Integrating Dark Humor and Compassion: Identities and Presentations of Self in the Front and Back Regions of Hospice

According to Goffman (1959), front regions are defined by the maintenance of proper appearances and adherence to rules of decorum. The front contains the setting (décor, physical layout, props) as well as the characteristics (rank, age, gender, ethnicity) of the individuals who serve as participants. The front exists separately from the individuals who fill the roles within in it, so much so that Goffman (1959, 27) notes that each participant enters an already established front and, simply by conforming to expectations of the social situation, helps reproduce the “collective representation” of reality. The front is highly scripted and often does not allow participants to express their personal thoughts, feelings, or desires.

In the workplace, front regions hold the official interpretations of the job at hand, the requirements for completing the job, and ideas about the worth of the job and other participants. Workers and those whom they serve do not always agree on the interpretation of the situation (Mangold and Babakus 1991), which may be especially problematic for workers who must keep up the appearance of caring (Abel and Nelson 1990). To keep the interaction on track, even as participants do not always accept the performances, these encounters often include staged behaviors for both staff members and consumers of that service (Grove and Fisk 1992). In addition, workers perform emotional labor and sometimes even exaggerate emotions for the audience in efforts to evoke a particular feeling in others (Hochschild 1983; Smith 2008).

Workplaces also typically have backstage regions that are out of view to the publics they serve. In these back regions, workers can express beliefs that are not permitted in the front stage (Hughey 2011), openly denigrate members of groups they do not like (Sallaz 2010), laugh at customers or the work situation (Tracy, Myers and Scott 2006), learn about and practice their responses to stigma related to work (O’Brien 2011), and perform tasks that would be inappropriate in sight of others (Turner 1976). According to Goffman (1959, 111), these back region behaviors must exist in order to make the front stage behaviors possible. They allow workers time and space to prepare for their roles, practice appropriate ways of being, blow off steam, and take a break from emotionally burdensome roles.

Goffman (1959) also noted that workers form teams, strategize about how to approach the work situation, and teach or critique one another on their performances in the back region. Smith (2008) notes how backstage activities with trusting coparticipants are essential for the production of effective front stage performances of emotions. Teamwork requires the establishment of consensus over rules of interaction (Futrell 1999; Manning 2008; Misztal 2001), so team practice especially helps in contexts where norms and rules of interaction are not constant, such as crisis-based situations. With enough practice, teamwork seems effortless, happening without the audience perceiving team communication or direction (Hindmarsh and Pilnick 2002).

Although workers frequently become skilled at hiding back region activities, the line between front and back regions is not always clear. Tanner and Timmons (2000) studied operating rooms and concluded that front stage regions included areas with patients, but as the patients underwent anesthesia the space transformed into a backstage area. Tardy (2000) found that the same play area could be front stage if children with unfamiliar parents were around, but transitioned into a backstage when children were not paying attention and parents trusted one another. These variations have led some scholars to argue that we should think of regions as having a front/back continuum, rather than as distinct geographic spaces or times (MacCannell 1973). This perspective seems especially applicable to caring work because staff members turn any and all settings into front stage areas when necessary, but they can also slip into back region behaviors if they think they are not under surveillance by clients or family members.

According to Tseelon (1992), impression management research following Goffman assumed that actors strategically manipulate their public displays to hide their true selves (see Bolino et al. 2008; Durr and Wingfield 2011; Kumra and Vinnicombe 2010 for recent examples). By extension, this scholarship often concludes that the backstage is more “authentic” than the front stage (Chriss 1995). This conclusion contradicts Goffman’s original theorizing, which emphasized that all social interactions include dramaturgy and performances. And while Tseelon’s (1992) critique was published twenty years ago, studies of impression management have either (1) focused exclusively on front region presentations of self, emphasizing how particular performances work to advantage some actors while sidestepping the issue of back region behaviors (Collett 2005; Greener 2007), or (2) implied that workers exhibit their true selves in the backstage and that their front stage activities include only performance (Huppatz 2010; Kumra and Vinnicombe 2010).

Hospice workers challenge these assumptions. I found that hospice workers see both front stage and backstage behaviors as important parts of their professional identities. This conclusion is consistent with Goffman’s original observations. In fact, he noted (1959, 111) that all social situations include performances: “when one’s activity occurs in the presence of other persons, some aspects of the activity are expressively accentuated and other aspects, which might discredit the fostered impression, are suppressed.” According to Goffman, all social interactions include some aspects of impression management, but what people conceal (and highlight) shifts depending on their audience and setting. By analyzing these different modes of dramaturgical concealment and display, I document the extent to which hospice workers describe their behaviors as both authentic and staged. Although my analysis makes no judgment about the actual “authenticity” of the hospice workers’ presentations of self, it does focus on how workers construct and enact authentic selves, drawing on elements from the front stage as well as the backstage.

Our conceptions of self emerge through our interactions with others (Cooley 1902). We form ideas about ourselves based on our interpretations of how others appraise us. However, given a particular view of ourselves, we must also constantly monitor and maintain a preferred identity (Stets and Burke 2003). In addition, we may have multiple identities at once, but characteristics of the situation help us to decide which identities matter most and how these identities will shape our actions (Ashforth, Harrison, and Corley 2008; Burke 2004).

Identities shape social action in the workplace by providing a “definition of the situation” and offering potential lines of action (Burke 2004). For instance, if a nurse provides care for someone in an official capacity, she might interact with the patient differently than she would if the person was also her mother. Ashforth, Harrison, and Corley (2008) argue that identities tie workers to organizations, making the study of identity at work especially important to understanding workers’ experiences. Identities also shift one’s orientation toward unpleasant or difficult tasks, such as dissecting a human cadaver on the way to becoming a physician (Madill and Latchford 2005) or learning how to communicate more like a physician than a student (Lingard et al. 2003).

Many studies of workers’ identities have focused on what happens when one’s identity is challenged or when a discrepancy arises between their actions and identity (Alvesson, Ashcraft and Thomas 2008; Pratt, Rockmann, and Kaufman 2006). For example, Brennan (2009) argues that discrepancies between how nurses see themselves and how they are expected to act lowers job satisfaction. In addition, Burke (2004) points out that we have numerous studies of the enactment of identity, but we need to pay more attention to the goals of identity, such as gaining legitimacy, providing meaning, or extracting more labor from others. In this article, I examine how workers negotiate identities and how they use those identities to account for discrepancies in behaviors.

While few scholars have explored the identities of hospice workers (see MacDonald 1991 for an exception), a number of researchers have documented the identities of other types of health care workers, especially nurses and physicians. After analyzing the content of introductory nursing textbooks, Goodrick and Reay (2010) concluded that nurses have shifted from serving as assistants to physicians to having identities grounded in a distinct sense of professional expertise and autonomy. Nurses in some settings defined themselves against the physicians and attendants by emphasizing their attention to holistic care (Chambliss 1996) as well as their ability to make independent decisions (Allen 2000). To establish a distinct medical identity, nurses sometimes manage information during interactions with physicians (Riley and Manias 2009). In settings where teamwork is emphasized, such as hospice, medical support staff tend to form an identity around working well with others (Lewin and Reeves 2011). Certified nursing assistants (CNAs) often form an identity around providing high-quality care to those most in need, sometimes accepting deplorable wages and work conditions because their identity as a caring person gives the work meaning (Stacey 2011). In addition, providing medical care often involves “dirty work” (Ashforth and Kreiner 1999), pushing some care providers to form an identity that is professional and compassionate as a way to ameliorate the disgrace of performing work that involves the management of disgust (Sanders 2010).

Nurses and nursing aides provide the bulk of medical care to hospice patients, but because the hospice philosophy emphasizes caring for all aspects of patient needs at the end of life, social support workers also play a prominent role. The latter group includes not only social workers but also counselors, chaplains, and volunteers. MacDonald (1991) found that hospice social workers did not have a clear set of tasks with which to define themselves, and consequently did not have a distinct professional identity within hospice. Other social support personnel form an occupational identity that includes a sense of calling (Christopherson 1994; Dreher, Holloway, and Schoenfelder 2007) or an emphasis on performing saintly work (Solari 2006).

Meetings were used not only to check in about patient care but also to address difficult aspects of the work. Hospice workers often did this with humor, teasing, and conversations that outsiders might regard as morbid. During one meeting a long-time nurse, Bonnie, reported that her patient had died unexpectedly. The medical director, Dr. Brown, asked Bonnie what the patient died from, and from the other side of the table, Ramon, a social worker replied, “She [the nurse] killed him.” In another situation, a social worker noted that a patient drank approximately three to six ounces of hard alcohol each afternoon. Dr. Brown laughed, and said, “I probably would too if I was in his situation.” Several others agreed and then revealed what kinds of substances they would prefer if they faced a similarly painful dying process. These jokes were not meant to be offensive, but they often presented otherwise serious issues in a casual manner, demonstrating the extent to which the hospice workers had routinized issues surrounding death.

Workers also frequently talked about their own deaths. Proximity to death broke down social norms about the inappropriateness of these kinds of conversations, permitting workers to have morbid conversations. Before one meeting, the dietician expressed her concern that all of her children are boys and that unless she has a girl, she fears that no one will take care of her as she ages and approaches death. In another situation, Keith, a long-time hospice chaplain, explained that hospice fit with his life “because basically to me it’s practice for my own dying. So that’s kind of how I approach each day.” He then elaborated this explanation by saying that working with people at the end of life forces him to firm up his own beliefs about death and the afterlife.

On at least two other occasions, workers confronted suicides of former colleagues. Although the hospice philosophy generally holds that with appropriate support systems and pain management, suicide would be less attractive to those facing the end of life, workers’ conversations showed ambivalence about the morality of suicide. During both of these situations, workers commented on the modes of suicide used and assessed their own perception of these tactics. When one former colleague hanged himself at work, the workers at Rose Hospice expressed sadness at his death, but also commented that “I could never do that in my workplace—how horrible for his coworkers” (Robin, Administrator). In general, the workers avoided judgmental language, but they did not hide their own preferences, should they ever take their own lives. This was a somber conversation, but one that workers did not avoid. On another occasion, Barry, a chaplain in his 70s, said, “I don’t believe in suicide, but with dementia I might consider it.” Suicide was frequently a serious conversation among the workers, but even more frequent was conversation about preferences for disposing of their bodies after death.

One conversation about cremation became humorous to the workers as they discussed a situation in which a former patient’s loved one tried to pour out his cremains, only to find big bone segments in the urn. Cremains is a term created by the funeral home industry, but accepted and used by staff at Rose Hospice. Robin, the key informant for this study, explained that after cremation the bones of the deceased are ground up and are the consistency of sand, not ash, so funeral directors are careful to use the word “cremains” instead. She explained that “‘ashes’ could be misleading to loved ones.” I recorded the staff’s discussion of cremation preferences in my field notes:

The monitoring of this conversation as the workers left the conference room signaled the move from a backstage of the staff meeting to the front stage of the public halls of the inpatient unit. Workers negotiated spaces like this throughout their workdays. In fact, one of the most common themes recorded in my field notes are moments when laughing in the nurse’s station became too loud and one of the other staffers (e.g., another nurse or the social worker) would chastise the group, reminding them to respect the visiting families. The following excerpt from my field notes illustrates this dynamic:

Yolanda did not think the laughter was inappropriate, but she emphasized that the family might not appreciate it. Laughing was almost universally seen as an inappropriate to front stage behavior within the inpatient unit. As Goffman (1959, 2) highlighted, managing these moments represents an attempt to keep what is “given off” in interactions consistent with intentional presentations of self.

During IDG meetings, workers also had frequent conversations about how to “educate” family members who were resistant to common hospice practices. Periodically, family members would not want their loved ones on pain medications because they feared the patient would not be aware of their surroundings, but the patient felt high levels of discomfort during bathing, transfer from wheelchair to bed, or any other kind of movement. During IDG the workers often reiterated that level of pain medication was to be decided by the medical power of attorney, but that they must make sure the family is fully aware of the level of pain. Implicit to this group discussion was an emphasis on strategies for changing the behaviors of caregivers and family members in the (presumed) interests of the patient, as demonstrated by the following interaction in IDG:

In this case the workers brought back region behaviors into a front region interaction in an attempt to persuade others. The team discussion of this strategy allowed the front stage encounters to go smoothly, even as workers tried to change the behaviors of caregivers.

Another situation where hospice workers strategized about changing the behavior of caregivers was related to hydration. Many patients at the end of life reach a point in which they can no longer swallow. Hospice, unlike hospital care, sees this as a natural process and advises caregivers not to try to give the patient food or water once they reach this stage. If the patient cannot swallow, but is given food or water, they could choke, thus hastening and making death more painful than it would be if they died from dehydration. Hospice workers frequently talked about how to educate family members about choking and how to persuade them to stop trying to feed their loved ones. During a training session for social workers, a group of ten hospice social workers discussed how to approach a son feeling guilt over not feeding his mother:

These educational efforts frequently did not succeed, prompting staff to have regular backstage conversations about how to get through to family members who thought they were doing more harm by withholding food and water.

Even during backstage activities, hospice workers found it important to maintain professional, and often unemotional, presentations of self. During IDG, staff regularly discussed the death of a patient, often saying things like “they went home—the big home” or expressing relief that the patient’s suffering had ended. But unless a particular staff member had grown very close to this patient, they rarely spent more than a few moments discussing him or her. During interviews, several staff said that outsiders often do not understand that hospice is not sad because they become accustomed to death and accept it as inevitable. Stephanie, a certified nursing assistant, said “It’s all in how you attach yourself. You have to know when to detach, and you can’t get too attached.” Others expressed more ambivalent perspectives, claiming that they try to remain detached, but sometimes still need help to maintain appropriate boundaries between themselves and their patients. In the front regions, the workers emphasized their caring self, even crying about loss if it felt appropriate, but during backstage activities they often kept their sadness quiet.

These findings contradict the assumption that backstage behaviors are a more authentic expression of self than behaviors in the front region. Both sets of behaviors include elements that workers describe as genuine to their sense of self, and both sets also include behaviors that are intentionally staged. While it is often taken for granted that the front stage includes managing one’s presentation of self, one CNA explicates how the backstage also includes staging: “It’s hard sometimes. I don’t always feel like being friendly or making jokes, but we all have to get along, so I try” (Darlene, CNA). As the opening quote, “We cuss in the conference room and cry with the family” (Nickie, Director), demonstrates, hospice workers recognized the discrepancy between their front- and backstage behaviors. They made sense of these contradictions by saying “This is part of hospice” (Nickie, Director) and “If we didn’t laugh, all we would do is cry” (Robin, Administrator). I argue, in fact, that workers used their hospice identities to account for their divergent behaviors to one another and outsiders.

Workers’ main explanation for feeling such affinity for hospice was the ability to feel authentic emotions while going about their work. In fact, several staff members told me that they like hospice because the hospice philosophy encourages them to make real connections with their patients and their family members. Keith, a chaplain, said that he liked hospice because “This is where the juice [of life] is!” and Kate, a social worker, said, “You’re with people when … the bullshit is over with and there is honesty.” However, like abortion clinic workers (Wolkomir and Powers 2007), hospice workers do not form emotionally intensive relationships with all patients. In fact, they find ways to balance the needs of the job and their own self-care needs by making connections with some patients and situations, while detaching from others. When I asked which patients really touched them, most workers told stories of patients they related to because of their age, family situations, or personalities. They described their relationships with these patients as being close “like a friend or family member” (Deanna, CNA), signaling that workers bonded with patients who permitted authentic emotional connections.

Even within close relationships with patients, however, staff members were careful to distinguish between their own emotional states and those of their patients. Ramon, a social worker, explained this separation: “sometimes I will express that [sadness] clearly aloud, okay, because usually my judgment would be is that it’s noticeable by the client or family,” but he added that he must appropriately moderate his emotional expressions. Ramon explained that he always reassures the family that he is not suffering and that their needs come first. Another social worker, Vonda, said that she often has tears when dealing with families who are emotional, but she tries not to sob or draw attention to her emotions. One nurse, Bethany, admitted that she did not cry when with family members, but noted that she felt confident that her job would not be in jeopardy if she did. In fact, Lisa, a CNA, mentioned in an informal interview that she sometimes feels like she is expected to feel sadder than she actually does. This ability to feel authentic emotions but not detract from the pain of the families is an important component of workers’ identities. Like the physicians in Coombs and Powers’ (1975) study, the hospice workers came to believe that the worker who “loses coolness and presence of mind … also loses the confidence of patients and staff” (251). Being able to feel emotions while also keeping them within “appropriate limits” was an important element of being a hospice worker.

Joking about death has the potential to be offensive and insensitive to those suffering loss, but hospice workers described their backstage humor as “understanding that death is inevitable” (Dr. Smith, Physician) and sometimes even funny. For instance, Michelle, a counselor, was known for keeping a running list of ways that she would not like to die, which included while sitting on the toilet and while caregivers were intoxicated. These preferences came from real-life situations of patients, and hospice workers sometimes laughed at the horror of the situation, while also discussing how to meet the needs of others who might be in a similar predicament. While many medical ethnographies have focused on gallows humor as a form of distancing (Becker 1976; Wear et al. 2006) and stress release, Chambliss (1996) argues that the routinization of death and tragedy first leads to distancing, and then that distance allows participants to see humor in death and tragedy. In Rose Hospice, staff used humor not only for distancing but also to align themselves with patients, especially against poor-quality adult care homes, inadequate home caregivers, or primary care physicians who did not seem to have the patient’s best interests in mind. For instance, physicians were often seen as a barrier to hospice. As Bethany, a nurse, observed:

Discussions of difficult physicians sometimes resulted in jokes at the expense of physicians: when one physician wanted to stop a patient’s medications for seizures, Dr. Brown, the hospice medical director muttered, “Sure, we’ll do what he thinks will help, but she’s just as likely to end up in the psych ward as feel better.” Several other staff members laughed at this comment while Dr. Brown signed the orders. Having a sense of humor in such situations enabled workers to deal with emotionally difficult times and uncooperative others while also allowing them to demonstrate their acceptance of death.

Hospice workers saw themselves as more enlightened about the inevitability of death than the average person. They emphasized the need to celebrate the ending of life in similar ways to the beginning of life. They also described time spent with the dying as a gift and reminded others that it is an honor to be present in the final moments of life. Hospice workers typically had significant experiences with death before entering hospice, as illustrated by the fact that several staff members described losses that led them to hospice and characterized the ideal hospice worker as one who had previous encounters with death and dying. However, these experiences did not necessarily make hospice workers adept at dealing with their own psychological issues. As Keith (chaplain) observed: “You’d think we’d be good at it, but most people just push it down and never really deal with their feelings.”

Hospice workers formed an identity around being enlightened about death and privileging real emotional encounters over superficial forms of medical care that focus too much on the body and not enough on the person. This identity allowed them to reconcile their front stage commitment to care and compassion with their backstage expressions of morbid humor, strategizing to change others’ behaviors and display detachment toward death. It did this by defining each set of behaviors as just “part of hospice” and essential to being able to continue to provide care. In fact, workers often characterized former staff who could not make it in hospice as “taking themselves too seriously” (Robin, Administrator).