Emotional preparedness is not a new phenomenon for paramedic and emergency service healthcare personnel across the world (Buick et al, 2020; Kent et al, 2020). However, the authors believe that the emergence and rapid spread of COVID-19 globally in the current pandemic has had an impact on human emotion, distress and loss of the greatest resonance since the Second World War. As a consequence, experiences in frontline healthcare, of which paramedics are an integral and invaluable part, have irrevocably changed in terms of everyday clinical and professional practice.

While the pandemic has affected all health and social care professional groups, the context of specifically providing acute emergency care for COVID-19 patients is nowhere more evident than in paramedic practice (Bergen-Cico et al, 2020).

A high proportion of patients with COVID-19 present as severely oxygen-deprived and in need of urgent hospitalisation (Grasselli et al, 2020), which sadly has become a new norm for paramedic and frontline healthcare personnel. In addition, the disease is highly contagious and potentially deadly (as evidenced by the mortality figures of medical staff, allied health professionals and carers); there are immeasurable pressures on paramedic staff in providing care and on families who are often having what may be the final opportunity to say goodbye to loved ones as they are transported away for oxygen therapy and sometimes ventilation.

The temporal impact of COVID-19 has been dramatic; over the initial 8-week period of lockdown, the UK has witnessed more than 35 000 deaths directly attributable to the condition, many of which have occurred in community-based settings (Roser et al, 2020). The impact on those who have lost loved ones and frontline personnel caring for patients with COVID-19 patients is something so tangible and raw on a human level to those affected that it has the potential to create a ripple effect for generations to come (Chowell et al, 2008).

In the middle of the distress and impact of this condition are paramedics, whose psychological wellbeing is imperative to their role and, perhaps most importantly, their capacity to cope when dealing with patients and their families and carers in difficult circumstances, when death may be imminent or unexpected, and loved ones cannot be present because stringent social distancing measures are required and enforced. The emotional cost of such scenarios has long been documented in the literature from parallel professional fields such as nursing (Theodosius, 2008; Schmidt and Diestel, 2014).

The aim of this article is to raise awareness of the concept of emotional labour that underpins the role of paramedics at the front line of patient care.

The concept of emotional labour is often overlooked in relation to the personal cost of having to cope, particularly during this intense pandemic, which is a new, rapidly changing scenario, fraught with uncertainty and unexpected outcomes.

Emotional regularity for firstline healthcare responders

As a result of critical world events, understanding emotions in the workplace has become more important and, since these events, our approach to emotional regulation and critical reflection has changed (Smith and Burkle, 2019; Peate, 2020).

Two key events in recent history that provide a useful comparison are the Ebola pandemic across the Democratic Republic of Congo and, to a lesser extent and contextually different, the accounts of how 9/11 responders' lives were irrevocably changed by the experiences they had at the time (Smith and Burkle, 2019; Peate, 2020). Although these were separated by culture, context and geography, as well as having different causes necessitating emergency response, in both incidents there was an emphasis on a clear separation of emotions felt on a personal level and those shown on a professional level; there was an engendered sense of separation from the true self in the workplace rather than an acknowledgement of how that, essentially, underpinned everything (Schultz et al, 2015; Matthew, 2020).

Theorists have explored this phenomenon in detail. Hochschild (1979; 1983) emphasised the concept of regularity in practice and operationally defined zones of emotional response and engagement—termed emotional labour and emotional work—where the two are equated to deep and superficial processes of acting. Acting in itself implies a sense of disingenuity in 21st century healthcare, where authenticity is a keystone, central to the foundation and building of genuine compassionate care.

Framing emotional response

An emotive response can appear insincere when it is acted, faked or actively modified to accommodate an organisational or societal norm (Grandey, 2003). Within the context of paramedic practice, it is wholly necessary for personnel to ensure certain human emotions stay concealed; for example, revulsion at a horrific injury. In the conceptualisation of the term, emotional labour, this constitutes the effort that paramedics have to apply to their expressed behaviour, rather than managing the feelings that underpin them with something that, in terms of organisational psychology, is constructed with no degree of authentic feeling.

One of the key areas of consideration in affective response for paramedic practice over recent years has been the concept of emotional intelligence. The delineation between this and the concept of emotional labour during the COVID-19 pandemic has been placed in the limelight. Essentially, they belong to the same psychological parameters but, while emotional intelligence is about processing complex information about an emotive response, emotional labour refers to the fact that, in paid employment, personnel are expected by virtue of their professional contracts to behave in a particular manner (McCann and Granter, 2019).

As such, emotional labour is a consequence of the capacity for emotional intelligence, necessitating the application to practice of specific skills associated with mental resilience. These skills are more commonly identified as the capacity to work amid complex ambiguity, to resolve conflict and to work collaboratively in team-based settings (Guy and Lee, 2015). All of these characterise the professional role of the paramedic at the front line of patient care.

Emotional labour in practice

In parallel disciplines of healthcare provision, for example emergency nursing practice and care, possessing specific expertise and authority in the choice and manner in which to interact and connect emotionally with patients and their families and carers helps practitioners to feel valued for the work they do (Hayward and Tuckey, 2011). It also boosts motivation to engage and take control of their contributions to working practice.

This article does not seek to engage with the deep philosophical debates around performativity that French postmodern philosopher Jean-François Lyotard perfected, but what is worthy of note is how it is linked directly to the concepts of what are termed ‘deep acting’ and ‘surface acting’ at the front line of care. Both contribute directly to strategic mechanisms of performing and articulating emotional labour (Eaton, 2019).

Emotional labour is most straightforwardly operationally defined and, for the purposes of this article, is used to ‘induce or suppress feeling in order to sustain the outward countenance that produces the proper state of mind in others’ (Hochschild, 1983).

Within the context of emotional labour, it is important to distinguish between the concepts of deep and surface acting. Both have distinctly different purposes in practice, which can largely depend on the patient's level of consciousness and, as a direct consequence of this, how aware they are in the context of any caring interaction.

Within the context of paramedic practice specifically, acting is how emotional labour is performed with patients. In surface-acting contexts, emotions are simulated and are not what is being experienced. An example of this is where a patient needs to be reassured during a terrifying situation such as being taken away in an ambulance with the prospect of being placed on a ventilator and not knowing whether they will see their family again. This could also include reassuring someone from a black and minority ethnic background while being fully aware that the latest research details starkly that there may be little to be reassured about if the patient receives a diagnosis of COVID-19 (Chakravorty, 2020).

At the opposite end of the continuum is deep acting, where the paramedic may consciously alter their inner experience and induce genuine emotions (Msiska et al, 2014). This is where a consideration of altruistic care by paramedics is best considered through the lens of Bolton (2000), who stated that the concept of emotional labour might be oversimplified because of personal choice rather than any degree of organisational expectation. It is also indisputable that, since emotion is socially constructed and consequently embedded within personhood, it is possible to learn mechanisms of engagement with emotion rather than being constrained by the emotions that have somehow framed our existence to date (Goffman, 1959).

Within the context of everyday practice at the front line of patient care is an acknowledgement of emotional labour and what it means in the sense of self-giving by paramedics at every shift, regardless of their personal circumstances or individual mindset. Alongside and influencing this perspective are the cultural and situated aspects of creating meaning from experiences that characterise all work and frame all interactions in the healthcare workplace.

There are clear gaps in the difference between theoretical thinking about being able to separate rational thought processes and approaches to emotional response in practice. This is particularly relevant when paramedics have to make functional decisions in emergencies and often rely on tacit knowledge amid the expression and intuitive understanding in relation to the needs of patients and their families and carers (Crinson, 2018).

Multidisciplinary teamwork

Mutual reciprocity is often overlooked within the context of emotional interaction at the front line of healthcare, particularly in relation to the interactive dialogue that takes place during interdisciplinary, multidisciplinary and multi-agency working (Takhom et al, 2019).

A key example of this is at the point of paramedic handover to secondary care, when paramedics leave the patients they have transported from outside hospital with their colleagues from other healthcare professions, such as consultants and nurses who provide care and expertise to move the patient along the next stage of their journey (Fitzpatrick et al, 2018). The authors define mutual reciprocity in this instance as the symbiotic relationship between partner agencies working together at the forefront of patient-centred care. This is particularly evident in the care of patients with COVID-19 for whom decision-making and ownership of it can be life-changing and, in some instances, influence the likelihood of surviving the condition. In particular, this is true in the context of critical incidents where there is a power imbalance created by the vulnerability of a patient and/or perhaps the extent of injury or illness they are experiencing. It is the power imbalance that is the focus of meaning- or sense-making for those working with COVID-19.

Physical care parameters

Social distancing in the context of medical and healthcare provision is the antithesis of what we associate with care (Ransing et al, 2020). Care is characterised by touch, warmth and human contact at the heart of interaction. Masks are a necessary part of personal protective equipment (PPE) but also further distance the patient from their carer at what is already a frightening time for most people. This is in addition to separation from families for an unknown length of time in the knowledge that they have contracted a disease that the public media report every day kills without a clear indication of who is at risk. With COVID-19, physical detachment is everything in the preservation of the lives of others and reducing infection rates.

The contextual and temporal significance of COVID-19 also provides a means of using Bolton's (2005) theory of being able to clearly delineate between four fundamental work-based emotional responses in practice. These are highly relevant to paramedics, whose work ultimately incorporates each of these on a daily basis:

• Adhering to social expectations of the presentation of an emotional response
• Emotional response consistent with prescribed and professional conduct rules and parameters
• Performing an emotive response for financial reward as a paid employee
• The sacrificial giving of emotion in the sense of a philanthropic or charitable gift.

Establishing what drives emotional response in practice

It is easy to see from the context of clinical paramedic practice that feelings can drive emotion in the context of patient-centred care. As humans with empathy and compassion for others, paramedics accept this as a social norm in work, where death and injury become everyday norms of reference (Clompus and Albarran, 2016).

Dirkx's work emphasised that, with thinking about and processing emotions that arise from experience at work, transformation in practice could occur (Dirkx, 2006). In the context of paramedic practice, this is of utmost importance in being able to make sense of what are often horrific scenes, which in terms of an everyday context would be regarded as unknown in everyday life for most clinicians. It lies at the heart of why processes of reflection and critical reflexivity, alongside the everyday coping mechanisms of paramedics, are so important in practice (Howlett, 2019).

During work, it is often not experience that matters most but how individuals, make meaning of it (Jarrett and Vince, 2017).

Nowhere is this more evident than in the paired professional clinical working of paramedic teams in practice. Their shared experiences as well as individual capacity to make meaning of them lie at the heart of what will become memorialised as the time of COVID-19.

In the context of clinical professional practice, a legacy of pyramidal, hierarchical structures of organisations means that detachment of emotion from care depended on the functional capacity of the caregiver. It was highlighted by Lewis (2005) that it should be recognised that detachment of emotion is not associated with competence.

Traditionally and historically, before the days of patient-centric models of care, those who treated and cared for people were delineated by the infrastructure of an organisational hierarchy that created division and separation between those in different professions. The typical pyramidal structure, with consultants at the top, followed by medics and with allied health and nursing staff positioned at the bottom, was not conducive to patient empowerment, nor optimal communication pathways.

It can be argued that COVID-19 has served to functionalise roles at the height of clinical emergency and then to sentimentalise care. This is largely attributable to the need for PPE and social distancing. Care is directly associated with acts of human emotion, which are not separated by plastic sheeting, the anonymising of facial features and the homogenising of appearance in human interaction via the necessity for PPE.

The complex ambiguity that paramedics face on a daily basis serves to highlight not only their competence but also their authentic compassion when dealing with patients and their families and carers with abject professionalism, while simultaneously never losing sight of the ‘human touch’ of compassion and care.

Conclusion

The pandemic affecting the global society has brought the concept of emotional labour to the fore of the healthcare workforce like nothing else contemporary society has experienced.

While allusion can be made to similarities in historical contexts, people's own cultures and contexts frame what these mean to them and the feelings these generate. Paramedics working in the midst of COVID-19 need to be supported with acknowledgement of both their invaluable contributions and the extent of the emotional labour they contribute above and beyond what is usually required of them.

Where paramedics are accompanying patients without family members present, the context of their care in the midst of social distancing has never been more important yet is fundamentally more difficult. While considering the theoretical perspectives on emotional labour is useful, seeing this actively applied in praxis is an invaluable part of the legacy this global pandemic will leave us, and allows us to draw lessons from across the context of clinical healthcare provision.

Key Points

• Paramedics' psychological wellbeing is imperative to their capacity to cope when dealing with patients and their families in difficult circumstances
• Exploring the concept of emotional labour allows a consideration of paramedics' degree of personal resilience and capacity to cope when working at the front line of emergency patient care
• During the COVID-19 pandemic, care has been characterised by physical barriers to human contact in an effort to reduce infection transmission
• Paramedic practice is characterised by complex ambiguity and the need for correspondingly complex yet rational decision-making

CPD Reflection Questions

• Reflect on how your scope of practice has changed during the COVID-19 pandemic. How far will this become an embedded part of practice and how will you accommodate this in the post-COVID-19 era?
• How have processes of reflection changed during the pandemic? Why and how will you change your processes of reflection to adapt to challenging circumstances in the future as a consequence?
• Consider the terms ‘risk’ and ‘harm’ in terms of the prognostic indicators of patients entering secondary care with COVID-19 and contemplate how you communicate each to patients who are travelling to hospital without their family or carers.