Caring Management in Health Organizations, Volume 3 E-Book

• Herausgeber: John Wiley & Sons
• Kategorie: Fachliteratur
• Sprache: Englisch

Seitenzahl: 388

Veröffentlichungsjahr: 2022

Beschreibung

Health organizations in social, medico-social and health sectors are not immune to the pressures of productivity, efficiency and quality. The race against time, which is far more problematic today than 20 years ago, makes care in the workplace much more difficult to implement, though it is essential. The onset of the Covid-19 pandemic in 2020 only reinforced this stance.

Caring Management in Heath Organizations questions the benevolent nature of management, understood here to mean taking care, according a central role to relationships. It takes a political, historical and international perspective on health management, examining successful implementations of this practice in health organizations, with all its difficulties, pitfalls and riches. Other sectors are also explored.

This book takes a critical look at the very foundations of "caring management". It opens up the debate between researchers from different backgrounds and professionals in the field.

Leseprobe

Table of Contents

Cover

Title Page

Copyright Page

Foreword

Introduction

Part 1: A Committed Vision of Caring Management

Introduction to Part 1

1 Caring Management and the Health-care System

1.1. A health-care system that is insufficiently caring toward its staff and users

1.2. Some ways to make the health system more caring

1.3. The impacts of the health crisis on a caring manner in the health-care system and potential lessons learned

1.4. Conclusion

1.5. References

2 Valuing Human Relationships in the Organization of Care: An International Approach

2.1. The devaluation of the caregiver–patient relationship at the level of the health-care organization: a worldwide observation

2.2. An example of a caring organization: medical humanism in Uruguay

2.3. The human relationship in health: toward a new indicator of performance of a caring manner in organizations

2.4. Conclusion

2.5. References

3 The Search for a Caring Nature at Work throughout History

3.1. Management, a recent discipline and function

3.2. The search for benevolence at work throughout history: representations that evolve over time

3.3. Is history a perpetual restart?

3.4. Conclusion

3.5. References

4 Caring Management

4.1. Caring management can be a lever for anticipating, managing and repairing crises, but it must assert itself as such

4.2. Caring management in the face of the COVID-19 crisis: case studies of health-care institutions in the AURA region (Auvergne-Rhône-Alpes)

4.3. Conclusion

4.4. References

Part 2: Management in the Health Sector: What Feedback Do We Get?

Introduction to Part 2

5 Between Illusion and Disillusionment

5.1. The contradictions of modern management

5.2. Consultants to the “rescue” of management

5.3. Conclusion

5.4. References

6 Implementation of an Innovative Project in a Nursing Home as a Catalyst for Managerial Innovation

6.1. Context, questions and conceptual framework

6.2. Levers to put the actors in a collaborative working mode

6.3. An innovative project as a catalyst for managerial innovation: the 4M project, “Mixons Moins, Mangez Mieux”

6.4. Discussion, putting into perspective

6.5. The PYA nursing home and crisis management during COVID-19

6.6. Conclusion

6.7. References

7 The Determinants of Happiness in the Workplace for Health-care Workers

7.1. Presentation of the empirical study

7.2. Analysis of the results

7.3. Discussion of the results and impacts on the managerial function

7.4. References

8 Management and Benevolence

8.1. Limits of a risk-based approach to work: links between managerial action and team health

8.2. Engineering spaces for discussion and decision-making on work: the example of an intervention in a nursing home undergoing restructuring

8.3. Evaluation of the process and discussion

8.4. Conclusion

8.5. References

Part 3: Let Us Take a Look Elsewhere: What Do Other Sectors of Activity Say?

Introduction to Part 3

9 Caring Management

9.1. The quality of the dialog

9.2. The methodological deficit

9.3. The decision to change

9.4. Conclusion

9.5. References

10 Caring Management

10.1. The health-promoting school: what is it?

10.2. Case study: implementation of ABMA in a school in Saint-Etienne

10.3. Discussion

10.4. References

11 Caring Management and Large-scale Distribution

11.1. Caring management in a French retail company

11.2. Benevolence at work and the subtle play of hormones

11.3. Discussion and perspective

11.4. References

List of Authors

Index

Other titles from iSTE in Innovation, Entrepreneurship and Management

End User License Agreement

List of Tables

Chapter 1

Table 1.1

Organization during the health crisis, mirroring the health system

...

Table 1.2

Permanent solutions to dysfunctions in the health-care system to m

...

Chapter 4

Table 4.1

Potential roles of caring management in crisis anticipation, manag

...

Chapter 8

Table 8.1

Results of the satisfaction questionnaire

Chapter 10

Table 10.1

Summary of the general organization

List of Illustrations

Chapter 7

Figure 7.1

Theoretical research model.

Figure 7.2

The results for the “happiness at work” variable.

Figure 7.3

Results to the question: “What makes you happy in your job?”.

...

Chapter 8

Figure 8.1

Process of engineering the discussion spaces by level.

Chapter 9

Figure 9.1

Diagram of the double level of interaction between staff represen

...

Figure 9.2

Scenario of a discussion in a “distributive” approach.

...

Figure 9.3

Levers of action to be taken according to the desired adherence f

...

Guide

Cover Page

Title Page

Copyright Page

Foreword

Introduction

Table of Contents

Begin Reading

List of Authors

Index

Other titles from iSTE in Innovation, Entrepreneurship and Management

Wiley End User License Agreement

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Health and Innovation Set

coordinated byCorinne Grenier

Volume 3

Caring Management in Health Organizations

A Lever for Crisis Management

Edited by

Christelle Bruyère

First published 2022 in Great Britain and the United States by ISTE Ltd and John Wiley & Sons, Inc.

Apart from any fair dealing for the purposes of research or private study, or criticism or review, as permitted under the Copyright, Designs and Patents Act 1988, this publication may only be reproduced, stored or transmitted, in any form or by any means, with the prior permission in writing of the publishers, or in the case of reprographic reproduction in accordance with the terms and licenses issued by the CLA. Enquiries concerning reproduction outside these terms should be sent to the publishers at the undermentioned address:

ISTE Ltd27-37 St George’s RoadLondon SW19 4EUUK

John Wiley & Sons, Inc.111 River StreetHoboken, NJ 07030USA

www.iste.co.uk

www.wiley.com

© ISTE Ltd 2022The rights of Christelle Bruyère to be identified as the author of this work have been asserted by her in accordance with the Copyright, Designs and Patents Act 1988.

Any opinions, findings, and conclusions or recommendations expressed in this material are those of the author(s), contributor(s) or editor(s) and do not necessarily reflect the views of ISTE Group.

Library of Congress Control Number: 2022941871

British Library Cataloguing-in-Publication DataA CIP record for this book is available from the British LibraryISBN 978-1-78630-795-8

ForewordCaring Management in Health-care Institutions: Oxymoron or Pleonasm?

The question may seem incongruous, so it is important to remember that, in the short-term, the return of care to the forefront has its roots in the crisis of psychosocial risks at the beginning of this century. This crisis, assuming that it has not become chronic, has highlighted the existence of abusive, sometimes malicious, work relationships, embodied in the worst of situations by moral harassment, that is, the harasser and the harassed, the executioner and the victim, trapped in a strictly interpersonal, often reductive, approach to the deterioration of the work relationship. This degradation was raised and documented fairly early on in the care environment, either in a general way through the systemic description of the undesirable effects of the reorganization of a health-care system in search of efficiency, or in an individual way, through the denunciation of the excesses of power of a particular official with regard to their collaborators. It is regrettable that the link between the two is often insufficiently highlighted, with the expression of personal failings, in practice, often made possible by the shortcomings of the organization.

In any case, we started talking about suffering at work, that is, work that destroys health, only to remember that if work can cause suffering, it is precisely when it breaks with its purpose to build health. As a result, for a long time, we thought that we had lost control over work, that we no longer had any room for maneuver, that we were condemned to experience a deterioration in professional relations that was made inescapable, sometimes by the transformations at work, sometimes by archaisms. Then we gradually sought to emancipate ourselves from a mortifying vision and to identify what in some circles was protective. The logic of the evaluation of constraints was counterbalanced by that of the mobilization of resources, and the logic of the evaluation of psychosocial risks (PSR) was counterbalanced by that of quality of life at work (QLW). Many people have seen this as nothing more than semantics, while others have perceived a possible paradigm shift. This change, beyond an ideological opposition between the two poles of a duality, testifies to the search for a new balance between an approach to work seen exclusively as a factor of exposure to risks and a more anthropological and developmental approach. The health sector is well placed to know the difference between a curative approach and a health promotion approach. The two approaches do not use the same resources, nor do they act on the same levers or in the same timeframe. Above all, the two approaches are not in opposition, but rather articulated in an iterative manner.

Also, just as the prevention of psychosocial risks echoes suffering at work, a caring manner echoes the quality of life at work. The question, therefore, becomes that of the organizational configurations that allow this caring manner to be learned and expressed, prevent deviations, even perversions, and encourage cooperation. Such configurations exist. But one must be careful not to be naive; they do not arise spontaneously or through magical thinking. Similarly, we must beware of demagoguery; they do not thrive in a context where the promise of total autonomy left to the teams would take the place of a caring manner. A responsible organization does not rely on the natural goodness of some to make others happy. It is interested in the work to be done and in the best combination of resources of all kinds available to do it.

Let us move on to the object of care. To watch means to be vigilant, to be awake. To be caring is therefore to be attentive to well-being, in this case well-being at work. Why is this? Because understanding what is going on allows us to act on the sources of our presence at work. Being caring in management is the opposite of negligence or managerial incompetence, which we now know has a significant cost for employees, organizations and users, in this case patients. The quality of work is above all the concern for work well done, which satisfies both the recipient of this work (the customer, the user, the patient, etc.), its provider (the manager, the employer, the financier, the prescriber) and its producer (the staff, whether caregivers or not).

The caring manager certainly has values and beliefs but is not a Samaritan. They are aware of the causal link between the care given to the caregiver and the care given to the person being cared for. They are concerned about what builds the health of their employees at work. They know that the quality of the work done by the agents generates the joint recognition of the patient and their peers, and therefore self-esteem, one of the pillars of psychological balance. To this end, the manager organizes the work, that is, does their organizational work: they support the activity of their colleagues, seek to solve their problems, facilitate interactions with other services, allocate resources and regulate activity, in particular the workload; they are interested in the work activity itself, in the real work, not only in dictating it and in overviews. They reassure and relieve their team so that they can work in a framework that is conducive to the calmest possible deployment of an activity that is by nature trying; they listen and bring up for arbitration problems whose resolution goes beyond their sphere of decision, even if it means reporting on a postponement of the solution or even on a failure. Of course, they can bring croissants to the morning service meeting, but this care is anecdotal compared to the expectations of managerial care! This is a real professional skill, among and in the same way as the others. It is a skill in its own right, one of the essential conditions of work and one of the components of working conditions.

The French National Authority for Health (La Haute Autorité de santé) has recognized that there can be no quality and safety of care without quality of work and quality of life at work (QLW). It has made QLW one of the 15 criteria for the certification of health-care institutions for quality of care. Paragraph 3.5 of the certification standard states that, throughout the health-care organization:

Professionals are involved in a quality of work life approach driven by governance with, on the one hand, a QLW policy, and on the other hand, measures to manage interpersonal difficulties and conflicts.

The implementation of such a policy goes far beyond a commitment to the principle, even if it is put on a charter. In addition to management’s stated commitment, it must be dedicated in the concrete, irreversible and constant deployment of an approach that is appropriate for all. This policy, which has become binding and the filter by which actions taken will henceforth be judged, must be based on principles of action that dictate the conduct of everyone, at all levels of the institution. The result is never final and is constantly reexamined, and this is both the difficulty and the greatness of the work, which will be reflected in the environment. Although complex to describe, this climate is nevertheless perceptible, through the experience of employees, as well as observable, through absenteeism, turnover, commitment, etc. This climate will promote the performance of care and that of the establishment.

This attention, this care for the work, not only depends on the good will of the actors and does not fit well with the only incantation of care. It implies the respect of methodological requirements that give it substance on a daily basis. It is based on a work environment and organization that are conducive to it and therefore well thought out, because, in practice, the intention of caring quickly comes up against real life and the constraints of the real activity. The latter must find a space where they can be expressed and regulated. A caring manner must be deployed and constantly secured in dedicated places and times.

Among the methodological requirements known, there is that of an approach developed in consultation with professionals and their representatives, monitored and evaluated in a shared manner. Above all, this approach, even if it is driven and informed by their views, must not remain the business of specialists, or be reserved for the establishment’s prevention or quality control officers. The worst pitfall of benevolence would be to be separated from the actual care activity and from everything that makes it possible in the field, at the patient level. Clearly, managerial benevolence is not the responsibility of a specialized department and cannot be guaranteed by a procedure. It is a working framework designed to ensure that each decision takes into account its impact on the work of the agents. For example, the purchasing department must bear in mind what the acquisition and generalization of a given piece of equipment will mean in concrete terms for the staff. This leads to a purchasing process that leaves room for consultation and experimentation, differentiation and collective validation rather than just price criteria, which can lead to unsuitable solutions that are a real source of irritation. Similarly, a department head will have to evaluate a priori what resources their clinical project will mobilize within their own department, but also in other departments, etc. In short, while benevolence cannot be prescribed, it cannot be improvised either.

On this point, Mathieu Detchessahar’s work on the deliberate enterprise sheds light on the HAS reference framework when the latter invites the creation of a new system:

within the work units of spaces – times for collective discussions that allow for a diagnosis and concrete proposals on the conditions and organization of work, as well as devices to support professionals in the search for solutions aimed at improving the organization of work as close to the field as possible.

It follows that management must be finalized. It is not good-natured, it does not shy away from controversy or confrontation and it is not naïve or manipulative. It is intended to solve problems, to improve situations, within a framework that is readable, intelligible and marked by organizational justice. When it fails, and it will fail in the future, the HAS says that prevention and regulation mechanisms must take over:

The aim is to maintain the cohesion of the teams. Management, and especially local management, plays an essential role in this area and must be supported in this function.

In hospitals, Article L. 6143-2-1 of the Public Health Code also enshrines this managerial and collective dimension of QLW. It stipulates that public health establishments must adopt a social project dealing in particular with training, internal dialogue within the divisions, the right to within the divisions, the right of expression of staff, the improvement of working conditions, the forward-looking and prospective management of jobs and qualifications. A specific section must be devoted to the QLW of medical and non-medical staff. It is this whole that must be taken into account.

But, let us face it, benevolence is ultimately not a very normative concept and we should be careful not to want to qualify and circumscribe it legally in the hope of naming it, recognizing it and, if necessary, sanctioning its absence. Similarly, it is not encapsulated in a standardized process and cannot be reduced to compliance with a decisional logigram. On the other hand, as we have seen, it does not escape a methodological framework that includes rigorous managerial devices and equipment. Otherwise, the promise it holds will end up as wishful thinking and, worst of all, as a form of disenchantment. The difficulty lies in finding the right balance between a compassionate veil lance, which depends solely on the individual qualities of the manager, and a prescribed and overdosed institutional benevolence.

In the first case, it would be enough to recruit people with a natural gift for care, capable of getting out of any situation, whatever the organizational configuration in which they would be placed, like mercenaries of care in a hostile environment! Other professional sectors have tried this, deploying what has been called dose-based management of their personnel. This consists of selecting the most suitable for the job and then separating them when they are worn out... before noticing the catastrophic effects of such an approach on the skills and attractiveness of the said sector.

In the second case, it would be enough to enter into benevolence, as one enters into quality, by equipping oneself with a multitude of procedures, the success of which would be based on the respect of instructions and standards that would allow one to check the “caring” box in the checklist of the perfect manager.

The in-between is all the more difficult to find as reality constantly reminds caregivers. They see benevolence as a slogan that is contradicted daily by the facts, or even as an instrument designed to divert attention from the real difficulties: resources. It is true that the budgetary context seems to make the intention a paradoxical injunction. To advocate caring management would be like wanting to confirm, endorse or hide restrictive policies. Does this mean that well-manned organizations are by nature proximal and caring? That they always give due consideration to all staff? That they guarantee their development and thus the quality of care? Or should we admit that the means do not lead to well-being or at least do not suffice? The truth is that, locally, there are services that provide job satisfaction. They help each other; the target is not the happiness of the caregiver but the care of the patient. The quality of the latter produces a positive perception of the former, and it is the effectiveness of this coupling that we must be convinced of in order to hope to work on the irreducible tensions of the means/mission duality. The examples in this book provide an illustration of what such a framework looks like in practice.

To think otherwise would be to assume that there is no room for maneuver at the local level. The head of department would be deprived of any power to act on the organization of the work of their teams, a convenient solution for dispensing with the work of organizing their responsibility. To deny the existence of the constraint would be wrong, but to think only in terms of the constraint would be to deny the existence of the resources that can be mobilized through a cooperative, collegial and supportive approach. Yet, even at the height of the social crisis that shook a large telephone company in the early 2010s, there were pockets of resources where managers managed to build local compromises that made it possible to reorganize in a humane way, to the benefit of all. This observation is universal. It applies to all fields of activity. This is why this book is smart to have devoted its third part to the inspiring exploration of professional worlds “outside health”.

In the end, benevolence is the expression of a non-gendered competence exercised in an organizational framework oriented toward the sustainability of the activity, which everyone – and this is the good news – can acquire through learning and collective experience, as well as to give an account in a logic of recognition of professionalism. This is what this book explains.

Hervé LANOUZIÈRE

Director of the Institut national du travail, de l’emploi et de la formation professionnelle

Inspecteur général des affaires sociales (IGAS)

Introduction

“Be kind” is the last instruction given to a manager.

Caring management, slow management, alternative management, etc. have gained ground in the last decade owing to the effects of multiple factors: the spread of new information and communication technologies, increased competition, intensification of work, aspiration to greater autonomy in the organization of work, evolution of markets toward an increasing personalization of needs and services, the development of independent work and so on.

These developments are encouraging traditional companies to adapt and to transform. We can see the development of liberated companies, telecommuting, autonomous teams, co-working spaces, etc. The objective is to find a certain compromise between performance and well-being at work. Compromise is understood here in the strong sense (Barel 1989) of a rewarding cohabitation between performance and well-being, generating value for the various stakeholders (beneficiary, employee, manager, suppliers, prescribers, etc.), and not a divisive fusion leading to a choice of sides (performance or well-being).

This search for compromise is not foreign to health organizations. Like other sectors of activity, the health and social sector is not exempt from the productivity contracts, which impose the search for efficiency, speed of execution or optimization of means, or from the constraints of quality, traceability or safety that create an intensification of work.

How then to reconcile performance and well-being at work? Is this possible? Are health-care organizations capable of transforming themselves and showing flexibility? Those working in the field seem to be limited in their actions by a work organization that is restrictive in terms of workload, on the one hand, and reporting, on the other hand, which prevents the development of benevolence to this day. This lack of time, which has become even more of a problem today than it was 20 years ago, makes benevolence at work more essential but also more difficult to implement.

In some respects, talking about caring management in a context where changes in the world of work are resulting in an increase in employee health problems may seem provocative and illusory. Some 63% of caregivers suffer from one or more symptoms of professional burnout, according to the ONI survey (Ordre national des infirmiers, 2018). Just over 42% of respondents thus report feeling burned out very often at the end of the workday, and a nearly identical proportion report feeling tired in the morning before facing another workday. Is it then a malicious management that is the cause or a health-care system that is not itself caring? The weight of reforms and procedures, recruitment difficulties, the growing power of administration, the plethora of management tools, etc.

It is not so much the search for culprits that interests us, but rather the valorization of innovative managerial actions because, faced with these signs that we can no longer ignore, it seems necessary to project ourselves into the future. Indeed, despite all the professional difficulties inherent in health-care institutions, we simultaneously note testimonies from caregivers stating that work contributes to their happiness. There are no “ready-made recipes” or “models to follow”, but rather contexts, people and teams that initiate and implement managerial innovations in their establishments.

It is with this in mind that a working group of researchers from different backgrounds (management sciences, medicine, sociology, psychology, education sciences, public health) and professionals in the field (health managers, nurses, health institution managers, project managers, health and social sector training center managers) decided to produce this book. This collective is not a passing phase. It is part of a history of nearly 20 years between three training institutes in the Loire working to develop managerial skills in health1 and bringing together researchers, students and professionals in the health and social sectors.

In addition, a research team from Saint-Etienne in management sciences (COACTIS) is exploring the so-called “caring” managerial practices of local organizations for better performance (economic, social and environmental performance). EHPAD2 clinics and hospitals are all fields of study investigated by this team, and made part of in the managerial training of the IAE de Saint-Etienne in order to raise awareness among the managers of tomorrow.

The objective of the book is to defend the idea that sustainable performance is no longer an option in health-care organizations. It is necessary to capitalize on and disseminate “successful” caring management practices. The current context linked to the COVID-19 crisis only reinforces this position.

Management can certainly be harmful, but it can also be very caring, a vector of performance and recognition. It is not just a matter of happy washing and must be translated into concrete practices. This book takes an interdisciplinary look at the issue of caring management in health-care and is based on experiments carried out, for the most part, in the Rhône-Alpes region and on interviews with professionals and researchers involved in the subject.

The book is structured in three parts:

– Part 1 offers a political, historical and international look at “caring” management in health. It is composed of four chapters highlighting the committed visions of two medical managers, the founders of an association campaigning for the enhancement of the human relationship in health and researchers involved in the topic of performance in health-care. One of the chapters will focus on caring management in the context of a crisis, and in particular a health crisis during COVID-19, in order to identify how this managerial approach can be a lever for crisis management. Indeed, COVID-19 required radical reorganization, in a very short period of time. What remains of caring management in this context? Does it still have its place?

– Part 2 relates the successful experiences of health-care institutions that have opted for caring management with all its difficulties, pitfalls and riches. What could be better than management by evidence? Here, four chapters provide concrete experiences expressed, discussed and analyzed through the views of psychologists, sociologists, managers and researchers.

– Finally, Part 3 explores other sectors of activity beyond the health sector. Indeed, the subject of caring management not only in health-care institutions; issues of organization and sustainable performance are multisectoral and openness to other professional cultures fuels the debate. This is why three chapters are dedicated to managerial issues in various national and international organizations, from sectors as varied as agri-food, industry and education.

Being kind is not a job! Neither is being caring! And managing with care: what is that exactly?

Enjoy your reading.

Notes

Introduction written by Christelle BRUYÈRE.

1

Located in the southeast quarter of France, in the Auvergne-Rhônes-Alpes region, the three institutes are the IAE (

Institut des administrations et des entreprises

) Saint-Étienne (and, more particularly, the MOSS Master’s degree in the management of health and social organizations), the IFCS (

Institut de formation des cadres de santé

) of the Saint-Etienne University Hospital Center and the ENSEIS (

École nationale des solidarités, de l’encadrement et de l’intervention sociale

) of Firminy.

2

EHPAD:

Etablissement d’hébergement pour personnes âgées dépendantes

are the most widespread forms of residential care for seniors in France, what we would call nursing homes in English.

Part 1A Committed Vision of Caring Management

Introduction to Part 1

The news of the last few years – social movements, conflicts, tensions and more – tends to show that the constrained context in which the staff of social and medico-social organizations develop is the cause of much dissatisfaction. Among them, we find, for example, feelings of lack of resources (human, material, financial, etc.), of a loss of meaning, or even of a deterioration in working conditions, a lack of time to provide quality care and a constant tug-of-war between economic objectives to be achieved and qualitative objectives to be satisfied. The COVID-19 crisis has only accentuated the debate around caring management. Is it a luxury that we can only afford when everything is going well? Or is it, on the contrary, what keeps our heads above water when everything seems to be falling apart? Is it a lever for achieving sustainable performance and well-being at work?

It is here in Part 1 that a political, historical and international look at the issue is proposed in order to define the stakes and limits and to see the favorable outcomes.

Chapter 1 takes a critical look at the very existence of caring management in the health sector based on interviews with two committed medical managers. The multiplication of reforms and procedures, recruitment difficulties, a hyper-competitive training system based on competitive examinations, strengthening of the powers of the administration and the massive deployment of management, control and surveillance tools are all among the factors that hinder the development of caring management of health-care institutions.

However, can we not project ourselves into a future where sustainable performance and well-being at work would be compatible? Under what conditions? With what means? Chapter 2 looks at the value of human relationships in health-care organizations, with a focus on Uruguay as an international exception with its care model centered on medical humanism.

Chapter 3 then provides a historical overview of the problem, reminding us that the question we are interested in is not a fad. It is rooted in our history and the current changes in work (intensification, productivity, traceability, etc.) make it all the more significant.

Finally, Chapter 4 raises the question of caring management as a lever for the anticipation, management and repair of crises in the health-care system, and the COVID-19 crisis in particular. We must learn from the current crisis and from past crises in order to be able to deal with them together in the future.

1Caring Management and the Health-care System: The Vision of Two Committed Doctor-managers

At a time when the words “management” and “care” are increasingly used in everyday language, it seems interesting, to study the link between caring management and health, to interview operational managers at the heart of the French health system. These two practitioners, who have been and are still in management positions, define themselves above all as doctors and researchers and do not necessarily feel qualified to talk about management. On the contrary, their experience as field actors places them at the heart of considerations, especially since they belong to the hospital world, the hub of the French health system.

Michèle Cottier, university professor – hospital practitioner – has been head of the histology-embryology laboratory of the University Hospital of Saint-Étienne since 2003. Regarding her research activities, she directed the interdisciplinary laboratory for the study of aerosolized nanoparticles from 2011 to 2015. Franck Chauvin, university professor – hospital practitioner – has been head of the public health department of the Institut de cancérologie Lucien Neuwirth since 2004. In 2004, he contributed to the creation of the Hygée Center, whose mission is to develop cancer prevention in the Auvergne-Rhône-Alpes region. He has been its deputy director since its inception. The complementarity of their profiles is even stronger and more interesting in their recent appointments: Michèle Cottier has been dean of the Université Jean Monnet de Saint-Étienne since November 2015, and Franck Chauvin has been president of the Haut-Conseil de la santé publique (French High Council for Public Health) since April 2017.

These two doctors, engaged in their different functions, have agreed to tell us, in the context of this book, about their view of caring management in the French health system, and more particularly in hospitals in individual semidirected interviews, conducted in parallel. The professional is at the heart of their reflections: whether it is through the quality of the care given to the people being treated or the well-being of the staff themselves. Both agree on the idea that it is difficult to talk about caring management without questioning the environment of people’s work:

What is our environment? Do we understand it? If we don’t understand it, it doesn’t seem to me to be a good basis for management. (Michèle Cottier)

In the hospital, it is therefore a question of questioning the health-care system.

Based on their reflections, we will explore how and why the health-care system is in crisis and what the possible ways forward are. We will then focus on the contributions of the health crisis linked to COVID-19. We will then conclude by highlighting their vision of caring management in health-care.

1.1. A health-care system that is insufficiently caring toward its staff and users

When asked about the notion of care and caring management, the responses of our two doctors were identical: it is difficult to talk about caring management in a system that is not caring itself. They both tried to explain to us how and why the health-care system is not caring enough in their eyes.

1.1.1. From the training of hospital staff to compartmentalization between different professions

One of the reasons for the lack of care in the health-care system is related to the way in which the training of health-care professionals is carried out. Let us consider that of physicians, which Michèle Cottier summarizes as follows:

It’s a hyper-competitive system where the principle of competition is permanent: you have to pass a competitive exam to get in, and pass a competitive exam to get out; whether you’re a university hospital worker or a hospital worker, you have to be appointed to a hospital, etc. By definition, competition does not develop the collective spirit! It is difficult to manage in a caring manner without a collective spirit! Similarly, the fact that the different types of professionals never meet during their training does not facilitate communication between them afterwards and inevitably leads to difficulties in getting to know each other, understanding each other, understanding each other’s issues and working together: in this context, how can we develop a team spirit?

This separation between the professions during their studies and professional training will contribute to the creation of compartmentalization in the hospital system: compartmentalization, for example, between the medical and nursing approaches, which “places the treatment and care of the patient before any economic consideration”, and the economic logic promoted by the administrative staff, which “advocates the pooling of costs and the definition of activities according to revenues” (Vallette et al. 2015). Similarly, access to the functions of directors being reserved to the body of hospital directors may have contributed to reinforcing the gap between the two approaches.

To go further, we can highlight the compartmentalization of administration, paramedical staff and medical staff, which differ in particular by their organizational structure with their own operating rules, by their forms of recognition and ethics, by their place within the hospital community and by their feeling of belonging to a different entity (respectively, the hospital, the department and the medical profession) (Romeyer 2001). All this leads to a lack of dialog between doctors and administration or between doctors and carers, even though they are supposed to work together in a coordinated way to ensure good patient care. More particularly, the people in charge of these different professions do not develop any shared analysis of the activity, each remaining within its own logic and aiming at its own objectives:

This whole system does not contribute to a dialogue between the people in charge and does not contribute to shared analyses. (Michèle Cottier)

Michèle Cottier also evokes the notion of trust: given the high level of responsibility a doctor has when faced with a decision (diagnosis, therapeutic decision), a responsibility that they bear alone and do not share, it is difficult to delegate under conditions that they do not control. Tensions and compartmentalization are thereby reinforced further. This issue of trust can also be found between management and physicians, as shown by Bérard (2013) and Gavault et al. (2014), with reluctance to consider that physicians can be managers responsible for their activity, which translates into difficulties in delegating this management to them at the level of the individual hubs, for example.

1.1.2. The impact of the reforms on the governance and strategy of hospital establishments

According to Valette et al. (2015), since 2005, reforms have aimed, on the one hand, to increase the involvement of physicians in the internal management of health-care institutions and, on the other hand, to strengthen the powers and responsibilities of directors of health-care institutions (see the Order of 2 May 2005 and the HPST Act of 21 July 2009). The objective is to encourage administrative and medical actors to take the economic impact into account more in their decisions and in their medical and health-care practices (Domy et al. 2014).

The words of our two doctors reveal the consequences of the implementation of these reforms on their activity and practice. Several ideas put forward in the interviews show a certain loss of points of reference on the part of nursing and medical staff.

A loss of points of reference linked primarily to the impression of a lack of a clear vision of the rules within the hospital, particularly due to the contradiction between the two logics (medical and economic) with which doctors are confronted. This is referred to as “role tension”, which has significant negative effects:

Decreased job satisfaction, organizational involvement and engagement at work can also manifest when the employee perceives their role as ambiguous or conflicting. (Loubet 2011)

The two physicians interviewed reveal throughout the interviews these tensions of role and this lack of understanding of the system, going thus far as to speak of a “nebula where nothing is understood” (Michèle Cottier), specifying that “the system does everything to hide the keys; physicians lost the keys a long time ago” (Franck Chauvin). In their roles as managers, they highlight the paradoxical injunctions resulting from the system, which is a “jungle in which there are no rules” (Franck Chauvin) and where “procedures have been piled up” (Michèle Cottier). Since the system is incomprehensible, health-care professionals have difficulty understanding the decisions made because they seem to be out of step “with the reality of the field and the reality of needs” (Michèle Cottier). This can generate behavior that can be perceived as violent, adding to the system’s lack of care: “people therefore force their arguments” (Franck Chauvin).

The loss of points of reference can also be linked to a loss of meaning. For doctors, it corresponds to the absence of a clear medical vision on the part of those in charge of the hospital:

There is already this question at the foundation of the hospital: the capacity of the person in charge to really manage and give direction to an activity that is the care of patients, because we must not forget that everything must be done from there. (...) Management is not necessarily imbued with what caring for a patient entails. (Michèle Cottier)

This lack of medical vision seems all the more regrettable in the eyes of the practitioner as he/she compares this situation to that of the university, where the definition of the institution’s strategy is in the hands of a teacher-researcher. This person is thus able to give direction and define a project that will make sense to the community of teacher-researchers (in terms of training and research) and students.

This loss of points of reference generates a certain uneasiness among health professionals, particularly among those in management positions. “I find the system aggressive (...) it is no more caring towards managers than towards agents” (Franck Chauvin). This malaise is explained by De Pouvourville (2010) as the injunction to be made of management, which would cause a weakening of identity among doctors. The malaise is also acute among university hospital doctors, who depend on both the hospital and the university institution and find themselves lost between the two, whereas until now they felt more involved in the hospital, making the project very meaningful to them.

In addition to a loss of points of reference, the reforms have resulted in a strengthening of the powers of the administration. Indeed, the HPST law of 2009 gave hospitals a supervisory board and an executive board, strengthening the powers of the director at the same time. The representation of the medical profession on the supervisory board is relatively weak, although its role is strategic (it decides on the strategic positions of the establishment and exercises permanent control over the management and financial health of the establishment). Within the board of directors, medical power is balanced by the fact that, on the one hand, the doctors – although they are in the majority – are appointed by the director and, on the other hand, by the fact that they have fewer duties compared to the executive council, which they replace. The director also appoints the doctors who head the divisions. The hospital administration is therefore seen by medical and nursing staff as a body “which controls, which supervises in the repressive sense of the term; it receives orders from above and is itself supervised” (Michèle Cottier). Hospital professionals have the impression that the objective of profitability of the activity (by contributing, for example, to the removal of beds) takes precedence over the main vocation of the hospital: to take care of the patients. Michèle Cottier notes that patients find themselves “in hellish conditions of care”. A documentary made by a teacher-researcher based on interviews with doctors from various public hospitals illustrates very well the impact of the implementation of activity-based pricing on the daily lives of caregivers (Marie-Astrid Le Teule 2020, “Le prix de la vie”). Moatti noted in 2018 these same impressions:

Caregivers are unwillingly thrown into a race to the bottom that rations time for patients, undermines the quality of care, and alters the meaning of their mission. (Moatti 2018)