Samaritans from the East: Emotion and Korean Nurses in Germany

In line with the increasing significance of the role of transnational migration in healthcare provision—especially in the West—slightly over 11,000 nurses and nurse assistants from South Korea moved as "guest workers" (Gastarbeiter) to the former West Germany mainly between the 1960s and the 1970s. This study explores the role of emotions in the professional practice of nursing care. Particular attention is paid to gendered and racialized aspects of the emotional labor carried out by the Korean migrant healthcare workers based on their experiences at work. The way in which the stereotypical image of Asian/Korean femininity has been shaped into care work will be examined. Another focus is the way in which the Korean female healthcare practitioners manage their emotions and act as compassionate nurses in care delivery. They perform or manage their emotions to demonstrate a sense of compassion and empathy in nursing practices. In the process of performing their duty of care and managing their emotions over the long-term, the Korean healthcare workers also have to negotiate between providing compassionate care and coping with "compassion fatigue" in healthcare settings by performing racialized gender in a recurring manner. Their emotional labor is thereby undertaken in intersection with gender, and race/ethnicity; factors which are entangled and mutually reinforced in the performativity of gender and race/ethnicity within the context of nursing care by the "guest workers."

Introduction

The significance of the role of transnational migration in healthcare provision—especially in the West—has been increasingly recognized. Facing a care crisis caused by a shortage of nursing professionals combined with the demographic issues of longer life expectancy and an increasingly ageing population in postindustrial countries, more and more healthcare delivery has been carried out by migrant workers. In the 1960s and 1970s, to resolve the deficit of nursing care provision for the young, sick, and elderly, slightly over eleven thousand Korean female healthcare workers—including registered nurses and nursing assistants—were recruited from South Korea (hereafter Korea) to the former West Germany (hereafter Germany) as "guest workers" (Gastarbeiter).

The recruited healthcare workers were trained as nurses or nurse assistants in Korea and had then worked in medical or nursing institutions such as hospitals, sanitariums, nursing homes, or hospices in Germany. They were mainly single and in their early 20s or 30s in a period when solo labor migration abroad as a young woman was very unusual in Korea. Socioeconomic factors such as financial reward at a time of high rates of unemployment and limited job opportunities, especially in professional jobs for women in Korea, motivated them to pursue work abroad. Apart from their sense of obligation and responsibility to support their family through remittances, personal aspiration for new opportunities with better future prospects was another motivation for job-related transnational migration by these female healthcare workers. Through outward offshore social mobility, the women migrant workers sought greater freedom and personal, social, and economic development for themselves and their families at home; a level of self-fulfilment that was perceived difficult to achieve in the homeland (Ahn, 2014:169–170).

The Korean healthcare "guest workers" contracts were limited primarily to three years on a rotation principle. As the term "guest workers" implies, they were a temporary labor force to fill the labor gap in postwar Germany. The spatial and temporal movements of these Korean healthcare workers take the form of multifaceted migration trajectories. Their migratory trajectories can be traced in three spatial paths through multinational space. The paths taken are: remigration to the homeland at some stages—either when their initial employment contract terminated or at a later stage, multiple migratory mobility flows from Germany to another destination country—mainly to North America—or settling down in Germany. Substantial numbers of Korean healthcare workers have stayed on, settled down and acquired German citizenship. Most of them worked till their retirement as nurses or nurse assistants in various healthcare institutes.

The existing body of literature on postwar German "guest workers" (Gastarbeiter) has primarily dealt with male workers such as the Turkish, Eastern European, and Southern European migrants, who make up the majority of migrant workers (Breitenbach, 1982; Dunkel et al., 2000; Hunn, 2005; Chin, 2007; Yurdakul, 2009; Oltmer et al., 2012; Berlinghoff, 2013; Aysel, 2018). The field of female "guest workers" (Mattes, 2005; Goel, 2019)—especially their gendered migration—has received less attention than that of their male counterparts. A handful of studies on Korean nurse "guest workers" who moved to Germany have been conducted in South Korea and outside; for example, regarding their migration history (Na, 2009, 2013; Pak, 2013; Noh et al., 2014), diasporic identity construction (Roberts, 2012; Lee and Kim, 2014), life history (Berner and Choi, 2006; W. Kim, 2009; Ryu, 2013; Chaedok han'guk yŏsŏng moim, 2014), interculturality (An and Hyŏn, 2013), the decision-making process to return or stay (Choe, 1987), and three of my previous works on gendered migration (Ahn, 2014), return visits to their homeland (Ahn, 2019), and the social dynamics of cross-cultural interactions between migrants and locals (Ahn, 2020). In previous scholarship on the Korean healthcare practitioners and female "guest workers" in Germany, the emotional dimensions of their occupational experiences have been underexplored.

Seminal literature on transnational care migration by Helma Lutz (2008, 2010), Williams and Gavanas (2008), Pfau-Effinger (2000), and Anderson and Shutes (2014)—among others—converges in shedding light on the types of care regime and welfare regime, which intersect together with migration regimes and gender regimes. These works are primarily concerned with policy and practice of care at a macro or a meso level. A growing body of literature on care migration has focused on inequity in the global political economy of care, transnational family of migrant care workers (Parreñas, 2005; Walsum and Alpes, 2014), global care chain (Hochschild, 2000; Yeates, 2004; Nadasen, 2017), deskilling (Cuban, 2013), racial and/or gender discrimination, and the precarious conditions experienced by migrant care workers including domestic workers, childminders, residential and home care workers, and nurses (Anderson, 2000; Parreñas, 2001; DiCicco-Bloom, 2004; Gutiérrez-Rodríguez, 2010; Lutz, 2011).

In order to make a further contribution to the prior scholarship on care migration, the current study aims to understand the underlying emotional aspect of migrant health care workers' occupational experiences. The existing body of literature on emotion in the workplace borrows from—and engages with—the Hochschild (1983) notion of "emotional labor," which explores the gendered process of various service deliveries such as by flight attendants (Hochschild, 1983), hairdressers (Parkinson, 1991), nail shop workers (Kang, 2003), call center representatives (Vora, 2010), professors (Bellas, 1999), physicians (Larson and Yao, 2005; Panagopoulou et al., 2006), and care workers including nurses (James, 1992; Theodosius, 2008, among others).

The research literature focusing on emotion in a healthcare context—among other categories of care literature—is primarily related to nursing studies and partly to sociology, management, and psychology. Focus is put on the roles of emotion in delivery of care or nurse education: such as the importance of emotional labor in nurse education (Smith, 1992; Msiska et al., 2014), various types of emotional labor and emotional management in nursing (Meerabeau and Page, 1998; Lewis, 2005; Theodosius, 2008), undervaluation of emotional skills or emotional components in healthcare settings (Aldridge, 1994; Staden, 1998; Henderson, 2001; Virkki, 2007; Gray, 2009), or occupational stress and job satisfaction (Meerabeau and Page, 1998; Mann and Cowburn, 2005; Panagopoulou et al., 2006; Erickson and Grove, 2007; M.R. Kim, 2007; Shirey et al., 2008; Yang and Chang, 2008; Park, 2009; Yoon and Kim, 2010; Wi et al., 2012). Some of the previous works—by Staden (1998), Virkki (2007), Gray (2009), Cottingham (2016) among others—engage with the gendered dimension of care and emotional labor. Their main argument is that the significance of emotional work in a nursing care context is considered to derive from the nature of femininity rather than to be acknowledged as a professional skill. Although Catherine Theodosius's (2008) empirical study on British nurses' experiences of emotion and emotional labor in nursing practices is a seminal work in the field, and does address gender issues to some extent, the race/ethnicity issue embedded in emotional labor is less well covered.

The politics of race, class, and/or gender discrimination and hierarchy—in the destination countries—as experienced by migrant nurses has received particular attention in a number of studies on migrant nurses from Indonesia (Saraswati, 2017), India (DiCicco-Bloom, 2004; Amrith, 2017), or the Philippines (Tung, 2000). Therefore, race/ethnicity issues are addressed in the context of global injustice or discrimination (Hagey et al., 2001; Isaksen, 2012). Another research area with a race/ethnicity aspect is looking into migrant caregivers' experiences from the perspective of their cultural value (Jones et al., 2002; Spitzer et al., 2003; Funk et al., 2013) or the state labor export policy of a sending county by framing the racial branding of Filipinos' care labor as caring, creative, collaborative, and colorful (Guevarra, 2014). These works articulate racial/ethnic issues involved in transnational nurse migration; however, scant attention is paid to the element of emotion embedded in the nursing care delivery. There is hardly any study on race and emotion/emotional labor in nursing care in the previous scholarship. Miliann Kang's (2003) and Kiran Mirchandani's (2003) case study of im/migrant workers or small business owners—not in the nursing care sector but in im/migrant-owned shops—is one of just a few studies to address the issues of race and emotion by embracing a gender, race, class perspective to examine the nature of service workers' feelings toward diverse customers in terms of race/ethnicity and class, and their emotion management.

Not only the gendered but also the racialized nature of emotional labor of migrant healthcare workers has remained underinvestigated in previous literature on emotional labor in healthcare settings. Since healthcare provision and direct caregiving tasks are increasingly assigned to and fulfilled by female migrant workers—in particular in postindustrial countries—the contributions of both gender and race/ethnicity embedded in healthcare practices need to be brought further into the discussion on significance of emotion in nursing care delivery.

With a view to contributing to the prior scholarship on nursing care migration, this study addresses the micro level of nurses' emotions in nursing care delivery within institutional healthcare settings. This study sets out to investigate the role of emotions in the professional practice of nursing care. Particular attention is paid to the invisible emotional aspects of nursing work and emotional management carried out by Korean healthcare "guest workers" in Germany. Their nursing care practice is conceptualized in the frameworks of emotional labor and body work to understand their lived occupational experience. By examining the ways in which the caregivers' emotion shapes—and is shaped by—interactive practices of nursing care delivery, I make the argument that gender and race are salient and intersectional categories of emotions in nursing care work carried out by migrant practitioners. In doing so, the highly relevant concepts employed in the current study are "emotional capital" (Virkki, 2007), "emotional labor" (Hochschild, 1983), and performing racialized gender derived from the theories of "doing gender" (West and Zimmerman, 1987) and "performativity of gender" (Butler, 1999).

This empirical study is based on personal accounts obtained from multiple in-depth life-history interviews conducted with a handful of Korean former female nurses or nurse assistants who trained in Korea and moved to Germany as "guest workers" during the late 1950s and the 1970s. The interviews were semistructured but mostly followed the participants' own temporal and spatial flows in narrating their life-history with little intervention from the author. All participants were women in their 60s and 70s and were mostly retired during the time of the encounters. The interviews were undertaken in Germany, Korea, and Canada between 2011 and 2019. Initially, my personal network was utilized to find respondents and then further participants were contacted using a snowball sampling technique. Interviews were conducted in different places such as their homes, the authors' place, or restaurants and lasted from two to four hours. They were recorded and then transcribed. Interviews conducted in Korean language and cited narratives were translated into English by the author. Among the participants, personal accounts of seven nurses and four nurse assistants are cited in the current work. During the biographical interviews, they shared not only their past and present stories but also their photographs, postcards, letters, souvenirs, documents including employment contract, certificate, or award with me. Some interviews became quite emotional as their memories of sadness, remorse, gratitude, excitement, and/or nostalgia surfaced. All names used here are pseudonyms.

Emotional Capital in Care

Care as Women's Role

Care theorist, Joan Tronto (1993), defines good care as a highly complex activity, requiring a vast range of tasks and skills, which demand attentiveness, evaluation of different alternatives to meet needs, and responsiveness. Nursing care embraces physical, technical, and emotional dimensions: including the micro practices of everyday care, ranging from the role of custodial caregiver to that of clinical practitioner. Delivery of nursing care consequently involves monitoring both the physical and emotional wellbeing of care recipients. Caregiving has been often considered "a labor of love imagined as a familial-type relation" (Anderson and Shutes, 2014:217); therefore, primarily perceived as a woman's role and related to the "natural" feminine qualities of nurturing and compassion rather than being seen as an acquired skill. Care theorists like Joan Tronto (1993, 1996), Nel Noddings (1984), and Elisabeth Conradi (2001) define care as a set of social and political practices, and a form of gendered and undervalued labor traditionally associated with women.

Furthermore, in a process of professionalization, medicalization, and technicalization of nursing tasks, the emotional work entailed in nursing care activities is downgraded to the lower strata of the workplace hierarchy (Philips, 1996; Herdman, 2004; Apesoa-Varano, 2007; Johnson, 2015). This hierarchy of values between emotional skills and technical or clinical competences in healthcare environments results in the emotional efforts by the healthcare workers being inadequately rewarded. Even though the care element in nursing practices is poorly acknowledged and undervalued, this element is a fundamental part of the nursing profession. Furthermore, in nursing care practices—which make high demands on emotion—emotional skills and the role of emotion are significant. Considering the intense demands of emotional labor, which is inevitably involved in nursing care practices, consideration of nurses' emotions in their occupational experiences is significant in attempting to understand their nursing practices.

Emotional Capital

As noted earlier, emotions are embodied—and intensively activated—in the process of providing nursing care. As convincingly elaborated in the concept of "emotional capital," emotions can be regarded as resources that derive from personal abilities, connections, and investments in and from the self and can be used and exchanged as a form of capital (Virkki, 2007:267–279). Possessing and accumulating emotional capital serves to deliver good quality of care and to maintain a positive emotional stance in care recipients. Thus, emotional capital deals with individual capabilities to achieve the ideals of relating to other people (Virkki, 2007:272). This includes the ability to decipher and respond to—the often unspoken—care needs of patients and to deal with emotionally charged and pressured situations.

Nurse Kim whom I interviewed shares her experience with an elderly woman resident, "M," she cared for at a nursing home. "M" frequently requested assistance for minor daily tasks such as spreading butter on a piece of bread even though she might be able to manage it by herself. Kim read M's request as her wish to get more attention to mitigate her feeling of loneliness. As nurse Kim picked up on her patient's indirectly expressed needs, she responded with more alertness and attention to take her elderly patient's emotional well-being into account, rather than responding with a detached demeanor or being irritated by her excessive demands. A challenge for her in dealing with those in her care who basically just want companionship, she admits, is her fast-paced day-to-day routine in which she was continuously pressed for time.

My findings from the Korean former healthcare practitioners' accounts confirm that they might develop emotional capital over time. Shin—who cared for children with different kinds of disability at her last workplace before she retired—tells of her ability to read the unspoken emotional states and/or needs of the children before they verbally expressed them.

One day Jan—who had a speaking disability—came into the kitchen and put his hand near his mouth trying to say some words with sound. It was difficult to figure out [what he meant]. I just sensed that he was thirsty while other young social workers [whom I was working with] kept asking and tried to find out what was going on with him. I was often able to catch what the kids wanted before they spoke by just watching their faces or gestures and most of time it was right. Well, the young co-workers waited till things became clear.

(Shin, former nurse)

Their ability to decipher any hints of the emotional states of the care recipients—as in the above two cases—enables the nurses to skillfully manage the clients' needs or feelings of discomfort. This kind of sensitivity to have the alertness and the ability to respond to often unspoken care needs is in itself an emotional skill, which can represent part of emotional capital. As addressed in studies of emotional labor in nursing care work by Aldridge (1994), Bowden (1996), and Gray (2009), the nurses' capability to employ emotional skills such as sensitivity and empathy to respond to situational and unspoken demands from patients should be recognized as a valuable professional skill acquired through their work practices rather than as gendered dispositions. The emotional capital is a socially acquired trait and accumulated as a resource over the time invested in nursing practices. Most of my interviewees value their caring role played out in a range of healthcare settings—integral to which are the qualities of sensitivity and responsiveness—and consequently maintain a positive view of their own emotional resources.

The caring and devotional role of a nurse is deeply embedded in their nursing education received in Korea. Many of the former Korean nurses or nurse assistants in Germany whom I interviewed share the "Nightingale" ethics such as sacrifice, devotion, and compassion, which are emphasized as the fundamental ethics of care during the nursing training they received in Korea. At the graduate ceremony of nursing school, they made the Nightingale Pledge. The Nightingale ethics are embodied in their nursing education and work ethic. Nurses are referred to as paegŭiŭi ch'ŏnsa (Angels in white clothes) in Korea, which evokes the image of a benevolent angel. The understanding of care characterized by the Nightingale ethics imply that nursing care work is undertaken out of a sense of vocation. This sense of calling is not only embedded in the nursing training and practice in Korea but also in traditional practices of nursing in Germany as well. As nursing care work had formerly been conducted by nursing sisters and nuns at Christian medical institutions in Germany, the sense of devotion and vocation in the process of caregiving was taken for granted. In fact, many Korean health care "guest workers" worked together with nursing sisters or were supervised by nun head-nurses in Germany.

In comparison with her German counterparts in actual delivery of nursing care, Na, a former nurse, observes the different emphasis put by her German local colleagues on cleanliness and efficiency with less emotional engagement: "The most important thing for my German colleagues was Sauberkeit (cleanliness) while for us it is giving good nursing care" (Na, former nurse) (Ahn, 2020:52). By equating quality of nursing with demonstration of care and emotion, she values the emotional capital in nursing care shown by the Korean healthcare workers as a vital resource in delivering compassionate care.

Emotional Labor of Nursing Care

Emotional labor is defined as "the management of emotion to create a publicly observable facial and bodily display" in occupational settings by Arlie Russell Hochschild (1983:7), which can entail inducing or suppressing one's actual feelings and hence might cause emotional dissonance between actual and displayed emotions. The theory of emotional labor is salient to analyze the work of nursing care delivery, which is related to continuous interpersonal relationships in the course of daily contact with patients, patients' families, and colleagues/supervisors. Care work involves the development of longstanding and interactive care relations; in particular, between care practitioners and those in need of care. When a harmonious and trustful interpersonal relationship between the two groups is established through this prolonged contact, it could contribute to an improvement in patients' emotional well-being and stability and to expressions of satisfaction from nurses as regards the element of compassion in their job as in Han's case:

When my patients recovered and left the clinic, I also felt very happy. They and their family members also appreciated me, some offered me chocolates, or a bunch of flowers and it made me feel good and that I had done a good job.

(Han, former nurse)

Through reciprocal practitioner–patient relationships, the narratives of the nurses in my interviews often show development of considerable empathy and concern for the patients they were caring for. Kathleen Lynch (1989) defines this emotion developed through work as a "solidarity relationship." She argues that caring—and being cared for—involves the construction of symbolic bonds regardless of the economic context in which they are embedded. Consequently, the caregiver practitioners are often emotionally involved with—and build emotional attachments to—care recipients.

Some nurse interviewees identify the extent of their emotional connections with their patients with their feelings toward their own family members. They take on the role of a caring mother or a daughter within a kinship group while providing nursing care. They often project their own family relations onto those they care for. Mun—who had left her three-year-old daughter behind at home in Korea—was recruited as a nurse at a pediatrics clinic in a German city, K expresses her feelings of motherly care and devotion toward her child patients as similar to her feelings toward her own daughter: "I did look after the children at the wards like my own daughter at home, it actually helped and soothed me. I was missing her so badly." Her subjective position as a migrant mother who left her baby daughter behind certainly gave her great concerns about care provision of her own child, but on the other hand, actually provided her with a source of emotional capital to bring her closer to her young child patients. Providing nursing care with compassion for the child patients enabled her to alleviate the sense of guilt associated with not meeting her care responsibilities for her own daughter and ease her longing for her baby.

Due to their emotional involvement in care practice, some of my interviewees—like nurse assistant, Park—describe feeling upset about a mortuary coworker's maintaining emotional numbness in the context of a patient's death:

How on earth he could just sing and hum along while cleaning a patient's body who had just died? I know it was his everyday work, but still didn't he have any feeling? I really couldn't understand it [his behavior]. It looked like he was working with an object not with a human.

(Park, former nurse assistant)

Her critical reaction toward his emotional state of detachment with the recently deceased patient shows that empathy and emotional engagement is so much embedded in her sense of nursing care practice and of professional standards. However, there is a risk of emotional involvement in nursing care leading to potential emotional distress when the carer becomes overly engaged in the process of providing care with empathy.

Effects of Emotional Labor

The majority of the literature on emotions in organizations like Hochschild (1983:7–19) has primarily focused on the harmful effects of emotional labor, which may create a means of alienation—as in the induction or suppression of feeling. But my interviewees' narratives show both negative and positive outcomes associated with emotional labor. These points are identified in the works by Catherine Theodosius (2008) and Tuija Virkki (2007). Virkki (2007:266) points out the rewards deriving from managing emotions in accordance with organizational objectives and professional ethics. In the context of the emotional care aspect of nursing, the nurses might experience both an emotional burden and a sense of satisfaction. The emotional labor of nursing care consequently has both beneficial and harmful effects on the practitioners who undertake it. These complex dimensions of the emotions embedded in nursing care are often narrated by the Korean healthcare practitioners who participated in this study.

My interviewees valued their emotional skills such as managing a patient's anxiety before surgery or the ability to distract or calm the fear of younger patients before giving them injections or taking blood samples, for which they were highly regarded: "Patients waiting for operations in the theatre usually got anxious, and I tried to comfort them, sometimes patting their arm and saying everything should be fine" (Lee, former nurse) (Ahn, 2020:46–47). In this way, she responded to and soothed patients' state of anxious emotion. Several interview participants observed that, when it came to injections, their patients showed a preference for the Korean nurses' technique, especially when blood tests were involved. The Korean nurses in return gained "emotional gifts" such as recognition, compliments, appreciation, or trust from the care recipients, coworkers, supervisors, or doctors they had worked with. The various kinds of emotional and material rewards like gifts from their recovered patients could give them a sense of satisfaction and empowerment through a feeling of self-worth and external recognition of the value of their work. This serves to increase the depth of emotional capital as a resource for nursing care professionals. In fact, the positive reputation of the female Korean healthcare "guest workers" as good carers associated with commitment and warmth was described in glowing terms in the German media. Der Tagesspiegel, on June 22, 1977 reported that they were "popular among the patients for their gentle, friendly character [and] valued among their colleagues for patient diligence."¹ They were seen to accomplish managing their own feelings within their profession of nursing care. Therefore, the interaction between managing and expressing emotions on the part of the caregivers in the context of nursing care practices is a complex process with repercussions for individual practitioners.

Body Work

Another factor, which has an impact on the healthcare practitioners' emotions, is the corporeal dimension of nursing care activities. Since nursing care work is undertaken on a real human body, this entails a physical dimension in addition to the emotional and medical aspects. During continuous face-to-face contact with those being cared for, healthcare workers experience physical proximity with the patients. Body work is defined as paid work undertaken directly on the bodies of others who thereby become the object of the worker's labor (Twigg et al., 2011:173). Body work is embedded in central activities in practices of care which include touch, smell, or sight of patient's physical bodies. In particular, intimate body care in nursing activities involves close work on others' bodies; often touching naked bodies for bed baths, toilet procedures, washing the soiled body, changing clothes, or catheter management.

My first workplace here [in Germany] was at an internal medicine ward. Several days after my arrival, I had to give a bed bath to a male patient from head to toe. He was quite a big gentleman, double the size of me, so heavy and lying on the bed. I had only seen pictures of a man's naked body in a textbook at [nursing] school. We nurses didn't have to do that kind of work in Korea. My face turned red and I really didn't know where to put my eyes. This job became one of my routines, so I tried hard to take it easy, and after several months doing that anyway I was able to wash five to six patients every morning without it being a big deal. But honestly it wasn't my favorite part of the job.

(Han, former nurse)

Her account illuminates that body work in a healthcare setting could evoke uneasy emotions for healthcare practitioners. While undertaking body-related tasks, nurses need to be aware of challenges in corporeal boundaries and the privacy of both patient and nurse, which demands emotional sensitivity and emotional management. Catheter care in urology appeared to be even more challenging to undertake for the Korean nurses:

When I was asked to do a catheter for a man I simple couldn't manage it in the first place … and told her [my supervisor] that I wouldn't do it and in Korea we [female nurses] didn't do this. …

(Chŏng, former nurse)

Being unable to suppress her uneasy emotion about performing the task on the private parts of the male patient, her refusal seems to be a manifestation of an effort to protect her privacy and dignity even though this attitude could be seen as irresponsible in a nurse. The accounts of these two participants—among others—in my study present uncomfortable encounters between the unhealthy bodies of patients and the racialized bodies of the migrant nursing carers, described in the German media in the 1960s and the 1970s as little "girls" with "almond eyes and black hair."²

The work on a physical body entails not only intercorporeal but also emotional aspects, which include sensations such as embarrassment, distaste, or even disgust. Ample personal narratives by my interviewees give insight into difficult emotions related to the body-contact work they had to undertake. Emotional work and body work are thereby interconnected components of nursing care work. As body work often requires intensive emotion on the part of the caregivers, they are faced with challenges to manage their negative emotional state while carrying on with their work on physical bodies on a daily basis. Not only the healthcare practitioners but also their patients with diseased, fragile, immobile, and/or old bodies might feel vulnerable or frustrated as they become increasingly dependent on their caregivers. Fragile patients with limited mobility could become excessively demanding or feel the need for more attention, frustration, or distress which could then be expressed—or transferred—to the nursing carer. This might necessitate emotional management on the part of caregivers to understand—and be sensitive to—the emotional vulnerability of both the care recipients and the caregivers themselves.

Caregivers' Emotional Burden

Although the delivery of compassionate care to patients gives a sense of recognition and empowerment to the caregivers, on the other hand, this could take an emotional toll on the nursing practitioners in the form of their feeling emotionally drained, distressed, stressed, or burnt out. Constantly dealing with and caring for "difficult," aggressive or traumatized patients—or those with critical illness—demands intensive emotional labor from the caregiver, which might lead to the condition of "compassion fatigue" (Joinson, 1992; Cross, 2019). This condition of care fatigue might put the caregivers themselves at risk of emotional exhaustion, job burnout, or depression from repeated exposure to others' suffering, operating in a high stress environment, and the continuous giving of self (Peters, 2018). Being at the bedside of a dying patient or facing the death of patients they had been caring for is one of the most difficult situations which the nurse participants in this study had to manage:

After several years, I changed my workplace to a "normal" clinic from a nursing home. There you don't see a recovered client discharged. The residents left the nursing home only when they died. It was too depressing to see that the elderly patients I had cared for were dying.

(Kang, former nurse assistant)

There are even cases where nurses felt a sense of fear when they faced a patient just about to die—or who had just died—leaving them responsible for dealing with the situation. Chang recalls her fearful feeling:

Once a patient just died during my night shift, I felt almost panic-stricken. It was the first time I had to take the first step and then move the dead body downstairs. That was the first time [that I had to do that]. I felt so scared. While taking him downstairs in the bed I was single-minded in praying to God to help me pull myself together to do this job.

(Chang, former nurse assistant)

Although infrequent, whenever a nurse had to deal with a patient's death, even more intense emotion is created, as in this case. Some healthcare workers even felt responsibility for the death of the patients they had cared for and this could be a source of emotional distress. Kim, a former nurse, still remembers one of her patients who committed suicide at a ward out of despair from her illness:

I was so upset about her when I got to know that she had killed herself by jumping out of the window in the ward where she was staying. I really tried to set her at ease so as not to worry that she would eventually recover … and really cared for her. She actually passed the first milestone [the most difficult stage] and started to recover. It seemed she didn't believe me. But it was worse for R, my colleague who was on duty that night [when she committed suicide]. R was devastated and felt so guilty for not having been able to prevent the young patient's terrible accident. R really struggled to get over this haunting sense of guilt. Clearly, it was not her fault, but even I felt very bad and deflated. What could we have done [to prevent it]? …

(Kim, former nurse)

Another source of emotional stress for the Korean healthcare "guest workers" comes from prejudicial or racist remarks overheard from—or directly expressed by—their patients. Pang, a former nurse assistant, still recounts a rude patient telling her with an angry tone, "Go back to where you came from!" when she made a mistake (Ahn, 2020:52). Her emotional reaction to this comment was very strong but she was not able to respond to or confront him, which made her even more frustrated:

Nowadays I wouldn't allow something like that to happen again and would either protest or tell him to calm him down. But well … at that time I was new here [in Germany] and my German [vocabulary] was limited … [to explain why that went wrong]. At that moment, actually I was so embarrassed and pissed off and didn't know what to do.

(Pang, former nurse assistant)

In the daily interactions with their patients the migrant healthcare workers might face sexism, racism, and other forms of abuse from sexual harassment to verbal abuse from patients. In these cases, the heath care practitioners might withdraw their emotional support from their challenging patients and have to manage the associated emotions.

Emotional Management: Performing Racialized Gender

There are ample narratives from the Korean healthcare practitioners concerning the diverse ways of dealing with the emotions aroused in the process of nursing care delivery. The successful internal regulation of emotions during patient–nurse interactions maintains their emotional and professional competence. This often causes emotional dissonance between what they actually feel and what they display, which has been identified in work on emotional labor (Hochschild, 1983; Thoits, 1990; Mann and Cowburn, 2005). For instance, a sense of disgust could be experienced while undertaking body-contact work like cleaning a soiled body or bed. However, this actual feeling is repressed because of the ideal work ethic of the nurse as remaining compassionate at all times. Sandi Mann (2004) suggests that the nature of emotional management within the context of the "caring" business is not necessarily in accordance with an organizational rule set by their employers as identified by Hochschild (1983). The healthcare professionals' internal regulation of emotions is rather in accordance with the moral disposition or moral responsibilities associated with care for their patients, and an important part of their professionalism and work ethic.

While providing nursing care, the healthcare workers experience tension between two contradictory positions: one is the position of a loving mother to provide compassionate care and the other is that of a healthcare practitioner to maintain professional distance. These contradictory positions might lead them to draw a boundary between the emotions of the carer and those of the cared for in order to manage their feelings. By their constant management of emotion in relation to the labor of care, they negotiate between a position of healthcare practitioner as their job, and that of a pseudo-familial relation like caring mother or dutiful daughter. This can be interpreted as balancing a labor of skill with a professionalized relation and "a labor of love imagined as a familial-type relation" (Anderson and Shutes, 2014:217), which is actually difficult to separate in the day-today reality of care provision.

Healthcare practitioners need to achieve a balance between supporting patients' emotional well-being through compassion and maintaining professional distance, in order not to become overly involved in patients' own emotional turmoil and also to avoid creating over-dependency on the caregivers. To find a balanced level of care, the Korean nurses seem to employ the acting of compassion when it is necessary. This balance could be maintained through skillful negotiation of the inherent contradiction between professional (emotional) distance from—and emotional bond with—the cared for. This negotiation could facilitate resilience, thereby protecting the caregivers from compassion fatigue. As noted earlier, nurses' skillful internal regulation dealing with emotionally charged and pressurized situations can be a valuable resource in efficient care delivery and ultimately in their job satisfaction.

Doing Gender

The current work connects the Korean healthcare "guest workers" diverse ways of emotional management to the perspective of "doing gender" (West and Zimmerman, 1987) and transposes the concepts of "the performativity of gender" (Butler, 1999) to racial or ethnic modality. The "doing gender" approach by West and Zimmerman (1987) theorizes how the differences between women and men are socioculturally constructed and used to reinforce and enact gender differences as intrinsic, normal, or biological through various institutionalized frameworks of society and explores how this enactment renders doing gender unavoidable.

Doing gender consists of managing such occasions so that, whatever the particulars, the outcome is seen and seeable in context as gender-appropriate or, as the case may be, gender-inappropriate, that is, accountable.

(West and Zimmerman, 1987:135)

A congruent idea of "doing gender" is found in Judith Butler's (1999) identification of gender as performed and her term "the performativity of gender," which eloquently stresses that gender is an embodied and embedded performance with sustained effects and consequently difficult to dismiss: "… performativity is not a singular act, but a repetition and a ritual, which achieves its effects through its naturalization in the context of a body, understood, in part, as a culturally sustained temporal duration." (Butler, 1999:xv)

Butler's (1999) identification of gender as performed or performative is utilized in this study to explore emotional management by the Korean healthcare professionals in the context of nursing care delivery. The nurses' or nurse assistants' situated conduct is managed by displaying "appro-priate" emotions in the nursing context such as acting out of empathy and displaying tenderness toward patients. Kind and compassionate care is considered part of women's role to play and the nursing carers are performing this discursively constructed gender disposition. Their gendered performance as caring nurses can therefore be identified as "doing gender." In fact, the healthcare workers are performing gender in a routinized and continuous manner in the course of their daily interactions with their patients over the long term. The socially constructed and sustained aspect of gender performativity, as Butler convincingly elaborated, is embedded in their nursing care practices. Gendered sociocultural expectations continue to draw the female healthcare workers into "doing gender" through the prescriptive practice of care work. Consequently, social norms around women's role of nurture and care are reproduced and embodied in nursing practices in a circular way.

Performing Racialized Gender

West and Zimmerman's (1987) and Butler's (1999) conceptualization of the socioculturally constructed and performative dimension of gender hints at the possibility of transposing it to the context of race/ethnicity. Certain characteristics are attributed to the intrinsic nature of a specific racial/ethnic group of people and the social expectation regarding racial/ethnic modality influences this group in terms of how they themselves perceive what they are. Racialized attributes and sociocultural expectations toward certain groups of im/migrants are constructed and sustained through social interaction in the host society. For example, the recurring stereotype of Korean femininity in the German media in the 1960s and the 1970s is an image characterized by kindness, gentleness, and a smiling, nonconfrontational or submissive demeanor (Ahn, 2020:40). Describing them in terms such as "innate lovability" (angeborene Liebenswürdigkeit)³ implies kindness as an inherent inclination of the Korean healthcare workers.

This media representation of racial/ethnic anticipation from the host society is operated in conjunction with "naturalized" gender norms of Korean womanhood and is socially and discursively constructed as part of racialized gender modality. The social code of Korean femininity prevalent in Germany is shaped into emotional labor carried out by the Korean healthcare "guest workers" in the context of nursing care: the image of the nurse as a caring mother figure overlaps with the stereotypical feminine image of Asian/Korean women.

Korean/Asian cultural values of caring womanhood are brought into play and carried over into their nursing practices. The former Korean migrant nurse groups I have interviewed mobilize emotional capital as part of their cultural resources in undertaking nursing practices to facilitate cordial relations and prevent any possible interpersonal tensions with their patients, coworkers, and supervisors. Indeed, some nurse interviewees share in connecting their emotional skills in care practice as an ethnic resource within an Asian/Korean cultural context. For example, when the healthcare workers care for elderly patients or residents at a healthcare institute, they might call on a sense of respect for the elderly and filial care from their ethnic cultural norms or values around filial piety.

Furthermore, Korean femininity is epitomized in a smiling icon in the German media. The image of the Korean female nurses played out in German media portrayals in the 1960s and the 1970s is on the lines of: "the quietly smiling beauties from East Asia (die still lächelnden Schönen aus Ostasien)."⁴ This bodily gesture of smiling is a way of expressing kindness and politeness, and also a means of negotiating a linguistic barrier, facilitating the maintenance of the flow of emotions in interactions with patients. Some, like Kang, found that smiling allowed her to communicate more easily with her patients and coworkers until she had gained linguistic proficiency in German: "As I didn't understand all that was being said [in German at the clinic where I worked], I felt at least I should respond with a smile. Our nicknames were all 'smiling girl'" (Kang, former nurse assistant) (Ahn, 2020:43).

The presentation of epitomized Korean femininity in a smiling image invites the women to perform this prescribed version of ethnic womanhood, which is positively perceived in the host society. This self-induced acting is not only "doing gender" but also performing racialized gender. Their gentle caring manners attributed to both their gender as women and their race as Asian/Korean are praised in describing them as "Samaritan from the Far East (Samariter aus Fernost)"⁵ or "soft angel (sanfte Engel)"⁶ in the German local media. This kind of reputation and social expectation might make them feel an almost moral obligation to perform and concurrently, willingly accept to do a compassionate Korean nurse in the destination country. The outcome of the self-presentation of caring nurses and their skillful management of emotion is gaining social recognition and job satisfaction but, on the other hand, it reinforces the enduring stereotype of Korean femininity based on gender and race/ethnicity.

Certainly, there are a few who refused to act out racialized gender stereotypes and thereby disrupt the cultural code of normative Korean femininity:

When I worked at a private clinic in 1976, one of the patients made a comment that I didn't look like a typical Korean woman. All Korean women he knew were quiet and shy. I responded that nursing is a profession where one cannot do a good job if one is shy. Why should I have fit myself into the frame [for Korean women] that he had made?"

(Son, former nurse) (Ahn, 2020:46)

Her undoing racialized femininity in an interactional situation caused this kind of questioning of her racial/ethnic origin.

As noted earlier, performing Korean femininity, which is constructed in the host society by presenting a smiling face, is also for them a means to overcome or reduce the possible tensions and/or distance caused by a linguistic barrier in their daily interactions. A smile is not only a way of responding to those being cared for, but also a way of actively performing to induce a positive emotion from their patients comparable to an actor's effort to perform well to get positive feedback from an audience. In this sense, they offer performing racialized gender as an active strategy of self-presentation in the context of emotional care. They were perceived as temporary "guest workers" who lacked competence in communication in the workplace—especially in the early stages of migration. Consequently, they make a cultural resource out of smiling and gentle kindness derived from an ethnic/racial stereotype of Asian/Korean womanhood and offer it to their patients as an act of care, demonstrating emotional commitment in the host country in return for the professional recognition they felt lacking.

Conclusion

Since care work is marked not only by gender but also increasingly by ethnicity/race, both gendered and racialized aspects of emotion and body work in the context of delivery of nursing by the Korean healthcare "guest workers" need to be taken into account. Their emotional skills are not only considered to simply derive from their feminine disposition but more particularly an Asian/Korean feminine disposition. The racialized attributes of caring Asian/Korean women behaving with compassion and devotion are assigned to the Korean female "guest workers" as inherent elements of their racialized femininity. Thereby their racial affiliation—interlocked with gender—further strengthens and legitimizes the enduring gendered disposition of emotional competencies.

This article puts a special focus on emotional work and emotional management of the Korean healthcare practitioners in the process of care delivery, which involves complex and interdependent relational work. They do perform or manage their emotions when they find difficulty in generating compassion and empathy in nursing practices. In the process of performing care duties and managing their emotions over the long term, the Korean healthcare workers also have to negotiate between providing compassionate care and coping with compassion fatigue in healthcare settings by performing racialized gender in a recurring manner. Therefore, the Korean healthcare practitioners' emotional labor is undertaken in intersection with gender and race/ethnicity. These intersectional categories of gender and race/ethnicity are not exclusive but entangled and mutually reinforcing in the performativity of gender and race/ethnicity within the context of nursing care by the "guest workers."