Have you ever been attacked by some­one whose life you were try­ing to save? Have you ever been asked by the police to iden­tify human remains? Taken a phone call from some­one try­ing to save their dying child? Prob­a­bly not, but this is all part of pro­fes­sional life for many peo­ple work­ing in Britain’s National Health Ser­vice. For some, such ‘extreme work’ is part of their daily reality.

These expe­ri­ences emerged as we (with col­leagues Paula Hyde and John Has­sard) spent time with Nurses, Man­agers, Para­medics, Emer­gency Call Han­dlers and Dis­patch­ers and oth­ers as part of an immer­sive three year study of work­ing life in the NHS. Some of these expe­ri­ences were recounted in inter­views, or as we accom­pa­nied peo­ple through­out their work­ing day. We spent a day with call han­dlers at an Emer­gency Con­trol Cen­tre who took 999 calls from peo­ple at the worst moments of their lives – but also, occa­sion­ally, the best; more than one had talked some­one through deliv­er­ing a baby. Good or bad, what struck us as researchers was that many of these were mat­ters, quite lit­er­ally, of life and death. In light of this, we were sur­prised by how young many of the call han­dlers were; peo­ple in their early to mid twen­ties, some hav­ing just swapped the lec­ture the­atre of a uni­ver­sity for a busy inner city emer­gency call centre.

While the theme of ‘life and death’ ran through the research (maybe not sur­pris­ing given the con­text), not all of the work we saw involved hor­ror and high drama. Often, it was more a mat­ter of pace of work, as well as the stakes involved. Man­age­r­ial meet­ings are per­haps not the most obvi­ous set­ting for fast paced, high inten­sity work, but in an organ­i­sa­tion under as much pres­sure as the NHS, they were often con­ducted at a tempo quite in con­trast with that we our­selves were used to. Once again, what is at stake is key – the impor­tance of var­i­ous per­for­mance tar­gets, for exam­ple on wait­ing times or infec­tion rates, meant that sta­tis­tics flew back and forth with dizzy­ing rapid­ity. While hard tar­gets for exam­ple are impor­tant to the orga­ni­za­tion, they also had a more overt, and imme­di­ate human ele­ment. With allow­ing a patient to breach a wait­ing tar­get, or the hos­pi­tal run­ning out of beds very much not the ‘done thing’ for the NHS man­ager on the spot and want­ing to stay in their job, things can get rather fre­netic as the pos­si­bil­ity draws near – phones are ham­mered, favours are called in, patient moves are co-ordinated with some haste, wards are opened, oxy­gen tanks checked… and dis­as­ter is (usu­ally) averted.

Spend­ing time with an ambu­lance con­trol cen­tre man­ager, we asked him at inter­vals through­out his 12 hour shift to rate the level of inten­sity of work. At 10am things were pretty calm at ‘level six’, but as the day drew on and the weather wors­ened, road traf­fic inci­dents began to mount up and demand for ambu­lances rose. By 4pm the man­ager was deal­ing with cars — which might or might not con­tain decap­i­tated teenagers — stuck under bridges, ambu­lances break­ing down, and bor­row­ing a heli­copter from another ambu­lance ser­vice in order to fly some­one hun­dreds of miles for a life­sav­ing oper­a­tion. While his team of 15 junior col­leagues were almost as busy, it was the man­ager to whom the most crit­i­cal inci­dents were handed. At the same time, he had to deal with per­son­nel issues such as pro­ba­tion and sick leave. We had never, until observ­ing this man­ager, seen a phone ring as soon as it is put down – over and over again. The inten­sity level by 4:30pm?-‘ten, but here it can go up to eleven’….

The ‘rapid fire’ prob­lem solv­ing we saw in this and count­less other instances gave us the sense of ‘man­ager as fighter pilot’, crit­i­cal deci­sions made rapidly in an envi­ron­ment of pres­sure and inten­sity. Other researchers had noted sim­i­lar lev­els of inten­sity, with David Buchanan’s research team, for instance won­der­ing if health­care jobs were becom­ing ‘extreme jobs’ (Buchanan 2011). While the NHS col­leagues we spoke to all accepted their lot as part of their job as pro­fes­sion­als, high lev­els of stress lurked, unspo­ken, in the back­ground, and lev­els of stress in the NHS are for­mally reported as being very high. Aside from the inten­sity of work, many peo­ple we spoke to, par­tic­u­larly man­agers, found that the amount of work they were expected to get through seemed to be increas­ing. Very often, work was taken home to be com­pleted in evenings and week­ends, because the large vol­ume of paper­work or data entry sim­ply could not be dealt with in the hospital/ emer­gency con­trol centre/ ambu­lance sta­tion because of ‘con­stant interruptions’

Widen­ing the soci­o­log­i­cal dis­cus­sion fur­ther, we have become inter­ested in how intense work and long-hours cul­tures are increas­ingly under­stood as ‘the norm’ in con­tem­po­rary work­places. Increas­ingly, many peo­ple take long hours and very intense work for granted, believ­ing it to be inevitable; an unspo­ken part of the employ­ment con­tract. In an attempt to char­ac­terise this sit­u­a­tion, com­men­ta­tors have used seem­ingly para­dox­i­cal or tau­to­log­i­cal phrases such as ‘nor­mal­ized inten­sity’ (McCann et al 2008). For many in the twenty– first cen­tury work­force, extreme has become nor­mal, nor­mal has become extreme.

As part of our devel­op­ing inter­est in extreme work in all its forms, we are run­ning a stream at the 2013 Crit­i­cal Man­age­ment Stud­ies con­fer­ence here in Man­ches­ter, and there will also be a spe­cial issue of the jour­nal Orga­ni­za­tion on this theme; please look out for fur­ther details and calls for papers, or con­tact us at edward.granter@mbs.ac.uk.


  1. Buchanan, D. (2011) Are health­care man­age­ment jobs becom­ing extreme jobs? , Cran­field Health­care Man­age­ment Group Research Brief­ing 7. Cran­field Uni­ver­sity, UK.
  2. McCann, L., Has­sard, J. and Mor­ris, J.L. (2008) ‘Nor­mal­ized Inten­sity: The New Labour Process of Mid­dle Man­age­ment’, Jour­nal of Man­age­ment Stud­ies , 45, 2: 343–71.

Acknowl­edge­ment and Disclaimer

Our project was funded by the National Insti­tute for Health Research Health Ser­vices and Deliv­ery Research (project num­ber 08/1808/241). Visit the HS&DR Pro­gramme web­site for more infor­ma­tion. The views and opin­ions expressed therein are those of the authors and do not nec­es­sar­ily reflect those of the HS&DR Pro­gramme, NIHR, NHS or the Depart­ment of Health.