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Original articles

Constraints, Normative Ideal, and Actions to Foster Change in the Practice of Nursing

A Qualitative Study

Martin, Patrick PhD; Bouchard, Louise PhD

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doi: 10.1097/ANS.0000000000000322
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Abstract

SOCIOECONOMIC DEVELOPMENTS in the past few decades have led to profound changes in the relations the province of Quebec, a predominantly French-speaking province in eastern Canada, has with its health care professionals. National standards for health care are laid out in federal legislation, the Canada Health Act, passed in 1984, under which provinces and territories offer a publicly funded health care system to ensure that all Canadian residents have access to hospital care and physician services free of charge. In the 1990s, private capital accumulation emerged in the public sector as a political philosophy borrowed from the realm of business. Since then, the emergence of new public management has taken hold in Quebec's hospitals, where nursing is now exposed to unprecedented challenges. From this moment, the health system will be articulate according a different logic. The quality of care and the importance of offering the widest service lines possible to the population will no longer be central concerns. Rather, it will be the way in which the health care system—embedded in neoliberal ideology—fits in using other elements of the dominant ideology—productivity, efficiency, and individual choice—that is going to replace these concerns.

Since 2003, in a context where the omnipresence of budget cuts influences the daily operations of health care institutions, the efforts deployed to preserve access to health care services have led to major impacts on the attraction and retention of nurses. Several writings, as this of Côté,1 report a growing exodus of recently licensed nurses, despite the recent increase in the total number of practicing nurses. In parallel, the available data of the largest nursing trade union in Quebec show that more than 15 000 nurses could currently access retirement or reach early retirement. However, the nursing world is not homogeneous and is especially irreducible, since the workplaces of these health care professionals are numerous and diversified. The literature consulted reveals that it is nurses who work within hospital centers, representing more than 65% of the nursing workforce in the province of Quebec, who experience the most constraints at work and who have been the most affected by budget compressions in recent years.

Statements of Significance

What is known or assumed to be true about this topic:

The working conditions of Quebec nurses are increasingly identified as deleterious.

Researchers have investigated the constraints and harms nurses have suffered as a result of health system restructuring.

It is widely recognized that nurses are victims of physical, psychological, or sexual violence as part of their practice.

What this article adds:

Few researchers have turned their attention to the power relations or power structures (including structures of domination) in which nurses' experience is rooted.

Our findings point out an intensifying drift toward authoritarianism in Canadian hospitals. Few studies have come to this conclusion. Few researchers dare to specify it.

Disciplinary power in hospitals exerted through political technologies, such as constant surveillance, reprisals and fear, the technicization of care, and mandatory overtime, contribute to the staff nurses' subjectivation. No study has yet made it possible to establish the register of these political technologies.

Although the nurse participants want to take action in the hospital to humanize care and achieve professional self-determination, the practical purpose of much of the action we recorded was, rather, their own protection and survival in a dehumanizing hospital system.

There are, nonetheless, staff nurses who raise conscientious objections, resort to individual or collective noncooperation, or engage in acts of civil disobedience with the aim of establishing a new power relation. Few studies have examined the subject, and to our knowledge, no study has made it possible to describe so precisely the actions and ideas of actions of nurses.

Studies of the nursing profession show that nurses in Quebec experience multiple constraints since the reorganization of health care services of the 1990s. Work overload is one of the most binding and recurring experiences nurses must struggle with in hospitals. The increasing speed and pace of work, the complexity, and the technicization of care services are synonymous to this work overload. Similarly, staff shortages lead hospital administrators to resort to mandatory overtime in a systematic way, asserts Bougie.2 All these constraints have devastating consequences on nurses, for example, professional exhaustion (burnout), a desire to quit employment, and mental health issues. According to a study conducted by Bourbonnais et al,3 in the province of Quebec, a high proportion of these nurses feel a sense of hopelessness about the future and have difficulties falling asleep or staying asleep, while 6% of them have even thought of suicide.

In Quebec, the practice of nursing in hospitals is also characterized by violence and psychological harassment, state Poulin-Grégoire and Martin.4 The results of a study conducted by Lemelin et al5 with nurses working in hospitals reveal that 86.5% of these nurses have been victims of physical, psychological, or sexual violence as part of their practice. These incidents are said to have been committed by a colleague, a concept known as lateral violence, or by an authority figure, a physician in most cases. At the international level, the studies done by Dewitty et al6 corroborate the results of these studies. The meta-analysis of Spector et al7 also showed that about a third of nurses worldwide have already been exposed to physical violence and bullying, and that two-thirds of nurses worldwide have suffered nonphysical violence. Other studies such as those of Maben et al8 and Strandas et al9 also revealed that organizational constraints have the effect of sabotaging nursing values and ethics. Ever since the beginning of this study, we have been interested in the experience and knowledge, in relation to staff nurses working conditions, of how they wish to live and the way they wish to express their political engagement. We were trying to better understand the effect of sociopolitical, ideological, and structural contexts on the lives of these nurses. We realize that various contexts, in which these nurses operate, are invariably the result of social relations in which power intervenes.

After developing on the concept of the use of power and the various theories that relate to it, we have understood that it is generally in response to constraints/limitations and disadvantages that nurses express their commitment to resist and to create new relations with power. In our literature review, the exploration of the concept of power would not have been possible without also having an interest in the concept of resistance that allows, among other things, to conceptualize power put to use by nurses, even in a dynamic of alienation, exploitation, and domination—a dynamic in which they cooperate and participate themselves. The emancipatory studies by Chinn10; Jacobs et al11; Rose and Glass12–15; and MacLeod and Zimmer,16 as well as the study relating to the concept of resistance of Garon17—an important study within the nursing discipline related to the concept of resistance—have proven themselves very useful to our research project.

THEORIZING AND STIMULATING POLITICAL ACTION

We started our investigation by using literature predominantly from authors who fall within political philosophy: Honneth,18 Keucheyan,19 Lamoureux,20 and Rancière.21 These writings invited us to examine the nurses' thoughts related to not only their working conditions especially to the constraints they live with daily but also their ideal working conditions as caregivers. According to Keucheyan,19 any thoughts on “what is?” and “what is desirable?” raise questions about social order and include a critical and political dimension. Lamoureux20 specifies that these 2 elements of reflection—the first, on the status quo or what is through the experiences of domination associated with nursing—and the second, on what is desirable by moving the gaze of the participants to another possible world—are inherent to stimulate one last element reflecting political action (Figure). According to this same author, the expression of social relations, what nurses appreciate, what questions they raise, or what they denounce, and the systemic constraints experienced (exploitation, impotence, violence), which forces them to act against their conscience, arise as imperatives in the dynamic of political action. These elements would highlight the magnitude and extent of the oppression of nurses by what Lamoureux20 calls awakening consciousness. According to her, what is desirable implies an effort of reflection on the experience: it is a way to free thought, to reconsider the status quo, and to envision new ways and strategies of mobilization, in other words, emancipating ideas or actions.

Figure
Figure:
Conceptual framework. This figure is available in color online (www.advancesinnursingscience.com).

According to Chinn and Kramer,22 theorists of the nursing discipline, it is by questioning and by thinking critically on the current state of affairs of a social, cultural, and political nature, which limits human potential, freedom, and justice, that it is possible to ask ourselves why the inequities present exist or persist in our social world. According to these same authors, hegemonic visions are often hidden or taken for granted in the status quo. They are considered as unchangeable facts, as the only possibilities, and have the effect of favoring certain groups over others. These visions tend to recreate, to constantly renew, so that it becomes difficult to put an end to the injustices that they generate. However, awareness of these hegemonies allows individuals to consider things in a different manner and to go beyond the limits of current possibilities.

METHODOLOGY

Research design

We conducted a qualitative exploratory study. This plan recognizes the need to explore and highlight the perspective of participating nurses on what they experience on a daily basis, on what they want to see come about as a transformation of social reality within hospitals, and on necessary action for greater justice and equity in their work environment. From the subjective point of view of politically engaged staff nurses, the 3 main research questions were as follows: (a) What are their lived experiences and the existing social order in relation to the conditions in which they work in hospital centers? (b) How would it be desirable (normative ideal) to organize the future conditions of the contemporary nursing profession in hospital centers? (c) What are the individual and collective actions that could be put forward to promote the transformation of contemporary nursing profession in hospital centers?

The qualitative design used to carry out this research project was articulated with the postmodern methodological approach proposed by Boisvert,23 who advocates for a critical and interpretative approach, based on the diversity and complexity of the experiences gathered that allows the juxtaposition of different theories—from postmodernism, poststructuralism, postcolonialism to feminism, and others to multiple possible interpretations. The postmodern analysis of Boisvert23 does not constitute an approach proposing to start from theoretical hypotheses to test and validate them. It facilitates the understanding of complex sociopolitical phenomena because it makes it possible to counteract the methodological misalignment of analytical instruments that have not been designed to capture a world in perpetual movement, like the contemporary world in which staff nurses evolve. Epistemologically speaking, the postmodern analysis proposed by Boisvert24 promotes the egalitarian status of these various interpretations, all of which must be considered socially useful for understanding complex social and political phenomena.

The postmodern analysis led us to approach our object of study from the daily life of nurses—from the “modest” and “ordinary” nature of their reality to better understand the world they represent. Furthermore, the openness characterizing this approach allowed us to juxtapose poststructuralist reflections and interpretations from organizational theories to favor the emergence of a tacit logic that can link them.

Recruitment and sampling

Nurse participants had to meet the following purposive sampling selection criteria: to be a staff nurse; to practice within a hospital center as a registered nurse; to be employed for at least 6 months; to be fluent in French; and to consider themselves as being politically engaged. The desire to recruit politically engaged nurses imposed itself naturally, since they would be better informed on the working conditions of nurses and they have a greater propensity to describe transformative ideas and practices. We contacted the senior representatives of 2 major Quebec trade unions by e-mail. Then, we contacted them by telephone to provide additional and more complete information about the project. Through them, it was also possible to establish a bank of key nurses recognized by their peers for their political involvement. Twenty-one politically engaged nurses were interviewed individually and 18 others were interviewed in 3 different focus groups (FGs) for a total of 39 participants. After having validated them with the selection criteria of the sampling, we asked them whether they considered themselves as being politically engaged and practicing on an ongoing basis a political or social action to change things in their workplace or elsewhere in connection with the nursing profession. The participants, from all over Quebec, were aged 23 to 68 years for an average of 39 years. Males made up 28% of our sample. Forty-one percent of participants had a university degree in nursing. On average, the nurses who participated in this study had been practicing in the same hospital for 14 years and had between 1 and 36 years of experience in these settings. Seventy-two percent of nurses interviewed worked full time. Most of the nurses were acting as union representatives during the data collection, representing 74% of the sample. Several of these participants, who were acting as union representatives, have indicated that they were also involved politically in other fields and not only as union representatives—either for the community: professionally, civically, or artistically. Participating nurses interviewed who were not acting as union representatives fought for the development of nursing, for women's rights, and for civic and community movements. These women were engaged politically and socially, particularly, to promote high-quality teaching, to increase citizen participation, or to fight against privatization of health care services. Some of these participants had written articles in newspapers and scientific journals, given lectures and seminars, and had appeared on television and in social media.

Data analysis

Audiotaped interviews, with an individual (II) and FGs, were first transcribed. The reasons for those recordings were also clearly explained to all participants, and to protect confidentiality, the names of participating nurses were replaced with pseudonyms. Steps were taken to ensure that no identifying participant or employer information was reported. As Paillé and Muchielli25 recall, any qualitative analysis must pass through a form of thematization that consists of “the transposition of a given corpus in a certain number of themes which represent the analyzed content.” The postmodern approach, critical and interpretative, that we have chosen to realize this research project is no exception to this rule. We proceeded to the thematization of the data collected as a part of this project based on the model elaborated by Paillé and Muchielli,25 the thematic axis, the thematic grouping, the theme, and the subtheme.

Rigor

The interviewee transcript review, as well as the validation during the FGs of a summary of the data collected in the context of the individual interviews, allowed us to promote the credibility of this study. The biases, as the reflections that they entailed, were recorded in the field journal and revealed this to increase the reliability of the study. Reflexivity also allowed the evaluation of our own beliefs and behaviors.

RESULTS

Participants had much to say about constraints and devices that oppress them and keep them captive of a system that controls and prevents them from speaking their minds. They denounced various situations; they talked about changes they envision. The interviews created a sense of freedom allowing them to express their concerns, suggesting a dissident verbal communication. Data collection was used, more so than we would have thought, as a tool for raising awareness. Here are 3 major thematic axes listed from the data that we have gathered:

Axis 1: Reflective look on current state of things

Description of the work overload: No longer having access to their role as caregivers

As collateral effects of being overloaded at work, participating nurses described a multitude of phenomena that make them feel that they no longer have access to their caregiver roles. These phenomena included the fact of constantly feeling like they are putting out fires and to be forced to omit certain nursing interventions, even essential ones.

A blood test [...], it is prescribed and nurses will not do it. Or dressings, [...] are not done three times a day, [but] once a day. Hence nurses are called to make professional mistakes. (Didier, 21II) Individual interview [II]

Many participants also recalled prioritizing care over others.

When you start with [...] seven patients in decompensation and you have three admissions [...], it becomes heavy. There, you no longer have access to your role as a caregiver ... The employer [tells you] to prioritize. [...] “If he wants to cut his veins, stop him, but leave it at that, for today.” (Isabelle, 01II)

Many participating nurses who have been staff nurses for several years told us of no longer being able to cope with the unexpected and to no longer interacting with patients.

It is not possible to be with the patient [...]. Over the past twenty years, the idea that I had of the nursing profession, it's now completely degraded. It has nothing to do with being a nurse anymore. (Linda, 04II)

Decrease in quality of care

Many participating nurses said that they had seen a decrease in quality of care. This is a situation that Sylvain (17II) attributes to the tendency of hospital nurse managers to want to increase the number of patients supported by each staff nurse.

What we manage to give [...] is a minimum. Patients [...] would have to be moved every two hours, but that's no longer the case. [...] We do not have time to lift them up anymore. We put them in disposable incontinence adult diapers, to save time. (Sylvain, 17II)

According to a number of participants, staff nurses are the ones who are generally held responsible for the decrease in the quality of care and to workload-related errors.

Participants explain the work overload and its consequences

Many participating nurses clearly articulated their ideas and feelings, readily explaining the work overload situation, in which they are forced to evolve as well as the consequences that stem from both situations in which they have had to sacrifice time spent comforting and talking to patients, because they are overworked and the wards are understaffed. Nurses have identified the cuts to nurse staffing levels as one of the main causes of countless problems from being overworked. Some have even called in question the existing discourse about the shortage of nurses.

I've wrestled a lot with it myself, “Is that a maintained shortage of nurses? [...] Uh, what happened in this case: oh, it's because of the cuts to nurse staffing! [...] Is that being used for political purposes? Yeah, I think so; the shortage of staff reflects the enormous stress and malaise in Quebec health care institutions, in Canada and elsewhere.” (Didier, 21II)

Some have plunged into the heart of the issues about the economic imperatives that govern them. Some of the participants conducted an analysis of the complexity of nursing, indicating that no additional human resources have been planned to cope with this reality. Others have been extremely critical of hospital management, which they see as responsible for their work overload. For many participants, the work planning/scheduling for nurses “is managed by people who are sitting in the office, and doing so, they don't know what is actually happening [in the field].” (Julie, 13II)

Current state of hospital management: Critical portrait of the hospital management

A number of participating nurses discussed the way in which management operates within various Quebec hospital centers. A critical portrait of the operations management role in strategic planning approach in hospital centers—a predominantly negative portrait—emerged from the FGs saying that hospital management is obsessed with economic imperatives that dictate all managerial behaviors. They reported that management prevailing within the different wards does not take into account the point of view of the staff nurses and fails to inform them of changes, even when these new procedures would affect them directly. They are being confronted with the challenge of continually deploying new projects in hospital wards, projects that directly affect their work as caregivers and make them feel as if they were literally dominated by change. Many of them denounce the failures of arbitrary management that is structured according to privilege granting.

“OK, this one works 12-hour shifts on weekends, and it works for me.” “So I will not move him/her to a different shift.” Well, let's see, according to the convention, it's the youngest [that should be moved], this one is in surplus and you say it works for you on a 12-hour shift on weekends, so you will not move that person? (Lisa, 31FG2) Focus group [FG]

For the most part, they also pointed out that there are too many nursing administrators hired in health care establishments and as well called attention to their constant turnover.

Perception of participating nurses toward the administrators

Although many participating nurses interviewed were critical of hospital management, many pointed out the limited flexibility that nurse managers have to improve the prevailing working conditions in various hospital care units.

This commentary by Judith (36FG3) succinctly describes what many participants think: “More often than not, heads of care units in the throes of any situation of conflict, they have very little ammunition to battle with only just the back of a spoon....”

Environment of fear: Problems in trusting and expressing opinions

The outcomes of our study show that nurses who practice in hospitals are afraid to express a single opinion freely that might go slightly against the grain. Overall, it was out of fear of possible retaliation from their superiors that they preferred to keep quiet. “We do not have the right to have an opinion without retaliation” (Julie, 13II). Such reprisals include various forms of harassment, violence (often public), confrontation, intimidation or threats, loss of privilege, and abandonment by colleagues. In retaliation, participants also reported increased monitoring by unit managers or assistant head nurses, sudden deterioration of relations with their superiors, ongoing tensions, and more frequent sanctions such as “going to the office.” Disciplinary notes, various forms of coercion, such as suspensions, and dismissal were also described.

The fear of denouncing reprehensible behavior by people in positions of authority has the effect of causing nurses to refuse to help their colleagues who find themselves in a precarious situation and who need support to gain credibility and assert their rights. “It's still a culture that thinks that [...] if you help others; you'll be penalized, even if you, you did nothing.” (Cecile, 03II)

Fear-based management

Drawn out of our data collection, we have included below some brief interviews with some of the participating nurses, speaking individually about fear-based management in an FG.

[...] if I used the data we collected and said that there is an increasingly binding power from a number of hospital managers, who exercise their authority through fear and anxiety, would you find that I exaggerate? (Researcher)

Not at all... No, no... you're right. (Fabienne, 27FG1) There is a coordinator who wanted to force me to work overtime. She threatened me to send an act of insubordination to the Order. I do not know if you know, when you're a young person coming out of school, how scary it can be. I saw nurses stay in mandatory overtime and crying. They were exhausted and afraid to make mistakes. The older ones often [...] will blow their nurse managers off: “I'm leaving, and that's all there is to it.” (Agnes, 22FG1) [...] Yeah, but there are ladies of my age who say to young people: “No, no, you are the youngest and you have to stay!” (Catherine, 24FG1) [...] Yeah, yeah, it's a fact, that's true too. That's because, in the history of mandatory overtime, everyone ends up simply defending their own turf. (Agnes, 22FG1)

Doris (25FG1) goes on to refer to the feeling of insecurity that staff nurses are facing when they are threatened with sanctions, for example, when there is a threat to add a written reprimand to their employee record:

People [...], from the outset, will be afraid: “you know, I'm going to have a letter on file, what's going to happen to me?” There is also this principle of the employer [...]: “I won't pay you extra hours, you don't know how to manage your time. And, if you persist in asking, I'll have you evaluated.” [...] Yeah, sure, meaning if you go to an assessment with a nurse counsellor, then you've got some flaws. And then anxiously, you ask yourself: “Gosh does anyone else have the same significant issues at work?” (Doris, 25FG1)

As Agnes (22FG1) alluded to the fact that many of the participating nurses referred to the fear of hurting patients when forced to perform mandatory overtime, some of them also referred to the fear of calling on their trade union. They are frightened of being associated with it, stemming from the dread of experiences such as collective reprisals resulting from past conflicts at work, when colleagues on the ward were publicly abused by a supervisor. Even if they have not experienced personally the same ordeals, it generates fear in them (Table 1).

Table 1. - Thematic Axis 1: Reflective Look on Current State of Things
Thematic Grouping Themes
Description of the work overload No longer having access to their role as caregivers
Decrease in quality of care
Participants explain the work overload and its consequences
Current state of hospital management Critical portrait of the management
Perception of participating nurses toward the administrators
Environment of fear Problems in trusting and expressing opinions
Fear-based management

Axis 2: What the participating nurses wish

Hospital structure change: Transforming organization of work

Several nurses indicated that they would like to see different types of structural change to some drastic strategic managerial procedures, which are put forward by hospital governance. In their view, the main focus should be on the disciplines required to improve their nursing practice by shifting nursing/patient ratios and by forecasting future long-term nursing workforce. This would in turn result in reducing their workload and increasing humanization of care to patients as well as nursing practice conditions to benefit greater self-determination of staff nurses.

Democratization of decision making

In this sense, many participating nurses proposed different strategies to democratize the decision-making process that is inherent to the functioning of the health care system in different hospital settings. Overall, our results indicate that participants want (a) staff nurses and patients to be part of the decision-making process in the hospitals; (b) collective deliberation bodies to be created at hand; (c) budget simulations to take place, and (d), in parallel, a greater effort to improve positive communication between staff nurses and nurse managers/administrators.

Solution for management performance: Proximity and possibilities

For his part, Charles (10II) suggests an increased presence of nurse administrators in the ward environment to compensate for the lack of recognition of staff nurses:

It [would help] if administrators would be more present in the field and less often in meetings [...]. They could see the whole scheme of things [that are done by staff nurses]. It would help [to] give some feedback to people. (Charles, 10II)

Through her testimony, Danielle (14II), in the same way as Philippe (19II), stresses the importance of reducing the number of nurse administrators in different hospital settings, but she insists that these administrators are not constantly monopolized by meetings. But these meetings, in her opinion, have the effect of making them lose contact with the reality in the field. According to Danielle (14II), the meetings should not be abolished, but they should be succinct and directly relate to what happens within the hospital wards.

You walk in: “OK, 10-minute meeting. There, I told you about respect, I told you about this and that [...], how could we organize ourselves?” It does not take money to do that, [...] it just takes some administrators, who are able to drop their paperwork, to look at the reality and to say: “No, this way [to work], it doesn't make sense!” And probing around: “You, what are you thinking? [And you,] what do you think?” (Danielle, 14II)

Serge (37FG3) proposes that nurse administrators, like other physicians, have the opportunity to adopt a mixed practice through which they would be able to act as nurse administrators while remaining active at the clinical level. This is a proposal that John (38FG3) and Alexandra (39FG3), who participated in the third FG, are in agreement with.

I find that interesting to see physicians who may have mixed practices will continue to [...] follow their patients and [...] will be able to manage at the same time. But for staff nurses [...] from that moment on, if we do nursing management, as well, absolutely under this approach, bygones would be bygones with respect to [...] the caring. (Serge, 37FG3)

Offer them better pay

To attract better nurse administrators within different hospital settings, Dominic (12II) proposes to offer them better pay:

We do not pay them enough and that's why they're not good! I'm under the impression that the biggest issue is the salary, their earnings are too low. (Dominic, 12II)

According to him, the savings achieved by not paying nurse administrators enough would be offset by the costs of the poor decisions made by these administrators, who could be described as “administrators at a discount.” For her part, Julie (13II) suggests that taking advantage of the upcoming retirements, in order to replace those who leave the health institutions with better administrators, is a strategy that, as Dominic (12II) points out, would require better wages (Table 2).

Table 2. - Thematic Axis 2: What the Participating Nurses Wish
Thematic Grouping Themes
Hospital structure change Transforming organization of work
Democratization of decision making
Solution for management performance Proximity and possibilities
Offer them better pay

Axis 3: Nursing resistance

Protection strategies: Working part-time and change sector of activity

Among the various protection strategies discussed with participating nurses, one of them is the reluctance of many nurses to work full-time.

If I'd have to work full-time, I'm going to burnout and I'm going to leave the profession. I work 7 days out of 15, but thank God, I'm having a life outside the unit! (Linda, 04II)

To protect themselves from the repercussions associated with an ever more hectic pace of work, some nurses are planning to change their sector of activity. This is the case of Isabelle (01II):

I left the physical care unit because I did not feel like I was giving any care. [...] Mental health unit came as a response to that need. (Isabelle, 01II)

Resort to outside help

When they are unable to get help from hospital supervisors, nurses are sometimes getting support from organizations or individuals who are not attached to hospital centers. Following an assault in connection with her work and having failed to receive adequate support, Leticia (20II) decided to file a complaint with the police. Then she got the most beneficial listening she has ever obtained. As a protection strategy, Danielle (14II), for her part, has used the support offered by a women's community center.

To get out of it, I went to a women's center. These are women who will engage and who will meet [other] women to carry us through. For me, it was my job. Because when you're a staff nurse, you have no help anywhere, you're abandoned ... as if we're supposed to be strong! So for me, it's the community action that took me out of it. (Danielle, 14II)

Conscientious objection

Within the individual interviews and focus-group meetings, some participating nurses shared with us some acts of resistance that could be qualified as conscientious objections, many of which fall into the category of acts of personal insubordination. In the following excerpt taken from an interview, it is about a conscientious objection:

... it was very cold in the rooms. [...] I saw children in their bassinets wearing snowsuits [...]. My head-nurse unit said, “You will tell them they are not at the hotel.” So I told the parents to go see the hospital complaint commissioner. [...] People would come back and [...] say, “It has achieved [nothing]”. So I called the complaint commissioner and I said, “Look, the parents [...] are talking about going to see ... you know the gentleman on the TV ...” She said, “my God” [...], I'll take care of it! She called me about ten times in the morning, the plumbers came in, the carpenters and the electricians showed up, by noon, the heat was back! (Laurier, 06II)

In these circumstances, Laurier (06II) prioritized the affirmation of his personal values by taking the liberty to tell the “Complaint Commissioner” that parents were going to report the situation in the media, even if it was not the case, so as to accelerate the resolution of this issue that affected the quality of life of young patients and their families.

Noncooperation and Nonviolence

By an action of noncooperation, Philippe (19II) managed to reverse the decision of his nurse administrator not to pay the costs of training that he and one of his colleagues considered fundamental to providing quality emergency care:

Training for advanced life support [...] was requested. “We have no money for training!” Me and a colleague, [...] said: “Give us a piece of paper that you refuse to train because we want to cover ourselves.” [...] If I have this paper stating that you refused my emergency care training ... then when I work in the unit, if one day a TV crew shows up and says, “how could you not revive a patient?” I'd say, “Well, too bad, huh, I asked for the training, but they never gave it to me.” (Philippe, 19II)

At first, by refusing to passively accept the decision made by their supervisors, Philippe (19II) and his colleague did not cooperate with them. By requesting a letter confirming their refusal to cover the costs associated with this training, they embarrassed—although very modestly—the establishment with the nurse administrator's point of view and in accordance with what constitutes an act of noncooperation. Even if they were only 2 individuals setting up the action of noncooperation, they somehow managed to collectivize the conflict by threatening to involve a third party, the public opinion, just in case an incident occurs that could have been avoided by providing this training—which caused the creation of a countervailing power. But it has to be noted that almost all of these actions of noncooperation had the intent to embarrass the structures of the hospital institutions, without calling into question a political system. Each of these acts of noncooperation entrusted to us by the participants is part of nonviolent action as a strategic political action and, more specifically, in what Derrienic26 identifies as methods of social, political, or economic noncooperation.

Civil disobedience

Although generally understood as the transgression of state authority, the concept of civil disobedience implicitly refers, as Durand27 points out, in opposition to a higher order, to institutional or administrative rules. When they communicated to us their ideas regarding collective actions, some participating nurses expressed some acts of resistance prohibited by certain rules now in effect. Louise (18II) with respect to membership cost charged by the Order of Nurses of Quebec (OIIQ) to nursing student trainees led her to consider that as an injustice and to the possibility of “direct actions” that fit into what constitutes civil disobedience:

There was a conflict with the Order [when I studied], because they forced us to pay our membership dues [...] at full price [...] for three months of training [only]. We should have gone in and taken over the public forum [...] warn the media, newspapers. Organizations, [...] when they don't move [...] well, it takes a small group [of activists] which agrees on a precise grievance; then carries it out on the public place. It can be occupancy of the place, maybe camping out; it may be any types of interventions. Recently, we went, with 10 to 15 women from a women's community center to conduct a group intervention at a conference that held a meeting about privatization of our public health care system [...]. We thought that it was a little exaggerated to speak of [the private sector as the only solution], so we went in and interrupted the conference meeting. (Louise, 18II)

Linda (04II) refers to similar ideas of mobilizing acts of resistance that she associates with an “extreme movement” or a “major action that will hurt”:

It takes an extreme movement. [...] People marching in the streets [...]. I think we need something symbolic, concrete, huge, which will say, “Hey! The issue with nursing, that's a problem that is always ending up in the same way.” Do you think a bedside nurse will let a patient die because she/he is going home, eh? At some point, we talked about it, in our care unit, the entire staff nurses, and agreeing that if we resign protesting “en masse” there will be patient deaths, that are for sure, but how far must we scream? (Linda, 04II)

For Linda (04II), the infringement of the law to ensure the survival of essential care services that exist in Quebec must be considered by nurses, and this would be justified by the fact that the practice conditions in which they exercise, on a daily basis, have some deleterious effects directly not only on the client/patient health but also on their own health. In her opinion, but also from the point of view of Danielle (14II) and Leticia (20II), they have witnessed situations that they identify as traceable to the prevailing nursing practice conditions and the risk factor of premature death in patients: “the life of people in hospital wards is in danger.”

Therefore, the main acts that may seem immoral from the outset because of the repercussions that may arise, such as “the mass resignation” of nurses from the same care unit, based on a grim reality that may appear legitimate to a group that decides to take the path of civil disobedience. This is according to the logic of Linda (04II) in which a group of nurses could consider that it is ethically conceivable to risk the health of a number of patients, over a given period of alleged claims, to end a situation in which patients are permanently at risk and where the core values of registered nurses/caregivers are flouted (Table 3).

Table 3. - Thematic Axis 3: Nursing Resistance
Thematic Grouping Themes
Protection strategies Working part-time and change sector of activity
Resort to outside help
Conscientious objection
Noncooperation and nonviolence
Civil disobedience

DISCUSSION

The discussion will be based on 2 axes. The first axis titled “the hospital status quo” will lead us to take a critical look at the social order and the power struggles that are rampant in the hospitals. This axis will have 3 components: the mutation of care, entrepreneurial governance, and the political technologies that contribute to nursing discipline and subjectivation. The second axis titled “the political action of participating nurses” will have 2 components: the political actions of nurses and the hospital democracy. Implications for nursing research and study limitations will follow.

The hospital status quo

Mutation of care

The undeniable finding of the status quo in the hospitals: the mutation of care is a phenomenon that emerged as being central in the framework of this research project. The nurses who participated in this study expressed clearly how difficult it is for them to be a trustworthy caregiver in hospitals that are becoming more and more dehumanizing. They point out being obligated to deploy actions they consider as opposed to their ethical values. They must also put aside patient education and prevention.

Participating nurses revealed to us a system of constraints and structures of domination, which have the effect of confiscating their power of caring and their professional autonomy. Atop many experienced constraints, the work overload causes nurses to continually function under pressure; and the recurring mandatory overtime is perceived by some participants as a violation of human rights, as a phenomenon of unprecedented violence.

Most of the participating nurses said that they are being contaminated by a managerial culture and getting bogged down in a clutter of documents and hospital procedures that are imposed on them. Many of them also deplore the control strategies and reprisals used by administrators to increase “productivity” within the health care establishments.

The results originated by this research lead us to postulate the emergence of a “new” form of nursing, which is now structured according to its economic “effectiveness.” It is an approach of speedy health care services that must be functional, and cost-efficient, and care that is neither based on the most valued theoretical nursing precepts such as holism nor on any long-term vision. This approach treats a given health problem, at a specific moment, and this, regardless of the actual needs of the patients, whose opinions are of little importance, and without taking into account the repercussions of the impact of minimal care on a long-term basis.

Entrepreneurial governance

Whether it was (a) the absence of health care administrators in the field; (b) the remuneration of administrators based on their performance; (c) the use of private placement agencies; (d) division of health care units into subsets, whose subsets must be profitable; and (e) the lack of full-time jobs available to staff nurses, we identify an agenda of entrepreneurial governance through these observations made by participating nurses. This type of governance is defined by Goulet et al28(p122) as a doctrine that aims for “parasitism by the private sector of the public social intervention” and to profile the public sector as “too activist or too aware of its democratic role.” Therefore, gradually there will be a substitution of public service representatives and hospitals' employees by so-called “independent” administrators. The initial objective of the Canadian health care system, which was previously to ensure public health care, will be perverted by an industrial conception of effectiveness, which is to sell health care as a commodity, like any other manufactured goods or services that generate profits.

Now, nurses must do “more with less” and they are absolutely drained by the sustained efforts they must deploy to provide proper care despite conditions that are incompatible with the foundational values of caring. As a wide range of participants pointed out, under the binding domination of these new staff management with methods, directly imported from the private sector, they will transform nurses as a business utility and are going to treat clients/patients as assembly-line work. The management in hospital centers will be done according to performance indicators and by using new public management principles such as the separation between decision makers and implementers. The results of this study indicate that the entrepreneurial governance is responsible for the onslaught of poor quality of care in hospitals and by extension causing physical and mental health issues in nursing staff. This so-called “optimization” technique process implanted in the health care network/system using political technologies (disciplinary power) to protect this newly established political order is ensured to survive by a perpetual reorganization.

Political technologies that contribute to nursing discipline and subjectivation

After having brought our attention to macro power representing governance, we now turn toward the microphysics of power, which means relationships based on power, on different scales, such as individuals, families, small groups, or institutions. This type of power that Foucault29 calls micro power emerges from everywhere; it has multiple relations based on power. It serves as a support to disciplinary techniques that do not rely on their own excesses to demonstrate its power even if this type of power could use punishment to achieve its goals.

By providing to “individuals both object and instrument of its exercise,” Foucault29(p200) identified, on the one hand, disciplinary power and the political technologies that characterize it, conditioned them to subjectivation, to interiorize the norm to view it as fair or necessary. On the other hand, it divides them hierarchically against the other in an economy of power. The mechanisms of subjectivation come to divide the subject; either it divides itself deep down internally or it is divided in relation to other subjects, in order to categorize it and make it an object. They eventually objectify a previously constructed reality associated with the status quo to maintain the overall system and to promote proper functioning of the institutions. Furthermore, Foucault29 specifies that disciplinary power is tolerated by individuals as long as it remains scattered and hidden in these technologies that prove to be numerous, complex, and imperceptible. We have identified in this study a definite number of components of disciplinary power such as surveillance, bureaucratic monitoring, technification of care, imposition of projects within care units, the therapeutic nursing plan, and the bureaucratization of care, as well as intimidation via the fear of reprisals.

The political action of participating nurses

Political action of nurses

The political action of the participating nurses was fuelled mainly by moral issues and humanistic purposes related to professional self-determination, as illustrated by the actions they deployed in the past or they intend to deploy. Other political actions previously identified were intended to help them “survive” or at least detect scores of different threats to protect themselves. Many needs, wants, and wishes formulated by participating nurses were related to the organization of their work, such as the importance of reducing the number of patients they care for; to establish a long-term planning to avoid work overload for a proper functioning of their practice; and to revolve around a functionalist normative ideal, without bringing into question the neoliberal and managerial political and ideological structures. These dominant ideologies not only, and namely, encompass the nurses in unequal practices, and into a system of constraints, but also restrict their thinking patterns by binding them to a “reality” frozen into rigid structures. It makes it difficult for them to project themselves beyond the constraints of these ideological boundaries which by performativity30 appear to have been assimilated and internalized by quite a few of them.

Participating nurses also described how they had already withstood too many types of injustices, oppression, or exclusion at work. Considering the constraints they had entrusted us with beforehand and the statements collected about their acts of resistance, political actions to end these constraints were far less numerous than we thought. The modest inventory of actions deployed by nurses who are engaged politically, as well as the multiple obstacles they have encountered while trying to put their plans into actions, brings us back to what we have identified as the hospital's disciplinary control and the abusive use of coercive political technologies that deny altogether any of their political action toward choice and autonomy.

Some participating nurses also deployed individual or collective actions of noncooperation, displayed civil disobedience, or wished to deploy that type of action in order to establish a relationship based on power to have their concerns taken into account. They showed us that it is important to resist through some forms of civil disobedience when there is disregard for people and values considered fundamental. These are determining facts that force nurses to act creatively in order to continually reinvent strategies of resistance.

Hospital democracy

In conformity with the principles of hospital governance, staff nurses are excluded from the decision-making process, even if these decisions have a direct impact on their practice. The outcome of our study shows that democracy in the hospitals is increasingly confined to boards of directors and jurisdiction bodies to which the staff nurses usually do not have access. A number of nurses with a high level of commitment are mostly confined to instances that have only the power of recommendations, as a technique implemented by the hospital authority to deploy their energy often to no avail and never succeeding in bringing changes, like in hospital professional nurse councils. Yet, consultations with health and safety committees, through which trade union representatives have the opportunity to talk with the employer during negotiations of collective agreements, are perceived by many participants as being inefficient to improve working conditions. They say that frequent techniques are deployed by the employer to paralyze discussions with the trade union representatives to postpone dispute settlements. Among these techniques, the employer constantly changes interlocutors with the trade union representatives throughout the adjudication, and according to participating nurses that is a tactic unfortunately exploited by a wide range of hospitals, which sometimes has the effect of considerably postponing the settlement of a grievance procedure. In some cases, this time lapse can range up to more than a year.

When it comes to action for change, Žižek31 states that it is important to question ourselves about the possibility that the effort deployed causes the reproduction of dominant discourse, as it would be the case when nurses are investing time and energy in committees that bring very little outcomes—hospital governance by far prefers seeing staff nurses running around in circles in some futile matters—rather than seeing nurses organizing themselves to resist the hospital governance authority. In these situations, Žižek31 specifies that it is sometimes better to do nothing rather than try to act the wrong way to transform the status quo. For a wide range of participating nurses, cooperation did not allow improving their fate on the wards whatsoever, so doing nothing at all would then become an act of resistance.

Implications for nursing research

Hospital managers are quite often stuck between a rock and a hard place—squeezed in between supervisors and staff nurses—but are left with very little flexibility and scarce resources to tackle constraints that weigh on staff nurses. It seems pertinent to look into their perspective about the challenging issues summarized in our research study.

Study limitations

The researcher's critical perspective necessarily guided the interpretation of the results. Participants could have altered their answers to express their ideas toward social desirability.

CONCLUSION

Our study concludes that there is an authoritarian drift on the rise in hospitals across the province of Quebec; thus, nurses have no apparent reason to disrupt the hospital status quo. In a profession where registered nurses value compassion as the highest ethical standard in their practice, we now face “ethics” based on efficiency, performance, and optimization, articulated directly by the semantic record of the stock market that is often considered the primary indicator of economic strength and development in our health care system.

While refusing to position ourselves in the role of the expert by telling nurses how they should act, we believe that they must break the isolation and speak, doing it together to put an end to the democratic deficit and the excesses of neoliberal governance. The power exercised by hospital governance can be thwarted by a collective nursing force equal to or greater than the institutional violence deployed, while choosing nonviolence as a form of strategic political action. It is imperative that Health Organizations, the Nursing Order (OIIQ) and Trade Unions in the province of Quebec, whose roles have been criticized by quite a lot of nurses in this research study, intervene decisively to participate in the renewal of democracy in the hospitals. Finally, we consider that college and university education should be able to provide intellectual resources to nursing students regarding significant concerns in the health care system, in which future registered nurses will be ensnared. A humanist and critical training would allow them to get a better understanding of the complexity of hospital management structures in order to face the challenge that will arise, and the means to take an individual and collective stand on relevant societal debates.

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Keywords:

constraints; hospital center; neoliberal governance; political action; political power; postmodernism; power relations; staff nurses; subjectivation; working conditions

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