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For a Radical Renewal of Democracy in Hospitals

Contributor: Patrick Martin

Editors’ note: Thank you to author Patrick Martin for contributing this further reflection on his article co-authored with Louise Bouchard, that appeared in ANS 43:4, October/December 2020, p. 306-321 (doi: 10.1097/ANS.00000000000003220)

The staff nurses, who gave us an interview in the research project being discussed in the article “Constraints, Normative Ideal, and Actions to Foster Change in the Practice of Nursing: A Qualitative Study,” recently published in Advances in Nursing Science, have felt left out of decision-making processes that prevail in hospital centers, even if decisions arising from them have a direct impact on the way in which they work. It should be noted that staff nurses who practice in hospital centers represent most of the nursing workforce. The same observation emerges from one of our research projects that is still ongoing, conducted with nurses working in different sectors of specialty care (clinical nurse specialists, pivot nurses, specialized nurse practitioners [SNP], etc.).

This situation, which is eerily similar to the one experienced by the subordinate citizen, systemically left out of places associated with the exercise of power, appears consistent with the broad trends our contemporary oligarchic societies are taking under the aegis of world governance and market globalization. Our results suggest overall that the hospital democracy is increasingly confined to hospital boards of directors and to instances in which usually nurses do not have access. In the words of some participating nurses, these instances would themselves be submitted to a strict hierarchy of command, itself dependent on guidelines, particularly ministerial directives, which would considerably affect overall positions taken by hospital centers. It should be noted that our research is taking place in Canada; our health care system is certainly a public one, which connects, however, to an entrepreneurial-style governance model that leaves more and more room for the private sector and is advocated in all care settings, a clear separation between decision makers and “implementers”.

Based on our research results, the nurses who stand out for their commitment are thereby mostly confined to instances that only have the powers of recommendations, such as the hospital councils of nurses (CN). Participation in instances where access is “open” to nurses was otherwise associated by some participants with strategies put in place by the hospital authority to ensure nurses deploy their energy with no success to make any changes whatsoever happen in constraints they live in their daily practice. Even the parity committees[1] within which union representatives have the opportunity to talk with the employer are perceived as being marginally effective for eliciting to improve conditions under which nurses work.

Although these instances may appear a priori as great opportunities to promote nurses’ interests to the employer for concrete changes can be made in work organization, the perceptions of those interviewed with access to these committees as union representatives are no way going in this sense. These testimonies rather suggest that, even within these instances, numerous techniques would be deployed by the employer in a way to paralyze the dialogue with the union and to push dispute settlements, which we think has the effect of accentuating the separation between decision makers and implementers, already very much present in hospital centers. The fact of constantly changing interlocutors with which the union must find common ground would be leveraged in many backgrounds; this context among these techniques sometimes has the effect of significantly pushing some grievance settlements, the delays may spread out more than one year. If, according to some participating nurses, this is the constant turnover of managers, which would be the source of these delays, the fact remains that the current situation benefits the employer, even if the phenomenon is not necessarily a planned strategy.

When acting for change, the Slovene philosopher Slavoj Žižek(2008a), who is very interested in political action, states that it is important to question ourselves about the possibility of efforts deployed to cause the reproduction of dominant discourse, as it would be the case when nurses are investing time and energy in committees bringing very little outcomes, the hospital governance by far prefers seeing them running around in circles in some frivolous proceedings rather than noting they organize themselves concretely to resist the hospital authority. Žižek will specify in these situations that it is sometimes better to do nothing rather than try to act the wrong way to transform the status quo. Not cooperating in the functioning of the hospital framework by refusing participation in these proceedings – of what, from the point of view for a lot of nurses who participated in our research, in no way enable to improve their situation – would thus become, in itself, an act of resistance.

Results from the research project being discussed in the article “Constraints, Normative Ideal, and Actions to Foster Change in the Practice of Nursing: A Qualitative Study” revealed as well that decisions are usually made in accordance with decision-making processes in hospital centers, always consistent with interests of small influential groups. Participants on numerous occasions made reference to staff nurses in their discourse, but also to link nurses who, based on tacit knowledge, the one marginalized by the good governance doctrine, had warned institutions relative to decisions, many of which would achieve savings that have proven to be serious errors. Decisions even resulted in the death of many patients.

Our results suggest in addition that ideas from nurses are usually taken into account only when they are able to demonstrate they are in fact the partners “of those who play the game of the good governance” [free translation] (Deneault, 2013, p. 41). The nurse who sees herself complimented by a manager after having proposed, through a corporate website promoting innovation, that her colleagues bring their own toilet paper to workplaces for achieving savings, is a disconcerting example of this fact.

What Good is it?

A number of participating nurses encountered in studies and questioned relating to their commitment and the registry for political actions from nurses asked us if we really thought that it was possible to “change things”, with respect to the practice of the contemporary nursing profession in different backgrounds. The situations, described and criticized by them, have effectively come to our mind the most desperate throughout data collections, many participants indeed having openly admitted to us not believe in the possibility of making favorable changes happen to conditions for exercising the nursing profession, more particularly in the hospitals. As Žižek(2012) who, in a lecture given in Toronto, emphasized being regularly confronted with similar questions relating more specifically to pessimistic representations made of the state we find the world we are living in today, we responded to these participating nurses not being exactly sure it is possible to “change things”. And definitely we still have no certainty. Although many are likely to believe that things cannot change, paradoxically, however, we can only see the hectic pace at which, right now, they are changing radically, in both different care settings and our advanced capitalist society.

Not only in capitalist dynamics, but also in all spheres of life, things are in fact already changing automatically to a hectic pace. The very nature of sociability, of what constitutes a human being is as well shifting now and, if we let these changes be deployed passively – the same is true for the comparison to care –, it is expected that we will be heading towards an articulation of the society,[2] which is going to be characterized by a new form, permitted and perverse, of authoritarianism (Žižek, 2012). For Žižek, with whom we are in agreement on this, things are thus already changing to a hectic pace and that has to give us the motivation to act concretely to ensure these changes are getting a foothold in the sense of what we want, consistent with what nurses do. If Žižek postulates we are living the end of the world as we knew it, we also believe that we are witnessing here the end of care settings as we understood them, and sort of – to the end of the nursing professional practice as we knew it. Thereby drastic changes occurred, are happening and will continue to occur and it is expected that these are going to happen in a way even more authoritarian, arbitrary and perverse, because everything seems now okay in the name of the triumphant economy, and these ways of doing things in our societies necessarily affect care settings.

It is not a matter for staff nurses to foolishly accept these changes that will continue to occur quickly, but for them to reflect on what they can do to direct/influence these as well, certainly in a sense which would be salutary to them, but more particularly so we have some humanity. Nurses could also refuse categorically these changes – or some of them –, just as they can propose new ways of looking at the nursing professional practice – and they do so increasingly. And to those who believe that no change is possible because small groups disallow any transformation to the social order, Žižek(2012) unequivocally responded it is wrong to think there is only one social class governing and manipulating what is going on. According to Žižek(2012), reality is in fact more complex, certainly disconcerting, but with no way out – because those who are standing at the top of hierarchies are as well constantly destabilized by this ever-changing world and have enormous difficulties adapting to it. They are thus always improvising, definitely with a lot of means, to promote the maintenance of their hegemonies – hegemonies which, in all of this improvisation are necessarily much more fragile than we would like us to believe. As nurses, as a group, it is extremely important to become aware of this fact, which in regard to what we experienced as a society with the COVID-19 pandemic in the last year, looks absolutely undeniable.

In accordance with the writings of philosopher Rancière (1991, 1999), we refuse, however, to position ourselves in the expert role – a posture which remains anti-emancipatory – or in the Sartre’s trend of the intellectual, by dictating to nurses how they should act to cause the desired transformations to the nursing professional practice. But we feel strongly, consistent with what Gene Sharp (2012)[3] wrote, the power exercised in a hostile way, particularly by the governance of major hospital institutions, must be thwarted by an equal or greater nurses’ collective strength, without which the policies associated with it will continue to be imposed on them. To direct in the sense which is salutary to them, but also so we have some humanity, the societal changes affecting the nursing practice, we believe as well that there is no point for nurses to set off on a crusade against capitalism even if as a group, they and patients to whom they are giving care suffer enormously from collateral effects of this socio-political way of organizing we have. As Žižek (2008b) reminds it, this reflex obsessing the “old left” (p. 29) is not conducive, especially in the way in which the reality of today’s capitalism is structured, namely from a globalized manner where it becomes, for all practical purposes, impossible to have a grip on the ongoing transformations this ideology imposes to our existences.

Like Rancière (2014) and Žižek(2012), we think it is in the radical renewal of democracy in our societies and institutions as citizens, we must deploy our energies and concrete actions, actions that will do harm to the powers-that-be and destabilize oligarchs who have literally appropriated our democracies. It is in this sense, without telling nurses what to do, but we believe it is relevant to move towards a radically renewed hospital democracy[4] as the ultimate central purpose to which their collective actions must be structured, but also their individual ones, because it is always preferable to act on several fronts. Maybe that, starting from these concerted collective and individual actions in the thoroughness of everyday living, nurses will cause the establishment of a new balance of power and they finally have the opportunity to debate on the direction that must take the nursing practice – which, need we remind is essential to life.

Deneault, A. (2013). Gouvernance : le management totalitaire. Montréal : Lux Éditeur.

Rancière, J. (1991). The Ignorant Schoolmaster: Five Lessons in Intellectual Emancipation. Stanford : Standford University Press.

Rancière, J. (1999). Disagreement : Politics and philosophy. Minneapolis : University  of Minnesota Press.

Rancière, J. (2014). Hatred of Democracy. Brooklyn : Verso.

Sharp, G. (2012). Sharp’s dictionary of power and struggle : language of civil resistance in conflicts. New York : Oxford University press.

Žižek, S. (2008a, January). Violence. Paper presented at: the London Review Bookshop, London, United Kingdom.  

Žižek, S. (2008b). Violence : Six Sideways Reflections. New York : Picador.

Žižek, S. (2012, September). Until the end of the world. Paper presented at: Toronto’s Nuit Blanche Symposium, Toronto, Canada.

[1]Given our results, the grievances of nurses can be expressed and tolerated only when they – through their representatives – are invited expressly to do so by their superiors, particularly during these parity committees.

[2] By describing this new entity of new perverse permissively authoritarian society, which will be most rigid but, in a new way, Žižek(2012) prefers not to make reference to what some people are calling a new form of fascism, because he considers that those who use this term do it because they are too cowardly to think what is really new in these ways of doing things. The term “management totalitaire”, used by Deneault (2013), appears to us, however, as a key concept to describe this new articulation of our societies.

[3] Note that these writings of Sharp (2012) do not specifically refer to the nursing reality.

[4] We think at the same time nursing actions must also be directed so we have some radical renewal of democracy in our societies because it appears unlikely that a renewal so radical of the hospital democracy is done without much larger reflections, at the societal level, isn’t it put forward in this sense?

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