Abstract
In France, the health system is characterized by both a centralizing State and strong market pressures (liberal medicine, pharmaceutical industries, etc.). Within the framework of budget reduction policies, this confrontation has led to savings on the productive wage bill within the public hospital rather than on medical fees or industrial profits, resulting in the elimination of beds and a reduction in the number of permanent staff, while administrative employment has increased for management staff. In the face of the pandemic, the mobilization of health care workers was able to demonstrate its effectiveness, compensating for the deficits in equipment and organization from above. Mutual aid is highly contextualized, based on local logics and interaction configurations. If mutual aid prevailed overall, exhaustion was spreading among the troops before the second wave and then the third wave. At the same time, the management did not involve the healthcare teams more in the decisions, contrary to certain participative attempts in the past. The management team, which was not involved in the crisis, tended to reassert its presence as if nothing had happened, even though a distinction had to be made between a type of management that was close to the patients and a type of management that was in control and enforced the hierarchy.
How can we move towards a ‘foundational economy’, compatible with a robust and sustainable democracy? From a health point of view, this is a sea snake in France: on several occasions, public health has wanted to become more firmly rooted in democracy by including its various stakeholders, patients and healthcare professionals. It has affirmed its territorial dimension, the importance of primary care, the role of lay people, the development of quality of care, pain management, the development of prevention, the extension of health coverage for the most vulnerable populations, etc. This non-exhaustive list, to which we shall return, shows, to say the least, the importance of public debate in terms of ‘health democracy’.
Has the pandemic crisis allowed progress in this direction? Although it is still too early to give a full answer, we can give some elements of an answer here, showing on the one hand the major trends at work over the last 20 years and on the other hand the recent feelings of care providers, faced with the organization of work in the context of the pandemic.
France has been ranked among the ‘poor performers’ for its management of the pandemic, due to a high mortality and infection rate (Paton, 2020, cited by Gay and Steffen). Ranked among the intermediate countries for the quality of its political response to the crisis, it is characterized both by the weakness of its proactive policies (number of hospital beds, available equipment, quality of intensive care, etc.) and by strict reactive measures to control the epidemic in order to contain the level of mortality (Rosental, 2020). Containment was the ‘default solution’ (Gay & Steffen, 2020) to compensate for the prevention deficit, the lack of provisions and forecasts. Other emergency measures have been taken, such as public funding to address health inequalities or the social crisis of covid. In the same vein, the over-mobilization of care-giving groups was the adjustment variable of the hospital system to the health crisis, which peaked in April 2020 with 32,000 covid hospitalizations (Gay & Steffen, 2020).
After having outlined the paradoxes of the health system, we will show the successive states of integration of the care-giving groups by putting into historical perspective and updating our understanding of the term health care mobilization during the pandemic in 2020.
A Documentary and Qualitative Methodology
Conducted mainly on a qualitative basis, but also on quantitative data as far as hospital executives are concerned, our previous surveys covered the whole of France in the public and private hospital sector (Castra & Sainsaulieu, 2020). In this article, we focus on paramedical caregivers, who play a critical role in the pandemic.
Reactivating our survey networks, we were able to conduct for this article ten interviews around the situation created by the pandemic. As shows, most of them are experienced caregivers, who have been working in their establishment and service for ten or twenty years, four of them having had local union mandates (unions named SUD, for Unified and democratic solidarity, or UNSA, for National unity of autonomous syndicates).
Table 1. List of interviews (establishment, medical specialty and seniority).
These ten semi-directive interviews (each lasting 3/4 h) were conducted remotely at the beginning of December 2020 and focused specifically on working conditions, working relations with patients, colleagues, and the hierarchy before, during and after the first wave of the pandemic in the spring of 2020. For a better cohesion of the data collected, we carried them out in a university hospital and a nursing home in the East of France, the region most affected by the pandemic (first wave). A large proportion of the hospital caregivers have been mobilized outside their assignment department to ‘covid services’, resuscitation, post-resuscitation or palliative care. As the stakeholders testify, we cannot understand the meaning of their intervention during the pandemic without referring to the initial conditions of their teamwork. So what were the impacts of the health crisis on health care collectives? Did the Covid-19 pandemic lead to new forms of cooperation? What happens to work collectives reconfigured by the crisis when it temporarily moves away? These are the questions that accompanied our immersion in the field.
The Contradictions of a Centralized Public and Private Health System
The hexagonal health system has taken a managerial turn, under the pressure of social and economic forces. Reputed to be exemplary, following the measures taken in the post-war period, this system has been reformed several times, not without consequences for the working conditions of care providers. At the turn of the last century, all international studies (EU, OECD, WHO) affirmed that France had one of the most efficient health systems in the world (WHO, 2000). Accessible to the entire population via compulsory health insurance, this system combines it with supplementary schemes and solidarity measures such as universal health cover (CMU) or assistance in acquiring supplementary health insurance (ACS). In principle, the French system is one of the most generous in terms of coverage, at the cost of a significant weight in GDP: 12% in 2012, 11.3% in 2018 (Gay & Steffen, 2020). The average for OECD countries was 8.8% in 2017.
The French model is specified by the traditional confrontation between the central state and liberal medicine, in contrast to the decentralized self-administration of German funds and the traditional association of the German medical profession with the management of the health system (Pierru, 2010). Recent developments confirm the institutional trajectory in France: although doctors joined the hospital as a result of its rise in power after the Debré reform in 1958, they have always kept the possibility of having a private activity and tend to take refuge in private clinics in the face of the increasing problems of the public hospital. On the other hand, the rise of taxation (CSG, CMU), the influence of Parliament (which votes every year on the financing of social security) and the administrative control over hospital medical activity have only increased the role of the state.
The French reform impulse reactivates these structural contradictions. The financing of universal health protection (ex CMU) relies on a residential basis (Gay & Steffen, 2020), as well as the organization of care by the public health system, in order to prevent unnecessary hospitalization (Oganesyan, 2016). In practice, these new structures affirm administrative power at regional level, whereas the reform of the T2A (i.e. pricing based on medical act) in 2004 had reaffirmed administrative power at national level (Sainsaulieu, 2011).
Health Business and Productivist Management
The record of the reforms has been severely criticized, in particular for concentrating power in the hands of the administration in favor of private social forces. A previous collective article (Leicht et al., 2009) noted that the health system in France seems to follow the trend of subjecting the medical professions to new governance structures inspired by the liberal market. The New Public Management (NPM) represents a state’s concern for pluralism in a context where the role of the state is being questioned and the number of actors is multiplied, particularly private actors (Lascoumes & Le Galès, 2005). Through the health agencies created from the 1990s onwards (Buton & Pierru, 2015), the state’s domination over the practice of health care was supposed to come to terms with this pluralism in order to emphasize the provision of health services.
Market pressures are considerable. Colleagues have pointed out that health is a considerable financial windfall that many companies would be well advised to capture (Juven, 2019). In 2017, the ‘consumption of health care and medical goods’, the CSBM, represents €199.3 billion, 77.8% of which is financed by compulsory health insurance (the ‘Sécurité Sociale’). The CSBM is made up of expenditure on hospital care (46.6%) and outpatient care (53.4%), which includes medical and dental consultations, as well as expenditure on medicines (Abecassis et al., 2019, pp. 142–150). According to the ONDAM (the official health expenditure indicator), the control of health expenditure weighs more heavily on the hospital sector than on private practice (Juven et al., 2019).
State and market are growing in parallel: while a new management bureaucracy is developing in the health system as elsewhere (Hibou, 2013), pharmaceutical firms and supplementary insurers are the big winners from the weakening of social security and the desocialization of a growing number of health expenses (Juven, 2019). Market logic in the health system results in the rationing of treatment for certain pathologies, the deterioration of care and working conditions in hospitals (Sainsaulieu, Citation2003), a higher burden on patients (Askenazy et al., Citation2013) and increases health inequalities (Dubost et al., 2020), while the medical shortage has increased the cost of ex-hospital doctors, who have become liberal but who work for half a day at the public hospital at a high price (Grimaldi, 2010).
On a professional level, the new management and financing methods have gradually stifled a hospital-centred system that is decried for its cost and complex operation (Juven, 2019). Traditionally important, medical power has weakened (Hassenteufel, 1997). At one point, the university hospital elite, leading an ‘open war’, was forced to turn it down, showing ‘the vulnerability of the professional world to the process of managerial integration’ (Pierru, 2013).
Similarly, the other hospital players did not stand united against the reforms because the new public management divided them according to their capacity to adapt, creating opportunities for some and not for others (Belorgey, 2010). Since the 1990s, measures such as the reduction in the length of stay have been implemented, a direct result of which is an increase in the work rate of care workers due to the increase in patient turnover in beds without compensatory hiring (Sainsaulieu, Citation2003, 2007). This has led to a deterioration in occupational health, including an increase in stress and back diseases (Benallah & Domin, 2017; Estryn-Béhar, 2008).
Both the big bosses and the care givers have had to give in to the administrative elite of finance inspectors ‘flanked by consultants’ from prestigious (and expensive) consulting firms (Pierru, 2013). The hospital reform has thus taken a clearly top-down turn, contradicting the idea of pluralism carried by the models of governance, if one assumes that this pluralism has a democratic tone (Sainasulieu, 2011). Nevertheless, the reforming reason had, in turn, to take into consideration the specificities of professional work in order to respond to the many contradictions between the individual quality of patient care and managerial standards.
Prior Experiences of Social Compromise
The improvement in the quality of care has provided a prior leitmotif for maintaining a virtuous confusion between budgetary rationality, tropism towards the private sector and professional foundations. Within the hospital itself, our surveys have suggested that nurses have experienced collective responsibility, that health care managers have reformed themselves as guarantors of quality assurance and that doctors have had to cooperate with the management systems. With regard to nurses, our analysis revealed a collective approach in the case of hospital accreditation, deeply rooted in the participation which they value and which values them in return (Sainsaulieu, Citation2012). Participants spoke of broadening horizons, developing professional and organizational awareness, the habit of self-evaluation and targeted responsibility (assigning responsibility for a particular aspect of work to specific employees, etc.). The first precondition implied close links between the evaluative logic of accreditation and the professional and organizational logic of nurses: nurses were (more or less) responsible for the coordination of care in their units and were sometimes in conflict with doctors over the control of patients. The second prerequisite was the existence of links between health professionals prior to the accreditation process. Small units with strong and dynamic collectives and measures of good performance were empowered by the collective evaluations of accreditation. Success was limited by the lack of time available for collective decision-making and by declining enthusiasm over time due to fatigue.
Middle managers were very supportive of the quality assessment process. Managers were in favour of the new accreditation guidelines because they saw themselves as the guarantors of quality health care, even if they had to focus on financial management. Health managers or middle managers are rather appreciated by the staff. In an earlier survey, a (short) majority of nurses interviewed found their immediate supervision ‘useful’, even if they rejected their claim to be ‘part of the team’ (Sainsaulieu, Citation2008). Most of the time, the department’s managers and doctors feel close to the difficulties endured by the nursing staff. Doctors have also been integrated into the new assessment procedures (Sainsaulieu, 2005).
While medical quality assurance in France was based on moral and professional control and continuing education (a legal obligation since 1996), under the supervision of the Haute Autorité en Santé (HAS), more guides to good practice have been drawn up by consensus conferences (a meeting of experts to take a joint decision on a medical problem). The assessment included: gathering information, choosing a reference group, self-assessment, writing the individual assessment and sending it to the authorities, a summary meeting during which the doctor proposes ideas for his or her own improvement and a confidential report drafted and sent to the doctor with proposals for further training. However, through the normative control of the High Authority for Health, the State has above all called upon professional standards to ensure that doctors remain in compliance with the new regulations.
In the eyes of professionals, care cooperation is a key issue for the quality of care in hospitals and nursing homes. Although it is compromised or limited by these reforms, the reforms do not eliminate all collective work, which remains inherent to cooperation in many care services (Sainsaulieu, Citation2012). Thus, we have previously shown the various components of what we have called consensual collective mobilization in the hospital: the ability of certain departments to work collectively, because of the particular conditions of work, for example in the emergency room, the operating room or the intensive care unit; the capacity for coordination between various professions, in particular between caregivers and social workers; the participatory mobilization initiated from above during campaigns to improve the quality of care; the ability to respond collectively in critical health situations, such as during the AIDS epidemic or, more regularly, in the face of bronchiolitis, or again in the context of health interventions abroad or in the face of natural events (storms, heat waves); finally, collective mobilization leaves traces in the representations of caregivers. Often presented as victims of managerial policies or impacted by the rise in hospitalization needs (particularly due to ageing), collective care groups also have a capacity for resilience, as it was the case during the mobilization in the face of COVID-19. This is what we shall see below.
But once again, what do we mean here by collective mobilization? As shown, there are several forms of collective mobilization, sometimes top down and sometimes bottom up: participation mechanisms and health campaigns, as well as particular forms of care work. In the latter cases, cooperation is such that it binds the group together by giving it a shared sense of belonging to the collective, a sense of community in the Weberian sense, consisting of equally strong links and a sharing of the ‘we’, associated with frequent interactions in co-presence (Bourgeault et al., 2010; Sainsaulieu, 2006). They are extended by shared representations: long afterwards, people live their daily lives according to representations acquired during significant collaborations (such as in infectious services, long marked by the egalitarian experience of AIDS). The health crisis, because of its scale and intensity, is a particularly formidable test to see how far the collective caring community can resist.
‘We Have Worked like Crazy People’: the Collective Commitment of the Health Care Community in the Face of the Covid
What happens to this compromise in times of crisis? The hospital system in France, a rare lever of action by the public authorities in the face of the crisis, has been the subject of three measures to mobilize healthcare staff and cope with the additional workload: removal of the ceiling on overtime, to extend the working hours of hospital civil servants; reassignment of staff in establishments according to needs, already provided for in the health emergency plan (the white plan, launched in March 2020); integration of various categories of staff, freelance professionals, students, retired healthcare workers and doctors, and foreign professionals (Gay & Steffen, 2020).
The comments gathered during the interviews fully confirm the hypothesis of a consensual mobilization, in other words the feeling of living an exceptional moment, as in the experience of a profound social movement, calling into question social relations, at least locally, without any question of contestation. Another element of comparison with a mobilization is the backlash: two nurses were even thinking of leaving the hospital: ‘I find it hard to like what there is to do in the hospital and I wonder if I'm going to stay’ (V, nurse anesthetist); ‘if I were three or four years away from retirement, I would leave’ (L, psychiatric nurse).
The discouragement that followed the commitment, as we shall see later, had to do with the return to normal work organization. But first let us look at the terms of this care mobilization.
The Egalitarian Outburst in the Face of the Unknown
During the first wave, the Eastern university hospital (CHU) came to a complete halt and was completely converted. Many care providers were redeployed to the ‘covid services’ (whose patients had covid). As mentioned above, the public authorities have, for the time being, made up for the chronic shortage of staff in the hospital. This has been strongly felt by the staff in the covid wards, who for once are working without staff shortages (even though the equipment was sorely lacking at the outset). Thus in pneumology, despite the stress, anxiety and a ‘very heavy atmosphere’, an unusual multidisciplinary mutual aid system is being set up. ‘We had a large number of staff, with physiotherapists, psychologists and doctors. The physiotherapists were very present to lift the patients, to teach them how to relearn lost gestures. Usually we have a physiotherapist for both services, so they are often not there, neither to lift them nor for anything else. We also had speech therapists we don't usually see, psychologists who came three times a week for the patients and for us too. They went to see our managers if necessary. We had a lot of hygienists too, who gave us the latest practical recommendations’ (A).
In addition, the ordinary approval of nursing work resulted this time in cheers that put considerable social pressure on the work: ‘We were applauded. When I left for work on my motorbike at 8 pm the whole neighbourhood applauded. I had chills. You feel obliged, you can't disappoint all those people who applauded you’ (M). This high morale leads to a high degree of acceptance of constraints and a personal commitment that is sometimes unreasonable. ‘The accepted workload is incredible,’ says M., who also explains that he forced himself to take two breaks and ‘forced’ his colleagues to take at least one break: ‘They are colleagues who find it hard to sit down for a drink. They are dedicated, they are afraid to leave their patients to others, to blame themselves, they are over-invested. But afterwards, they burn out’ (M). In spite of the constraints, no complaints from the covid services have reached the management, via unions.
In covid services, a feeling of equality is developing. Everything is unknown (‘with unknown people, in unknown places and in the face of unknown disease’) and the unknown puts everyone in front of their limits, on an equal footing in the face of death. M. describes ‘highlights in the evening when ten people from the day shift leave and ten more from the night shift arrive: ‘We didn’t know each other and we shared the experiences of the day; people died like that, we didn’t understand, we had people in front of us, we didn't complain about people, the patients had no pain, no discomfort, they were tired with a moderate temperature. All of a sudden they had an incredible clinical profile, they became in respiratory difficulty, with strong diarrhea, but without complaining about anything. We were unsettled: we could see that they were falling, but we didn't see it coming. You have to accept your limits’ (M).
This emotional and existential sharing corresponds to equal conditions, a strengthening of professional exchanges and a tendency to share tasks. In EHPAD (establishment for dependant elderly people), the nurses testify to an egalitarian moment of task-sharing in their work, with upward shifts in tasks. For example, nurses prepared the pills but allowed the care assistants to administer the medicines, or to use the thermometer to take the temperature. ‘We didn't have labels or grades,
we all did the same thing. Again, it didn't last long: ‘After that it was different again, each one in her own job’. In pneumology, the moment of task-sharing was more widely experienced in the euphoria of tidying up, after the first wave: ‘We had a week’s break, we were all there, nurses and service agents, to clean up with a very … we were happy to get together and we thought we were turning over a new leaf. We took the pressure off’ (A).
This flattening of ranks corresponds to a flattening of the hierarchical line, the feeling that the hierarchical relationship faded away during the first wave. ‘We’re not bored, the managers are listening to us’ (M). ‘During the covid we were all in solidarity and everything in the field of HRD and management we felt empathetic, we were congratulated, there was no longer any hierarchy. We didn't see the managers, they were in their offices by e-mail and they had meetings to redeploy people. We didn't see them much’ (V).
The flattening of the ranks would not be complete if it did not include those who symbolize superiority, both professional and hierarchical, but also cultural and social, the doctors: ‘We had moments of rapprochement, ASHs spoke with doctors, there was communion between the ranks’.
This configuration is accompanied by an intense feeling of satisfaction at work, of accomplishment in one’s profession, despite the proximity of death: ‘There I had two deaths in three evenings and I must say that I came out of my three evenings fulfilled. We had worked well, we were able to call the families’ (M). Greater job satisfaction is inseparable from the feeling of professional learning. For V, ‘the storm’ covid is an opportunity to get to know oneself better, to test one’s professional skills and to progress.
On a collective level, it was also an experiment in greater professional autonomy. In palliative care, ‘the doctors only came in at our request’ (SP). The paramedical team is very isolated because of the protective measures but also very autonomous, ‘we had to reinvent everything we do’, in particular hygiene measures and the management of waste bins. A habit of discussing ‘as the action unfolds’ is created and ‘a colleague calls me to tell me that we're going home together, we’re doing everything together’.
This exceptional collective dynamic is sometimes based on background. In the experience of some care givers, ‘the team’ is always synonymous with helping each other on a daily basis. On the other hand, it is not always synonymous with open-mindedness and integration of newcomers.
Strengths and Weaknesses of Service Logics
One would think that, dedicated to care and always working in a department and as a team, the care givers all experience a pleasant working atmosphere. In reality, they most often work in pairs (a nurse and a care assistant) and do not always experience solidarity within the whole team. This is more of an opportunity. In intensive care pneumology, A, a young nurse (2 years of service), clearly has the feeling that she lives in a different group from the others:
‘Before I was in the replacement pool, I saw the difference, it’s not the same atmosphere in the other pneumology department focused on palliative care. In cardiology, it wasn’t the same, I didn’t feel particularly… In cardiac thoracic surgery, there wasn’t a very good atmosphere either. We hear gossip…’ (A). As a result, the covid has not changed the way the team operates.
In palliative care, a collective substratum would also pre-exist, based on listening to each other. ‘We are already a fairly autonomous team. We’re not in the execution, we’re in the exchange with the doctors and managers’ (SP). This reality is unknown from the outside because it is counter-intuitive: ‘People have the impression that it's a very sad service when in fact it’s not at all, it’s one of the more lively services I've ever worked in’.
On the other hand, this experienced woman, who is also a trade unionist, does not mythologize her service and finds limits to this mutual empathy. ‘In our department, we have solidarity within the team but not with colleagues from other departments in our center. (…) For example, a few years ago the geriatric colleagues went on strike for working conditions, I proposed to make a gesture, I was not heard’ (SP).
And what about the capacity to integrate new people into the service's collective? On this subject, the experience of two nurse anesthetists in the operating theatre can be compared. Like others, they testify to the lack of equipment at the start, masks considered non-essential by the hierarchy, gowns which tear easily, and contradictory hygiene instructions. The first wave is brutal, the operations in the operating theatre are cancelled and they are redeployed in various intensive care units. ‘There were a lot of assignment units, I was well received, I found colleagues and others who came from the clinics. (…) I was scared before, mainly because of the lack of equipment, but afterwards there was good mutual help. We supported each other. It's rare, it worked well, we were all quite motivated, boys and girls’ (V).
Welcomed in another department, C had a more mixed feeling, that of having experienced solidarity limited to her ‘colleagues who knew each other from the block’, and not extended to strangers in the intensive care unit where she was arriving: ‘I wasn't well received and I wasn't the only one. I worked with people I didn't know in resuscitation and I found it hard. At the end of the day the colleagues were eating and they didn’t wave to us to sit with them. It felt like we were invading them’ (C).
The hierarchy between levels of qualification is a usual obstacle to exchange between colleagues, which is indirectly testified to by the other nurse anaesthetist, for whom the welcome was better: ‘We are specialist nurses, it's true that we don't usually have a good image, and there they appreciated that we mixed and mingled, and there were exchanges. With the nurses' assistants and hospital care workers, it went well too. (…) We did what we could. I had previous experience of working in pairs’ (V).
In the opposite case, the logic of service prevailed over mixing (between nomads and sedentary people). In other words, the domination of doctors over nurses, which is inherent in the medical and paramedical field (Longchamp et al., 2020), is just waiting to resurface. For example, it is important for caregivers that doctors greet them in the common service and call them by their first name. In doing so, they are bridging the social divide on a daily basis to re-establish a less asymmetrical relationship between medical and paramedical agents that allows for exchange (Sainsaulieu, 2007).
Mobilization in the face of the covid changes the situation. Thus, the reception in intensive care by doctors was better than that of the nurses, according to A, a nurse in pneumology, during the second wave. The context is dramatic in October 2020, as the staff are told that the wave will be more difficult and more serious patients are expected. After a short training session (‘I had two days of theoretical training, then two days of dubbing’), the volunteers are placed at the foot of the bed and the locals are afraid of having an extra workload when training them. ‘This lasted a month and a half. I wasn't badly received, but the atmosphere was very heavy. (…) On the other hand, I found their doctors very accessible, the most open. They introduced themselves spontaneously, asking me where I came from. And they thanked us right away. They were nicer than the care givers’ (A).
The Hierarchy Blows Hot and Cold
The relationship with the hierarchy was much discussed during our interviews. The particular profile of our small group of respondents, half of whom are very experienced and members of unions, should be noted here. They probably allow themselves more than average to judge their hierarchy. However, it is also an opportunity to bring out different elements of analysis, based on their experience, which is not contradicted by the others, as far as we know.
While most managers are considered ‘good P&MS’ (these ones represent ‘the ¾ of community P&MS’, according to L., in psychiatry), it only takes one manager to poison the atmosphere. For example, a nurse in the EHPAD felt strongly about what the head doctor had said, accusing him of having introduced the covid to patients. In psychiatry, a ‘doctor in communication’ executive was recorded unknowingly shouting for half an hour at a pharmacy dispenser. ‘You quickly become incompetent when you don't know how to stay close to your team’, remarks L. In psychiatry, the erasure of the executives during the first wave turned into a scandal, denounced by means of a leaflet: ‘They were gathered in a pizza dining room and in the evening they drank rum among themselves. In the services we remember, they were expensive’ (L).
Most often, the hierarchical levels are differentiated. Local managers, as well as the doctors in the department, are more appreciated than senior managers, managers or head doctors (‘during the covid, our managers were there all the time’, says C, a nurse in the unit who was seconded to the intensive care unit with her managers). With local managers, one can make an arrangement, for example agreeing not to take time off during the school period in exchange for being able to free up half the time for training (L.). In EHPAD, the staff is also more in favor of local management: ‘Our service manager is super good, she takes care of you’. She knows how to defend her staff, staying on site ‘until 10 pm’. In the spring, she was subject to decisions from above like everyone else. Because of the confinement, she could not attend the ‘crisis meetings of the management, twice a day, and twice a day they changed the instructions’ (V).
Nevertheless, senior managers are less appreciated. They are sometimes suspected of not being real professionals, some of them having gone up to seniority, or on the contrary very quickly, according to appointment procedures that are more political than professional (‘4 senior managers have never set foot in school, they have gone up to seniority’, testifies L., in psychiatry). The hierarchy blew hot and cold in the covid episode. In the spring, the attentive attitude of some was praised, even their disappearance allowing more autonomy. On the other hand, the grievance relates to the inconsistencies in the instructions given, sometimes contradictory between morning and evening, particularly with regard to the wearing of masks or hygiene measures. They are accused of bad faith: they explained to the caregivers that they were not afraid of anything without masks to justify the lack of masks. As an example, some did not work for two months while others were over-mobilized during the same period.
But the grievances mainly point to a return to normal after the first wave. At that moment, the excuse of unpreparedness for the pandemic and the improvisation which followed was no longer valid. In several services, the discouragement of the staff and the sick leave of the stronger caregivers during the second wave are attributed to the management.
In the operating theatre, for example, managers saw fit to change the organization of work after the first wave by setting up a multi-purpose operating theatre, in the belief that ‘in any case’ this should have been done later. This reorganization is ‘painful’ for the care givers. It is difficult to accept the contrast between the effort required for the covid and the lack of consultation of the staff in return. As a result, the latter consulted each other before going to ‘see the managers’ (C). ‘Afterwards we made proposals and then at the end they included us in the reorganization’. They are often obliged to work with doctors they don't know and therefore they have to explain themselves all the time, or even explain to the doctor, instead of understanding each other instantly: ‘once it's OK, but otherwise it's exhausting’ (C).
In EHPAD, the nurses also underline a strong contrast between spring and autumn, in connection with a criticism of their supervision: ‘we thought it was going to change things. But we didn’t get much recognition afterwards, nobody came to see us to ask us what we'd done. No one from the management side, not a call. They said they would make returns, see what worked or didn't work, but we were not consulted’. The situation of the patients deteriorated, they have learned not to eat by themselves, to move around, ‘they have lost a lot’. Work has increased, in a climate of fed up and weariness.
A new director ‘took matters into his own hands’, introducing a willingness to reform in the name of efficiency. For the second wave, the staff was better armed, with a ‘well thought-out protocol’. The staff is better protected, the director confined ‘from the beginning of March’. However, ‘he sees the financial aspect rather than the human side. The previous ones were more human’. And at the end of the first crisis, he communicated thanks without convening a meeting: ‘we had a little paper’. He feels that he did the right thing but without trying to meet expectations.
This contempt for management is also perceptible in palliative care: ‘They didn’t tell the truth (…) They had to explain things to us, to admit the shortage. But there was no honesty, as always with the staff’ (SP). In geriatrics, it was necessary to dress or not to dress in protective clothing for each room, because the covid patients were in the same building. More generally, the anger rumbled in this second wave. Wage increases planned for the year 2021 were brought forward to September 2020.
Conclusion: Back to Normal?
In the face of the pandemic, the strength of healthcare work lies in its collaborative capacities, its egalitarian dynamics within the framework of a consensual mobilization (Sainsaulieu, Citation2012). That dynamic is confronted with a symbolic and hierarchical order. In hospitals, and even more so in EHPADs, geriatrics or psychiatry, the departures or absences of permanent staff clearly express the limits of working conditions and quality of care. Without sufficient staff, the working conditions of those who remain worsen, their moral and physical health deteriorates at the same time as the service provided. It is a vicious circle.
In order to cope with this situation, the health care collectives not only need resources, they also need a policy that relies on them, that gives them the necessary autonomy to organize themselves and the resources they need to serve the collective, and therefore the patients. However, through the criticisms of the actors in the field, the organization of work appears in all its traditional cleaving force, almost Taylorian, between design and execution. It is paradoxical that this organization is capable of mobilizing caregivers, of counting on them to the point of stepping aside when necessary (by necessity or by choice), of providing them with everything they need on occasion, before telling them, in the end, that the separation must be re-established. It is as if the caregivers could only contribute to the organization of work by default. The cut is quasi-permanent, often adjusted by a close supervisor in contact, but who also knows how to replay the cut. Thus, during the covid episode, while all sorts of external contributors multiplied in pneumology, only the elite met with the managers, as this nurse testifies: ‘In the spring of 2020, we were not participating in the meetings with the health executive, the doctors, the psychologists, the speech therapists, the interns, the senior managers, the head of the department… It would have been nice since we were the first ones concerned. Our manager would report to us. When they met, it's true that there were no nurses and it's still true now’ (A).
What lessons can be learned from this crisis? Colleagues have concluded from the pandemic that managers should be trained to deal with uncertainty, relying more on critical input from the social sciences (Bergeron et al., 2020). But if the top must change, the bottom must also become more powerful: the French hospital is too hierarchical, and does not know how to leave the initiative to the bottom, especially the nurses. Yet this human resource should be able to bear fruit in a world dedicated to the common good. In the past, participative attempts were made, in a limited space of time, but there too, the soufflé rose and fell. Today it is not the time for even temporary participation. Despite the speeches of recognition and thanks, the government is still following the same policy of reducing hospital costs, notably by closing beds and refusing to hire permanent staff, in order to rely on a pool of precarious workers that already represents about a quarter of the workforce. In this context, it seems difficult to rely on the initiative of caregivers in the organization… outside the pandemic.
References
- Askenazy, P., Brigitte, D., Pierre-Yves, G., & Valérie, P. (2013). Pour un système de santé plus efficace. Notes du Conseil D’analyse Économique, 8(8), 1–12. https://doi.org/https://doi.org/10.3917/ncae.008.0001
- Sainsaulieu, I. (2003). Le malaise des soignants. Le productivisme de soin à l’hôpital. L’Harmattan, coll. Logiques sociales.
- Sainsaulieu, I. (Ed.) (2008). Les cadres hospitaliers. Représentations et pratiques, Lamarre, coll. Fonction cadre de santé. Gestion des ressources humaines.
- Sainsaulieu, I. (2012). Collective mobilisation in the hospital: protesting or consensual? Revue Française de Sociologie, 53(3), 371–461. https://doi.org/10.3917/rfs.533.0461