Doing extreme work in an extreme context: situated experiences of Chilean frontline healthcare workers during the COVID-19 pandemic

Abstract

This paper problematizes micro-level conceptualizations of extreme work to develop new research directions. The paper shows how frontline healthcare workers interpret and articulate ideas about doing extreme work during the COVID-19 pandemic. Two interconnected themes are discussed: a narrative of professional opportunity, related to identifying the extreme context as a space of opportunity to re-shape understandings about their professional purpose and gain professional legitimacy, and a narrative of occupational heroism, related to a way of doing extreme work that focuses on establishing dependable relational dynamics and working extremely as a means to become indispensable. The article reinforces the importance of the situated understanding of work settings and suggests a research agenda that can help to inform HRM policies and practices to manage and develop specific groups of professionals.

Keywords:

• Extreme work
• working extremely
• extreme context
• work and employment
• HRM
• COVID-19 pandemic
• frontline healthcare workers

Introduction

Debates about extreme work (EW) continue to develop amidst rapid changes in the landscape of work and employment, which have been accelerated by the conditions created by the COVID-19 pandemic. Evidence of worker experiences speak to increased complexity due to extreme contextual conditions where continuous pressures have added to already intense work demands and high levels of stress (see Antonacopoulou & Georgiadou, 2020; Buchanan et al., 2013; Cai et al., 2021; Fana et al., 2020; Hadjisolomou & Simone, 2020; Jecker et al., 2020; Labrague & De Los Santos, 2020; Stuijfzand et al., 2020; Wankhade et al., 2020; Willis et al., 2021). Against this backdrop, the significant changes in scope, levels of risk and degree of visibility of the job in the public domain (see Hennekam et al., 2020; Jecker et al., 2020; Luan et al., 2020; Nyashanu et al., 2020) could be said to have shifted the meaning of EW from an understanding of the extreme as fracturing or unsettling conditions that have a bounded temporality to an understanding of extremity as ‘the new normal’ feature of jobs in the contemporary landscape of work and employment.

Scholarship about EW has been developed primarily exploring features at the macro-level (structural, environmental) and meso-level (workplace settings and jobs) with limited exploration of the micro-level (individuals). Work focusing on the macro-level has explored features that characterize extreme contexts, such as danger (Pinto et al., 2017), environmental hostility (Gannon & Paraskevas, 2020; Posthuma et al., 2019; Reade & Lee, 2012), terrorist threats (De Clercq et al., 2017; Haq et al., 2019; Howie, 2007), and insecurity and political instability (Bader et al., 2020; Dickmann et al., 2008). At the meso-level, work has explored the characteristics of different sectors, such as the police force (Turnbull & Wass, 2015), the hospitality sector (Mousa et al., 2022), and the ambulance service (Granter et al., 2019; Wankhade et al., 2020). Some work has also interrogated the relationship between the nature of work and the characteristics of workplaces; for instance, exploring the extremity of physical and emotional demands of dirty work (Ashforth & Kreiner, 2014; Mikkelsen, 2022) and the impact of extremity on organizational systems (Ramirez et al., 2016). At this level, attention has also been placed on the features of extremity of particular occupations, such as architects (Sturges, 2013), media creators and game developers (Ekman, 2015; Labrague & De los Santos, 2017; Legault & Weststar, 2017; Peticca-Harris et al., 2015), hotel general managers (Blayney & Blotnicky, 2018), project managers (Delisle, 2020), healthcare managers (Buchanan et al., 2013), paramedics (Brewis & Godfrey, 2019), and nurses (Mousa et al., 2023). At the micro-individual level, occupational-based analyses have highlighted the consequences of EW demands on those working in the occupations, and some work has looked at individual disposition in relation to EW (Gascoigne et al., 2015). However, the overall emphasis has been on the negative consequences of EW on workers’ wellbeing (Aguilar Velasco & Wald, 2022; Khakimova et al., 2020; Neirotti, 2020).

These works have made a significant contribution that advances our understanding of the multilayered complexity of EW. There is, however, scope for more work focusing on micro-level conceptualizations of EW. In particular, there is scarce work (see Grima et al., 2020; Mousa, 2022) that explores workers’ interpretations of and responses to doing EW, which is essential so that individual ideas of extremity embedded within environmental and political histories in different contexts and workplace settings are brought into the discussion. In this respect, situated relational (micro-level), organizational (meso-level), and structural/environmental (macro-level) differences are relevant to enrich discussions and avoid theoretical essentialism. The views of workers are of importance because business and management knowledge has tended to universalize concepts that would benefit from more context-specific insight to move away from Western-centric interpretations (see Cooke, 2018; Girei & Natukunda, 2022). This requires bringing in theoretical articulations that emerge from workers themselves and their experiences in different contexts (Rojas, 2007). In addition, an aspect of EW that remains under-explored in the literature is the problematization of contextual differences resulting from culturally mediated and socially constructed articulation of its meaning (Granter et al. (2015).

In this paper we draw on in-depth qualitative data generated by interviews with 40 kinesiologists working in an accident and emergency (A&E) hospital in Chile during the COVID-19 pandemic to discuss frontline healthcare workers’ own interpretations and articulations of doing EW. The paper addresses the question: How have frontline healthcare workers interpreted and articulated their experiences of extreme work during the COVID-19 pandemic? Conceptually, the paper brings together literature on EW and extreme context, centering socio-historical, political, and economic dimensions to present an integrated framing that shows the situated nature of workers’ experiences. The paper identifies two interconnected themes that emerged from participants’ accounts about doing EW: the theme of professional opportunity, which relates to identifying the extreme context as a space of opportunity to re-shape understandings about professional purpose and gain professional legitimacy, and the theme of occupational heroism, which relates to the form taken by EW, in this case focusing on dependable relational dynamics and working extremely as a means to become indispensable.

The paper is organized in five sections. After this introduction, the first section discusses EW, focusing on issues of conceptualization and setting the theoretical foundations for the work developed in the paper that advocates for more attention to micro-level conceptualizations that engage with situated understandings. The second section situates extremity in context; in line with our argument of the importance of situatedness, in the second section we bring in socio-historical, political and economic contextual dimensions to highlight the relevance of problematising extreme beyond encompassing narratives about neoliberal workplaces. The third section explains the methodology used in the study reported in this paper, organized under three subsections discussing the research setting of the research, which brings together information about kinesiologists in Chile and their struggles for professional legitimacy, data collection and data analysis. The fourth section discusses the two interconnected themes that emerged from our data analysis: professional opportunity and occupational heroism. We close the paper with a concluding discussion that reflects on key messages, contributions and future research directions.

Conceptualizing extreme work

Conceptualizations of EW bring together ideas about work intensity and its associated consequences (e.g. Bozdağ & Ergün, 2021; Duncan et al., 2021; Hines et al., 2021). The term has its roots in discussions about the micro-individual level that report that individuals engage positively with intense work (see Blayney & Blotnicky, 2018; Hewlett & Luce, 2006). Subsequently, the notion of extremity was expanded to discuss contexts, events, jobs and occupations, and EW was developed in relation to work intensification and its consequences. This has made the concept more multifaceted, with most discussions now addressing the features of work that have a negative impact on individuals, such as long hours, time pressures, risky job demands and complex group dynamics (see Brewis & Godfrey, 2019; Bryant & Aytes, 2019; Granter et al., 2015; Mauno et al., 2023; Wankhade et al., 2020).

There are different approaches that discuss the impact of EW yet commonality in the understanding that its features include that the work is stressful, unpredictable, risky, intense, and physically, psychologically and emotionally demanding (Cai et al., 2021; Granter et al., 2015, 2019; Hewlett & Luce, 2006; Turnbull & Wass, 2015). Analytically, two distinct approaches are identifiable in the discussion of EW; on the one hand, some works focus on the psycho-social dimensions and consequences of EW, such as endurance, wellbeing, stress and burnout (Boxall & Macky, 2014; Carnevale & Hatak, 2020; Cham et al., 2021; Somaraju et al., 2022). These works, which mainly adopt quantitative approaches, correlate EW with levels of motivation, performance and assess the overall impact on individual wellbeing. On the other hand, some works adopt a workplace-specific approach that centers on the EW embedded in work practices within sectors and occupations. These works tend to rely on qualitative approaches and present a nuanced positioning that embeds managerial and organizational drivers that lead to EW. These works assume extremity to be something that is outside of workers’ control either by virtue of the way organizations work or by particular ways in which occupations are structured. In this respect, there is a fundamental limitation in these discussions as they show limited interrogation of how individuals understand and engage with EW or their agency in relation to it.

Two notable exceptions that illustrate this interrogation are Hewlett and Luce (2006) discussion of professionals doing EW in the US and Jordan et al. (2019) discussion of the work of funeral directors in the UK. Both works highlight, from the perspective of workers, how the extreme is embedded in the meaning of work. For example, Hewlett and Luce (2006) report their participants speaking of EW as ‘stimulating/challenging/gives me an adrenaline rush’ (p. 52), whilst Jordan et al. (2019) link extremity to the labour of emotional neutrality required by funeral directors: ‘a habitus capable of composure in the face of heart-wrenching emotional distress and repugnant sights and smells’ (p. 702). In both cases, individuals engage agentically with EW, which speaks to how the micro-individual level (how EW is done and understood) is deployed in order to bridge the gap between an extreme job (meso-organizational level) in an extreme context or event (macro-environmental level). Based on the previous point, the interrogation of the micro-individual level is then central to advancing understanding of the relationship between EW and extreme contexts/events. As noted by Gascoigne et al. (2015), EW needs to be analytically located in a multidimensional spectrum that includes the macro-institutional, the meso-organizational and the micro-occupational/individual.

Against this backdrop, understanding EW during extreme circumstances, such as the COVID-19 pandemic, requires capturing the meaning of extremity and what it means to engage in EW from a micro-individual conceptualization in order to contextualize it as part of how people adapt, develop mitigation strategies and increase resilience to navigate and survive the extreme context/event. In this respect, the conceptual possibility is to consider EW as both a demand and a strategy where different levels shape EW; recognising the individual agentic context that underpins EW then becomes important as offering the potential to conceptualize it as an intentional power move (see Iszatt-White & Lenney, 2020). The case of workers in the healthcare sector provides an example of this; a micro-individual level conceptualization of EW would consider how their high levels of affective commitment (Thanacoody et al., 2014; Yáñez-Araque et al., 2021) have been disrupted by the extreme reality of the pandemic. This has required constant crafting, reformulation and transformation of working practices (Cai et al., 2021; May et al., 2021). Having to operate and exert agency under ambiguous and unpredictable conditions has tested workers’ resilience and, in this respect, EW responses might be connected to abstract and ambiguous links between EW and a sense of moral duty and commitment to professional identity (See Curtin et al., 2022).

Contextualizing extreme work

Approaching the discussion with more granularity recognises regional/national-level distinctions; for example, by both distinguishing as well as establishing the relationship between EW and extreme context. Hannah et al. (2009: 898) refer to a context being extreme ‘where one or more extreme events are occurring or are likely to occur that may exceed the organization’s capacity to prevent and result in an extensive and intolerable magnitude of physical, psychological, or material consequences to—or in close physical or psycho-social proximity to—organization members’. In this paper, the link between EW and extreme context is relevant given the socio-cultural, economic, and political history of Chile, which is part of the Global South, but which served as a site of experimentation for the Global North Neoliberal ideology (Escobar, 2003).

Understanding EW in context requires situating the discussion in socio-historical, economic and political terms. The Chilean context could be characterized as extreme as it is a setting with a complex history of extremity. Politically, the country was shaped by 17 years of military dictatorship during modern times (1973-1990), followed by an accelerated implementation of neoliberal economic policies in the 1990s that shaped the institutional transformation of welfare systems through the marketisation of social security, social rights and property, and deregulation that has seen the labour market ‘become an instrument of the reproduction of poverty’ (Escobar, 2003:70; Julián Véjar, 2020). The idea of extremity in the Chilean context can also be traced back to its environmental features: the country experiences intense seismic activity, which some have argued make Chilean geoecology ‘an ancestral ingredient of national identity’ (Rubilar Solís, 2011: 155) and shapes a general sense of societal fatalism that pervades social and economic life (Gomez Diaz & Rodriguez Ortiz, 2006).

Some research has classed Chilean socio-political and economic environment as extreme given an unresolved social question and the country’s neoliberalism crisis, which has seen a failure to address increasingly dramatic environmental and social inequalities (Schlack, 2020). The country has also been characterized as having naturalized inequality (Parada-Lezcano, 2021). In terms of labour, the rise of precariousness is seen as central to the identity of workers, regardless of sector and social class (Blanco & Julián Véjar, 2020). Julián Véjar (2018) has noted that, whilst having been praised as a success story, the Neoliberal project in Chile has served to normalize historical dynamics and markers of precariousness, racism, vulnerability, and violence. Whilst there is scarce evidence about working conditions of professionals in the healthcare sector in Chile, some general insight speaks to a highly feminized sector where most workers are on fixed-term contracts (Alarcón Henríquez et al., 2020; Cárdenas et al., 2014). Evidence also suggests that working conditions are extreme and precarious, with workers engaging in pluriemployment/pluriactivity, with extra work being customary alongside double and triple role responsibilities. This results in a high incidence of labour burnout, chronic stress, emotional exhaustion, depersonalisation and an overall perception of imbalance between effort and reward (Luengo-Martinez & Montoya-Cáceres, 2020).

The socio-political landscape of the last three years has seen the context experience an intense period of social and socio-sanitary conflict from two disruptive events: a social outburst (Estallido Social) and the COVID-19 pandemic (Delgado, 2022). These events could be seen as merely introducing a new instability into an already unstable context, creating further challenges in the country where a large portion of the population already lives in marginality, precariousness and poverty (Rasse Figueroa et al., 2021). The social outburst erupted in October 2019 and saw marches and protests in the capital city of Santiago de Chile, denouncing injustices, abuse and human rights violations, corruption, weaknesses in systems of social protection, and sustained socio-economic inequalities, as well as demanding social and constitutional changes to support inclusive, equitable development (Castillo & Molina Milman, 2019; Madariaga, 2019; Waissbluth, 2020).

In contextual terms, there is an important relationship between the social outburst, the COVID-19 pandemic, and the healthcare sector. One of the key demands underpinning the social outburst was a call for reform of the healthcare system to make access more equitable (Centro de Estudio de Conflicto y Cohesión Social, 2019), which was, ironically, made more visible due to the system’s inability to cope with the number of hospitalizations following police brutality during the protests and marches. During this period, there was increased spotlight on professionals in the healthcare sector, who have had a particular protagonism related to keeping things afloat amidst a sectoral collapse resulting from the failure of Neoliberal policies that has resulted in hospitals struggling to cope due to lack of investment, insufficient resources, and under-staffing (Obando-Cid & Infante-Grandón, 2021).

Like many countries in Latin America, the Chilean public healthcare system is chronically underfunded –figures suggest that in 2018, the healthcare system had a deficit of US$1.15 billion and severe understaffing meant that there were 2.5 doctors, 2.7 nurses and 2.0 beds per 1,000 inhabitants (Saavedra, 2020). The former, coupled with the country’s historical socio-economic disparities, has meant that the public system survives at the extreme given that it is easily overburdened with, and unprepared for crises and emergencies (Canals et al., 2020; Gozzi et al., 2021; Litewka & Heitman, 2020). The demands leading to the social outburst were exacerbated by the COVID-19 pandemic and the centrality of healthcare professionals to support public health throughout the pandemic created further challenges. Frontline healthcare workers in Chile have experienced extreme labour precariousness through increased workloads, extended hours, stress, and high levels of personal risk due to inadequate provision of personal protective equipment (Alvarado et al., 2021; Julián Véjar, 2020; López et al., 2021; Traub & Sapag, 2020).

Methodology

This article identifies and problematizes micro-level conceptualizations of extreme work in relation to the work of frontline healthcare workers during the COVID-19 pandemic. The study draws on in-depth qualitative data generated by interviews with 40 kinesiologists working in an accident and emergency (A&E) hospital in Chile. Conducting and analyzing data throughout the pandemic allowed us to generate novel insight into a live phenomenon and its impact on the experience of a group of frontline healthcare professionals who were treating primarily COVID-19 patients.

Research setting

The study of Chilean kinesiologists offers a good opportunity to understand the transition into EW and how workers interpret and articulate their experiences in an extreme context. Chile was noticeably a country with one of the lowest case fatality rates from COVID-19 (Johns Hopkins University, 2020). This has been attributed, among other things, to the role of kinesiologists in A&E, dealing with respiratory therapy and ventilatory rehabilitation. In the hospital in this study, data available (up until March 2022) shows there were a total of 3172 workers, of which 1137 got infected with COVID-19 since 2020 to date, 23 were hospitalized and 1 died.

There is a complex history to the Kinesiology profession as its roots are traced back to a concern with movement analysis/performance (Hamilton et al., 2011) so it has always been considered as concerned with sports rehabilitation. There is an important tension related to the place of kinesiology within medicine and some (e.g. Andrews, 2008; Braniff et al., 2012; Rikli, 2006) argue that kinesiology is in crisis as the result of epistemological hierarchy, empirical ambiguity, and political impotence, which has resulted in intensified sub-disciplinary specialization and professional fragmentation.

In Chile, despite a shift from a biomechanics approach concerned with musculoskeletal injuries, to a biopsychosocial approach that adopts an interdisciplinary well-being approach that integrates biological, psychological, and social factors (Cabrera-Aguilera et al., 2020), the profession has had continued historical struggles to gain legitimacy within professional medical teams. The professional status of Chilean kinesiologists is ambiguous; despite discursive value being placed on the profession, it has lower market value in terms of salary and job prospects compared to other healthcare professionals, and public perception has historically seen the service provided by kinesiologists as optional, expensive, and bureaucratic (Hidalgo, 1984; Arcaya et al., 1998).

Against the historical backdrop of struggle to establish and maintain a legitimate space within healthcare teams, alongside emerging medical evidence of the role of physical therapy in post-COVID-19 rehabilitation (see Wang et al., 2020), kinesiologists’ role in primary care medical teams has become central in respiratory care of patients treated with COVID-19-related critical respiratory illnesses and those undergoing post-COVID-19 ventilatory rehabilitation. Kinesiologists have recognised this change in their occupational and work circumstances, referring to pre and post pandemic occupational realities (Acosta-Dighero et al., 2020; Amolef, 2020; González-Seguel et al., 2020). Studying this group provides an important opportunity to gain insight into how workers interpret and articulate their experiences of EW, and identify new research directions to contextually situate HRM knowledge.

Data collection

Data were collected from a sample of kinesiologists working in an A&E hospital in Chile during the COVID-19 pandemic, who were accessed with the support of the Head of Service. We conducted a total of 42 semi-structured interviews −40 with a sample of kinesiologists and 2 with the Head of Service, whom we interviewed as a key informant. Informed written consent to take part in the research was obtained from each participant prior to the interview. The interviews were conducted remotely through a web conferencing platform and lasted from 1 h and 15 min to 1 h and 22 min. One interview (with the key informant) lasted 2 h and 55 min due to a combination of technical issues and work circumstances. Whilst the use of the platform facilitated the interviews as they took place during a time when lockdowns were enforced, the length of interviews was significantly impacted by lower bandwidth, discordant audio-visual feeds and drops in connection (see Oliffe et al., 2021). As part of the ethics of care toward participants, following any instances of technical disruption, we sought confirmation from participants that they wished to continue the interview.

We interviewed the key informant at the start of the interviewing cycle to discuss the hospital as a work context, the historical characteristics of the service, and the impact of the pandemic on the structure of work. Our second interview with the key informant took place at the end of the interviewing cycle, which allowed us to further clarify structural features of the work context. With participants, interviews explored three dimensions: First, their interest in the profession, focusing on turning points that shaped their motivation, commitment, and career paths and goals. Second, day-to-day work practices, focusing on activities, roles, and relationships, and exploring differences between pre- and post-pandemic contexts. Third, views about the future of the profession, focusing on changes, opportunities, and challenges. See Table 1 for a sample of questions from our interview protocol. To draw insight into the spatial, temporal and relational contexts of the study, we asked participants for concrete examples to illustrate points in discussion, unpack the meaning they attributed to their accounts and avoid narrative smoothing (see Chase, 2003; Mishler, 1986).

Table 1. Sample questions from the interview protocol.

Dimension	Questions
Background about and involvement in the profession	How did you decide to become a kinesiologist? Can you tell me about yourself and your career to date? What makes a kinesiologist different from other healthcare professionals like a doctor or a nurse? What do people (e.g. your friends, family, the general public) know about kinesiologists? Do they understand what kinesiologists do?
Work dynamics	How did you come to work at the hospital? Could you take me through a typical day at work? How does this compare to a typical day at work before the pandemic? How do you think others at the hospital (patients, other healthcare professionals) see the kinesiologist and the work they do? What do you think they want/expect from you? How has this changed during the pandemic?
The profession and its future	Are there ways in which the profession has changed or evolved? What does the future hold for the profession? Has the pandemic had any impact that will affect the future of the profession?

Interviews were conducted in Spanish and transcribed in full. Quotes used in this paper were translated into English by the researchers. We conducted two interviews per day and following the first 4 interviews, we met to discuss impressions and make notes about the interview process. Subsequently, we met every two weeks during the interview cycle, developing an iterative discussion process to reflect on our interpretations of participants’ accounts and reinforce confidence in the quality of the data.

Data analysis

Our data analysis framework involved three stages of systematic analysis that supported our efforts of credible data reduction to move from raw data to consensual interpretations (Gioia et al., 2013). Data analysis was triangulated across the researchers. During the first stage, we conducted individual open coding, where each of us read the transcripts and moved through them, identifying participant-centered terms, such as wanting professional recognition, public awareness of the role of kinesiologists, kinesiologists’ multiple roles, and doctors treat kinesiologists like peers. We then met to discuss our individual codings.

In the second stage, we conducted axial coding (Scott & Medaugh, 2017) where we contextualized the codes by grouping them into themes that spoke to participants’ ideas about the connection between EW/working and extreme context. We identified four themes: The extreme context as a space to re-shape the understanding of professional purpose, the extreme context as a space to gain professional legitimacy, extreme work as dependable relational dynamics and working extremely as a means for indispensability. In the third stage, our analysis led us to identify two interconnected aggregate dimensions: Professional opportunity and Occupational heroism. See Table 2 for a sample of our coding.

Table 2. Sample of coding.

First-order codes	Second-order themes	Aggregate dimensions
Injustice of patients dying alone questions sense of purpose Kinesiologist now recognised Managing undefined disciplinary limits Claiming space of respiratory therapy	The extreme context as a space to re-shape the understanding of professional purpose	Professional opportunity and legitimacy
Kinesiologists now part of medical teams Challenge to prove professional worth in A&E medical teams Working as hard as other medical professionals Kinesiologists not just assisting professionals	The extreme context as a space to gain professional legitimacy
Explaining deaths to patients’ families Having doctors’ backs Spending more time with patients than others Building trust Being there for patients and their families	Extreme work as dependable relational dynamics	Occupational heroism
Sacrifices needed to do the job right Emotionally and mentally demanding work required	Working extremely as a means for indispensability

Findings

The extreme context as a space for professional opportunity and legitimacy

Participants’ accounts alluded to a re-configured understanding of extreme context as a space that provided an opportunity to reaffirm their professional purpose. They considered the hospital setting of this research as extreme given its focus on unpredictable emergency situations, catastrophes that require medical teams’ utmost effort and attention during a constrained period and where minute-by-minute critical decision making has life or death consequences for patients. However, they saw this as an opportunity to demonstrate that they could thrive professionally. Their accounts highlighted that working at the hospital during the pandemic created an enhanced sense of extremity constantly characterized by high-tension unpredictability that tested their professional and personal resilience like never before:

“It is when the doctor says we are not going to intubate her, a very vague example, I don’t know, she has lung cancer and has COVID, what do we get out of intubating her and doing a tremendous procedure if this person is already tired, she is probably not going to endure the procedure and you only do palliative care, […] that really causes me… to see that he is going to be alone and that he is going to die alone, for me that is a challenge to be able to take care of that patient and continue my life and not get stuck in that… that is a huge challenge”

“When I see that there is no dignity, now, in a patient who is LTE’d [limitation of therapeutic effort] and is going to die alone. Then I feel like leaving, I don’t know if I’m going to hold on and then I sleep and it passes, I wake up with more desire again and we keep at it, that’s it. But the injustice makes me very angry”

With the pandemic, Chilean primary healthcare was stretched to the limit and the introduction of kinesiologists as part of medical teams was seen by participants as a catalyst for a stronger sense of professional purpose that translated into actions to affirm their expertise and showcase their contribution. Participants saw themselves as part of a ‘new normal’ future that they could also build for themselves as a credible professional group because, whilst extreme and unknown, it was seen as an avenue to overcome professional invisibility. Participants relished the recognition and felt positive about being seen as an important professional group:

“… now in this context and with everything that is happening now and for a while, I feel that now the kinesiologist has become a person […] He has become an important person within the team, his voice and opinion has come out much more, it has come out much more now”

“There was a moment in the course of the pandemic when the ministry said that the hospital is a COVID hospital, therefore all the existing beds had to be reconverted into COVID beds, and all the other services had to be referred or treated elsewhere, so this is a notion of emergency, a state of war in a way, of catastrophe and it is assumed that we cannot be eternally in a state of permanent catastrophe, that is to say, there will come a time when this will have to return to normality, to a normality that will not be the same as before”

Speaking of this enhanced sense of purpose, participants highlighted the importance of thriving amidst the extreme circumstances, where any sacrifice was a small price to pay to achieve their ambition to have more legitimacy and recognition. In practical terms, this involved making choices that radically altered their everyday lives; for instance, some participants reported renting rooms closer to the hospital so that they could be on call at any time whilst others took up residence in a labour hotel for frontline healthcare professionals arranged by the government via the National Health Service to reduce the risk of COVID-19 spread and infection to family members. Similarly, to enhance their presence and voice in discussions between medical teams, kinesiologists created WhatsApp groups to participate in discussions and share insights during and outside their shifts:

“Yes, it is very demanding, I have realized that many times my partner challenges me because I am looking at WhatsApp from work, knowing that I am not on shift and I should not have to look at it, but I am thinking; they categorized that patient that I saw the night before, will he be okay? Suddenly I feel that I’ve become very internalized with the situation”

“After being here, being in a labor hotel, I could not go to Curicó for fear of infecting my family and when I was able to travel now, on August 10th, it seems that it was very… I got emotional, because my daughter had a growth spurt and I wanted to hug her and she looked at me, like in shock that I was there, my son was looking at me and all I wanted was for them to hug me”

However, these efforts were presented as both required and necessary to demonstrate professional commitment to the ethos of service and quality of patient care and ability to exert control in extreme circumstances:

“There’s an adrenalinic component, so that’s how it goes, because I like that, there may be chaos, but I keep my cool and know what needs to be done, I know how to make decisions, so that’s what I like, the challenges. And as kinesiologist there are many challenges, and since I left university, I have faced the challenge of demonstrating that the kinesiologist is necessary in emergencies and all that”

Despite the impact of the extreme conditions on their personal and professional lives, participants alluded to the pandemic creating ‘a space for the taking’, which they seized by engaging fully with the challenges facing their everyday practice at the hospital. Participants saw the pandemic as providing them with the opportunity to gain professional legitimacy, an opportunity they embraced through coordinated team efforts that involved developing new skills (e.g. mechanical ventilation) and ensuring that their presence and professional opinion were considered in decisions taken by medical teams. In participants’ views, the pandemic created a unique opportunity for kinesiologists to secure a legitimate place within these teams, allowing them to show their expertise, strengths, and commitment. They considered this an opportunity that had not been previously available to them due to a combination of historical, social, and institutional factors that had undermined the profession:

“We are now part of the team and that is very gratifying […] what I used to hear about us: the kinesiologist is that one who helps footballers, the one giving massages”

“[during the pandemic] For example, aspiration was a huge problem for both the nursing profession and us, because they think they own aspiration, and in this case we own aspiration because it is part of the airways, but for them that is a conflict, because that is in their programme of study, and they should do it, but the nurse does ten thousand other things, therefore, that function started to get relegated, and we have already owned it”

For participants, an important aspect of this relationship was about ‘having doctors’ backs’ as peers and moving away from the clinical-attendance role that had characterized the profession (see Damiani et al., 2021). This included, for instance, spending more time with patients than doctors were able to and creating informal alliances with other professional groups to secure participation in consultative exercises. At the same time, their participation in medical teams was problematised in relation to the challenges of teamwork. Given the background of invisibility, participants noted that there was a tradeoff between teamwork and professional autonomy. Many saw successful teamworking as the result of gaining spaces of legitimacy within the team without being overbearing or imposing, showing flexibility to successfully negotiate relationships with others and operate without disrupting existing hierarchies:

“I think it shows in what I’m telling you, like suddenly… in this work, when you try to do this multidisciplinary work, and for everyone to participate and everything that I have told you, you also have to know that sometimes you have to give in, as if to do what is best for the patient, and the flexibility shows in the ability to do that”

Working extremely as a means for occupational heroism

Narratives by participants suggested an understanding of extreme work as a way to create dependable relational dynamics. At the height of the pandemic, kinesiologists were publicly hailed as the heroes of the pandemic by Chilean health authorities. With this visibility, they felt a responsibility to develop dependable relationships with the different groups they regularly engage with (e.g. patients and their families, hospital management, and other healthcare professionals) to live up to the public expectation created about them. Their efforts included actively seeking to be part of the treatment of the most extreme cases in order to claim a space within the core medical teams.

However, they recognised that ‘it’s hard to be included in some services of the team’ and they addressed this by strategically engaging with other professional groups. Some participants recognised that this had led to positive shift in their relationship with doctors and recognition that despite the doctor-centered approach in primary care teams, they now engaged as peers and doctors trusted kinesiologists’ clinical judgment:

“… we are still with paternalistic medicine remnants, still the “Godtor”, he still has the last the word, and that’s fine, because it means he assumes responsibility, but in the exercise of having the last word we can intervene and give our point of view, and obviously validate it”

There were two dimensions to these efforts. On the one hand, they identified the importance of communicating to doctors and nurses more explicitly the work kinesiologists to simultaneously increase trust and gain professional independence in medical decisions:

“… in critical units there are discussions between the nurse, the doctor and the kinesiologist, there’s a very important participation in the recommendations made by the kinesiologist, who also does individual interventions and then informs the rest”

On the other hand, they highlighted the increased social, psychological, and emotional labour required to develop relationships with patients and their families. Participants alluded to these relationships as complex and multifaceted, involving adopting different roles: therapists, psychologists, and advocates to build trust whilst maintaining professional control of the interaction:

“I think it is fundamental, but for us, that is, I think that if you are not close to the patient, if you are not proactive, apart from being a kinesiologist you have to be many other things, that is, the function that we have does not start from the beginning, but we also have a bit of containment with the patient, our therapy goes beyond the motor or neurological, or respiratory, it also goes hand in hand with psychology, a little more… or a more holistic view, in this case, because that is how I see it, or at least that is how I see kinesiology”

Participants spoke of the importance of extending their care to the families in the form of being responsive to their needs for information and clarification and becoming an important point of contact. Establishing relationships with families was seen as complex due to the difference between closeness with the patient and keeping family involved whilst maintaining professional distance. Some noted that this became particularly challenging when it came to providing information or dealing with traumatic outcomes, such as patient deaths, where participants felt that given their closeness with patients, their families would turn to them for answers:

“…it’s no small thing being in hospital without the family and at times they don’t have a clue about what’s happening”

Amidst the contextual enhanced extremity, participants normalized working extremely in order to cement their indispensability. This involved engaging with the number of working hours, number of shifts and established new protocols without raising any questions about the level of demand on their time and effort:

“. It was, let’s see, at the peak of the pandemic I had the same meeting, I was more stressed, I did not sleep, I woke up at 4 AM and at 6 AM I was up, I did the elliptical and then came to work. The most intense thing was to go up and see that people were intubated, people in the emergency room waiting for the PCR, So, I would go up to the floors and I would go down to the kinesiologists and say "go take a sample, go do this other thing", in other words, directing things more, faster, more intense, we have always been intense in this hospital, we have always been fast, but…”

“At least for me, as I work rotating shifts, I have to work 24 hours a day, now that we have been working since the social outburst, since October of last year we’ve been working for 24 hours then off. Being 24 hours locked up with people who are generally very nice and very human and friendly is ok, but it gets you to arrive home, to spend a night at home, or to miss some Christmases, or to miss some of your nephews’ birthdays. But at the end of the day these are vectors or factors that you assume when you enter this system of attending patients in shifts, ultimately”

Working extremely was seen as a way to remain visible and recognizable, which they saw as part of the effort to strengthen their professional status as a group and in relation to others. They narrated the indispensability in relation to expectations that they would be able to re-frame the scope of their profession and claim the distinct expertise they see themselves as having:

“We want to be more than respected, we want to be necessary, that they [hospital management, doctors and nurses] realize that we are necessary […] we want to be part of the core team”.

Participants explained their commitment to excel at and develop their subject expertise to continue creating spaces for kinesiologists in different hospital areas and alluded to this as a goal that could only be accomplished on the ground and that required being there at every opportunity. This was the explanation participants gave for taking extra-shifts and being available 24/7, whilst also alluding to being needed.

In sum, the two themes are centered around the possibilities for professional recognition, legitimacy and indispensability that the pandemic had given the profession in the context. Many referred to the pandemic as ‘unfortunately positive for the occupation’ with some recognising the irony of what they saw as a positive outcome during a time of such unprecedented and extreme crisis:

“We are one of the ones we could say… of the professions that has been most validated with this pandemic, because there is no doubt about our absolutely decisive role in the treatment of any critical patient, like the critical patient who has COVID-19”

“We have grown in numbers, there you can notice it. When I arrived at the hospital we were four kinesiologists for thirty-two beds. Today we are one for six patients so it’s the case that the kinesiologist has gained a position, has won a place and has been respected a bit more”

Discussion

The paper problematized micro-level conceptualizations of extreme work to develop new research directions. The notion of EW was expanded via the analytical positioning of workers’ interpretations and articulations within the socio-historical, political and economic contextual dimensions where they are produced, which constitutes the first contribution of this paper. The idea of extreme context was used to frame interpretations and articulations about EW. Following calls to pay attention to context-specific insights that bring theoretical articulations that emerge from workers’ experiences (see Cooke, 2018; Girei & Natukunda, 2022), this paper adopted an integrated framework that looked at EW conceptually and contextually to develop research directions.

When looking at how frontline healthcare workers interpret and articulate ideas about doing extreme work during the COVID-19 pandemic, two interconnected themes were drawn upon. The first was professional opportunity, where the extreme context was seen as a space of opportunity to re-shape the understanding about professional purpose and as a space to gain professional legitimacy. The second was occupational heroism, where EW was used to develop dependable relational dynamics and working extremely deployed as a means for indispensability. These interconnected themes present us with a situated micro-conceptualization of EW that agentically responds to factors in the macro-environmental (e.g. recognition) and meso-organizational levels (e.g. work relationships).

The literature has extensively framed EW discussions in three ways, looking at the disruptive and disempowering effects of extreme contexts on workers (Hällgren et al., 2018), the features that characterize extremity in sectors and occupations (Buchanan et al., 2013) and the efforts that organizations undertake to manage extremity and extreme work (Bamberger & Pratt, 2010). An important assumption here is that workers have limited agency due to the pressures of work, setting and overall context. Findings in this study support this idea because EW emerged both as a response to joining the frontline, working in an A&E hospital, and doing this in the context of the COVID-19 pandemic. However, the nuances of how EW was agentically deployed suggests more intentional ways to capitalize on the deployment of effort and a multi-layered agenda of self-interest.

The themes resonate with the underpinning point made by Hewlett & Luce (2006) that ‘extreme professionals don’t feel exploited; they feel exalted’. This suggests that the articulation of EW as something that is done to workers requires more nuanced interrogation. Participants’ accounts placed a lot of attention on strategies that could be used to adapt through the reconfiguration of their professional praxis (developing specialist skills in mechanical ventilation) or making life-changing choices (moving to a hotel and leaving family and children behind). This strong focus on individual strategies highlighted limited questioning of wider structural and organizational forces, which would be consistent with the idea that EW has been normalized to the point of becoming an unquestioned part of work (Granter et al., 2015; Turnbull & Wass, 2015).

The EW literature has highlighted the need to explore extremity as a culturally mediated and socially constructed phenomenon (Granter et al., 2015). This paper has enriched the HRM literature by adding a situated explanation of how EW is interpreted and articulated by workers themselves. The paper has shown a contextual use of EW where the nuances of extremity are framed as a professional opportunity for legitimacy and to cement the need for the occupation. In line with previous arguments (see De Rond & Lok, 2016), the paper shows that the specifics of context are central to how people ‘filter, frame, and cope with their experience’ (p. 1965). What we have presented here epitomizes the challenges faced by frontline healthcare workers but also brings in the importance of their interpretations as being situated within an occupational and national context that shaped those interpretations. On the one hand, the context was the catalyst where their accounts were situated within relevant historical, socio-political and economic trajectories. This situatedness helped us to understand the foundation for the way in which ideas of extreme and their implications and opportunities were perceived by this group of kinesiologists. For instance, working as part of primary care medical teams was a longstanding goal that had not been achieved due to a historical lack of legitimacy of the profession in relation to doctors and nurses, and the understanding of the profession as being primarily a role of assistance to those in core medical teams.

The paper contributes an understanding of how interpretations and articulations of EW and its interplay with extreme context are mobilized for advantageous professional and occupational purposes. The paper showed two interconnected themes: professional opportunity and occupational heroism; the first theme showed an understanding of the extreme as an opportunity for frontline workers to redeem themselves in professional and occupational terms in a way that interpreted the pandemic as a space for disciplinary vindication. The second theme showed how ideas of indispensability and dependability were translated into working extremely as a way to seize the opportunity for occupational re-positioning. The third contribution of the paper is to show that amidst the extreme disruption created by the pandemic, for workers who have endured the worst of the pandemic (e.g. risk and death), the interpretation of an extreme context as an opportunity and its materialization through doing EW presents an important theoretical question about the conceptualization of extremity. For this group, doing EW was presented as part of a wider aim of professional repositioning to gain legitimacy, credibility, and indispensability.

Conclusion, limitations and future directions

Based on the findings and discussion presented in the paper, we conclude that it is important to problematize EW as both fluid and contextual. Even when many jobs and occupations have components with outcomes that can be understood as EW, there are also dimensions that, whilst emerging from contextual circumstances that make the conditions of the work extreme, are articulated by workers in different ways, e.g. as spaces of opportunity. This is an area of discussion that could be linked to the political economy of opportunity and be integrated into more regional/national level discussions that bring together structural and institutional frameworks and their relationship with work, employment and HRM. In multidisciplinary terms, the findings could help to inform more integrated analyses that engage with work on identity, prosociality and prosocial motivation to understand responses to extreme events (e.g. Maki et al., 2019, Caldas et al., 2021; Ntontis et al., 2021; Politi et al., 2021). The specific potential lies in the possibilities to use this foundation to help us to explore worker sensemaking and agency in the face of extremity.

In terms of limitations, whilst this paper has shown the value and importance of exploring and expanding situated micro-individual level conceptualizations of EW, there are two main limitations that we identify in this study. First, there is an important tension in interrogating EW during the COVID-19 pandemic because the framing of extremity during this period could be seen as temporary; this work has become extreme (Bozkurt, 2015) so the focus on micro-individual level risks overemphasizing meanings and interpretations that could have a limited temporal framing. In addition, there is limited interrogation of the interplay with features at macro-environmental and meso-organizational levels, such as national professional regulation and organizational HRM policies and practices. In this respect, future work would benefit from adopting a cross-sectional approach with a broader framing that includes a triangulated exploration of EW to highlight the interaction and interdependence of the features at different levels. In this case, for instance, the legitimacy of the profession in the study is also linked to overall macro-environmental regulatory structures so a contextual change in the framing of regulation might re-shape the way this group is managed and the spaces they have in hospital settings. In turn, this could impact the HRM policies and practices used in organizations to manage this group. Second, the focus of this study on workers within a single research setting during a specific time of crisis frames the findings in relation to the particularities of the organizational setting, in particular, work culture. Schein (2010) has noted that the strategies used by individuals to cope with organizational issues are part of situated learnings and discoveries. In this respect, future work could look at broader sectoral exploration as well as enhance micro-level conceptualizations by undertaking comparative work.

Moving forward, findings help to delineate an emerging research agenda that focuses on issues that are currently not critically interrogated. In general, the paper has highlighted that HRM research needs to pay more attention to micro-individual conceptualizations in theorization. The prioritization of HRM on the meso-organizational level leaves scarce understanding of different understandings of EW. This makes it necessary to critically question the theoretical scope and limits of extremity based on situated understandings. For example, how do we account for countries’ histories of extremity in labour, work and employment practices and conditions in the way we theorize concepts and apply them in HRM discussions? The idea that extreme work happens to workers presumes that they have limited agentic power to navigate it and use it to their advantage, and more research is needed that analyzes this. The recognition of the COVID- 19 pandemic as the most extreme public health crisis confronted by humanity in this century, coupled with the significant personal and professional impact on frontline healthcare workers (e.g. given the additional considerable risks attached to the direct, physical contact with patients and others in hospital settings), makes the connection between EW and the worker not difficult to imply. However, there has been limited space in extant scholarship that has looked at the pandemic to explore differentiated experiences and accounts from workers that center their agentic efforts within situated structural and institutional characteristics and constraints. It is at the intersection of these nuances that more research about doing EW is needed.

Regarding discussions about the future of work, there are important considerations that our findings bring, which are related to sustainable HRM. Situated understanding of work settings have much potential to inform HRM policies and practices to manage and develop specific groups of workers. Against this backdrop, this paper offers support for Cooke’s (2018) call for a fundamental reappraisal of how we consider context in the field of HRM. It is not just a case of identifying where on a scale a particular national or regional setting might be placed: the whole basis of the scale–indeed the idea of a scale itself– needs to be subject to scrutiny. In our case, we used context as a multidimensional construct that combines the occupation, the organizational setting and the country and situated it in socio-historical terms. Calls for a more sophisticated approach to the way wider contextual conditions are incorporated into the study of experiences of work and employment allude to contextual problematization that is less mechanical and superficial and situates experiences within analytical frameworks that open opportunities to explore variability in responses to contextual characteristics (see Cooke, 2018). The potential here is to consider diverse interpretations of extreme work or extreme work in context. This would help to further unpack Granter et al. (2015) idea of EW as culturally mediated and socially constructed.

Acknowledgments

The authors are indebted to all the kinesiologists who took part in this study. The authors wish to thank the two anonymous reviewers for engaging with the ideas developed in this paper, and for their useful comments and suggestions.

Disclosure statement

The authors have no interests to declare.

Data availability statement

The data that support the findings of this study are available from the corresponding author, upon reasonable request.