From Close Cooperation to Its Unravelling: A Political View of the COVID Crisis Management in Hospitals

4.1.1 Three Types of Relationships

Hospital personnel shared with us their ambivalent feelings about the crisis during the first wave. It was an extremely difficult period due to the workload and the number of victims they had to deal with. They had never experienced having to manage so many patients and so many deaths on their ward, over such a long period of time. The scale of the pandemic, even for referral hospitals, was unprecedented. At the start of the pandemic, they also feared for the lives of healthcare professionals when knowledge of the virulence of the virus was unclear and protective equipment was in short supply. Unlike these referral hospitals, which prepare their staff for epidemics annually, the other hospitals were not at all ready for it. In all the hospitals we studied (apart from the 2 referral hospitals in the sample), infectious disease and emergency professionals acknowledged that their preparedness plans were adapted to terrorist attacks (which had become the political priority) but not to major pandemics. Although they therefore found it difficult to make sense of this unprecedented situation, for which they were completely unprepared (this constituted a situation conducive to organisational collapse as analysed by Weick 1993), the professionals were impressed by their team’s ability to rally, despite fear for their own lives, and to face up to the situation. It was also, paradoxically, the best professional experience of their lives, as they put it. They were surprised by their capacity to work as a team, including colleagues with whom they were in conflict, or whom they barely knew before the crisis. According to the relational perspective of Anteby et al. (2016), the relationships between healthcare professionals, between hospital management and healthcare professionals, and between professionals and their families, played an important driving role in collective action during the first wave, improving the conditions for collaboration between hospital professionals.

4.1.2 Suspension of Competition Between Healthcare Professionals

Doctors from several specialties and nurse managers had to interact intensively and even collaborate from the onset of the outbreak. The main specialties directly involved in COVID19 management were intensivists, anaesthesiologists, infectious disease specialists, and pulmonologists. It was essential to ensure that dying patients received care, and that those who needed it had access to resuscitation treatment. Most of the interviews we conducted with doctors highlighted an unprecedented level of cooperation between these different specialties. However, as has been widely demonstrated, at least since Freidson (1970), relations between medical specialties are often characterised by competitive struggle (Abbott 1988). This competition, ordinarily very present in French hospitals (Bazin 2014), seemed to be absent during the first wave. More specifically, two types of competition between professionals seemed to disappear: for access to scarce resources (patients and funding) and over which legitimate issues to prioritise. Since COVID-19 was the only priority, all other activities were suspended.

Such cooperation was by no means simple between anaesthesiologists and intensivists who admitted patients to critical care and who, before the pandemic, had a poor relationship. In France, there is an official overlap between intensivists and anaesthesiologists in terms of prerogatives and types of medical activity. Intensivists do not perform anaesthesia in operating rooms but work in intensive care units, sometimes on purely medical conditions only. Anaesthesiologists can be involved in both activities, depending on the setting and on their willingness, the latter frequently being linked to their previous training. The overlap between the two distinct specialties has long been a source of competition in France:

In France, unlike the rest of the world, intensive care is divided into two categories. In France, we differentiate between medical intensivists and anaesthesiologists. It’s a distinction that, in my view, should not be there, since we are doing the same job. However, as you will see in your various interviews, it fuels an old, petty academic rivalry. (intensivist, hospital 3)^[1]

This explains why there was tension between doctors of these two specialties in the early stages of the pandemic. The anaesthesiologists we met felt that the intensive care specialty had sought to “capture” the crisis (to gain ownership of it, as Joseph Gusfield (1981) would put it) in the media, to gain more legitimacy with regard to regulators and professionals-in-training (particularly junior doctors and student nurses) compared with anaesthesiology departments, and hoped to benefit from this once the pandemic was over.

I thought that the fact that the medical intensivists spoke out about [the crisis] at a very early stage was as much for political reasons as for scientific reasons. And that’s understandable. I’m not suggesting that it was opportunism, that’s not it, it was something that existed before the COVID-19 crisis and will exist afterwards. (anaesthesiologist, hospital 4)

Locally, this was reflected in a lack of coordination between intensivists and anaesthesiologists at the very beginning of the first wave in two of the university hospitals where we conducted interviews. In these two hospitals, the first seriously ill COVID-19 patients were treated by the intensive care team, which was slow to hand over the first COVID-19 patients to the anaesthesiology team, even though it had been agreed that this would happen so that they could begin training in how to treat them.

So it went pretty well, I’d say [between anaesthesiologists and intensivists]. After that, of course, there were tensions, mainly over the distribution of patients. At the beginning, intensive care medicine had emptied its beds, so we acted as a valve to get them to empty their beds, because we had said: “in the beginning you would take the first COVID-19 patients”. Then we agreed with them that after 12 patients, to avoid saturation, since they had 18 beds, after 12 beds they would hand over to us to avoid saturating their team. And on that point, they didn’t play ball. In other words, they overloaded their ICU, and once they couldn’t do anything more, they said “help us”, and then we took over and managed everything. That’s pretty much how it went, actually. It was a bit disappointing. (anaesthesiologist, hospital 4)

Yet, this lack of coordination is not specific to the relationship between anaesthesiologists and intensivists. It also affected the relationship between the intensive care teams at the referral hospitals and the intensive care teams at other hospitals: the referral hospital teams waited until they were overwhelmed before referring patients, which hindered training. Several doctors also reported tensions between doctors working in pulmonology departments and those working in internal medicine, over the treatment of the first COVID-19 patients who did not require intensive care. In short, the competition that characterised relations between doctors did not spontaneously evaporate with the emergence of the COVID-19 threat.

These tensions decreased as soon as the hospitals in Paris and in the north and east of France were overwhelmed with patients (between the first and third weeks of March, depending on the regions where we carried out our survey) and the French President declared a national lockdown.

At the very beginning, there was an impression that there were claims from some people, saying ‘I’ll do it’. Very quickly, it became clear that the problem was of such a scale that everyone would need to get stuck in. (internal medicine, crisis unit, hospital 2)

These data show that the danger posed by the virus to both professionals and patients does not in itself explain the ability to cooperate. During the first lockdown (March to May 2020), surgeries other than the most urgent were cancelled and suspended, as were other medical treatments, and people were ordered to “stay at home” to avoid overcrowding the hospitals.^[2] Public hospitals in the regions hardest hit by the pandemic were sent reinforcements in the form of doctors and nurses from nearby private hospitals as well as from regions that were less severely affected, as was the case for part of western France during the first wave. They also received reinforcements in the form of professionals from other departments in their hospital that had closed due to the suspension of non-urgent care. For example, the staff interviewed were struck by the assistance provided by some surgeons, who represent the hospital elite, in turning patients over on their intensive care beds (a practice known as prone positioning) or in moving them between departments as stretcher bearers.

Even the surgeons, senior doctors and surgical house officers came every morning and turned the patients over, placing them in the prone position. They were pretty quick to offer their services, spontaneously. They came back in the afternoons. In the mornings they put patients on their backs and in the afternoons they turned them back onto their stomachs, so they could spend the afternoon and night on their stomachs. (intensivist, hospital 2)

In fact – though not to minimise the commitment of these surgeons - this assistance was possible because their main activities had been suspended. In short, the scale of the pandemic and the decisions taken to contain it (requisitioning staff, suspending operations and other non-urgent hospital activities, and putting the population in lockdown) halted both the battle to capture patients and the struggle for access to limited resources (beds and nursing staff), two factors which normally lie at the root of competition and conflict within hospitals.

Relationships were instead simple, on the whole, because when the hospital more or less became devoted to a single disease, no one was fighting to claim that they needed more or fewer beds for their disease or their specialty. We were all doing the same thing, it wasn’t very complicated. (crisis medical director, head of the emergency unit, hospital 2)

Although this suspension of surgical activity was imposed, the ways and means of redeploying surgical resources were instead the subject of group discussions among professionals: it was precisely because they were able to discuss and debate their own interests and constraints, and find solutions that went beyond them, that they committed to working together.

Another source of tension in hospitals relates to access to “good” patients, whose conditions match the areas of specialisation of the relevant hospital departments. However, the interviews showed that COVID-19 cases were all very similar,^[3] with the only differences being whether or not oxygen therapy or intubation were required. Under these conditions and considering that some oxygen therapy and intubation techniques cannot be improvised, hospitals were able to put in place an organisation based on severity, without this leading to competition between departments. The medical departments held on to patients for as long as possible, waiting for intensive care beds to be freed up, that in normal times they would have sent to the intensive care unit sooner.

Let’s say that for us, the peak of the pandemic was in late March and early April. At that point, we were doing four transfers to intensive care during the day, which is not normal for the department. Four is the most we’ve done in a day. And especially people aged 65 to 70… Normally, these people don’t come via the department, they go directly from the emergency unit to intensive care in the event of problems. And when we’re talking about four patients passing through the department, that was when the intensive care departments were starting to be inundated, when intensive care beds were opened pretty much all over the hospital, and when patients were waiting for a bed, they were brought up to the infectious diseases department because they couldn’t be left in the emergency unit. It had to be fluid. (infectious diseases specialist, hospital 6)

Thus, cooperation was enabled by the suspension of competition, but this change was supported and managed within the hospitals. It is not only shared meanings, status rules or emotional scripts resulting from ex ante cross-cutting demographics that facilitated cooperation between different groups (DiBenigno and Kellogg 2014). New organisational structures were put in place, placing staff who were normally scattered across their own departments in supervisory groups to find solutions. These interconnected structures, under the leadership of crisis units (see the next section) supported the capacity for collective action. Constructed according to a principle of subsidiarity, given real decision-making authority and focused on immediate work, these forums enabled participants to talk to each other (in areas where the departments did not usually do so) and to work together to develop solutions appropriate to their situation. These groups fulfilled multiple functions which supported cooperation during the crisis: an expertise function, where the combination of skills contributed to decision-making, situation analysis and the development of realistic responses; a social and political function, by facilitating acceptance by heads of medical departments of the decisions made by the crisis unit; a networking function for healthcare workers and a coordination function for departments that do not talk to each other under normal circumstances. Within these groups, staff made arrangements among themselves, in accordance with their constraints (number of patients, available resources, location of premises) to spread the burden of opening up beds.

4.1.3 Relationships Between Healthcare Staff and Management: A New Form of Governance

For several decades, Western hospitals have been subject to the tenets of new public management, which strengthened managerial personnel to the detriment of the medical professionals. The professional bureaucracy described by Mintzberg no longer corresponds to Western hospitals, although the extent to which the medical profession has been weakened remains a matter of debate (Scott et al. 2000; Levay & Waks 2009; Numerato et al. 2012). French hospitals were no exception to this trend, and the pandemic occurred against a backdrop of intense professional mobilisation against management reforms (Gelly & Spire 2021). Top managers and health professionals told us how astonished they were at how quickly they were able to work together to manage the pandemic, after years of tension or conflict.

In most hospitals, relationships remained strained in the early stages of the pandemic. Participants reported tensions and conflicts during the first two weeks of March: doctors and nurse managers felt that they did not have the full support of their top management and had to take initial decisions on their own, including the triage between patients suspected of having COVID-19 and others, training staff in specific procedures, and explaining to some surgeons the need to plan for the suspension of operations. There was a gap between the perceived urgency of certain hospital departments and the expectations of top management, so these departments took initiatives without delay. As this anaesthesiologist put it, echoing many other similar interviews:

We had a short period of uncertainty, when we waited for orders from the top, then quickly we were making requests to the top - when I say ‘the top’, I’m talking about our clinical directors, our executives and our management team - and then very quickly, not getting anything back, we took the initiative to get things going [i.e. staff training], while trying to respect everyone as much as possible. In other words we at least informed our managers, but very quickly we decided not to wait for orders from managers but to take decisions at our own level. (anaesthesiologist, hospital 4)

However, once national lockdown was declared on March 17, the same doctors and nurse managers shared their surprise at how well they were able to work with the top management at their hospital. This surprise was all the greater for those doctors who had been protesting in the streets a few weeks earlier as part of a national, interhospital demonstration against the managerial reforms undertaken over decades in France.

Firstly, in every hospital we studied, doctors and healthcare executives were included in the crisis units for decision-making along with top management to take and implement strategic decisions together.

The dialogue that we were able to establish between the emergency unit, doctors and management and, of course, all of the top managers as well, really everyone, was hugely supportive. Everyone was very responsive. (crisis medical director, hospital 1)

The crisis units were not vertical at all. There was a very easy-going, very fluid space for discussion with the hospital director. They were fantastic at understanding and effectively managing the crisis. (internal medicine, crisis unit, hospital 2)

Doctors and nurse managers participated in the crisis units and had a decisive voice, a fact that was readily acknowledged by top management. Although top management was present in the crisis units, decisions about organisation and treatment were delegated to doctors and nurse managers, who proposed solutions based on what was happening on the ground and their understanding of the needs of the health workers. Top hospital managers helped to implement these decisions and to ratify the choices made by the doctors.

The managers put themselves in the position of helping the doctors to achieve a ‘medical objective’ rather than the doctors helping the managers to achieve a ‘financial objective’. (pulmonologist, crisis unit, hospital 1)

Beyond the decisions taken in crisis units, healthcare professionals were given considerable latitude in organising their own activities. An intensivist in hospital 3 told us that he had been amazed at how easily he had been able to transform an orthopaedics department into an intensive care unit when they ran out of intensive care beds. Top management not only immediately approved the cost of the work required to carry out the transformation but also agreed that a start-up could work on it and access the hospital’s IT system, even though the same managers had previously been very hesitant about working with start-ups in the past. This was also the case in a university hospital in another region, where an infectious diseases specialist, member of the crisis unit, noted a clear shift in the position of the top management team following the announcement by the French President on 12 March 2020, with top management acting on decisions made by medical specialists:

It was a joint management effort between the general director and the chair of the hospital medical committee, and top management really listened. When I say that they didn’t believe us [at the beginning of the pandemic], it was that they didn’t want to believe it… from the moment Macron said ‘whatever it costs’ [i.e. 12 March], it was valid… We were living through a tragedy, but we were doing it calmly (…). There were huge decisions to be made but, if you like, when the financial straitjacket was removed, the relationship with management was simple and the director acted on decisions and every time suggestions were put forward by the infectious diseases specialist, the intensivist or the pulmonologist, as long as it was consistent with the current situation then fine, that was it, they always went with it. (infectious diseases specialist, hospital 6)

Some actors seemed reluctant to admit the idea that management of the crisis had been left to the doctors. In her interview in 2020, the director of hospital 2 defended the collegial management of the crisis within the crisis centre and said that she had appreciated this collegiality with healthcare professionals, which she had not experienced before. Nevertheless, she explained that she had remained the “orchestra conductor” of her hospital during the pandemic, even if, unlike before, she had become “a conductor of autonomous instruments” (sic). In June 2021, when we briefed the hospital staff on our analysis, she was keen to clarify that, contrary to what some doctors said, she had “remained in full control”, but she conceded that she had given “the reins to the doctors”. This distinction corresponds to the distinction between formal authority, which remained in the hands of management, and actual power.

Thus, while the relaxing of budgetary constraints was a favourable condition for improving relations, it does not explain why hospital professionals experimented with a new form of governance that corresponded neither to professional nor managerial bureaucracy. Doctors and nurse managers made the main decisions on bed organisation, patient flow and resource allocation, but top management was kept informed and ratified these decisions. The agreement between staff and management does not only lie in the ability of the actors to communicate decisions or to mobilise additional resources available to build an “organisational layout” appropriate to the situation (Girin 2011). Their collective decisions and actions are the result of a compromise between the interests of occupational groups, a balance between professional constraints that support the insertion of new solutions and strategies into the rules of the organisation. To this end, the real activity and its constraints are the focal point of exchanges and relations between professionals. During the first wave, doctors and health professionals had the kind of expertise that made them indispensable to top management. This explains why power relations – in the sense in which Crozier and Friedberg (1980) defined power, i.e. reciprocal but unequal – tended to favour them.

4.1.4 A Reaffirmation of Medical Authority Vis-à-Vis Patients and Their Families

Many analyses have noted the shift toward an empowerment of patients and their representatives, particularly since the advent of HIV (Epstein 1996). This has led to a questioning of medical paternalism and a call for greater participation by patients and their families in decisions affecting them. This general trend in Western health care systems has had a specific impact in France, where a law was passed to strengthen patients’ rights (in March 2002). Doctors are ambivalent about these developments, which they sometimes see as a challenge to their legitimacy (Timmermans & Oh 2010). The sociology of medicine (Freidson 1970) has clearly shown that patients and their relatives are factors that disrupt the routine operation of medical departments in normal times. Staff try to limit this disruption as much as possible. Not only do families question the appropriateness of decisions made, but they also demand attention, care and services that healthcare workers do not consider to be part of their core role. However, the conditions of lockdown during the first wave also changed things in this respect.

Although this point was expressed less explicitly in the interviews, collective organisation of treatment during the first wave appears to have been facilitated by the absence of families from hospitals, and the delegation of dealing with them to students or colleagues who were not involved in critical care. During the first lockdown, families were not allowed access to hospitals. Several accounts showed a kind of ambivalence: on the one hand, there was less disruption to the medical organisation; on the other, this lack of contact with families ultimately resulted in a sense of uneasiness:

Because the hospital was closed, we only had a relationship with the patients and not with their families. It was very different. Although we said to ourselves early on, it’s not bad, we don’t have the families under our feet, we don’t have to keep explaining things, in the end, it was quite unpleasant. We lost that interaction with people, there was something missing. (crisis medical director, head of emergency unit, hospital 2)

The example of hospital 2 is interesting because the collective solution identified to manage this tension helped to further strengthen the good relationships between peers and top managers. While the head office of the hospital group had banned these visits, the hospital management team and the hospital hygiene department, responsible for the safety of care, made a point of looking the other way to enable healthcare workers to arrange such visits. This reflects one of Gouldner’s (1954) classic lessons: suspending the rules enables a positive exchange between those who are responsible for making them and those charged with applying them.

I remember that one of the intensivists called me at home at 7.30 on a Saturday evening, and said: ‘It’s not possible, we can’t do it like this. How can we equip families so that at least one person can go and see their husband, wife or whatever to say goodbye.’ Whereas the instructions from the top were ‘no visits’. It was dehumanising. Of course we didn’t want dozens of families, dozens of visitors in the corridors, because we couldn’t keep them safe. But at least one person, minimally dressed and with instructions not to touch this or that. (hospital hygiene, crisis unit, hospital 2)

Doctors in the COVID-19 medical and intensive care departments did not have the time to organise family visits or even provide families with information. So doctors whose departments had been closed during the first wave stepped in to maintain this connection, something that was highly appreciated by their peers.

The understanding of collective action in this first wave is explained by the temporary suspension of the constraints that structured ordinary activity, opening up a new organisational framework for collective action. This framework opened up spaces for negotiation and exchange between professionals about the most effective ways of providing care and their possible contributions, making it possible to overcome the tensions between them resulting from the division of labour (Muzio and Ackroyd 2005) and the challenges of territorial control and competition over legitimate boundaries (Freidson 1970; Abbott 1988). It has also placed healthcare professionals, particularly doctors, in a favourable power relationship with hospital management, on the one hand, and patients and their families, on the other. Conversely, this disappearance of constraints was only temporary. It was not the case in subsequent waves, which explains the reappearance of difficulties in interprofessional cooperation, as we will see in the next section. This supports our main argument that organisational factors and structures supporting reciprocal exchanges, i.e. power relations, clearly facilitate collective action more than shared normative and cognitive beliefs and goals.

4.2.1 The Resurgence of Intra-Hospital Competition

From the second wave onwards, the challenges faced by departments came to the fore: dealing with the backlog of treatment for their patients, rebuilding their patient lists, maintaining surgical activity (a source of income and a factor in attracting professionals), managing the lack of resources within departments. All these challenges re-emerged in a significant way. These interests, which had been attenuated during the first wave, returned to centre stage in subsequent waves, provoking tensions between the different specialties and thwarting the cooperation established during the first wave. Symptomatic of the return of competition between anaesthesiologists and intensivists, the president of the Society of Intensivists stirred up controversy when, during the second wave, in October 2020, he publicly declared to a parliamentary committee that patients had been treated better in critical care departments than in anaesthesia departments. Locally, the tensions created by the existence of empty beds in the context of increased demand for care, the requirement of managing competing flows and facilitating day-to-day planning brought back to the fore – and in some cases even intensified – the usual constraints that had been suspended in the previous period. The reappearance of these habitual constraints is crucial to understanding the difficulties of cooperation between actors. The medical departments were anxious to get back to work as soon as possible, both to catch up on the treatment of their patients and to escape the boredom of treating exclusively COVID-19 patients.

The medical departments are all very striking within a fairly individual system. We call it the medical group, but it is important to remember that these are very different specialties and disciplines. In medicine, there’s never that thing, and these are disciplines that often do not have any management in common. (pneumologist, crisis unit, hospital 1)

From the second wave, there definitely was a return to battling for access to the beds in each department:

Everyone loaned their beds, everyone made an effort to bring the patients up quicker. I didn’t have an argument with anyone in March or April. (…) By the end of May, it was somewhat back to everyone for themselves. We were back to being the same. I thought it had made a bit of an impact on people’s thinking, but no! It lasted four or five weeks. By late May, early June, we were back to everyone for themselves. (nurse manager, emergency unit, hospital 2)

The challenges of maintaining treatment for non-COVID-19patients among doctors who no longer wanted to suspend their consultations could also be found among surgeons, who were also keen to resume their activities.

We really reduced our activities in the operating room. It was a source of enormous worry and concern for our patients. We might end up carrying out their surgery too late. We were worried about team cohesion, about training younger members of staff, about the atmosphere that there might be in the various departments, about recruitment. Lots of people talked to me about this, because we’re all in somewhat competitive sectors, with surgeons in training, reputations to maintain. (surgeon, crisis unit, hospital 1)

Resumption of the full range of treatment, coupled with the insufficient number of hospital beds to care for all patients, marked the return of the competition between departments that had all but disappeared during the first wave. The coexistence of the two streams exacerbated tensions over the specific skills needed to “fill” beds that would otherwise remain empty. The allocation of nurses was then the subject of intense discussion and negotiation between departments over which would have priority in order to maintain their own activity.

In this context of tension over resources, the surgical departments had a special status because they hold a key resource: nurse anaesthetists, who were vital in the setting up of the critical care departments and intermediate units created to ease pressure on intensive care. Surgeons thus had an interest in limiting as much as possible the reassignment of these vital personnel, so that they could return to their usual duties and allow for the reopening of the operating rooms. Observations of the meetings held by the crisis unit and the surgical working group showed that the decisions taken regarding the opening or closing of beds always sought, as far as possible, to maintain this activity, which is essential to a hospital’s financial health and prestige. Resumption of this activity also became imperative to enable treatment of seriously ill patients, and to safeguard particular fields.

Defending activities and fields thus again took precedence over the cooperative distribution of effort developed during the first wave. In hospital 1, although attention was paid to continuing to ensure an equal distribution of effort between medical and surgical specialists (all medical departments reserved beds for COVID-19 patients; all specialties had operating theatres for their surgeries), the compromises made to get there were more difficult to reach.

In conclusion, the characteristics of interdependence between healthcare professionals are key to understanding the dynamics of mobilisation during the COVID-19 crisis. During the first wave, medical departments were highly interdependent and no longer competed over access to scarce resources and the establishment of priorities. These conditions disappeared with the second wave and the pre-existing competition re-emerged.

4.2.2 An Attempt by Top Management to Take Back Control

In addition, managerial constraints returned with the second wave. From the second wave onwards, hospital 1 and 2 managers attempted to regain control over general operations, notably by taking management bodies back under their authority, and relaunched hospital transformation plans, including those concerning cost containment:

It was just a complete joke. In October [2020], the director asked us to correct our road map and said: ‘There’s a problem. We need to re-confirm the [hospital transformation] roadmap for January.’ I said: ‘Wait, I didn’t have anything to do with the roadmap for January, we were right in the middle of the COVID-19 crisis.’ She had completely fallen back into her administrative stuff. (…) I mean, we’re really into issues of power and territory. (anaesthesiology, hospital 1)

I definitely wondered whether I should leave the hospital. It wasn’t the workload. It was really more the way [the management] saw things. It clashed with my view of work in quite a significant way. With the discussions, when we were short of people during the second and third wave and needed reinforcements, we had to fight and justify the smallest request (…) You could feel the control increasing. (…) So there really was a disconnect between ‘the fantastic healthcare workers’ and what was happening. (nurse manager, intensive care department, hospital 2)

Some participants suspected from the outset that hospital top management would not indefinitely give doctors greater decision-making power:

During this period the doctors really were in full control, and it worked really well. It’s been working much less well since we switched back. (…) We had a certain role and we got more power and got taken more seriously during the COVID-19 pandemic, but I’m not fooled. (anaesthesiologist, hospital 5)

It was more difficult for staff and management to agree on priorities because traditional constraints were returning or, for some, becoming more acute. For example, the significant imposed reduction in surgical activity during the first wave was no longer sustainable for management, since this activity was central to the prestige and financial wellbeing of their institutions. Surgeons used strategic arguments (deterioration of patients’ health, preservation of their activity, attractiveness of disciplines, training of young professionals) which, although legitimate, came into conflict with other specialties and made collective action and joint decisions more difficult.

We note, however, differences between the two hospitals due to their size. At hospital 1, collaborative work between the crisis medical director and the hospital management (hospital director and care director) to meet the needs of healthcare teams helped to maintain the balance throughout the three waves. The particular position of this institution as a referral hospital gave the doctors a key card to play when dealing with top management: COVID-19 was a priority mission for this hospital. Therefore, top management could not afford to alienate doctors. Conversely, in a smaller hospital like hospital 2 (although within the same public hospital group), managing COVID-19 became less of a clear priority as the crisis became chronic.

It was then necessary to make up for the disappearance of these special conditions by putting in place more formal arrangements for cooperation and learning new forms of collective action in crisis management: new forms of working together in working groups (regular discussions between specialists, discussion of substantive changes (day 0 hospitalisation), speed of decision-making and implementation of decisions, distribution of roles between managers and doctors, etc.).

4.2.3 Relationships Between Staff and Patients: The Return of Patients and Their Families

From the second wave onwards, noting the treatment delays that had resulted from the suspension of their activities, medical and surgical teams campaigned to be able to resume treating their patients. Although this produced tension related to finding space for them in units at a time when pressure to reserve space for COVID-19 patients remained high, it also had the effect of “reintroducing” patients and their families into the hospital, from which they had been “excluded” during the first wave.

Guided by the principle of equality of treatment, a desire to catch up on things that had been put on hold during the previous period and to avoid unacceptable deterioration in certain conditions, as well as a weariness around treating COVID-19 patients and a desire to get back to patients from their own specialties, this resumption was also motivated by the need to allay the societal impacts of keeping families away from patients:

We realised that we were in the process of creating a horrible situation, and that it was probably the worst thing that could be imposed on people within a society: you have to put yourself in the shoes of families who saw ambulances come and take away their loved ones, often on a respirator, asleep and ventilated, who learned that their loved ones were in a hospital department, that they were dead, without ever seeing them again. It was horrible from a social point of view, so in the third wave, families were made the focal point, to the extent that we had to put more structure back in place for family visits, because it was no longer possible. (intensivist, hospital 1)

This move to bring families back also reflected the determination to rebuild the connection, lost during the first wave, between patients and their loved ones. However, this desired return was received with ambivalence and brought with it difficulties for healthcare staff. The compassion of the first wave was in some cases replaced by criticism of healthcare workers:

There was a difference in atmosphere between the first and second waves. It was managing the families, families who hadn’t been coming to the hospital anymore. That was challenging to manage. During the first wave, we were giving news by telephone, providing serious updates by telephone, people were dying all alone. But this was accompanied by a huge amount of compassion shown towards healthcare workers at this time, with the applause. Families were very understanding. That really changed in the second and third waves when, conversely, families were much more demanding because public opinion towards healthcare staff was clearly a bit more hostile. (intensivist, hospital 1)

Drawing on the scientific controversies playing out in the media and especially around the treatments promoted by Dr. Didier Raoult, families were becoming more critical of doctors’ treatment decisions:

The mistrust of some families with respect to the treatments we were using or, more accurately, not using, notably the hydroxychloroquine of the first wave. Families were pushing us to prescribe it for our patients, and particularly when they died, they would say: ‘But you didn’t give them that, that’s why they died’. (nurse, intensive care department, hospital 1)

Above all, the return of families was accompanied by the return of a psychological burden that had been removed in the first wave:

In the third wave, we had families who were really not happy at all. During the first wave, families were not allowed into the hospital, so there wasn’t that confrontation with them. We weren’t being watched by families, and there were no judgements or demands. The third wave felt almost as tough as the first, we didn’t understand it. In the first wave, we were being praised to the hilt and this time we were being lambasted. There were families who wanted to make a complaint, who were unbearable, horrible. I remember one family. They’d given each other COVID-19 within the family and they came here. Sadly, the father died. It was as if it had been us who’d killed him. It was difficult. There were some families who were terrible. (nurse manager, ICU, hospital 1)

There were, however, some positive aspects to bringing families back: it alleviated the psychological burden of treatment, putting it back onto the family, and made admission to hospital more bearable. But the negatives were clear: it (re)exposed healthcare workers to outside scrutiny, forcing them to again confront questions about their decisions and the care they provided.