CAIRN-INT.INFO : International Edition

1 “Hospital–silence: ” the well-known sign is emblematic of the social climate in hospitals. It is a paradoxical situation: how can we explain why a growing mass of qualified employees concentrated in large public institutions, [1] exposed to more and more stressful and divisive working conditions, but with comparatively secure statuses, [2] do not make more “noise?”

2 One paradox can hide another. Mobilization and collectivities are built on protests, but protest mobilization is more characterized by moderation in hospitals despite a concentration of resources available for confrontation. Does this mean that in organizations of this size that individuals experience their work in a juxtaposed and isolated way with no collective coordination, cooperation or representation, thus with no work collectivities? The popularity of the hospital institution is based on the work of teams within departments in a public healthcare institution where the concerns of patients are, for all staff, part of their public service mission, and where increasingly they abide by a professional code of ethics of caregivers, doctors or otherwise. Beyond observing the existence of a particular type of work in hospitals (both prescribed and with strong ethical components), the hospital community is neither uniform, nor universal, the dynamic of collective mobilization is hugely uneven, varying between place to place and at different times. Work is not necessarily as committed to as required even if it has a moral purpose. Sociology shows us that, on the contrary, there is a gap between work stipulated and work done, motivation and feelings of belonging to a collectivity do not “come with the job,” but result from interactive networks. It is in these interstices that we believe that the processes of collective mobilization can be found. While solidarity is disappearing (Linhart 2009), notably under the influence of critical managerial policies (Alter 2009; Dejours and Bègue 2009), some remains and has even been renewed in a different form than that of confrontation.

3 After having examined the concepts of collective mobilization, notably as understood by sociologists of mobilizations, we will consider two types of collective mobilization in hospitals in turn: confrontational and consensual mobilization. The difficulty is firstly to specify how the two types are based on a common concept of collective mobilization, then how they differ. Then we must distinguish between the conditions for mobilization and forms of action. We will thus examine the conditions for the existence and forms of mobilization of administrative and healthcare labour within a well-organized and institutional hospital world.

4 Mobilization can be classified as confrontational when there is an adversary (a social group, institution, etc.) designated to take intentional and concerted collective action against. Less classical, consensual mobilization is understood in general terms as collective action without an explicit (even implicit) adversary but which conforms to the institution that it serves, [3] it is collective (largely participative) and voluntary (as opposed to an involuntary aggregation). It is deployed at a variety of levels (organizational and institutional), includes a transversal dimension, interprofessional or interinstitutional, is based on the normal repetition of the day-to-day as much as it is on unusual (exceptional or periodical) events and takes place in the workplace (and not in the public sphere) which limits its content in terms of democratic debate. Over the course of this article we will specify the empirical elements of this definition before presenting the synthesis in conclusion.

5 Our aims are essentially six-fold. [4] This article is based on survey material accumulated from seven investigations into various hospital healthcare jobs and services, [5] preceded by a participant observation of strikes in the hospital sector. [6] It is as a result of these successive investigations that the pertinence of the distinction of the two types of mobilization became apparent as a means of systematizing ways of working and links with the mobilization of different healthcare professionals. Thus, we have been able to tackle different aspects as we go along: the contexts of cooperation at work, interprofessional cooperation and participation and their consequences for representations of hospital workers.

6 We have interviewed a broad spectrum of medical, caregiving and non-caregiving professionals across the whole field to provide an account of the hospital “world of work” and not just isolated professions (see methodological Box 1 and the Appendix). This permits us to relate mobilizations to work contexts and not only to the characteristics of a professional category.

METHODOLOGICAL BOX 1.–Outline of successive surveys on labour relations in hospitals

The first survey focussed our attention on hospitals on the notion of local context by reconstructing social worlds based on an analysis of organized labour relations. The actors themselves are aware of the imprint their “departments” make on their practices but they attribute the “ambience” in the latter to a single boss or the medical speciality and not to collective ways of working (Sainsaulieu 2006a).
The second survey on paramedical participation during accreditation procedures showed striking examples of staff mobilization at the time of developing treatment protocols for accreditation (Sainsaulieu 2007). An informal dynamic unfolds in a formal setting, leading to a mobilization that is paradoxically in accord with the institution, even occasioning greater participation than during confrontational mobilizations under trade union control (Sainsaulieu 2008c).
The third survey increased our knowledge of the hospital world from a regional perspective and centred on a professional body. This time the issue of participation arose within consensus meetings that developed recommendations for good medical practice: hospital doctors (in this case in the South-West) followed these more when they felt included, that is to say consulted or represented.
The fourth survey allowed us to ascertain the strength of the communities in certain departments, those where patients are unconscious, in a different context (Ontario, Canada) (Sainsaulieu 2009).
The fifth survey, based on a double questionnaire carried out among managers and staff,[7] showed us the highs and lows of participative management, its mythology, but also its performative strength, the managers presenting the collective healthcare idea to the caregivers (Sainsaulieu 2008b). The representation dimension is therefore added to the practical one. This survey was also an opportunity to update our work on unionism (Sainsaulieu 1999, 2008c) by analysing the managers’ involvement in trade unions.
Finally, the two last surveys allowed us to tackle the question of the interactions of hospitals with their environments. Hospital departments interact with each other and intervene in health policies beyond their walls, in a system that nevertheless remains essentially “hospital centric.” These different elements have fed into a reflection on forms of collective mobilization in hospitals, presented here below in two ideal-types.

[7]10,000 questionnaires were sent to managers (with 1,522 returned), 5,000 questionnaires to nurses (with 890 returned).

Approaches to collective mobilization revisited

7 Whether considering labour relations in hospitals or our problematic of mobilization, our analysis brings a transversal dimension to the sociology of work, organizations, professions and health and particularly to the sociology of mobilization. We will thus firstly define the perspective that we adopt by discussing related conceptualizations which we distinguish from our own.

Neither negotiated compromise...

8 If the question of mobilization in hospitals has not more frequently arisen, it is perhaps because it leads to relations between prescribed work and real work being treated differently. Whilst we intend understanding the two sides as working together, the sociology of organizations emphasizes negotiation as resulting from a conflict between the two. Strategic analysis, which has contributed to the training of hospital management, highlights the actions of actors in areas of uncertainty overlooked by the rules (Crozier and Friedberg 1977). Since rules do not resolve everything, it is above all negotiation, finally brought about through conflict, that can overcome divisions and bureaucratic inertia. Similarly, Reynaud ( [1989] 1997) introduced the notion of “regulation of compromises” between two regulations, namely “of control” and “self-government” to professional relations. The idea of twin powers (administrative and medical) has been formulated on several occasions with respect to hospitals, this “professional bureaucracy” giving rise to constant negotiations that are more or less lengthy, even deadlocked (Binst 1990; Stasse 1999). The expression: “negotiated order” is even specifically devoted to hospitals from an interactionist perspective (Strauss 1992). [8]

9 Surveys conducted in hospitals, though from the outset conducted through a filter of strategic analysis as if they are composed of social worlds (Osty and Uhalde [1995] 2007), have not revealed negotiation as a central characteristic. There are certainly symbolic, strained, even broken discussions between anaesthetists and surgeons (because of their overlapping operations) between representatives of emergency departments and specialized departments (on the hospitalization of patients entering accident and emergency), between the management of operating theatres and surgeons (around planning operations)... However, apart from these textbook cases, which more often involve managers, day-to-day work is based on a synergy of professionals making constant adjustments ( “Where are the syringes? Who has treated this patient? When is the doctor coming?”) in a strained atmosphere tied to working under pressure (Goffmann 2002; Sainsaulieu 2003). Teams are welcomed or, rather, staff frown upon the “individualism” of colleagues and the “aggressiveness” of patients. Hence our investigation of teams who succeed in working in harmony, working together and sharing a sense of belonging (Sainsaulieu 2006a).

10 The concept of mobilization is appropriate for contemplating the link between “cooperation” and “coordination” and for avoiding a theoretical framework that is based too much on negotiation. Both “cooperation” and “coordination” at work are based on collective action that is both voluntary and prescribed, the former in a more informal form than the latter. Cooperation is defined as all the “professional norms: ” transmission, tricks of the trade, explanations, participation, contacts and sociability (Alter 2009: 42). “Participation,” “contacts” and “sociability” characterise consensual mobilization as we understand it. Closer to cooperation in its informal character, the concept of mobilization signifies a better foundation than cooperation limited to a few individuals from the same profession. Seemingly unconnected with formal bureaucratic coordination, collective mobilization can, however, also be the result of a participative managerial impetus or the practice of interprofessional coordination, as we shall see.

Nor simply collective practice…

11 In what way is it pertinent to distinguish collective mobilization from simple collective work practices? While we take forms of collectives into account in our notion of “mobilization,” we take care to specify in each case their intentional nature, particularly of consensual mobilization. Indeed, a social movement like confrontational mobilization can easily be conceived of as a voluntary action, because of its agonistic dimension that stimulates the will of participants. Even if the consensual mobilization that we are seeking to describe is already part of a predefined institutional framework, is the intentionality of the collective action any less proven? It seems to us that the tension that results from all mobilizations, because of the collective efforts required, is to be found in the fight against illnesses and against the inertia of others (colleagues, patients and managers). There is, in effect, no obligation to join forces to conform to an institution. The scale of intentional effort specific to any mobilization, even of “struggle” in an existential sense, [9] is in addition to basic integration in an institution and is found in all cases of cooperation, coordination and participation analysed below. [10]

12 To be interested in a perspective of mobilization in hospitals supposes adopting successive different levels of analysis, from organizational practices to those of day-to-day work, to understand the totality of coordination and cooperation. [11] The thesis that we will support is that, despite, or because of, constraints on them, hospitals do in fact construct mobilized communities, with the proviso of wanting to identify its forms and to leave to one side professional or organizational boundaries, to consider interactions at different levels between doctors, managers, nurses, healthcare assistants and general ancillary staff. In reality, this means nurses, the largest professional (gendered) category, especially in public hospitals.

Nor social movement

13 The term “collective mobilization” is polysemic: sometimes it takes on the general sense of modernization of societies (Chazel 2003), sometimes it becomes more technical, as in the sense developed by the sociology of translation (Callon 1986) or in the sense of “resource mobilization.” If we feel justified in using it in the two opposing senses (confrontation and consensus) it is because we want to avoid the alternative: either collective mobilization (confrontational) or individualism (consensual). This choice could indeed lead to a reduction of the social either to the individual or to struggle—a solution should be found at all costs so that the collective can be retained. Mobilization is the “creation of new commitments and new identifications” giving rise to “a rallying of actors or groups of actors” for a specific purpose (Chazel 2003). [12] We borrow the dynamic and relational approach from the sociology of mobilization, the triggering role of the event, “the meaning of places invested in by actors” (ibid.), without neglecting questions of leadership, individual charisma and transformation of identities.

14 It is, on the contrary, essential for us to distance ourselves from what could be called agnostic facts, where the centrality of policies is confirmed and signified by the name of the analytical framework encapsulated as contentious politics. While this analytical framework takes into account the eruptive and discontinuous character of mobilization (made up of fluxes, processes and episodes), as opposed to “routine institutional policies,” it can neglect “organizational effects” at the meso-sociological level (Sawicki and Siméant 2009). Mobilization and social movements should therefore be dissociated. One can make a connection between the latter and confrontational mobilization, with which they share an agnostic specificity, “action against: ” “a social movement is defined by the identification of an adversary” (Neveu 2000: 6). But social movements maintain close relations with politics, as true “twins of politics in democratic societies” (Tilly and Tarrow 2008: 12). Yet, mobilization in organizations, even confrontational, does not resemble confrontational mobilization, which is both social and political (Oberschall 1973). Moral connotations can be attributed to it (Dubet et al. 2006), proto-political or standard political overtones. Owing to various events, a process of politicization can also be attributed to it, in the sense of an increase in the generality of issues and a perception of antagonisms (Sainsaulieu and Surdez 2012). Even if the threshold is sometimes fluid, confrontational mobilization only becomes a social (or political) movement by going beyond the confines of an organization and associating with new actors. [13]

15 The notion of mobilization has already been disconnected from that of conflictuality in order to reject an exaggerated division between organizations and movements (Friedberg 1992). In a global context of weak strike actions (Groux 1996) and a redefinition of public action (Muller [1990] 2003), social movements can no longer claim exclusivity of engagement, [14] nor of social change [15] or of mobilization. [16] However, one can attempt to borrow from it to explain either organizations in disputes or mobilization of resources in institutions. One can also take into consideration the two sides of mobilization.

Confrontational mobilization in hospitals: its infrequency, forms and elements of explanation

16 Confrontational mobilization has undergone a sociological shift. For a long time the blue-coated group of hospital workers took its place at the centre of other marches by the labour movement. In the last half a century the “organic composition” of hospital labour has truly changed in favour of the white coats. [17] At the turn of the 1980s-90s, nurses took part in a cycle of protest that was as strong as it was unexpected (Kergoat et al. 1992). This movement had the merit of bringing an end to the image of nurses as subordinated to doctors and administrations. For all that, its exceptional character presents a sociological predicament that is perhaps even greater, if confrontation by nurses becomes possible, why does it still remain so uncommon? Responding to this question supposes taking into account this paradox as well as existing protests.

The unrest of nursing staff and statistical silence

17 When hospital directors and human resources directors are interviewed, fear of unions continues to be evident. Yet, while hospital unions can be strong institutional counter-powers, the number of strikes and levels of unionization do not support this fear. Militants and decision-makers are inclined to wait for an end to the silence while scrutinizing discontentment that neither erupts nor crystallizes.

18 Until recently, staff numbers, including doctors, have only increased, and the nursing corps is weakly differentiated. [18] With the addition of 250,000 healthcare assistants (increasing more slowly), without even including medical, technical and medicotechnical staff, their numbers are greater than those of railway workers, twice those of postal workers and five times those of the RATP. Here is a concentration of female employees with no equivalent, with levels of qualifications well above the average, in a public sector where employment is protected and where conflicts are more common than elsewhere.

19 In addition to these objective indicators, there are “good reasons” for complaint. In the public sector, hospitals suffer from pressures on work-rates (deadlines, peaks in activity, heavy workloads, work that is dependent on colleagues, etc.) and working hours (night and weekend work, being on call, unpredictability of hours in the coming months, etc.). Official sources indicate a worsening of working conditions for care staff in particular who are nevertheless better qualified and paid than ancillary staff. Due to the requirements of equal access and continuity of care in hospitals “working hours obligations, working Sundays and nights, are much more widespread, notably for the care and medical staff, than in most other commercial sectors of the economy” (Cordier 2009: 5). More than half of the employees in healthcare (in hospitals) state that they frequently work on Saturdays and a little less than half on Sundays. Moreover, they claim to be “put under pressure by the sustained pace of work, short deadlines, and demands that require immediate responses” (ibid.: 3), while half of nurses and healthcare assistants (as opposed to a third of doctors) claim they are not able to take breaks from their work. Recent changes over the past three years have not improved matters: “one in two employees said they had felt an increase in pressure on their pace of work, especially when their institutions were confronted with a rise in the isolation or impoverishment of their users” (ibid.: 6). Traditionally greater for nurses than for healthcare assistants, [19] workloads have tended to equalize in a context of a restriction of available resources, where growth in the number of ancillary staff has declined since 2004 (Fichier général de l’État, INSEE) [20] and where reduced hospital spending in the Objectif National de Dépenses de l’Assurance Maladie is common (Cour des Comptes 2010).

20 The silence of the caregivers is thus paradoxical and requires explanation. The first order of silence is statistical: figures can be found for the number of strikes in the three major public sectors (DGAFP 2009). But only a few thousand members of staff of the ministry of health are included, not those in “private non-commercial institutions whose dominant characteristics are public” as hospitals are. What is more, none of the three major sources on collective action at work covers [21] the three major public sectors. [22] There is no public instrument to measure situations of conflict in the public hospital sector and very few in the three major public sectors.

21 In the face of what we could call a remarkable statistical silence we must turn to cross-checking available sources: scientific, trade union and media. Note the fragmentary and incomplete nature of published information. [23] Within these limits, two profiles of confrontational mobilization of employees can be drawn. Nevertheless, the question that first arises concerns the independence of other categories of healthcare staff from doctors, given the role of spokespersons the latter are recognized to have. Situations of social conflict in hospitals are indeed above all the preserve of doctors. Not only do the latter benefit from being able make themselves heard to defend their interests (professional organizations, access to the media and the press, ties to supporters and parliament), but they also possess a driving-force such that they often confuse their interests with those of other hospital professions, their mobilizations with those of the “public hospitals.” There are three sides to this capacity: the symbolic formulation of the interests of all ( “the defence of public hospitals”); a moral and hierarchical authority over staff who are professionally (and often socially) subordinate to them; alliances with other trade unions on different issues. A convergence of interests is certainly possible, but the medical mobilization of doctors is more often confused with the general interest than in other categories. Their driving-force sometimes acts on paramedical professions and more often on medical students, notably interns, somewhat under the influence of their “bosses.” It is not the only source of “heteronomy: ” in the private sector, the general strike for wage increases in 1996 was started by the directors of clinics themselves, in response to a call from the Fédération des Hôpitaux Privés.

Strikes and unachieved professional identities

22 Non-medical hospital staff appear to take part in two types of strike. The wage type, often associated with the slogan of defending public services, involves all staff (by trying to involve doctors), but more often mobilizes non-healthcare staff. Wage mobilization follows the outlines of unionism. The trade union strikes and demonstrations do indeed rally union members who are in the large majority non-healthcare staff (Sainsaulieu 2008c). In terms of categories we should note the uncomfortable position of healthcare assistants in an intermediate position. The latter can take part in classic wage strikes and march with ancillary staff, administrators, workers and technicians with whom, moreover, they are unionised; or equally “choose” a caregivers strike that is more appropriate to their practice, at risk of being poorly received by their more qualified nursing colleagues as was the case during the benchmark caregivers movement in 1988-89. [24]

23 Nurses form the spearhead of another type of strike, the strike for professional identity, with or without the support of paramedical and indeed medical staff. Indeed, these movements can concern a sole category of staff (for this reason classed as “sectoral” actions by unions): occupational therapists, radiographers, nurse anaesthetists, etc. These have succeeded with various employment demands, for both healthcare and non-healthcare staff in the 1990s, in apparent contrast with the 1988-89 movement. In fact, these large and small professional movements are the product of the same process of diversification and professionalization of the great body of hospital wage earners, resulting in skilled trades with no established recognition. Hence the initiative to establish a new hospital “répertoire des métiers,” and hence also the “identity” character of these large and small movements. Identity is defined here as “a recurring process of activation of the interrelationships between individuals” (Melucci 1985). The issue remains that of the nurses’ actions in 1989: the claims of a professional role of women (Kergoat et al. 1992), the claims of a closeness between the rank and file and its representatives through coordination (Hassenteufel 1991), the other component of a profession.

24 These movements thus seem to be characterised by an uncertain quest for professional autonomy. Because of its significant number of members, its degree of specialization and its direct dependence on doctors, the nursing group is situated at the centre of a professional problematic. This characteristic is part of a context where the model of class struggle has seen a decline in its foundation and frequency and where governments already have enough to do to control their payrolls let alone develop professional aspects.

The scarcity of conflict and trade union involvement

25 The silence is not purely a statistical construction. Scientific literature since 1989 on wage (or professional) disputes in hospitals is quasi non-existent. [25] If one takes a look at press cuttings, strike days and demonstrations by hospital staff have been rare, all categories taken together (Sainsaulieu 2008c). Essentially, and taking as a starting point the 1988-89 cycle, “sectoral” disputes alternated with a resurgence of demonstrations rather than strikes in 1995, and to a lesser extent in 2009. Appearances by doctors in the street are very sporadic, and there has not been a reoccurrence of the compact processions differentiated by institution, that were so characteristic of the participation in demonstrations by hospital staff in general and by nurses in particular.

26 Union sources on this are converging (Sainsaulieu 2008c): the initial movement has remained isolated and has not changed the relationship between nurses and union involvement and strike mobilization. Surveys carried out in 2007 and 2008 showed that no union had registered an appreciable increase in members. The total membership remains low in the public hospital sector (12 % in the public sector, and less than 8 % in the private sector), incomparable with the “bastions” of the public sector (national education, SNCF [railways]) but a little above the national average (7 %). The unions themselves complain of a certain distancing from employees: they also lament the rate of electoral abstention, on the increase since 1999 (5 % up over ten years) and particularly high among paramedics where it reached 50 % in 2008. The CGT and above all the FO are reputedly poorly established among nurses. [26] Sud laments “the lack of respect” from the healthcare professions, for all unions, while the CFDT observes “caregivers taking a backward step with respect to confederated trade unions.”

27 It would be wrong, however, to see corporatism as the best means for achieving involvement from nurses. Voting in professional elections, like union membership, reflects the difficulties in the socio-professional positioning for nurses. Traditionally, it is the more or less qualified salaried groups in hospitals who take part in professional elections and labour relations oscillates between the predominantly white collar, largely incarnated by the FO, and the blue collar, by the CGT (Siwek-Pouydesseau 1993). Does the common self-assignment of nurses to the “middle-class” change this order? It is clear from an analysis of recent professional elections that they do not support purely nursing unions or organizations: nursing unions only received 2 % of the vote in elections to the Commissions Administratives Paritaires (CAP) [joint administrative commissions] in late 2007, while only 17 % voted in the elections of representatives to the Ordre Infirmier in 2009, the compulsory payment of a fee to the Ordre was also greatly disliked (interview with the Coordination Infirmière in 2009).

28 In other words, nurses favour generalist unions, which conforms to the multi-professional context of their work and the strongly focussed character of hospital staff. [27] However, according to the unions themselves, unionization rates and mobilization of nurses (strikes and demonstrations) are lower than those of other types of hospital employee— “in accordance with” their service obligations.

29 The major reason for supporting general unions in professional elections seems rather negative: staff approve the existence of unions in an environment unsettled by reforms that always bring new cause for anxiety. In hospitals the well-known price fixing of activities put into place to better adjust expenditure should have been 100 % effective (Plan Hôpital 2007), when the unions instead demanded a mid-term assessment in the face of the “catastrophe of 75 % of hospitals being in deficit” (Fédération des Hôpitaux de France) and the risk of termination or under-representation of the less profitable procedures because they are more complex, such as those aimed at the elderly, social deprivation and mental illnesses (interview with the CGT, 2007). Nurses thus seized upon the elections as an opportunity to protest.

30 To conclude this point, unions themselves should not be exempted from all responsibility for the low levels of confrontation. Public recommendations are moving towards a strengthening of social dialogue, in agreement with the most representative trade union organizations. [28] Studies on conflict have shown how such an involvement in the renewal of social democracy is often accompanied by a reinforcement of social control and usually a rejection of direct democracy in the social movements underway (Hassenteufel 1991; Sainsaulieu 2006b). Generally, ordinary trade unionism fails to provide caregivers with a cause that is as invigorating or as vital as healthcare itself.

The caregivers’ three causes

31 A quantitative approach is not sufficient to provide a verdict on predispositions to mobilization. The sociology of mobilizations has highlighted the diversification of resources for action and the capacity for mobilization of a priori weak social groups like the “have nots” (the unemployed, homeless, illegal immigrants), so-called “minority” groups (homosexuals, ethnic) or also for “unlikely” mobilization.

32 However, nurses, as a group to mobilize, accumulate impediments rather than assets. The requirement for continuity of service affects healthcarers more than any other group in the public sector, with the exception of the military. They have, on occasion, been able to adapt to it, by replacing their normal operations with a strike organization (Sainsaulieu 2006b). But this obligation is less a legal constraint than a moral (compassion) or psychological (identification) one, stemming from relationships with patients.

33 Nursing disputes resemble those of women in general: if historians are to be believed the latter are mobilized during great historical events (Duby and Perrot 1992). While not, nevertheless, being permanently submissive, we can highlight the social obligation of childcare: in the survey on hospitals we saw the proportion of nurses in couples with children was 68 %. It increases with age without reducing with a move into management (Picot 2008). Caregivers bear witness to the burdens that encumber them as couples and to the difficulty of the relationship between professional and private life. What time do they have for discussions in cafés or for union militancy [29] when they have to do “two working days” (Zilberberg-Hocquard 1981) that are historically “looked down on” (Honneth 2006)?

34 Additionally, we can ask ourselves to what extent do “gendered” social dispositions constitute another obstacle. With the same responsibilities, female nursing managers attach more importance than men to relationships (Picot 2008), even though activists work on the sociability and cohesion of the group in an unseen way (Taylor 2007). Conversely, men attach more importance to techniques, responsibilities and intellectual matters. [30] Despite the secularization of the healthcare profession, there remains a striking resemblance between current professional discourse and ancient religious sacrificial vocabulary to invoke a commitment to caring ( “vocation,” “service”). Continuity between the religious and the secular, highlighting the role of the symbolic in practice, is detected in successive forms. If we invert the perspective, we can examine the changing social status of women: nursing sisters would only have been exalted as the apogee of the female sacrificial ideal in the male household. “We would throw ourselves out of the window for the doctor: ” this stereotypical expression is used with irony in interviews by “experienced” nurses, seeking to highlight the differences in commitment from the youngest, reputedly more concerned with their “private lives.” In this perspective, sacrifice becomes the appropriate symbolic accompaniment of traditional domestic activity, imported into hospitals with the invention of the caring profession: the sacrifice for children substituted for that of patients, the sacrifice of a wife for her husband/children for that of the nurse for the doctor. It is undeniable that the historic socialization of nurses does not predispose them to political protest.

35 It is, nevertheless, possible to invert the problematic and consider the gendered predisposition in the sense of those who put practical, moral, concrete and feminine, even feminist dimensions of care ahead of everything, are particularly numerous in hospital work as in the domestic world (Molinier, Laugier and Paperman 2009). It would indeed be quite “masculine” to consider the interest of others, close relatives or patients, to be a double bind! The eruption of the social movement of 1989 promoted an image of the female worker fighting for her rights, whose slogan “ni nonnes, ni bonnes, ni connes” [ “neither nuns, nor skivvies, nor bitches”] reprised and vulgarised a feminist slogan from the 1970s. The feminist approach to care has the merit of “overturning the stigma” of the social disposition of women to care for others. Rather than essentialised and instrumentalised feminine qualities leading to a lack recognition of the skills involved with the work (Wajcman 2003), the invisible feminine commitment and the, according to Jean Gabriel Contamin, “closeness to experiential, emotional or humanitarian familial issues” (Fillieule, Mathieu and Roux 2007: 4), would be pioneering in a service society, where work in the service of others becomes central (Lallement 2007; Laville 2010), and nurses are symbolic in the same way “steelworkers” were in the industrial world. New working class heroines, in short, with a sense of a job well done, of a common good and of sacrifice.

36 The definition of care is, however, quite loose, ranging from its objective purpose (social utility, notably assumed by the welfare state) to face-to-face relations, which are only one of the possible means to render services. What is certain is that reciprocal relational intensity can be brought about by face-to-face contact, by the absorption of caregivers in multifaceted relationships of compassion and agapè (Corcuff 1996), of solicitude or of moral practices. A housekeeper thus finds recompense for her work from “patients” expressing their satisfaction ( “that smells nice!”); a healthcare assistant defines the richness of her work by the variety of conversations with patients “always from different jobs.” A contrario, a nurse prefered to take “refuge” in emergencies rather than continue to work “on the wards;” rather than having to end episodic relationships struck up with patients. In these moral relationships there is little place for disputes, because struggles are against nature and not against society, for cures or the wellbeing of patients. Carers themselves (men and women) invoke, with a certain modesty, the inherent “humanism” of their task. Understood in this way, care can become an absolute cause. It brings about a generous heart, even subverts social relationships by establishing reciprocal relationships between carers and cared for, but sustains a non-confrontational vision born out of the same relationship. The cause of care is all-consuming, leading to work to which everything is committed, conversations, energy and emotions; it also impinges in the evening, with worries brought home. The problem for caregivers, in other words, is that they have difficulty in stopping their care to start strikes.

37 In the face of the “productivism of care” (Sainsaulieu 2003), changes in mood for the (large) care corps cannot be excluded. If they are not so frequent, it is perhaps because the organization of hospital work both constrains and contents caregivers. The moral cause associated with caring, or simply the defence of public healthcare, can favour as much as disfavour the confrontational mobilization of caregivers. They thus constitute a potential check on the latter. However, it also supports another type of collective mobilization to be situated in organized work contexts. As we shall see, collective mobilizations, whether confrontational or consensual, do not stem from a series of personal motivations nor from isolated intersubjective relationships with patients.

Forms of and conditions for consensual mobilization

38 While concern for others provides substance to a cause that is not necessarily recognizable in confrontations, we still need to specify the context in which this cause emerges. There are indeed personal reasons for devotion to care (such as having been socialized with carers), but also local contexts that make effective collective mobilization possible. We will reveal forms of caregiver mobilization that are neither confrontational, because they strictly follow guidelines defined by institutions, nor purely stipulated, because the actual mobilizations of employees do not align with managerial intentions or administrative injunctions. As we defined it in the introduction, consensual mobilization is intentional and institutional, it brings together individuals to achieve a given objective. Three methods will be distinguished (cooperation, coordination, participation), before considering a dynamic element, the practical representations that accompany them and that in turn feed off them.

39 It is firstly necessary to recall the structural or global ideological conditions for collective involvement. Nurses do not value, a priori, the idea of the collectivity any more than that of the struggle. The diffusion of “liberal ideology,” association with liberal professions (notably medical), identification with the “middle class,” from which roughly half of them come (Sainsaulieu 2008b), stressful work situations reinforcing their sense of isolation, their role supportive of doctors or on the contrary individual attachment to professional autonomy: it is difficult to establish the relative importance of these factors, the fact remains that they are averse to believing themselves to be part of a whole. The variety of their work identities, more centred on their skills or patients, but also on organizations, colleagues and private lives, has often highlighted and restricted the emergence of a homogeneous self-aware profession (Vega 2000; Dubet 2002; Sainsaulieu 2003).

Cooperation, an active socialization

40 Nevertheless, there is a parallel strong need for mutual aid between staff (Cordier 2009). The latter appreciate a good working atmosphere and lay claim indirectly to being a community through their attachment either to their team or department. Beyond the (indirect) needs of the community, at the level of the department (or rather “care unit”) there are contexts for cooperation in which strong feelings of collective membership exist.

41 Recent Anglo-Saxon ethnographic research has emphasised locally rooted communities of practice in many medical, technical and commercial activities (Vallas 2006). Provided that they understand its sense and necessity, sharing the same effort, exhaustions, risks and discipline creates a feeling of a common destiny and solidarity, even strong norms and automatic reflexes, such as drills, these habits being incorporated into coordination through repetition of common actions (Ardant du Picq 1880). Work situations also create these collective effects in hospital healthcare departments such as emergency rooms, operating theatres, intensive care and maternity, etc., where traits establish a community dimension: team spirit, partial self-management, assistance between professionals, departments and night and day teams, accessibility of immediate supervisors, [31] which is an implication and a complimentarity of work where exposure to (vital) risks supposes both reactivity and interactivity (Sainsaulieu 2006a). These factors are sources of identification with a community and of demarcation of a space of common interactivity. They explain an ability to unite against all intrusion or threat of dissolution from outside, such as bureaucratic burdens, intensification of the pace of work (Barret 2002; Sainsaulieu 2003). At the same time, these work conditions that favour cooperation are directed towards a goal that has to be strictly defined by the institution and is shared by its managers. They are collective practices that abide by the injunctions of service but result from ties that are built on daily activity.

42 The symbolic locations of some units, such as operating theatres and intensive care, present these traits in an acute fashion. In some cases, the homogeneity of membership transcends the care unit, individuals being fully aware of being members of a community, that of “small closed worlds,” on the basis of strong collaboration with colleagues and confidence in the initiative of the head doctor. Attachment to collective work and patients is a source for reciprocal confidence, of defence of interests against the boss and the department. The staff are particularly close-knit. It is seen outside of work, such as on “departmental nights out” to restaurants or dancing to which all staff are invited. A degree of harmony makes it possible to reduce uncertainty, as well as enriching professional tasks where there is a partly automatic complementarity, through the valuing of each skill and use of its full autonomy. For a team or a unit to create such a situation it is necessary for it to control all its parameters for action. And, in fact, work satisfaction increases in departments where feelings of belonging are greater and interaction with the public weaker (Bourgeault et al. 2010). In sum, “a good patient is under control,” that is to say that in so far as he is unaware, he depends entirely on the professionals and allows them to better cooperate (Freidson 2001; Sainsaulieu 2009). Examples of where these “worlds apart” have been achieved are rare, but where they have been, they update the theme of the day-to-day community with variable intensity (Sainsaulieu, Salzbrunn and Amiotte-Suchet 2010).

43 The community is a social phenomenon encompassing consistent aims, practices and identities. It is, therefore, as much a form of mobilization (close and durable cooperation) that is inherited (used to working together) and reproduced (daily recommencement, integration of newcomers), as a condition of a mobilization to come: small close-knit groups are predisposed to mobilize in a broader context (Olson 1965).

Campaigns and mechanisms for participation in hospitals

44 Are slogans to improve the quality of care likely to greatly mobilize personnel? Summing up the experience of participation in the 1980s, Martin (1994) observed a failure of “a utopia of industrial democracy” and characterized participation as the result of a tension between democracy and mobilization. The consent of the employees is not only the result of ideological manipulation, it reflects an expectation of taking responsibility and the existence of mediation, especially in skilled circles. The dominant norm, as with the case of ISO norms, has a power to constrain, but this does not prevent it being important to put this into context: “the fates of norms hang in the balance in their implementation” (Mispelblom [1995] 1999: 23). Participation often reflects a compromise between leaders and existing occupations, even a trade union partnership (Kelly 2004), which is less often the case in France. [32]

45 The thematic of responsibilization is certainly at the core of the text of the 1991 law reforming hospitals. French hospitals had initially moved towards autonomy to imitate the American model, with a corresponding “commitment by managements to new, more rigorous, prospective and participative hospital management” (Pierru 1999: 25). Participation, however, remains incantatory, “a managerial revolution on paper” (ibid.: 28). Neither internal coordination, nor new tools, such as computerization, has resulted in the innovative mobilization of staff (Contandriopoulos and Souteyrand 1996). The “state partner” remains in contradiction (even more visible today) to the reinforcement of control and the autonomization of institutions. Experiences have, nevertheless, developed with advances in medical evaluations (Castel and Merle 2002), with the quality of care (Setbon 2000) and with hospital accreditation (Boix 2003). Despite resistance, the changes given impetus by the state have initiated new implications for traditional actors and new participation from staff. Participative management has been one of the major projects of modern hospital management (Bonnici 1998). As in the car industry, quality is a theme seized upon by various actors, precisely because it is an incontestable injunction: “this type of action, that we could call participation, consists of fighting from within by contributing to the management of the scheme over which you believe you have lost control” (Cochoy 2001: 105).

46 The accreditation of care institutions occasioned some participative mobilization. Our 2003 survey showed that a dynamic exists when there is a legitimate political will that is based over time on regular and strong management leadership. The director is the key element for legitimating and explaining the issues and stages of the evaluation process. He lends credibility to the first effects of the action knowing how to respond quickly to failures that come to light, then, at regular points “providing means” to initiate and sustain, even bypassing the chain of command through personal relationships with the rank and file, “[there are discussions] even with the big boss: we see him often, he doesn’t hang around, but if you have something to tell him, he listens” (healthcare assistant). Management leadership also supposes finding effective intermediaries, close “spokespersons: ” to obtain responses and transmit the return of information and to carry out checks. It is a sort of militantism of translation that commits middle management or human resources to develop interactions with one or several services, acting in a consistent manner throughout the process. For example, the putting into place of traceability, which is particularly “burdensome on the nursing team,” requires leadership: “It is a huge participative and communicative job, you have to convince, encourage, correct, discuss, and pose questions. It took a year to draft a trauma sheet.” (quality coordinator). To this management model are added the actions of human resources (local opinion leaders or pioneers generating initiatives). “For a long time I have wanted to do something on pain, there was a circular and I seized the occasion” (night healthcare assistant). Management support and the provision of training for pinpointing malfunctions has revived the process by putting it in the hands of the actors. [33]

47 Two levels of participation in improving the quality of care (within the framework of accreditation) could be distinguished. Delegated participation affected all staff, even if it remained partial, even bringing about divisions between “those who participate” and those who kept their distance from the process or ignored it. “We took part in working out the protocol… we wrote what we did every day… it took off, it’s interesting. I don’t know if everyone took part.” (day healthcare assistant). Some took part regularly but at infrequent intervals, without necessarily understanding the final goal, even if they may have appreciated the openness and desegregation that the work allowed. As such, this delegated participation nevertheless renewed transversal coordination by creating perceived effects on the circulation of information, awareness, broadening horizons and discoveries. “Writing allows reflection. We do things mechanically and here we took a step back.” (outpatient nurse). Several work groups were set up to establish a repository for care, social and prevention plans.

48 Widened participation does not contradict but stimulates delegation. It is based on an alternation between wide consultation and the operation of project teams, of sub-groups for the targeted work: “70 % of staff took part in its development [then] we devised a division by work groups: … we all worked for the same thing, across groups intra- and interdepartments” (nursing manager). Staff are appealed to in both an individual and collective way, since this large-scale participative movement includes a distribution of individual responsibilities (especially formalised after the accreditation process): “We are all individually consulted on something. When the representatives of each department get together there are twenty or so of us” (night healthcare assistant). Thus broader mobilization favours, more so than limited participation, the emergence of individual actors, whose capacities for initiative, creativity and cooperation crystallize in a network of work and of exchanges that in some ways replicate the formal structure of work.

49 The participative approach also encounters limits, such as the danger of excessive formalization ( “red tape”) at the expense of practicality. “We needed to clarify our profession, but young nurses no longer know how to take decisions, to have good sense. That’s what the older ones in the departments tell me.” (radiology nurse). Frequently, the obstacles caused by bureaucratization are associated with criticisms of staff shortages or staff turnover. Mobilization does not last long and presupposes antecedents on which it rests, such as fertile ground for cooperative groups (see supra). Whether restricted or broader, participation to improve quality can constitute a medium for consensual mobilization that is probably under used in the healthcare environment. [34] It favours the expression and delegation of power.

Interprofessional coordination, or the attraction of paramedical interdisciplinarity

50 In addition to intensive cooperation and the participation process, interprofessional coordination constitutes a third form of consensual mobilization. By comparison, this is a less intensive form that is aimed at a more strictly professional population; for all that it is constructed in a more egalitarian way, less controlled from on high than participation, it is by definition more open to the outside, unlike cooperation within closed groups.

51 The success and visibility of the term “coordination” invites prudence. It echoes the injunction for transversality in the new public service management (Varone and Vissher 2004). Hospitals regularly dream of “creating transversality” with the aim of improving the use of existing resources. The notions of “coordination” and “participation” are exploited by managers to standardise practices, having regard for the requirements of management, without gains in terms of collegiality or symbolic recognition always being obvious, as in the case of “médecins coordinateurs” [coordinating doctors] (Robelet, Serré and Bourgueil 2005). Beyond these rhetorical and management incitements, each professional is encouraged to collaborate more with other professionals within or outside their institution. For example, the spread of project management aimed at bringing specialised products to market in the shortest time possible (Bouffartigue and Gadéa 1997), is characterised by the number and responsibilization of “competing” engineers over the whole course of realizing a project (Charue-Duboc and Midler 2002). What is true for engineers is true for caregivers: management by division in principle favours the development of the same “project course.”

52 It is, therefore, important to define the scope of the investigation that allows us to speak of coordination as a form of mobilization. In the case we studied, [35] the generalization of “mobile teams” (in psychiatry, palliative care, nutrition, ergonomics, diabetes, alcoholism, etc.) is based on “interdisciplinarity” necessitated by encounters between professionals from different backgrounds. Analysing the mechanisms in terms of mobilization highlights the specific issues at work: under what conditions can the integration of different processes be achieved?

53 Let us first look at the institutional context and organization of the mobile teams. Faced with ever-aging patients, the geriatric plan of the mobile geriatric team (MGT) aimed to introduce some flexibility to the running of the hospital by bringing expertise to the patient’s bedside. The presiding reasons for setting up mobile geriatric teams are medical (to face up to what can be called “poly-pathological” aging), managerial (to better use expertise) and organizational (to fight against departmental isolation). Within the inner structure of hospitals cognitive resources are always shared (they are more unequal in extramural coordination). Also the mission of the MGT is not to deal with patients who are already being looked after, but to support professionals in their departments by consulting elderly patients with specific geriatric needs (social, psychological and medical) that are in part beyond the doctors treating them. To do this it brings together interdisciplinary expertise: a nurse, geriatrician and social worker form the core trio, who are occasionally joined by a secretary (non-mobile), occupational therapist or a psychologist. The visits are most often done by two or three people, sometimes alone, at the request of a doctor having difficulty treating an elderly patient. The team visit to make a geriatric assessment, which consists of examining the patient followed by a social investigation by telephone interviews with the families and institutions involved. It provides immediate comfort for a patient unsettled by emergency treatment or disoriented in a department where they have spent a long time (degrading their morale or even mental health), unable to turn elsewhere.

54 Successful coordination is a challenge because it clashes with the structure of the departments encountered: the medical reception of the mobile teams varies according to department; they are received more or less favourably in accident and emergency, variably in medicine and poorly in surgery (especially trauma surgery). Cooperative practice in emergency departments echoes that of the mobile team. Conversely, the cognitive tendency of surgeons and anaesthetists to reduce all to its “biological root” (Robert Barett, cited by Darmon 2005) contrasts with the “comprehensive approach” of caregivers and doctors, even coming into conflict when surgical and medical paths overlap. Interprofessional cooperation is thus rendered uncertain by its confrontation with the inertia of milieus that rub shoulders higher up (managerial or bureaucratic supervision) or below (difficult patients, uncooperative colleagues).

55 Faced with these obstacles, sharing the same objectives is a condition for success. The professional diversity within the mobile teams operates on the basis of twin common goals: not only do members of the team believe in their mission to help elderly people “neglected in departments,” but they hope through their actions to build up geriatrics as a discipline, improving its visibility. In contrast, the goals shared with staff in the care departments visited are few or insufficient for them to be included in the same movement. While medical standards have evolved and increasingly legitimized social and comprehensive approaches to disease, a gap persists in practice between “generalist” and “specialist” approaches, while the economic factor has come to instrumentalize relationships between doctors: the visit of a geriatrician can succeed in moving on an elderly patient blocking an expensive specialist bed, sometimes for long time.

56 A divergence of interests is also revealed within the mobile teams. While the geriatricians find the mobile experience to be formative but “wearing,” paramedics find they have more room for manoeuvre within them compared to more “sedentary” working conditions. Occupational therapists can “build projects,” within the teams, social workers escape stress and administrative routines and nurses reduce their work rate and long hours. All appreciate the opportunities offered to them to take the time to care for patients. However, mobile geriatricians face the dual problem of recognition of their discipline and acceptance of their recommendations by colleagues preferring to move the elderly patient to geriatric care rather than be advised on how to look after their patients.

57 Coordination is, therefore, not done for pleasure. Neither the good of the patient nor the tastes of others and their knowledge is sufficient to account for the quest for interdisciplinarity or the hybridization of practices. Interprofessional coordination thereby particularly highlights the potential for mobilizing paramedics in general and nurses in particular. The lack of recognition of nurses constitutes a “hidden variable” of hospital mobilization. Nurses have an interest in acting as go-betweens in the development of geriatrics since they are both confronted by the suffering of the elderly and by a lack of recognition for their profession. They can become a potential axis for the necessary social, health and care coordination [36] since their workspace and means for finding work satisfaction are not monoprofessional: it is often to the extent that nurses can play a role beyond their job assignment that they manage to mobilize, cooperating with doctors or coordinating various stakeholders. Nurses are not satisfied with their classic “roles;” they also play a pivotal role in the actions of all, extending to their roles as leaders which they assume when they are managers (Sainsaulieu 2008a).

58 They are thus predisposed to coordinate even though they are subordinate employees. In contrast to doctors, who occupy greater positions of power, they have no freedom of choice. Interdisciplinary mobilizations thus present them with the opportunity to live.

The dynamic of representations

59 With this last form of coordination, we largely entered the explanatory field, the field that stems from the sociology of consensual mobilizations. Before returning to this in conclusion, we should consider the evolution of mentalities that accompany the mobilizations. If revolutions and feats of activists are sources for subsequent confrontational episodes, to what extent does an equivalent mechanism exist concerning consensual mobilizations where they make a lasting impression on minds?

60 If we set aside the purely prescribed “mobilizations,” [37] we are a priori tempted to detect some continuity between day-to-day and occasional mobilizations, as in the case of chronic epidemics. Every year paediatric departments are mobilized against chronic bronchiole epidemics (surveys with the Trousseau Hospital, 2003). Without having observed the paediatric departments closely during these health mobilizations, we can nevertheless suppose a certain interdependence between the day-to-day mobilization and these more exceptional circumstances, given the work relationships between teams throughout the year, contributing to maintaining a feeling of belonging across paediatrics and not to a solitary healthcare department (Sainsaulieu 2006a). In this way daily work prepares the way for extraordinary mobilizations.

61 The inverse hypothesis of a continuity solution is however more supportable: the fact of having taken part in a formative event imprints on minds in daily life, once and for all. One can cite the example of the “bush” for military doctors and carers who have taken part in an operation overseas—military or humanitarian (interviews with military doctors, Bordeaux, 2005). “Going to the front” feeds the imagination at work and encourages everyday practices of cooperation. The military are not the only ones affected: infectious disease departments underwent the “AIDS revolution” (nurse in infectious diseases, 2003). Since the AIDS epidemic, sufferers associations were not the only to mobilize: hospital infectious disease departments experienced radical changes in social work relations since “nobody had the answer” (ibid.). The unknown acted as a driving force, levelling opposition and hierarchies, putting everyone on “a war footing.” As a result, an interprofessional collegiality was put into place where any opinion counted. Twenty years later a nurse at the CHU Bichat Claude Bernard in Paris still felt the effects in the relationships between medical and non-medical staff and in the more general vision of work relationships. The storm at the end of 1999 and the 2003 heat wave (Le Grand-Sébille and Vega 2005) also furnished other illustrations. Resulting from the storm, it was the turn of the technical departments to distinguish themselves and salvage their lack of recognition within hospitals, even within public opinion: “The storm put everyone on the roof.” (worker in the technical department, Limoges, 2006). Activating an egalitarian and solidarity logic, it made their normal work visible.

62 This driving force effect of mobilizations and representations on practices, allows us to answer the question of how experiences are widened: how can practices rooted in local contexts or limited in time affect the whole hospital? By serving as an example for the involvement of caregivers, working in conditions or temporalities that are less favourable in terms of collective synergies. The quasi-permanent mobilization of operating theatres or emergency rooms also captures the imagination of hospital workers ( “the mood in the theatres spreads through the whole hospital” porter, Lyon, 2006). This symbolic role is supported by practice, that of serving patients in most departments. The collective representations that are brought to bear on the actions of carers are not necessarily the effect of beliefs or “values” (religious, philosophical or politics), [38] nor personal motivations ( “vocation”): they can also be practical representations, from interactions in situ.

Collective mobilization and its two types

63 Over the course of this analysis of two types of mobilization, their forms and their conditions, we presented consensual mobilization as a more common form of healthcare mobilization. This does not result from an adherence to a managerial ideology, nor from a simple submission to class or gender, but more from the construction of a practical ethic (care) with local work contexts, around a more or less explicit unifying theme: “the improvement of the quality of care.” It is clear there is strong integration through social utility: an institutional hospital framework that is exemplary, the daily involvement of outsiders in departments, potential coordination with other professions and a recognition by users. One can add a “dependence on the path” followed, according to which present choices are influenced by those of the past (Pierson 1994): if “struggle calls for struggle,” consensus calls for consensus. Consensual mobilization of caregivers is based on the reciprocal effect of the impetus of organizational components and ethical and practical representations, despite the pressures experienced at work and the expectations of the legitimacy of public service. While nurses have good reason to mobilize “gainst,” they have a strong propensity to mobilize “for.”

64 An initial question that results from the identification of this “consensual” side concerns the limits of its validity: is consensual mobilization specific to care or does it instead cut across diverse productive sectors, notably across the generalization of the “quality” thematic and problematic? The concept of care, as much as the forms of consensual mobilization, permits us to widen the professional and sectoral bases of the latter. Indeed, nothing restricts the sphere of validity of women’s work, absorbed by an increased concern for others, because of the cumulative effect their own domestic sphere (caring for relatives) and that of the service relationship, as much as the presence of a service activity. The same is true for the local organization of work: the forms of mobilization allow for an extension outside of hospitals, whether this in the form of cooperation, participation or coordination, as well as representations that emerge and on which they feed. [39] However, if we must add all the contexts for the organization of work that allow these forms to exist to the aims of care, hospitals appear to be repositories outside the norms.

65 Another reflection on the relationship or articulation between the two types of collective mobilization imposes itself: how to think about their common core? Paradoxically, the distance between them is not that great, a common character of collective mobilization emerges if we take into consideration their conditions of existence. Like the themes of public service or the quality of care, as well as the “gendered” dispositions to care work, two sociological factors are in fact reversible and can thus give rise to one or the other type of the two mobilizations.

66 The first is that of the mobilization of the dominated in search of recognition, namely professional. Collective mobilization sounds like a revenge: cooperation, participation and coordination satisfy the dominated more because of the egalitarian relationships that are established in the collective dynamic which allow them to enrich their work and broaden their horizons (Sainsaulieu 2006a). In hospitals, doctors thus have fewer professional reasons to support this, even if they do not remain unconcerned by it.

67 The second factor for reversibility is collective socialization as a common driver for mobilization. The small close-knit group remains symbolic of collective action (Olson 1965), because it is permanently mobilized and can serve as a go-between in wider collective action. It has been shown that cooperation, as well as constituting a form of action, also prepares the ground for participation and coordination, as a favourable precondition, as much as it feeds—not unreciprocated—collective representations.

68 But, while “forming a group” can incite mobilization in two opposing directions, how does one move from consensus to confrontation and vice-versa? The move is more an individual experience of limits than a daily collective adventure. There are certainly politicization and depoliticization processes at work: the collective effort can drive some to discover obstacles resulting from social antagonisms—and conversely disillusionment with the collective struggle can lead an individual to limit their social contribution at work (Sainsaulieu and Surdez 2012). The process or raising consciousness through experience nevertheless concerns, from the top to the bottom, a deepening of a professional, ethical and organizational apprenticeship, of care or of the quality of service. Furthermore, it is notably a flaw in social integration, a division from the elites, that leads to a group uniting in protest (Oberschall 1973). Are the caregiving groups not so integrated in relations to the state and other social groups that they have no recourse to confrontational mobilization? Without strong professional or political representation, they are, nevertheless, the supports for a strong institution, as “prisoners” of their own social utility based on a strong social mix. The crisis in public services certainly includes a political dimension in the sense that it “impacts at the level of norms and, even more, on values” (Chazel 2003: 88); yet caregivers overwhelmingly vote for fairness and equality (Sainsaulieu 2008a). One can thus see how they might protest, it is less obvious that they will yet mobilize.


Surveys on labour relations in hospitals

Title and subjects of survey Mondes sociaux de l’hôpital Participation dans l’accréditation hospitalière Application des recommandations médicales Communautés de service Cadres de l’hôpital « gestion et métier » Inégalités sociales de santé Équipes mobiles gériatriques
(end of survey)
2002 2003 2005 2006 2007 2008 2010
Number of interviews 360 54 38 52 25 34 45
Number of interviewers 4 2 3 1 2 4 1
Number and type of institutions CH
4 clinics
2 clinics
6 public institutions (1 CHU,
1 military establishment)
1 large regional hospital CHU 1 hospital
5 social institutions
Length of fieldwork 2 years 12 months 14 months 8 months 16 months 10 months 14 months
Place of survey Paris region
Hamilton (Ontario
CFDT national network Centre
Analysis of data Thematic analysis Thematic analysis Thematic analysis Computer
QSR Nudist quantitative
Thematic analysis quantitative Thematic analysis Thematic analysis
Sponsor (s)[40] AP-HP
ANAES (future HAS) HAS (Haute Autorité en Santé) McMaster
figure im1

Surveys on labour relations in hospitals


  • [*]
    I would like to thank Guy Groux, Lilian Mathieu, Muriel Surdez, Anne Vega greatly for rereading this article and making suggestions, as well as the anonymous members of the editorial committee.
  • [1]
    In 2004, in more than 1,000 public health institutions, 31 centres hospitaliers universitaires (CHU) [university hospitals] accounted for 35 % of employees, 560 centres hospitaliers [main hospitals] 50 % and 350 hôpitaux locaux [local hospitals] 5 %. The average institution size is 1,200 employees.
  • [2]
    Of the non-public hospital employees, the proportion belonging to category C is two thirds, but “only” 13 % of caregivers belong. On the caregiving side, which represents 70 % of non-medical staff in public hospitals, 50.4 % of employees belonged to category C at the end of 2007. In other words, while healthcare assistants can be insecure, nurses are much less so, although, unlike doctors, part-time working has increased (by 3 % on average since 2004, according to the report of the DGAFP [2009]).
  • [3]
    Without confrontational aims, it does contain tensions and confrontational relationships within it.
  • [4]
    Despite the high degree of similarity between labour issues in healthcare (short staffing, stress, etc.) throughout the world (Clark and Clark 2004), few studies compare the confrontational or consensual processes these problems give rise to.
  • [5]
    These studies are predominantly qualitative (see Methodological Box 1): LSCI/CNRS-Ministère du Travail-APHP-Fédération des Hôpitaux Privés (FHP) report, Les mondes sociaux de l’hôpital (2002); LISE/CNRS-FHP, La participation paramédicale à l’occasion de l’accréditation des établissements hospitaliers publics et privés (2003); LISE-Haute Autorité en Santé, Les facteurs contextuels favorisant l’application des recommandations médicales (2005); LISE-McMaster University partnership, to analyse healthcare communities in the hospital services in a regional institution in Ontario (2005-07); LISE-CFDT Report, Les cadres hospitaliers entre métier et gestion (2007); partnership between LISE and CHRU of Lille, L’impact des équipes gériatriques mobiles dans les services de soin hospitaliers (2010). Finally, consensual mobilization was the subject of my habilitation thesis at the Université de Paris Ouest Nanterre La Défense in October 2009.
  • [6]
    We also followed the emergence of coordination in the Val-de-Marne and repeated mobilizations at CHU Henri Mondor of Créteil and at the Saint-Maur-des-Fossés psychiatric hospital (1998-2000).
  • [8]
    In this perspective on “coordination” (Carricaburu and Ménoret 2004), analysis of differences in service operations can be included (Kuty 1994) and their similarities from the point of view of work cultures in Europe (Vassy 1999), as well as questions on management (Moisdon 2000), professionalisation (Kervasdoué 2003) or the implementation of the healthcare networks “Ville-Hôpital” (Bercot and Coninck 2006).
  • [9]
    We will return in the conclusion to the professional dimension in which this confrontation takes place.
  • [10]
    Conversely, confrontational mobilizations are not exempt from all pressure, or unconscious imitation phenomena.
  • [11]
    With or without patients: too weak and dependent, hospital patients are not often actors, unlike the chronically ill (in consultation) and victims associations.
  • [12]
    Here we borrow elements from the definition of political mobilization based on a social movement, which if not always confrontational does at least “when needed” confront the authorities in place (Chazel 2003: 88).
  • [13]
    In the Tourainienne problematic of “new social movements,” they precisely unfold outside the company—thus displacing the “centrality” of the labour movement to reclaim “historicity” from it.
  • [14]
    On the one hand, sociologists of professions want to open a breach: “The primacy accorded to ‘politics, ’ which is present in a number of these works, thus leads more often to neglecting forms of social, practical and intellectual hybridisation that are joined together in action itself, notably between militant practices and the professional activities of the people involved in them. In addressing the commitment professionals bring to their work itself or to the objectives of their work, one can indeed discover a link between involvement and mobilization, not solely of general skills but of specialist professional knowledge.” (Champy and Israël 2009: 14). On the other hand, the porousness of the borders between professions and militant activity has increased with respect of social movements on the issue of AIDS (Rosman 1994; Dodier, 2003).
  • [15]
    “America in the 1960s saw significant changes for women… These changes were not all linked to social movement campaigns.” (Tilly and Tarrow 2008: 223).
  • [16]
    There are some bridges between collective mobilization, social movements and consensus, at least for classic social movements. Neveu, thus, accepts the existence of “movements with no adversaries” (White March, antiracism). Their emotive “consensual character” guarantees them large effects, but prevents them from lasting and from having effects on a policy point (2000: 13). Similarly, while they often challenge institutions, social movements “also act within” the latter (Tilly and Tarrow 2008). Moreover, ascribing an adversary to a mobilization as it begins is less easy than doing so a posteriori. Perhaps we would not be undergoing a process of rebalancing if mobilization had not been constructed as an “action against” through a somewhat reified reading?
  • [17]
    There were 170,000 hospital workers in 1965. This number increased five-fold in thirty-five years (Siwek-Pouydesseau 1993). Also, from 1990 to 2005, midwives, nurses and healthcare assistants have increased in number continuously. The number of nurses has risen from 300,000 in 1990 to 480,000 in 2009 (including the for-profit and not-for-profit private sectors). There are more than 200,000 in public sector hospitals and they represent 26 % of staff in 2006 (against 145,000 healthcare assistants). In contrast, the number of technical staff and administrators is declining, representing 23 % of hospital staff against 70 % being caregivers and doctors and 5 % being medico-technicians (in radiology, laboratories) and 1 % being socio-educational (sources: DGAFP, DREES, CGT). Level C (general ancillary staff, employees, healthcare assistants, etc.) is the majority rank in the three public sectors, but is smaller in the public hospital sector than level B (above all nurses).
  • [18]
    The cumulative total of general nurses (70,000), specialist nurses (anaesthetic nurses— IADE—or operating theatre nurses—IBODE), senior or middle managers ( “of healthcare”) is less than 100,000 individuals. The number in the for profit and not for profit private sector reaches 750,000 members.
  • [19]
    In 2006, nearly half of nurses claimed to be faced with workload peaks against a third of healthcare assistants. The contrast is even greater when looking at respect for working hours: 45 % of nurses claimed to work beyond them against 20 % of healthcare assistants (DGAFP 2009).
  • [20]
    From 2004 to 2007, the number of non-medical staff (on equivalent to full-time) has increased by 0.6 % per year (DGAFP 2009).
  • [21]
    “Réponse. Relations professionnelles et négociations d’entreprise” (DARES 2005), “Acemo—Négociation et représentation des salariés” surveys and the census of the Inspection du Travail [labour inspectorate] (see note 22).
  • [22]
    DARES, Les conflits collectifs du travail, 27 April 2009 (see the table: “Comparaison des différentes sources de conflits” [ “Comparison of different sources of conflict”]). Website:
    http : //, 76/statistiques, 78/relations-profe ssionnelles, 85/conflits-collectifs, 243/les-conflits-collectifs-du-travail, 2300.html.
  • [23]
    Without fuelling a conspiracy theory, one can easily suggest obstructions to publication. In addition to the duty of confidentiality of high officials, who notably receive annual social reports on hospital institutions (obligatory since 1988 but for which there are only a few syntheses with no mentions of conflicts, such as the Bilan social régional 2004, carried out in 2005 by the Agence Régionale d’Hospitalisation en Île-de-France–ARHIF), we can also cite trade union strategies (in the treatment and diffusion of information) and the rules of the media and scientific agendas: indeed, while the former is too constrained by current events, the latter is not much, while it is more so by being publically funded. Note for example the abundance of available work on infectious diseases, their associations and mobilizations. There is no regular scientific monitoring of hospitals, but disparate work notably on social history, management, public health, the sociology of organizations and professions, political sociology and the anthropology of health.
  • [24]
    In the general assemblies of nurses, heated debates took place on the participation of healthcare assistants supported by the CGT.
  • [25]
    In the last decade no article on these questions can be found, for example, in the reference journal, Sciences Sociales et Santé.
  • [26]
    Nevertheless, the trade unions claim that they have no statistics on the number of union members by profession (interviews with the CGT, CFDT and Sud Santé, in 2007).
  • [27]
    An international survey of nursing organizations shows that the priority of trade unions is salaries and that of professional associations, quality of care (Clark and Clark 2004).
  • [28]
    Signature of the 2 June 2008 Accords de Bercy on the restoration of social dialogue in the public services.
  • [29]
    There are three times fewer active women than men who are trade union members across all sectors (Le Quentrec and Rieu 2003).
  • [30]
    Having recently taken on more care jobs, men represent a little more than 10 % of nursing staff, more than 20 % of managers or specialist nurses (in anaesthetics, psychiatry — the latter requiring physical strength) and 25 % of health directors (Bessière 2005; Picot 2008).
  • [31]
    Sometimes, however, management slip into authoritarianism and clientelism…
  • [32]
    Participation remains more often uncertain in France. Even though trade unions collaborate on themes connected with institutions, they have difficulty seeing how to reconcile “mobilization” and “participation,” assigning disputes to the first and a betrayal of employees to the latter, or fearing a type of mobilization outside their influence. In hospitals, however, the theme (associated with participation) of the improvement of the quality of care has been largely reclaimed by trade union organizations (but mostly dissociated with participation).
  • [33]
    The nurses interviewed by questionnaire have much less confidence than managers in the existence of participative mechanisms in their institutions: while they are more or less for them in general, only 17 % of them, against 81 % of managers, think that their work is valued by healthcare managers… A similar gap is perceptible on the subject of the claims for a hierarchical principle by management (49 % of nurses perceive it against 3 % of managers), few favour participation (19 % against 75 %), negotiation (26 % and 43 %) and training (12 % and 36 %). Contrary to their wishes, management does not play an integral part in teams (36 % and 63 %), it is kept at a distance to better supervise. In contrast, it is considered useful by both sides (56 % and 59 %), it encapsulates the need for the unity of the groups for which it serves as a referent and so that it continues to lead through its presence (Sainsaulieu 2008b).
  • [34]
    The new governance (2007 and 2009) is based more on the association of traditional actors than on the participation of staff to which it does not refer (Sainsaulieu 2011).
  • [35]
    Research in geriatrics in 2010 supports this reflection.
  • [36]
    We, nevertheless, come up against tradition here that states that doctors are the key figures in all healthcare approaches in hospitals whether they are in favour or not of more independence for a nursing field.
  • [37]
    In the case of the requisitioning of nurses on holiday for service, large-scale national mobilizations can be expressly ordered and compulsory. It was thus that we were able to observe caregivers protesting against the conditions for their mobilization during the outbreak of the H1N1 virus.
  • [38]
    Their effect on the motivations of caregivers is weak (Sainsaulieu 2008b, 2009).
  • [39]
    Social work is another area for the deployment of such a mobilization (Bureau and Sainsaulieu 2012).
  • [40]
    The sponsors are firstly public in origin (Direction Hospitalière de l’Organisation des Soins), parapublic (HAS, Assistance Publique des Hôpitaux de Paris, Institut National de Prévention et d’Éducation en Santé, Centre Hospitalier de Recherche Universitaire, McMaster University) and also semi-private (Fédération des Hôpitaux Privés, Confédération Démocratique du Travail).

This article focuses on labour relations in hospitals, the claim being that collective mobilization in this sector is not just a matter of protest but may also involve consensual efforts to improve conditions. To demonstrate this, types of protest movements in the hospital sector are reviewed and hypotheses put forward to explain the empirical rarity of such movements in the sector in France. Subaltern status (in terms of class, gender, etc.) is not sufficient to explain the moderation of conflicts in the sector. The symbolic “public service” and practical “care” dimensions, both relevant to the public hospital framework, play an ambivalent role. An examination of organizational contexts leads to the development of an explanation of the “silence” of hospital nurses by identifying modes and conditions characterizing what I call a “consensual” mobilization dynamic: intense cooperation in some units, participant campaigns to improve care quality, interprofessional coordination on ad hoc projects, and the influence of practical representations produced by earlier (consensual) mobilizations. These fundamental components of healthcare contribute to creating a profound adherence to a profession that is both demanding and valuable, even though local responsibilities of this sort only raise the same question concerning the boundaries for action by caregivers in hospitals at a more general level.


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Ivan Sainsaulieu
Université Lille 1 Laboratoire Interdisciplinaire pour la Sociologie Économique (LISE)–CNAM-CNRS 59-61, rue Pouchet 75849 Paris cedex 17
Toby Matthews
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