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Drawing on interviews with two types of essential workers – wound clinicians and care workers – the chapter examines stigma management in dirty care work through the lens of emotion management. The study combines two dimensions of dirty work: physical taint in relation to bodywork and social taint linked to working in close proximity to socially stigmatized clients. Hence, stigma management extends to dealing with the physically and socially dirty features of essential care work. In addition, the authors’ assessment of social stigma includes how essential care workers also sought to alleviate the social stigma encountered by their clients. In so doing, the authors extend the literature on dirty work to identify how emotion management skills are central to the stigma management strategies of the essential care workers in this study. The authors demonstrate how both groups deal with their stigma by emphasizing the emotion management skills in ‘doing’ dirty work and in the ‘purpose’ of this work, which includes acknowledging how the authors attempt to address the social taint encountered by their clients. Additionally, by comparing two occupations with different contexts and conditions of work, the authors show how complex emotion management skills are gendered in care work to expand the understanding of gender and stigma management. Furthermore, these emotion management skills emanate from the deep relational work with clients rather than through occupational communities. The authors argue that by focussing on emotion management, the hidden skills of dirty work in gendered care work are illuminated and contribute to contemporary debates about whether stigma can be overcome.

In this article, we outline our views on the appropriateness and utility of Return on Investment (ROI) for the evaluation of the value of healthcare quality improvement (QI) programmes.

Our recent research explored the ROI concept and became the genesis of our viewpoint. We reflect on our findings from an extensive research project on the concept of ROI, involving a multidisciplinary global systematic literature review, a qualitative and Delphi study with mental healthcare leaders from the United Kingdom National Health Service. Research participants included board members, clinical directors and QI leaders. Our findings led to our conclusions and interpretation of ROI against the broad QI governance. We discuss our views against the predominant governance frameworks and wider literature.

ROI is in-line with top-down control governance frameworks based in politics and economics. However, there is evidence that to be of better utility, a tool for the assessment of the value of QI benefits must include comprehensive benefits that reflect broad monetary and non-monetary benefits. This is in-line with bottom-up and collaborative governance approaches. ROI has several challenges that may limit it as a QI governance tool. This is supported by wider literature on ROI, QI as well as modern governance theories and models. As such, we question whether ROI is the appropriate tool for QI governance. A more pragmatic governance framework that accommodates various healthcare objectives is advised.

This article highlights some of the challenges in adopting ROI as a QI governance tool. We signal a need for the exploration of a suitable QI governance approach. Particularly, are healthcare leaders to be perceived as “agents”, “stewards” or both. The evidence from our research and wider literature indicates that both are crucial. Better QI governance through an appropriate value assessment tool could improve clarity on QI value, and thus investment allocation decision-making. Constructive discussion about the utility and appropriateness of ROI in the evaluation of healthcare QI programmes may help safeguard investment in effective and efficient health systems.

The article raises awareness of QI governance and encourages discussions about the challenges of using ROI as a tool for healthcare QI governance.