*3.3. Emotional Territories?*

Axelsson and Axelsson (2009) use the word 'territoriality' to refer to the problems of cross-boundary collaboration. They claim that not only animals but also human beings tend to defend their 'own areas'; in the case of integrated care for people with multiple complex problems professional (doctor, nurse, social worker) and sectoral (primary care, specialized care and social care) territories.

It is natural that specialization has resulted in boundaries between care professions and sectors. An interesting question here is now, whether (and if so, how) emotions are related to the differences between professions and sectors. Emotional burden due to complexity of client's problems may be shared by collaboration, but it may also cause additional tensions and challenges in the interaction, if the ways of dealing with emotions differ.

The findings of the study reflected here did not directly address emotional differences between the professions and sectors. However, the professionals felt that there is still a clear distinction between the territories of care professions and sectors. Extreme (but quite general) stereotypes and prejudices underlying cross-sectoral collaboration regarding the three sectors persist and were described in the BEL project seminars by professionals as follows: Primary health care thinks it is omnipotent. Specialized health care isolates itself (due its allegedly superior know-how compared to others). The professionals in social care believe they are the only ones who are able to take a holistic view of a client, but at the same time the health sector wonders whether social care is actually needed. A certain kind of territorial defence seems to be embedded in these stereotypical summaries evidenced by the professionals.

The holistic person-centered view of patients and clients is one potential way to approach the 'emotion-related differences' between professions and sectors. Holistic person-centeredness (patient-centeredness, client-centeredness) is a vital part of integrated care (World Health Organization 2016). Further, the emotional dimension is an explicitly stated part of person-centeredness (Scholl et al. 2014; see also Van der Heide et al. 2018). In the integrative model of patient-centeredness by Scholl et al. (2014, p. 5) 'emotional support' is described as part of patient-centeredness as follows: "Recognition of the patient's emotional state and a set of behavior that ensures emotional support for the patient." In addition, the model states other related dimensions such as 'patient as a unique person' and 'patient empowerment'—while also emphasizing the dimensions addressing collaboration between diverse professionals.

According to the professionals interviewed in this study, in the health sector a patient is often still seen as a 'disease' and in the social sector client is seen 'a holistic person'. This (naturally highly simplified) distinction outlined below is mirrored in the stereotypes of doctors and social workers. A nurse working in the primary care reported as follows:

. . . I am working at a health care center . . . and from the perspective of health care, we are there not able to think, or we have not been able to think of a person as a whole ... we take care of the disease, and we take care of that single thing. (Care professional P3)

The same professional described the role of the doctor as follows:

... [W]hen patients come to a health center, or come to see a doctor, very many of them still think ... they regard a doctor as an authority, an awfully big authority. You go as you were going to see the Almighty ... this is what you have picked up at your mother's knee: you have to [have] a fear of the Lord when you go to see a doctor. And you go to ge<sup>t</sup> a

solution to one problem only ... When one goes to social work professional, the attitude is totally different. (Care professional P3)

Another professional confirmed this and claimed that this hierarchical status is maintained by other actors:

... [A]lso when other people, when they look at the doctor, they look upwards. Like nurses, and especially clients. So, the doctor stays up there if everyone looks up to her/him. (Care professional P5)

A totally different picture of social work and social workers was outlined by two of the managers interviewed in the study. They emphasized the importance of the relationship and a holistic view of a client.

Altogether, about support work and the basic principles of social work: it is still salient here that you [as a client] form a bond with someone [professional]. That you have a care professional with whom you have some kind of a relationship. And that [relationship] opens up the world for collaboration [between a client and professional] or otherwise that world stays closed. (Manager M1)

I would say like this, in a rather caricatured way, that in a way social services start from the holistic wellbeing of human beings. In health care there is more that old thing, that one has a medical problem which has to be solved and go<sup>t</sup> rid and that's it. But this is, I would claim, it has changed and is changing and it has to be changed. But surely it is still like this. (Manager M9)

The differences between health and social sector are not only boundaries, there also seems to be a distinction between specialized health care and primary health care in how to orient toward holistic patient-centeredness, as shown in the following extract.

Whereas we think that it is not the task of the specialized care this continuous life-long support. It has to be built in the primary care, nearer . . . where people live. (Manager M7)

The different basic tasks of the sectors are mirrored naturally in the work of professionals. Especially when dealing with people with complex problems, the competencies of a professional may be challenged because they may be required to collaborate with professionals with completely different expertise and from sectors with completely different orientation towards patient-centeredness. In addition, power embedded in diverse sectors and professions is of course present: for example, it may be more difficult for a social worker to ge<sup>t</sup> her voice heard in the context of specialized health care. The uneven power relations embedded in the hierarchy and bureaucracy of the health and social system reinforce territorial thinking and increase mutual suspicion (Axelsson and Axelsson 2009).

If we extend the idea of territorial differences and tensions, through holistic patient-centeredness thinking, to emotional orientation, we could perhaps sugges<sup>t</sup> something like 'emotional territories' embedded in other kinds of professional territories. From the point of view of emotional labor (Hochschild 1983), these emotional territories would refer to the different feeling rules (display rules) (Diefendorff et al. 2011; Humphrey et al. 2015) that different care sectors and different care professionals have. Each territory has to defend its own ways of acting, based on their education, role, status, ethical principles etc. on which their professionality in general is based on (Axelsson and Axelsson 2009)–also in an emotional sense. Diefendorff et al. (2011) define emotional display rules as shared norms, or emotion norms, governing the expression and regulation of emotion at work and claim these can differ depending e.g., on occupational requirements. It is quite understandable that these rules or norms vary across different professions, organizations and sectors. The professional hierarchy in health and social care further reasserts these differences.

For example, although emotion work is generally considered as part of nursing work, in Gray's study (Gray 2009, p. 171) on emotional labor among nurses the respondents felt–in addition to gender stereotypes–that emotions were seen as 'weaknesses' by other staff members, such as senior nurses and doctors. Conventionally, social work in particular is considered to be emotionally demanding work, in which paying attention to emotions is seen as a critical aspect (Morrison 2007). In spite of this, even in social work sharing feelings and asking for help may be seen as a weakness and lack of professional capacity (Revell and Burton 2016, p. 1595). The differences between professions are, however, changing, while patient-centered care is also getting more attention in medicine. Epstein (2000), for example, includes identification and responding to patient's ideas and emotions regarding their illness as an important component of physicians' behavior.

In integrated care, different feeling rules are encountered when professionals representing different sets of feeling rules work together in cross-boundary teams. In the context of people with multiple complex problems, the emotional burden described above constitutes an extra underlying challenge and complicates collaboration among professionals. We may ask if in such a situation a social worker, for example, dares or is otherwise able to act according the feeling rules of her/his own profession or sector, giving that a medical specialist may be socialized to a very different set of rules. Conversely, for a highly specialized doctor it may be against the conventional work role status and role expectations to become involved in emotional issues. Ashforth and Kreiner (2002, p. 230) refer to problems of 'collective face work' and 'emotional comparison', which may also be of relevance in cross-boundary collaboration between professionals in health and social care. Feeling rules related either to professions, organizations or sectors could also be called emotional climates or emotional cultures (see Grandey and Melloy 2017, p. 412) and merit special attention in the context of implementing integrated care.
