship has been to map and explore how these structural transformations are lived and acted upon in the everyday interactions in the workplace, and among a particular group of women employees. In this sense, I would like to locate my research within the emerging field of ethnographies of neoliberalism. Within this field, researchers are beginning to investigate ethnographically the ways in which neoliberal reform reshape social and political institutions as well as ways and spaces of identity formation, social and political subjectivity, resistance, consent and protest (see ­Greenhouse 2009). Ethnographic methods, and institutional ethnography in particular, are powerful tools for exploring and locating such practices in spaces of work, knowledge and power. Ethnographic investigations that begin in the experiences of people can explore and illustrate the ways in which subjectivities are formed through different experiences, processes and settings. Institutional ethnography directs attention not only to experiences and the means of their production, but also to the institutional framework and relational character of experiences. Research into the transformation of the public sector has mostly produced other types of data and drawn on other empirical sources. Few studies have actually considered if and how ethnographic data could advance the understanding of the ways in which public sector employees experience, negotiate, and resist neoliberal transformations and processes of work intensification in the everyday. My study contributes to this field by producing new forms of data and knowledge, and by paying attention to experiences of those dealing with effects of the neoliberal change. Following Dorothy E. Smith’s enterprise of institutional ethnography, this study makes the

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everyday of neoliberal transformation in the workplace problematic, and takes people’s experience of this problematic as the point of departure of the analysis.

Investigating the relationship between women, labour, identity The letter from 59 doctors published in that Friday’s paper could be read (and was read) in different ways. The first way of reading it, and perhaps the most common way of reading it, was as a form of confirmation. The letter bore out what most Swedish citizens already ‘knew’ about the crisis of healthcare. I use the term ‘confirmation’ here because this time the criticism did not spring from patients, but from those with authoritative power within the organisation. Now even the doctors, known for their collegial loyalty, professional distancing from politics and for being accustomed to cyclical political reorganisations, were saying that the system is actually falling apart. I did share the feeling that the letter was a confirmation of what many of us already knew or suspected, but I could not stop thinking about my informants, the many nurses whom I had met during my fieldwork. Despite their intensified workloads and despite their sometimes-harsh critique against the healthcare system, they had not been able to articulate any form of collective resistance and their individual resistance seemed highly limited. The (failed) collective protests they had levelled during recent years had also been aimed at raising their salaries – not at protesting cutbacks affecting patients or workloads. If one of the central contributions of this thesis is to provide an understanding of the everyday life of neoliberal work organisations, the other one lies in its exploration of the relationship between women, labour and identity. Issues of labour have paradoxically been at the margins of both gender studies and sociology in recent years. While sociologists in the context of the cultural turn (Sayer 1999) have argued for the relevance of other identities in late modernity (­Bauman 2000), feminist scholars have moved away from the category of ‘woman’ and its location within labour/life processes into an exploration of genders. My point of departure is that (paid) work is fundamental in people’s lives. Specifically, it is fundamental in the creation

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and reproduction of identities. In other words, I argue that femininity is shaped and regulated (and contested) through the ways in which labour markets are organised, workplaces are structured, and different professional identities are called into being. An argument evolving from my empirical material is that the forms of femininity that a neoliberal regime demands of nurses also shape nurses’ possible response to these changes.

Gender, labour and power in the new millennium Some scholarship asserts that femininity is increasingly recognised and sought after in the labour market of ‘late modernity’. While this is not something I started out to investigate, the statement illustrates the field in which I explored femininity: between processes of work, processes of neoliberalism, work identities and politics of belonging. I use the concept of belonging here to indicate inclusion, peer respect, visibility and security – the opposite of exclusion, or of being deemed deviant in any way. It is not necessarily about power on a structural level, but in this context rather about being welcomed into local communities and accepted as ‘normal’: who gets to belong? In essence, I use the concept of belonging here to illustrate how accommodation rather than opposition is emphasised in the construction of proper work identities. This study has shown that in this context belonging is conditional on the embodiment of a certain kind of femininity. The concept of normativity captures this process through its focus on the specific relation of femininity that is associated with mothering and with the moral duties of the welfare state. It has been used here to uncover the expectations placed on nurses under neoliberalism, and the transformations as well as continuities in what it takes to belong to this group of employees. Further, the term ‘normativity’ has contributed to the discussion on how and what kinds of different femininities can be conceptualised. Others (such as Schippers 2007 and C ­ harlebois 2011) have argued that femininities that are privileged should be thought of as ‘hegemonic’, in the same way that the form of masculinity that legitimises patriarchy should be thought of as hegemonic (Connell 1995). I argue, along with Connell (1987: 188), that while some forms of femininities are privileged in relation to other forms, femininity is

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primarily about adaptation to men’s power and to masculinity and thus cannot establish hegemony, a term referring to both force and consent. Women are continually located outside the extra­local relations of ruling, and often located in work processes that sustain and are essential to those relations. But while nursing shades off into power over those whose bodies are being worked on, the profession is still placed between abstracted modes and the local and particular actualities in which they are anchored (Smith 1987: 83), illustrating the continuation of women’s location not within the forces of power but within mediating positions.2 Normative femininity brings attention to women’s responsibilities of caring and the moral obligations that not only come with caring, but also the boundary work and the reproduction of norms and values that care work entails. The power over those cared for and the cultural and often micro-political dominance that care work and care workers hold over, for instance, certain kinds of service and domestic work (Roberts 1997) is captured by ‘normative femininity’ without the notion of hegemony of women that I think ‘hegemonic femininity’ implies. Normativity in this sense also speaks directly to politics of belonging: who can be part of the project of caring in this context? On what terms? Under what circumstances? By extension, the concept of normativity and the question of belonging under normative femininity also opens up for competing notions and conceptualisations of femininities. This study has shown that while the neoliberal transformation of the public sector and its workplaces involves an increased individualism, for example in terms of salary-setting practices, there is still a strong collective regulation of the ward workplace. This regulation is linked to and stems in part from the ways in which the heterosexual matrix operates on the shopfloor. The interaction between different groups of employees is shaped by hetero-normativity in which nurses avoid conflict by accommodating their subordinated role in gendered professional hierarchies. The playing out of hetero-normative accommodation and care for the family and the home, I have argued, can 2.  Here, it is relevant to explore further the changing conditions of doctors as well. An increasing number of doctors are women, at the same time as doctors are reporting significantly worsening working conditions and levels of autonomy (Bejerot et al 2011).

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be understood as the performance of an ideal worker, part of a ritualised normality that is provoked by the anxieties involved in working with death, dirt and an increasingly complex and unpredictable labour process. While there is increasing diversity within the nursing profession, with new career paths opening up and more administrative power being within reach, as well as possibilities of an academic career in research and teaching, this study has illustrated that femininity regulates this type of mobility. It is still available mainly to those who come from privileged backgrounds, and even for them, moving up within the hospital hierarchy is associated with hard work and some degree of chance. However, the ever changing organisation at the hand of contriving politicians3 and ambitious top management means that new career paths keep opening up; at the same time, though, more nurses are hired within the organisation, and so there is a vast number who will stay within ward nursing. In regards to claims from within the social sciences of women’s new capacities and possibilities of success under neoliberal globalisation (McRobbie 2007), including economic independence and success, it should be noted that in Sweden nurses’ salaries significantly lag both in terms of comparable worth and in terms of actual wage development.4 Many of the nurses I interviewed, especially those who were single or whose partners were unemployed or retired, had a long way to go before attaining what can be called economic success. With living costs on the rise, these women lived securely but still had to struggle to afford life’s little extra. This was especially true for the assistant nurses. For them, one argument not to go on and study nursing was the student loans, which they feared would set them back financially to a significant extent. As the nursing profession is differentiated it is key to note that, while some nurses 3.  As research has pointed out (Jessop 1990), neoliberalism is not about ‘freeing’ the market from political and state regulation (deregulation), but rather through the means of political re-regulation to create markets – something that often requires embedding the market in what has been called “new webs of governance” (Larsson 2010). In the case of Swedish healthcare, county politicians have shown a high level of interest in governance and control; the NPM paradox of decentralisation of responsibility and centralisation of resources and executive power. 4.  Nurses have often gone on strikes in Sweden on this issue, although the outcomes have been modest.

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do move into more powerful positions within the hospital hierarchy, a vast number of nurses are tied (socially and spatially) to the ward floor and left to struggle with the consequences of the neoliberal transformation. Based on these results of the study, then, I argue that new conditions of care work produce new forms of femininities. I have been able to explore both change and continuity in the conditions of care work, and have shown that the nursing profession is put under new forms of pressure that force new forms of femininities. Nurses are still the first and last frontier of the hospital. As Menzies Lyth (1960) showed in her study on nurses in a British hospital some fifty years ago, nurses are still made responsible for the boundary work within the hospital. They are the ones who meet and greet or hold off the patients; they are the ones who are yelled at; they are the ones mediating knowledge and results; they are the ones keeping patients in place and negotiating their demands, as medical knowledge is increasingly democratised and available. Nurses in the new millennium work with and on patients who demand more, and who know more. Before, patients were supposed to receive comfort; today, they demand explanations and accountability. The responsibility of dealing with such demands is continually put on nurses to deal with – representing a new form of emotional labour and boundary work, two areas that reflect a continuation of what have always been nurses’ responsibilities. This study has illustrated changes in the hospital organisation and conditions of work, but also the continuities – subordination prevails for nurses and for women. A salient result in this aspect is the notion of professionalism as linked to administration and technology alongside care. This should be viewed in the light of a deskilling of some nurses’ work, whereby they must assume auxiliaries’ tasks of hightouch, ‘dirty’ body work such as washing patients, changing diapers, cleaning patient’s rooms and making beds, et cetera. Bessant (1992: 159) has argued that the historical link between ­middle-class women and nursing has been central in regulating nurses’ behaviours and professional identities. Becoming a ‘good nurse’ has historically been closely linked to being a ‘good woman’. Thus learning how to be a good nurse has involved “reinforcing the proper habits and attitudes, a sense of responsibility, attention to detail and ­obedience to

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the rules and regulations of the hospital and to superiors”. The consequences of this embodiment of normative femininity have been real, as “respectability, loyalty and the capacity to combine the qualities of caring and distance became part of the popular re-representations of nurses”. This, however, has also been used by “politicians, administrators and the public alike to justify poor conditions and poor pay” (Bessant 1992: 159). I agree with Bessant, and my study supports her argument. What I have shown, though, is some of the ways in which normative femininity is reproduced within the hospital organisation and how it fits with current austerity ideology. I would argue, in light of this, that nurses have entered into a Faustian pact with neoliberalism. Research indicates (Nylinder 2011: 670) that nurses are better at maintaining budgets and more careful to consider (respect) economic ramifications than doctors are, who tend to emphasise autonomy and medical considerations over demands of balanced budgets and “bureaucratic principles determined by the county councils” (ibid.). A central aspect of the professional project of nurses that is closely linked to the gender project of normative femininity is the construction of respectability, which in this context implies responsibility. The responsibility here is not only to the patients, but also to the organisation and its bureaucratic principles which nurses take pride in maintaining. One of the things I discovered on the topic of work-pride is the nurses’ sense of being better at organising work than doctors are, and a fundamental critique against doctors was that they were unable to adhere to agreements on organisational issues. A principal area of responsibility for nurses historically has been to bring order to the hospital, in terms of cleanliness, emotional and physical boundaries towards patients, and in terms of organisational principles (Bohm 1961). With NPM, nurses have been given renewed responsibilities for maintaining the organisation and its budgetary and administrative ramifications. This has aided in affirming the distance between nurses and assistant nurses, and has also provided the nursing profession with new positions of power within the hospitals. In relation to this, successful nurses who are able to attain mobility and locate themselves within these positions of (adjunct) power are the ones who are able to successfully perform and practise the kind of ‘individuality’, ‘energy’ and ambition that is celebrated in

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today’s working life. Herein lies the ideological and practical support of neoliberalism and NPM that offer such ‘successful’ nurses new avenues of power and ward nurses on the floor increasingly difficult and draining conditions.

Work and femininities I posed four questions at the beginning of this book. The first one was: How does the organisation of labour in a public hospital setting intercede to create and reproduce varying forms of femininities? One aspect of this question is space. I have illustrated that spatial distinctions are a central feature of power relations in the workplace. Mobility is continually linked to power, and ward nurses are still tied to the confines of the ward; I have noted the continuity of gendered spatial arrangements of workplaces across the productive/reproductive divide, as I compared my findings to ethnographies of industrial work that have shown that women tend to be “bodily tied to their workstations”, while men are more free to walk about (Wolkowitz 2012: 182). I have also noted that more than gender, this is a question of class, as other groups of employees within the hospital – also predominantly women – move around the hospital. Thus I have shown that the organisation of work frames spatial attachment and links it to hierarchies of power and knowledge. A key finding here, I would argue, is that the content of work, coupled with the organisation of work that offers no other ways of dealing with sickness, distress, anxiety and suffering, creates a desire for and an emphasis on normality: a ritualised enactment of normality in a context which is not normal. I have argued that the extreme identification with what is associated with womanhood: the focus on immediate family, children, pets, and nesting in the form of decorating the home, cooking, planning family celebrations – the fact that it is home talk, not shop talk, that is expected and produced by nurses – all this can be seen as ritualisation of normality and disidentification from suffering and sickness. But it can also be seen as performing a work identity which is sought after by an organisation that is increasingly dependent on care workers to assume women’s traditional caring responsibilities and act as a buffer between what the organisation

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sets out to deliver and the resources distributed. Both these processes create a distance between patients and staff and work to affirm the boundary between them; a boundary that earlier research (Menzies Lyth 1960) has proven to be essential in order to contain nurses’ anxiety in the highly stressful and emotionally draining environment of the hospital. While this environment is inclusive and protective of those who can succeed in embodying normative femininity, it also rejects those who cannot. The space here is extremely narrow: not having a family by the age of forty is seen as suspicious. While perhaps it is not heterosexuality per se that is the only accepted form, at least heteronormativity is expected in the form of a nuclear family consisting of two adults and their children. I have shown that the concept of normative femininity is useful in understanding ideal worker constructs, whereby the performance is rendered invisible and naturalised as this particular form of femininity is associated with refusing overt aesthetisation of the body. Another aspect of how the organisation of labour in the hospital creates and recreates femininities is the insistence on nursing as an intermediate position in the hospital. This position grants nurses a certain amount of power (which varies within the nursing profession as well), but it also heightens the importance of sameness. This is why nurses are not supposed to have an accent; they are supposed to be able to work as interpreters between patients and doctors, as the face of the hospital, in a sense – as liaison in the ward. The concept of femininities is more easily linked to racial identities and experiences of racism than the category of woman is, and my analysis of the role of language has illustrated more clearly how the nursing profession in Sweden is being constructed as a job for women who are thought of as natural communicators – of a certain kind of communication, wherein subtle nuances in jokes or comforting gestures may get lost if the nurse does not master the language perfectly. The second question posed at the beginning of the book was: What kinds of boundaries are created to define normative forms of femininity for nurses? This book has illustrated that unlike women doctors, nurses who are (identified as) women are uncontested in their professional positions, and that the move into nursing is for the most part seamless and uneventful. But as the nursing field is differentiated, embodied

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class practices are increasingly important and can be used as a resource within the organisation in attaining mobility and respect. The study shows that a contradiction has emerged in neoliberal working-life regimes of the hospital, whereby successful employees are supposed to dis-identify from caring and long-term commitment to high-touch body work. There is a tension between career mobility and care work, which restructures normative femininity: while nurses should be caring and family-oriented, directing their energy towards and deriving their joy from interactions with patients and skilled interventions, crucially their skill and zeal should nonetheless be focused on administration and communication. Here, disidentification from service is key. Service is linked to subordinated women: to waitresses, to workers whose bodies are readily available for clients; whose bodies are called on to serve rather than represented as bearers of theoretical ­knowledge and thereby power over other bodies. Servers do not administrate or manage, and nurses should strive for positions like that. The practices of guarding and conceptualising tasks involved in distinguishing between care and service are perhaps counterintuitive in a context where nurses do not want to serve anyway, and as ‘care’ is distinguished and guarded from ‘service’, while at the same time seemingly melded together as something nurses would rather not do. The reason why service is constructed as a negative, I would argue, is precisely because it is constructed as a powerless position tied into menial tasks. As nurses, then, are made to serve patients more, and forced to take over assistant nurses’ unskilled tasks, it becomes increasingly important to guard a position of middleclass, adjunct power. The concept of femininity has been important in baring these tensions and in showing how the concept of service ties in to conflicts over historical and changing expectations put upon femininity and responsibilities associated with it. I would further argue that the distinctions between service and care and the tensions surrounding tasks conceptualised as service in the everyday at the hospital illustrate the difficulties in empirically separating out occupational class from status (see Crompton 1998: 116 for an overview on current sociological debates on class and status). The third question referred to the role of categories such as gender, class and ethnicity in shaping and regulating women’s positions within the hierarchy of the healthcare organisation. I have shown that middle-class

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habitus can be used as a form of capital to attain mobility – to move up and away from physically and emotionally straining work, high workloads, and high levels of exploitation. I have further illustrated that the space is narrow when it comes to being able to embody the kind of normative femininity needed in order to attain mobility. I have demonstrated that, while it has been argued that “the higher the status and power, the stronger the preference for the (embodied) profile as white, masculine, heterosexual, middle-class, married” (Essed & Goldberg 2002: 1079), it seems more likely that in contexts such as the hospital, it is the middle position that has the strongest ability and need to reproduce sameness. I have shown that from the nurses’ perspective, the expectations on them to embody ‘Swedishness’, cultural cohesion, are greater than for doctors. This is a significant contribution to studies on the public sector workforce. There are few studies on processes of racialisation among healthcare professionals in Sweden, despite the increasing political emphasis on diversity. Femininity allows for more finely-meshed explorations of ethnicity and racialisation than the category of woman; this is probably one reason why earlier studies on care, gender and work in Sweden (such as Lindgren 1992) have ignored these issues. In addition, the analysis of processes of racialisation in the hospital is an example of the analytical strength in Acker’s concept of the inequality regime. The study has exemplified how a focus on recruiting practices as well as understandings of responsibility and content of work combine to project some employees as problems, and some as good examples. My contribution here is the employment of the conceptual framework of the inequality regime in ethnographic research, thereby uncovering the complex ways in which racialised class practices are carried out and reproduced in the everyday. I have shown that while individual initiatives to promote diversity are important, informal workplace interactions as well as conditions of work are central in regulating the composition of the workforce. Hundreds of thousands of women are involved in paid care work in Sweden alone, performing labour that is linked to unpaid care work in other arenas. It is no surprise that the concept of care has been such an important one to feminists through the decades, since this type of work signifies the division of labour and the contradictory understanding of reproductive work as the most meaningful and the least

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meaningful responsibility at the same time. Care and caring has been said to define “what it feels like to be a woman in a male-dominated capitalist order” (Graham 1983: 30). However, one of the significant differences between this study and many other studies on care workers in the Scandinavian and Western European context is that while feminist researchers have been focused on the concept and practices of care (such as Szebehely 1995, Franssén 1997, se also Graham 1983 and Ungerson 1983), I have rather focused on labour processes, work practices and experiences of work in and beyond care. That has also meant that tensions and contradictions in experiences and attitudes towards care and caring practices have been explored critically; I have shown, for example, that nurses both identify and disidentify from care and service – and I have placed such distancing mechanisms in a wider context of institutional change and professional ambitions. By doing this, I have illustrated that in the project of establishing a successful middleclass self, formal knowledge is still emphasised and the mental and manual divide in labour still made relevant as distinctions of class and racialisation. But I have also shown that gender is central in regulating subjectivity and work identity. The fourth and final question was about the relationship between normative forms of femininity and strategies to cope with, enact and resist neoliberal transformations of healthcare and changing conditions of work. One aspect of the neoliberal influence over public sector management regimes is the increasing emphasis on service and patient-centred care. This study has illustrated that it is nurses who are made responsible for actually performing the service towards patients – they are the ones who deal with patients and perform emotional labour. It can be argued that it is nurses who are the face of the hospital organisation and the ones who are supposed to embody fantasies and demands from patients and kin, as well as from management. Nurses are in a position to use their professional status as a way of countering and drawing boundaries towards patients. But through NPM, “bureaucracy, responsibilities, accountability and working hours increase the professional autonomy and resources of professional groups decrease significantly” (Henttonen et al 2011: 2), as researchers have argued. Nurses in Ward 96 faced heightened levels of exploitation and were unable to find ways out of increasingly stressful and draining working

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conditions, except for the very few who could attain mobility within the organisation. Increased demands on emotional labour were coupled with the restriction of creative altruism, which also diminished work-pride and the joys of the job. The demands on nurses were contradictory. They were called on to perform normative femininity, specifically embodying ‘modern’ womanhood that emphasises youth and energy. They were supposed to live up to notions of individualism and strength. But the discrepancy between discourses promoted by the hospital and the county on ‘patient-centred’ high-quality care and the resources provided also called for nurses to assume women’s traditional responsibilities of caring beyond the contractual agreement. This way, nurses were double-punished for not resolving conflicts without it affecting patients or their own health.

epilogue Nursing beyond normative femininity?

Just a few months before I finished this book, four hundred nurses and nursing students gathered at the town square in Lund where I live. They were part of the 24,000-kronor protest, a movement that had started among nursing students at Umeå University and that rallied for nurses not accepting entry-level salaries below 24,000 SEK per month. Across the country, nurses protested several times during 2012 for their cause, hoping to force employers to raise salaries for new nurses. The nursing student who was part of the original organising committee was featured in newspaper articles where pictures showed her short hair, dyed in the style of leopard fur. During the autumn of 2012, the number of nursing protests grew and drew considerable attention. Despite the fact that what the students rallied around was a strategy essentially challenging the union and the regular Swedish model of wage negotiations,1 the new leader of the trade union, Sineva Ribeiro, supported the students and showed up at rallies in Stockholm. Local organising committees were helped by the trade union in staging the protests across Sweden. While the protests were on the whole successful in drawing attention to the pay gap between nurses and comparable male-dominated occupations, such as engineers (whose average entry-level salary was about 16 percent higher than what the nurses were asking for), the short-term results in salary-settings were insignificant. In fact, in some county councils, the refusal to meet the nurses’ demands was so adamant that hospitals instead opted for hiring recruitment companies to 1.  Essentially what they were doing was employing the ‘register-method’, recently employed by the syndicalist movement in organising so-called undocumented migrant workers.

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find cheaper nurses during the summer, when temps were needed to fill holiday vacancies. Some hospitals and county councils accused the nurses of dangerous behaviour for refusing employment, and argued they were putting patients at risk; some employers claimed that they refused to raise entry-level salaries because it would be unfair to nurses with seniority – despite the fact that the protesters’ demand was supported by their union. Arguments drawing on nurses’ moral responsibilities to the public, and subsequent calls on strikes to end, as nurses ought to think of patients rather than themselves, have followed on nurses’ protests before (Bessant 1992). Nonetheless, nurses who were active in the 24,000-kronor protest movement claimed many of its members had in fact found jobs that paid the demanded amount. Few of these jobs, however, were offered by hospitals, especially not university hospitals or hospitals in the major cities; rather, it was the municipalities that matched the nurses’ demands in geriatric and psychiatric care. I found the protests invigorating. Many of the signs, petitions, speeches and articles that were produced during the protests explicitly challenged the notion of nursing as a calling. The protesters argued that nurses’ work is essential, skilled, demanding and expanded to include new forms of responsibilities, including technological advances necessary to modern medicine, and that care work consequently should be valued as a central contribution to society. The protesters’ claim, which was built on a strong sense of collective power and solidarity whereby nurses relied on their own bargaining power in promising each other not to accept salaries below the agreed-upon amount of 24,000 SEK, represented a break from the individualist stance of the trade union that I discussed in chapter 8. I wondered whether it was the case that it was easier for nursing students, rather than already employed nurses, to mobilise a protest that aimed at rising salaries before the employment contract was settled. The nurses I had interviewed spoke of bitterness when it came to the union, but also felt it was hard to engage politically in protests. There were two main reasons for this, it seemed: even though many worked part-time, they felt exhausted at the end of a shift, “completely dried-up”, as one nurse put it. And they all talked of the difficulties of leaving patients hanging if they staged collective protests, especially strikes. The loyalty towards patients meant few

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Ulrika Blumfelds, part of the organising committee in the 24,000-kronor protest, interviewed by the Swedish news agency TT during a demonstration in 2012. Published with permission of Vårdförbundet. Photo by Lasse Bengtsson.

nurses could think of individual strategies of resistance that would not inflict on their medical responsibilities for the patients in their care. Furthermore, going on strike, as a means of labour power for public servants, is not really that effective since, essentially, the work stoppage tends to save the employer money rather than the other way around, and any inconvenience will hit a third party (patients, clients) rather than the employer. As has been pointed out by researchers studying nursing strikes in other countries (Bessant 1992: 155), industrial campaigns have been represented as a challenge to or even the demise of professional status for nurses, who both in Sweden and internationally have rejected “blue-collar trade behaviours”; an attitude found among the nurses interviewed in this book as well. The strike in 2008 was deemed a massive failure among the nurses I interviewed, and most of them thought the only thing they had achieved was to have created some ruckus, which mainly affected the patients. But the most important reason why I felt these protests were encouraging was the shift in the practicing of femininity through

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work identity among the demonstrating nurses. Actually staging a protest like the nursing students did during 2012 seemed to me to represent a re-conceptualisation of the link between ‘the Good Woman’ and ‘the Good Nurse’, to use Bessant’s (1992) words. It was in light of this historical and ideological link between normative femininity and professional identity that I found the protests to represent a transformation of the collective understanding of appropriate behaviour among nurses. However, I also noted that the protests were again referring only to the nurses’ wages – not to the current neoliberal hegemony which affected their working conditions and the situation for patients. Refusing to take up employment is different from staging collective protests directed at hindering ongoing work. Reading scattered reports from local media across Sweden, I noticed that quitting seemed to be an increasingly common protest strategy for nurses (and doctors). In places such as Malmö, Umeå, Stockholm, Västerås, Avesta and U ­ ppsala nurses were handing in their resignations in protest against growing workloads. This is a development that can also be seen in other countries from time to time. As Henttonen et al (2011: 5) have pointed out in their article on industrial action among nurses in Finland, the history of the nursing profession is marked by ‘cycles of discontent’ wherein growing workloads and low levels of pay lead to periodic crisis. In Finland in 2007, 12,800 nurses signed a resignation document as part of the trade union’s resignation campaign aimed at forcing employers to agree to a significant salary increase. At the last minute, the union and the employers agreed on a four-year deal with salary increase of 16–28 percent. Nothing like that has been tried among the Swedish nurses on a mass level in recent years, although in the case of one hospital, more than 25 nurses quit together in 2011 as a way of protesting against cutbacks. Such actions often provoke critical reactions from employers. At Karolinska, one of the major hospitals in Sweden, a nurse who quit because he was dissatisfied with his salary found management commenting on his resignation in a weekly letter sent out to his former colleagues: People who take up care work primarily to make money have chosen the wrong business and should look for positions in sectors where money is what matters. I hope that most of the people whose job it is to take care of oth-

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ers do it because it is meaningful, but of course wages and other conditions should be reasonable even within public sector care.

The letter, which later was published by Swedish papers (Dagens Nyheter 2011), indicates that employers still actively call on notions of nursing as a vocation in order to keep salaries down and punish nurses who use exit as a strategy of resistance. Considering the data presented in my study, which indicates that there exists very little space for nurses to complain on the floor about their anxieties and feelings of stress, it is quite possible that the authoritarian quality of a healthcare organisation’s inequality regime suppresses “voice” and makes “exit” the only functioning strategy (Hirschman 1970). Another indication of nurses choosing exit rather than voice is the increased migration of Swedish nurses to Norway (Dagens Medicin 2012). I find the development of increasing collective protests among nurses contradictory. On the one hand, younger nurses were sought after by management at City Hospital because they were thought of as better workers, who could embody the right kind of notions of individualism and ambition; they did not complain as much as the older nurses did, and they generally seemed to handle the pressure better than those who had worked for a long time. They were more open to ideas of measuring and rewarding individual performance. On the other hand, it is young nurses who are now staging protests against worsening conditions and who seem to be the driving force in this cycle of discontent. One way of looking at it is that it really is the notion of nursing as a calling that is being negotiated, and that the increased emphasis on the service character of care work means that new generations of nurses are more open about the performative character of emotional labour and recognises the performative character of work identities, rather than it being reproduced as naturalised skills and essentialised feminine demeanour. Combining such a renegotiation of the nursing profession with increasing emphasis on high-tech work could also aid in the process of raising salaries and inclinations to collective resistance, as such a process could contribute to fracturing the link between nursing and normative forms of femininity. That would at the same time, however, represent the continuation

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of devaluation of labour associated with mothering and caring, especially considering what this book has illustrated in terms of processes of de-linking between care and work pride among nurses. On that note, I would like to quote a nurse’s comment on salarysettings. During the same period as the 24,000-kronor protests were happening across the country, I found a blog about the conditions of ward nursing. The nurse, who wrote all her posts anonymously because she feared losing her job otherwise, echoed the words of the nurses I had interviewed as she talked about work growing increasingly intense, stressful, fractured, and physically and emotionally draining. But her internet-persona nurse had a dry and ironic tone, and her caustic tales from the hospital corridors were clearly appreciated by an amused readership, many healthcare employees themselves according to a survey on the blog. One of the posts about feeling exploited by politicians I found particularly interesting and quite fun to read, as it commented – through the myth of Lysistrata’s strategy during the Peloponnesian war – on difficulties in getting (male) politicians’ attention regarding the impossible conditions of nurses in today’s healthcare system: I would like to know a county politician. Or why not live with one? That would be great! So he could see me come home tired and ready to cry each and every day. All day he would listen to me complaining about how tough it’s been at work. How huge my responsibility is compared to my salary. I would, for instance, tell him about all the times I’ve saved both the doctor and the patient by not administering the prescribed dosage. After dinner, he would rub my tired feet or massage my aching shoulders while I tell him about how many beds I’ve been pushing around during the day. I would also tell him how many kilometres I’ve walked and explain to him about all the people calling on me just when I was about to sit down and document my work. Then he could make me some juice. You need to rehydrate and get rid of the headache after a day at the hospital. Then it would be time for a shower. There are a lot of germs around nurses: feces, urine, antibiotics, blood, vomit, and some resistant bacteria. He would fetch me a clean towel. Maybe put lotion on my back. He would massage my shoulders. Let his hands slide down towards the rear of my back, and over my behind. Touch my thighs, move towards my vagina … STOP! I would flinch. Turn around and stare at him. No sex! How can you think I would want to have sex after a day like this? The county politician would walk away, tail between his legs. Nothing today either. Then he would think about how damn sorry he was about never getting laid. And then maybe he would start to listen. And sort of get that it’s never

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going to move past the occasional holiday sex if my workplace keeps this up. And then, just maybe … So, what do you think, should I pick up a county politician? (Syster Frida, http://fridasyster.blogspot.se, 19 April 2012)

In another post, Sister Frida called for “an Arab Spring in the hospital”, and pleaded with nurses to “open your eyes and question cutbacks”. She argued that wards are places where nurses put each other down, telling each other not to complain, because women and nurses in particular are not supposed to be “loud and critical”: We’re supposed to put ourselves aside and think about the patients, and the doctors. Questioning and criticising the organisation can be dangerous; I know of several managers who had to quit because they … stood on the side of the staff, wondering how the hell it would all add up. … [At the ward], you’re not supposed to be critical and suggest change. No, you’re supposed to … laugh and smile and be good and happy. This is what we’re being taught. … The word bitter is a derogatory label used to shut us strong sisters up. And I am neither bitter nor quiet. (Syster Frida, http://fridasyster.blogspot.se, 28 October 2012)

Sister Frida, this ironic and painfully honest internet nurse character, reminded me of Nurse Jackie, the American TV series featuring Edie Falco as an emergency room nurse who “juggles patients, doctors, fellow nurses and her own indiscretions” (according to the press release). Nurse Jackie is not exactly a typical warm and loving TV nurse character: besides being high on the job, she cheats on her husband with the hospital pharmacist, talks back to doctors, and is unyielding towards the patients. Like Nurse Jackie, Sister Frida transcends the typical stereotype of a selfless, respectable nurse. Her text refers back to the responsibilities of women, whereby the major domain of power lies within the private sphere, and she mocks this responsibility, turns it upside down. It was in this sphere that nurses in my study experienced their loss of energy. While nurses in Sweden currently seem to be in a cycle of discontent, they are still battling the same old paradox of care – of being valued as a vocation, but undervalued in terms of remuneration, status and conditions of work. Sister Frida’s take on how to get attention on these issues breaks with traditional images of nurses as disciplined,

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loyal, caring and moral. It reflects on and challenges, just like nurse Azime did in the quote that introduced this study, the idea of nurses being ‘good girls’ and their desire to be ‘fancy’, respectable to the core. I believe that moving nursing and care work beyond this paradox requires moving beyond gender and ending male domination. The hope of resistance lies in a changing femininity, a femininity that is more transcending, less involved in respectability – and more eager to confront inequality across all spheres of life and labour.

Sammanfattning

Den här avhandlingen tar sin utgångspunkt i relationen mellan kön, arbete och identitet. Den utforskar etnografiskt konstruktionen av specifika former av femininitet inom ramen för vårdarbete utfört av framförallt sjuksköterskor på en kirurgavdelning. Avhandlingen bygger på intervjuer med nitton sjuksköterskor, fyra undersköterskor, fem läkare och tre sjukgymnaster, samt observationer av sjuksköterskors och undersköterskor arbete på ett svenskt akutsjukhus. Samtliga informanter arbetade på sjukhus inom ett landsting, och på ett av dessa sjukhus genomfördes observationer. En avdelning fungerar som en fallstudie: där genomfördes ett längre fältarbete och majoriteten av informanterna arbetade på denna avdelning. Metodologiskt knyter studien an till den feministiska tradition som betecknas institutionell etnografi (Smith 2005). Teoretiskt är avhandlingen lokaliserad inom ramen för materialistiska förståelser av könade och rasifierade klasspraktiker (Acker 2006a, b) men går också i dialog med såväl marxistiskt som poststrukturalistiskt influerade analyser av maskuliniteter och femininiteter, där genusforskaren R. W. Connell (1987, 1995) utgör en viktig inspiration. Syftet med avhandlingen är att analysera förkroppsligandet av normativa former av femininitet inom ramen för sjuksköterskeyrket och den förändrade sjukvårdsorganisationen, samt att utforska betydelsen av femininitet i återskapandet (och utmanandet) av maktrelationer inom arbetsplatsen. Frågeställningarna är: – På vilket sätt griper arbetsorganisationen inom ett offentligt sjukhus in i skapandet och återskapandet av varierande former av femininitet? – Vilka gränser skapas för att definiera normativa former av femininitet för sjuksköterskor?

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– Vilken roll spelar kategorier som kön, klass och etnicitet i formandet och reglerandet av kvinnors position inom sjukvårdsorganisationens hierarkier? – Hur ser relationen ut mellan normativa former av femininitet och strategier för att hantera, sätta i spel och motstå förändrade arbetsvillkor inom ramen för en nyliberal transformation av sjukvården? Sjuksköterskeyrket är en profession med en historia av komplexa förhandlingar av könad underordning och klassrelationer. Yrket har konstruerats ideologiskt genom föreställningar om klass och femininitet, heterosexualitet, och etniska och kulturella stereotyper (Mohanty 2003: 142). Betalt vårdarbete har varit en central arena för institutionaliserade former av kvinnlig underordning, men har också skapat utrymme för kvinnor att bli ekonomiskt självständiga och tillskansa sig yrkeskunnande. Samtidigt har värdet av vård och omsorg konstruerats motsägelsefullt: å ena sidan som mer än ett yrke – som ett kall – å andra sidan som mindre än ett yrke, som något som kommer naturligt för kvinnor och därför inte behöver värderas genom löner som motsvarar traditionellt manliga yrkesområden. Den här avhandlingen utforskar relationen mellan betalt arbete utfört på och i förhållande till kroppar och de sätt på vilka könade praktiker upprätthålls, skapas, och omformas inom ramen för en arbetsorganisation. Begreppet ”femininitet” används för att beskriva de kollektiva mönster och konfigurationer av praktiker som struktureras av genus­ rela­tio­ner (Connell 1995). Det som förenar femininiteter inom en social kontext, enligt Connell (1987: 179), är ”den dubbla kontext inom vilken de formas: å ena sidan i relation till bilden av och erfarenheter av den kvinnliga kroppen, å andra sidan i relation till sociala definitioner av kvinnors position och den kulturella binariteten mellan maskulinitet och femininitet”. I fokus för avhandlingen står de sätt på vilka varierande former av femininiteter skapas inom ramen för vårdarbete i den offentliga sektorn, i synnerhet i sjuksköterskors arbete under nyliberala styranderelationer. Begreppet ”styrande­rela­tio­ner” är hämtat från den institutionella etnografin och syftar på trans-lokala och sociala dominansförhållanden.

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Connell (1987: 181) har definierat sjuksköterskeyrket som ”en aspekt av könsarbetsdelningen, ett yrke som blandar en specifik version av femininitet med yrkets tekniska krav”. Jag har valt att kalla denna specifika form av femininitet för normativ, för att på så sätt uppmärksamma hur vissa former av femininitet är ideologiskt kopplade till moderskap och välfärdsstatens moraliska uppgifter. I avhandlingen utforskar jag hur kvinnor relaterar till och förkroppsligar femininitet på arbetet, och på vilka sätt arbetet formar deras subjektivitet. Den frågan har tidigare utforskats i sammanhang där män utgör den dominerande gruppen. Även om det finns en rik tradition av etnografiska studier ägnade åt att studera den här frågan i relation till kvinnliga arbetare (till exempel Westwoods studie av kvinnliga fabriksarbetare i den brittiska textilindustrin), så har de som intresserat sig för sjuksköterskor framförallt fokuserat kvinnors görande av vård snarare än på vilka sätt arbetsvillkor sätter ramarna för och interpellerar olika former av femininitet. Avhandlingen tar fasta på just de förändringar inom arbetsorganisationen som är kopplade till den nyliberala omvandlingen av välfärdsstaten, och kan på så vis lokaliseras inom det växande fältet av etnografier av nyliberalism. Inom detta fält har forskare etnografiskt undersökt de sätt genom vilka nyliberala reformer omformar sociala och politiska institutioner, men också deras påverkan på utrymmet för identitetskonstruktion, social och politisk subjektivitet, motstånd, samtycke och protest (Greenhouse 2009). Etnografiska metoder, och – hävdar jag – institutionell etnografi i synnerhet, utgör kraftfulla verktyg i utforskandet och lokaliserandet av sådana praktiker inom spänningsfält som arbete, kunskap och makt.

Bakgrund: den nyliberala omvandlingen av välfärdsstaten Under 1980- och 1990-talet sammanföll den nyliberala omvandlingen av välfärdsstaten med ”den internationella managementrevolution” som ställde krav på omfattande förändringar inom den offentliga sektorn i syfte att reducera kostnader, inför marknadsmekanismer och förbättra servicen (Montin 2012: 2). Dessa förändringar inom de offentliga verksamheterna, som skedde i de flesta västländer under

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1990-talet, kallas vanligen New Public Management (NPM). NPM innebär en genomgripande förändring av normer och värderingar vad gäller den offentliga sektorns utformning och dess relation till den privata sektorn (Blomgren 1999). Den vägledande principen är att offentliga organisationer ska efterlikna privata aktörer eftersom dessa sägs ha en inneboende förmåga till kostnadseffektivitet baserad på deras vinstmaximerande syfte och behov (Gustafsson 2000). Eftersom något vinstsyfte inte föreligger i offentliga verksamheter blir de ineffektiva, enligt NPM-förespråkare. Således har den offentliga sektorn infört interna marknadsmekanismer, utlokaliserat vissa verksamheter och lagt verksamheter på entreprenad. Samtidigt innebär NPM en ökad betoning på ekonomistyrning. Budgetbalanskravet har inneburit att den finansiella disciplinen skärpts och flyttats ner på exempelvis kliniknivå (Hasselbladh et al 2008: 59). NPM rymmer samma motsägelse som nyliberal politik, det vill säga politikens förändrade roll i att skapa och upprätthålla marknadsmekanismer. Forskare har pekat ut att NPM föreskriver ”både mer autonomi och mer centraliserad kontroll”. För sjuksköterskors del har NPM inneburit en ökad differentiering av professionskollektivet, där vissa sjuksköterskor ges i uppgift att från chefsposition leda och ta ansvar för exempelvis klinikers ekonomi, medan sjuksköterskor på golvet erfar en allt mer uppsplittrad arbetsprocess och intensiv arbetsbörda. En central del av NPM är betoningen på professionalisering. I Sverige har detta märkts inte minst genom utfasningen av undersköterskor från sjukhusen och den ökade rekryteringen av sjuksköterskor och läkare. Detta har också bidragit till den ökade differentieringen inom sjuksköterskekollektivet, där sjuksköterskor på avdelningarna numera utför många av de arbetsuppgifter som tidigare ålades undersköterskor och biträden.

Analyser av vårdarbete och femininitet Genom att använda Goffmans (1959) begrepp ”scen” har jag kunnat beskriva hur ojämlikhetsregimen inom sjukhuset tar sig konkreta uttryck bland annat genom tillträde till olika typer av rum. Medan läkare rör sig genom olika typer av rum är sjuksköterskor som arbetar på en vårdavdelning i huvudsak låsta till just avdelningen. Till skillnad

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från läkarna har sjuksköterskorna begränsad tillgång till rum som kan beskrivas som bakom scenen, deras arbete utförs synligt för patienter och anhöriga. Sjukhusbyggnader är ofta underdimensionerade för dagens sjukvård och utrymmen för administration et cetera är ofta begränsade, vilket kan leda till konflikter mellan anställda. Vem som har tillgång till egna rum är således fortfarande en fråga om makt. Avhandlingen visar också att trots en social och rumslig distans mellan läkare och sjuksköterskor präglas interaktionen mellan dessa grupper av heteronormer. Sjuksköterskor undviker öppen konflikt trots deras ibland stora missnöje med läkarnas attityder. Ändå återskapar sköterskorna den könade underordningen genom att exempelvis bekräfta språkbruk från läkarnas sida som innehåller uttryck som ”sköna flickor”. Det finns också en stark betoning på familjeliv bland sjuksköterskorna på avdelningen. Jag argumenterar för att detta är ett uttryck för en ideal arbetsidentitet. Att sjuksköterskor också vägrar en estetisering av kroppen och själva betonar en naturlighet i sitt utseende förstärker föreställningar om sjuksköterskeyrket och sjuksköterskekollektivet som naturligt kvinnliga kvinnor vars viktigaste identifikation är med hemmet snarare än med arbetet. Jag kopplar också detta till ett behov av ritualiserad normalitet som drivs fram av en hektisk och känslo­mässigt krävande arbetsmiljö och ett känslomässigt laddat arbetsinnehåll. Den ritualiserade normaliteten skapar stark gemenskap men är också exkluderande för dem som inte kan eller vill passa in. Den normativa femininiteten bland sköterskorna återskapas också genom skapandet av distinktioner i arbetet. Sådana processer är klassmärkta och rasifierade. Distinktionen blir levande i förhållande till kollegor och överordnade, till patienter och till utomstående aktörer som Försäkringskassan. Att markera avstånd till ”service” handlar i detta sammanhang om att skapa distans till underordnade grupper, vars arbetsuppgifter sjuksköterskorna i ökande utsträckning delar (hämta och servera mat, städa, tvätta kroppar). Överidentifiering med vård och omsorg konstrueras vidare som länkat till underordnade (arbetarklass-, rasifierade) kvinnor som förkroppsligar en ”omodern” femininitet. Samtidigt kan service och omhändertagande fungera som en lyckad strategi för vissa kvinnor, eftersom de får uppskattning från patienter och överordnade. Här knyter jag an till studier som identi­ fierat skiktningar inom reproduktivt arbete, där mer publikt och

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moraliskt laddat arbete (så som vård på sjukhus) utförts av vita, privilegierade kvinnor, medan osynliggjort, enformigt arbete utan krav på utbildning utförts av underordnade kvinnor från (den rasifierade) arbetarklassen (Roberts 1997). Den offentliga sektorns etniska regim är i förändring. Medan sjuksköterskor fortfarande domineras av etniskt svenska kvinnor uppvisar läkaryrket en betydande mångfald. Detta faktum motsäger påståendet om att ju högre status, desto större betoning på (etnisk eller kulturell) likhet (Essed & Goldberg 2005). Avhandlingen utforskar detta specifikt i relation till sjuksköterskors medierande (och kommunikativa) position inom sjukhushierarkin. Medan det medicinska språket neutraliserar exempelvis brytningar upplever sjuksköterskor höga krav på att kunna kommunicera på perfekt svenska med patienter. Sjuksköterskor utgör sjukhusets ansikte utåt och förväntas också ansvara för kommunikationen mellan medicinen och subjektet, det vill säga mellan läkarna och patienterna. NPM, som i sig betonar individens betydelse, har åtföljts av en (diskurs om) politisk vilja till ökad mångfald inom den offentliga sektorn (Tahvilzadeh 2011). Avhandlingen visar dock att nedskärningar inom den offentliga sektorn leder till ökad betoning på likhet, snarare än på mångfald. Inom arbetskollektiv med hög arbetsbelastning minskar utrymmet och toleransen för olikhet. I situationer där vardagen är extremt betungande, osäker, präglad av en fragmenterad och intensiv arbetsprocess, blir homogenitet i arbetskollektivet viktigt för den som rekryterar och leder arbetet. Å andra sidan kan språkkunskap användas som en resurs när tolkservice utgör en administrativ utmaning. Samtidigt erkänns denna resurs inte som värdefull i prestationsbedömningar relaterade till löneutveckling. Det innebär också en ökad arbetsbelastning för individuella sköterskor vars ansvarsområden plötsligt utvidgas. Avhandlingen visar dock också att sjukhuset som plats skyddar rasifierade sjuksköterskor från den våldsamma rasism som förekommer framförallt inom hemtjänsten.

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Normativ femininitet och sjuksköterskors arbete Differentieringen av sjuksköterskeyrket, som innebär att nya karriärvägar öppnas för och mer administrativ makt tillhandahålls sjuksköterskor, inklusive skapandet av ett akademiskt fält med egna karriärvägar, sker i relation till regleringen av femininitet. Den här studien tyder på att de sjuksköterskor som kan göra karriär har priviligierade klassbakgrunder. Samtidigt som sådana karriärpositioner öppnas upp tvingas också ett stort antal sjuksköterskor hantera konsekvenserna av arbetsintensifiering kopplad till nedskärningar och kontinuerlig kostnadsreduktion inom den offentliga sektorn. Avhandlingen har visat på både förändring och kontinuitet i det här avseendet. Trots nya maktpositioner är det fortfarande sjuksköterskor som ansvarar för upprätthållandet av fysiska, rumsliga, maktrelaterade och emotionella gränser mellan olika aktörer, främst mellan patienter och anställda. Det är sjuksköterskor som förväntas hantera det emotionella arbetet i att bemöta och vårda patienter, men det är också sjuksköterskor som förväntas bemöta och sätta gränser för patienters krav och missnöje. Det är sjuksköterskorna som i främsta hand möter patienternas nya krav på service, och deras nya kunskapsanspråk; patienter idag kräver inte i lika stor utsträckning omhändertagande, utan snarare besked, kunskap och ansvarstagande. Detta ansvar representerar en ny dimension i sjuksköterskors emotionella arbete. Detta arbete har också expanderat eftersom sjuksköterskor tillbringar allt mer tid hos patienter, särskilt som antalet undersköterskor minskat kraftigt. Utvidgat ansvar på detta område hör också samman med ökat ansvar för det fysiskt intima arbete som också är kopplat till ”smuts” – sådant som hanteras när patienter tvättas, exempelvis. Forskare (till exempel Bessant 1992: 159) har hävdat att den historiska kopplingen mellan medelklasskvinnor och sjuksköterskor har varit central i att reglera sjuksköterskors beteende och professionella identitet. Att bli och vara en ”god sjuksköterska” har varit sammankopplat med att vara en ”god kvinna”. Att lära sig att bli en god sjuksköterska har därför handlat om att ”understryka de rätta vanorna och attityderna, ansvarskänsla, noggrannhet och följsamhet vad gäller sjukhusets och de överordnades regler och riktlinjer” (ibid.). Detta har också utnyttjats av politiker och chefer för att legitimera dåliga

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villkor och låg lön. Min studie stödjer sådana påståenden, men visar också att normativ femininitet återskapas inom organisationen i relation till NPM och nedskärningarna inom den offentliga vården. Jag hävdar här att sjuksköterskor slutit en pakt med nyliberalismen och NPM, där delar av dessa regimer gett delar av kåren fördelar – samtidigt som dessa processer varit till nackdel för de flesta sjuksköterskor på golvet. NPM bjuder delar av kåren att excellera i ansvarstagande och noggrannhet, vilket också innebär en slutning neråt i hierarkin (mot undersköterskor) och en öppning uppåt (mot läkare och den övriga administrativa makten). Teoretiskt bidrar avhandlingen till utvecklingen av begreppet ”femininitet”, och visar att detta begrepp öppnar upp för intersektionella analyser av kvinnors erfarenheter och positioner. Begreppet ”normativitet” ringar in den speciella form av femininitet som är kopplad till moderskap och välfärdsstatens moraliska uppdrag. Här har begreppet ”normativ femininitet” öppnat upp för de motsägelsefulla förväntningar som ställs på sjuksköterskor i ett nyliberalt tidevarv. Begreppet har också bidragit till diskussionen om olika typer av femininitet, hur de kan – och vilka som kan – blottläggas. Medan andra forskare (Schippers 2007, Charlebois 2011) argumenterar för användandet av begreppet ”hegemonisk femininitet” hävdar jag att normativ femininitet bättre fångar den ambivalenta och motsägelsefulla position som privilegierade kvinnor intar i den patriarkala strukturen. Vidare uppmärksammar begreppet den moraliska dimensionen i det arbete som kvinnor utför inom ramen för den offentliga sektorn, inklusive deras arbete med att upprätthålla och återskapa gränser, normer och värderingar.

appendix 1 Informants

Not all people mentioned by name in the book are listed here. I have only included the people I interviewed or shadowed. Informal, conversational interviews are not listed.

Nurses Name Agneta Azime Danuta

Age Position

Birthplace Family situation 46 Ward nurse, Lake hospital Sweden Married, union rep. two children 31 Ward nurse University Turkey Live-in, hospital two children 54 Ward nurse City hospital, Poland Widow, Ward 96 one child

Hanna

38

Workplace

Helena

52

Nurse manager Nurse manager

City hospital, Sweden Ward 88 City hospital, Sweden Ward 96

Janet

59 Ward nurse

City hospital, Sweden Ward 96

Josephine

42 Ward nurse

Kadia

34 Ward nurse

City hospital, Sweden Ward 96 City hospital, Libya Ward 96

Interaction Interview, Trade union office Interview, café

Interview at Ward 96, shadowing x2 Married Interview at Ward 88 Married, Several intertwo chil- views at Ward dren 96, shadowing x 2 Married, Interview two chil- at Ward 96, dren shadowing x2 Single Interview at Ward 96 x 2 Single, Interview at three chil- Ward 96 dren

337

Name

Age Position

Kerstin

59 Ward nurse

Majken

49 Ward nurse

Malin

34 Ward nurse, University union rep. hospital

Nela

42 Ward nurse

Ros-Marie

63 Primary care Primary care Sweden nurse, union center, forrep. merly ward nurse at City hospital 44 Clinic nurse City hospital, Sweden surgical division (Ward 96)

Sara

Selma

37 Ward nurse

Stefan

50 Ward nurse

Ulla

Birthplace Family situation City hospital, Sweden Married, Ward 96 two children City hospital, Norway Married, Ward 96 two children Sweden

City hospital, Bosnia Ward 70

City hospital, Bosnia Ward 96

City hospital, Sweden Ward 96 46 Ward nurse, Middle hos- Sweden union rep. pital

Viktor

28 Ward nurse

Ylva

53

338

Workplace

Ward nurse

University Sweden hospital City hospital, Sweden Ward 66

Married, one child Single

Married, two children

Interaction Interview at Ward 96, shadowing x 1 Interview at Ward 96, shadowing x2 Interview at Trade union office Interview at Ward 70, shadowing x2 Interview at Trade union office

Divorced, Interview two chil- at surgidren cal clinic, shadowing x 2 while at Ward 96 Single Interview at Ward 96, shadowing x 2, multiple conversational interviews Single Interview at Ward 96 Married, Interview at three chil- Trade union dren office Single Interview, e-mail Married, Interview at two chil- Ward 66 dren

Doctors Name

Age Position

Workplace

Ali

36

Anja

48

University hospital University hospital

Eva

61

Herta

33

Maria

33

Resident, orthopedics Doctor, internal medicine Doctor, internal medicine Resident, psychiatry Resident, obstetrics

Birthplace Family situation Iran Single Sweden

Lake hospital Sweden City hospital Sweden Lake hospital Sweden

Interaction

Interview, e-mail Lives with Interview at partner informant’s home Married, Interview at two chil- informant’s dren home Single Interview at informant’s home Married, Interview at one child restaurant

Assistant nurses Name

Age

Position

Workplace

Birthplace Family situation Britta Born Ward assis- University Sweden Married, in the tant, union hospital three chil1940s rep. dren Henny 62 Ward assis- City hospital, Sweden Married tant Day surgery Lisa 37 Ward assis- City hospital, Sweden Married, tant Ward 90 two children Marie 38 Ward assis- City hospital, Sweden Married, tant OB/GYN two children Monica 61 Ward assis- University Sweden Married, tant hospital four children Sanna 24 Ward assis- City hospital, Sweden Single tant Ward 96 Titti 58 Ward assis- City hospital, Sweden Married, tant Ward 96 one child Veronica 37 Ward assis- University Sweden Married, tant hospital two children

Interaction Interview at Trade union office Shadowing x2 Shadowing x 2, interview at workplace Shadowing x2 Interview at workplace Shadowing x2 Shadowing x1 Interview at informant’s home

339

Physiotherapists Name

Age Position

Workplace

Mia

33

Pia

46 Physiothera- City hospital Sweden pist

Viktoria

32

Physiothera- Middle hospist pital

Physiothera- University pist hospital

Birthplace Family situation Sweden Married, one child

Sweden

Interaction

Interview at informant’s home Single, Shadowing x three chil- 2, interview dren at City hospital Married Interview at informant’s home

Wards observed Ward

Type of ward

Ward 96

Surgical ward

Hours of observation

Ward 90

Emergency intake ward

10

OB/GYN

Birth clinic

10

Ward 70

Psychiatric ward

Day surgery

Surgical clinic

8

Ward 100

Pediatric, multiple wards

11

Ward 69

Surgical ward

> 100

9

> 20

appendix 2 Interview guide

Background Why did you become a nurse/assistant nurse/doctor? Why did you not become an assistant nurse/doctor/nurse? Parents’ occupation? Did anybody in your family do care work?

Family Family situation? Partner’s occupation? Living conditions? Work: do you work fulltime? How about your partner? Motivate decision. Do you have enough time for your family life? Do you have enough time for your work life? Is there a struggle for time in this regard? How do you solve it?

Workplace How long have you worked at your current job? Why/how did you end up at this workplace? What is good about your work? What is bad? How big is your workplace? What is the relation to other occupations? Is the job stressful? What is stressful about work? What do you usually chat about during breaks? What is the pros and cons about your current job? About being a nurse in general?

Content of work What does your schedule look like? What is a normal day at work, could you describe it?

341

What tasks do you like? What don’t you like? Describe interactions with patients: what do you work with in relation to patients? How do you deal with their emotions? How much do you deal with kin?

Career path/management Have you had a career path? How did that happen? Do you think in terms of career? How do you interact with management? What is management like? Does it matter what management is like? Are you a good nurse? What do you do to become a good nurse? Can anybody be a good nurse? What does a good nurse look like? Can you tell from appearance? Does ‘look’ matter? Body appearance?

Coping et cetera Describe working conditions. What do you do to find joy in work? What do you do to cope? What do you do to recuperate? Will you work till retirement (in this job)? Have you ever had a breakdown of some sorts at work?

Plans for the future What are your plans for the future? What do you think you’ll do to get there?

Social hierarchies What are the hierarchies at your work? How are they related to gender? Do you notice any changes in this area (female doctors, et cetera)? Do you think of yourself as a woman? What are your thoughts on nursing being dominated by women? Would it be better if more nurses were men? What does femininity bring to nursing? Masculinity? Have you ever come across sexual harassment at work? elsewhere? Have you ever come across racism? What do you think about diversity in the workplace?

appendix 3 Documents studied

Documents 1–4: City hospital budget reports, 2008 (no. 1)–2011 (no. 4) Document 5: Report on developments in emergency healthcare from County Department of Health Policy, 2010 Document 6: Report from County Department of Health Policy: Restructuring process, 2004 Document 7: Report on Financial Control of three County hospitals including City hospital Document 8: Report from the Swedish Work Environment Authority on the situation of City Hospital, 2008

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A note on terminology

I use the term ‘doctors’ and ‘physicians’ interchangeably. ‘Resident physician’ refers to doctors in specialist training (specialty registrar/ ST doctor, ‘specialisttjänstgöring’, ‘ST-läkare’). ‘Chief ’ refers to medical directors (senior registrar, ‘överläkare’, ‘specialister med medicinskt ledningsansvar’). ‘Nurses’ refer to registered nurses, who have undergone three years of university training. ‘Nurse manager’ refers to first line management, which has many labels in Swedish hospitals, including ‘avdelningschef ’, ‘sektionsledare/ sektionschef ’. ‘Assistant nurses’ refer to employees who have a diploma in care work, ‘undersköterskor’. ‘Auxiliaries’ refer to other care workers who have no diploma in care work (‘vårdbiträden’). ‘Orderlies’ refer to care workers in psychiatry, who may or may not have a diploma (‘skötare’). ‘Physiotherapists’ refer to licensed physiotherapists, who have undergone three years of university training (‘sjukgymnaster’). ‘Clinic’: ‘klinik/mottagning’. ‘Division’: ‘sektion’, ‘division’, ‘område’. ‘Ward’: ‘avdelning’.

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In Femininity at Work Rebecca Selberg gives new analytical perspectives and fresh insights into this area. Selberg situates the new conditions for nurses’ work firmly in the neoliberal transformation of the S ­ wedish welfare state. Nursing has undergone dramatic changes in terms of work intensification and new forms of subordination and class boundaries. At the same time, the nursing profession has embraced nurses’ new role as adjunct managers in running the clinics and taking on new responsibilities offered by New Public M ­ anagement. The key contribution of Selberg’s work is her use of the concept of femininity. Through ethnographic explorations of material and ideological conditions of care work, she shows that gendered subjectivities can best be grasped by using the ‘plurality of femininities’ as a conceptual tool. Rebecca Selberg offers an empirically rich investigation of change and continuity in the relationship between femininity and care work among Swedish nurses. In addition to insights into changing conditions of care work within the public sector, the book makes a significant theoretical contribution through its analysis of how labour processes shape and are in turn shaped by femininities. Rebecca Selberg is a sociologist at Linnaeus University. Femininity at Work. Gender, Labour, and Changing Relations of Power in a Swedish Hospital is her doctoral dissertation.

Rebecca Selberg • Femininity at Work

This is a book about gender, labour, and changing relations of power in a Swedish hospital, and presents an ethnographic study of nurses and their work. Paid care work has been a domain of institutional compliance to male dominance, as well as a critical space for women to become economically independent and skilled.

Femininity at Work

Gender, Labour and Changing Relations of Power in a Swedish Hospital ●

Rebecca Selberg