Feedback from experiments
in health care institutions
Cathel Kornig[1] and Christophe Massot[2]
The democratisation of work organisations and production relations is a theoretical, practical, and political issue. And the plurality of definitions and forms of functioning of democracy opens up different perspectives for its possible deployment. But our aim here is not to open a discussion on the comparative relevance of these definitions and perspectives. We would like to examine the problem of the democratisation of production relations from two specific angles. First, by posing this problem in an ordinary environment, i.e., in a professional environment that is neither the site of particular collective struggles nor led by individuals with unusual abilities, or governed by an already democratic organisation. Second, by posing this problem not upon a definition of democracy as a political or institutional mode of operation, but as the initiation of a movement to develop the employees’ capacity to discuss and act on the content of their work. In other words, our question is whether, in the ordinary environment, democratisation movements can be initiated from the problems posed by work and the workers. To answer this question, once having specified our theoretical framework, we will resort to the experiments carried out by the Quality of Life at Work (QLWW) Social Clusters in health establishments. According to their initiator, the Haute Autorité de Santé (HAS, after its French initials), the aim of these experiments is to develop the employees’ power of expression and action on the content of their work, in pursuit of a better quality of care.
1. Prospects for the democratisation of social relations at work
After exposing three central perspectives on possible forms to democratise the social relations of production, mobilised today in social science research, we will explain the partly different perspective we would like to try to adopt here.
1.1. Three perspectives
Several types of analysis in the social science literature on work and organisations conclude that contemporary organisations function undemocratically or a-democratically after noting the damage to workers’ health, the deterioration in the performance of organisations or the opposition to collective regulatory activity.
The damage to employees’ health, particularly their mental health, is analysed as the effect of opposition to both the regulatory activity of management (Detchessahar, 2011) and the operational activities (Clot, 2010), which are nonetheless necessary for the performance of quality work (Petit and Dugué, 2013). In this analytical framework, the essential means of preventing occupational health problems is the development of discussion forums (Detchessahar, 2013) to support the employees’ expression and action on the content and conditions of their work (Abord de Chatillon, Desmarais, 2017). The activity clinic (Bonnefond, Clot, 2018) considers these spaces to be a way to check unrest at work, a condition to develop psychosocial and health resources for employees at work.
Second, the imbalance of power between capital and labour, or suppliers of labour and capital (Segrestin, 2015), due to the increased power of shareholders, the corporate governance, and shareholder value, is analysed as the cause of internal dysfunctions resulting in an ‘institutionalisation of short-termism’ (Montagne, 2009), the degradation of ‘performance’ (Favereau, 2016) and the ‘capacity for innovation (and) creation of future capacities’ (Hatchuel and Segrestin, 2012) of organisations, with these dysfunctions ‘jeopardising their economic development’ (Benquet, Durand, 2016) or, at least, ‘weakening them’ (Plihon, 2004). The rebalancing of power between labour and capital is called for in the name of the efficiency and stability of companies and, more generally, the very functioning of market economy, since this imbalance, by ‘deforming’ the company, has contributed externally ‘to the explosion of inequalities, to an unprecedented mistrust of the company [and] to the economic crisis’ (Favereau, 2014).
Finally, the opposition to employee participation in the analysis and organisation of their work is analysed through its effects on these employees’ exercise of citizenship and on the functioning of democracy, beyond the space of organisations. If we follow, for example, the distinction made by ergonomics between task and activity, work requires not only the coordination of prescriptions but also of activities. And this activity of coordination is, notably for C. Dejours, the place of collective learning of cooperation and deliberation, and therefore of the democratic exercise: ‘To participate in the space of deliberation and to make a contribution to deontic activity is to learn democracy’ (Dejours, 2016). Work calls for deliberative activity, which is a condition for both its effectiveness and the effective learning of democratic exercise. But the current retraction of regulatory spaces (Gomez, 2013) and the work relationships of subordination, extended by the Fordist compromise that consisted in ‘exchanging economic security for dependence on work, (making) companies pay the price of an alienation deemed inevitable’ (Supiot, 2012), have separated the citizen from the worker, opening up an ‘explosive contradiction between a worker, citizen in the polis […] but deprived of the right […] to obtain independence by participating in the decisions taken in the workplace’ (Trentin, 1997). This separation, rather than making professional spaces a-democratic, is analysed as what makes democracy itself impossible, so much so that ‘this dialogical asphyxiation, this jamming of conflicts around work well done […] is an unsuspected poison for democracy […] draining politics of its blood’ (Clot, 2016).
Thus, in the name of the workers’ health, the efficiency of organisations, the stability of the functioning of market economy, and the possibility of democratic exercise, there is a call for a re-democratisation of social relations of production. The problem is then that of the possible paths for the evolution or shift towards this re-democratisation. Three types of perspectives seem generally open.
A first perspective places collective action, whether or not organised by a trade union actor, at the heart of a possible shift towards a form of self-management organisation. The aim of the research is to follow these collective actions in order to understand the logics of their emergence and the forms of political organisation of work they produce (Quijoux, 2019). The examples of cooperatives or self-managing reappropriation are thought of and presented as potentially exemplary forms of a shift towards democratic organisations of work, enabling to draw a possible horizon for collective action, even if the question of their generalisation poses problems that have not been much examined (Gulli, 2015).
From a second, more managerial perspective, this shift is driven by management with singular or exceptional capacities, voluntarily initiating the transformation of authoritarian management practices towards practices that present themselves as broadening the autonomy and participation of workers. A key element of this shift, according to I. Getz, a central figure in the so-called ‘liberated’ companies movement (Carney and Getz, 2012), is that these managers need to ‘let go’ in order to achieve the elimination of bureaucracy and leave the ‘how’ to the employees, while the definition of strategy remains the manager’s responsibility. For T. Weil, from a more empirical perspective that seeks to investigate the issue of so-called ‘liberated’ companies, the role of the manager remains essential, as ‘in all but one of the cases we have studied, the decision to transform the company or one of its departments is that of its manager’ (Weil and Dubey, 2020), this manager often presenting an atypical profile of ‘cultural wop’. Without raising the question of the effectiveness of these liberations (Rousseau and Ruffier, 2017), they depend on the will of a leader with particular qualities.
In a final perspective, this shift should or could be carried out by civil society and the actors in charge of legislating, i.e., in representative democracies, by elected representatives and voting citizens. The condition for this changeover is the activation of the political and legislative power of the social body in order to ‘liberate work [by allowing] workers to control their work and, as citizens, to decide on its purposes’ (Coutrot, 2018), ‘find ways of fully bringing the company into the democratic public sphere’ (Ferreras, 2012), ‘rebuild the powers in the company […] and establish new forms of accountability, based on new rules of responsibility not derived from property rights’ (Favereau, 2014), or ‘create a corporate norm based on a company with an extended social purpose’ (Segrestin et al., 2015). Here, the fulcrum of company transformation, to make its democratisation possible, is at the border of the organisation, or more precisely on the line separating, or uniting, the worker and the citizen. This perspective raises the question of the conquest of political power or, in a Marxist formulation, of the state apparatus, i.e., the ‘conquest of the power to govern beyond the enterprise’ (Cukier, 2016).
Collective mobilisation, the manager, the citizen-worker, civil society, or parliament are these possible actors of a democratisation of social relations of production. And this democratisation is called for in the name of workers’ health, the efficiency of work organisation, or the effectiveness of democratic institutions. Finally, this democratisation is understood as the modification of the relations of power, whether instituted or not, through the displacement of hierarchical authority or the transformation of the companies’ right of ownership. Without asking here the question of the effectiveness of these democratisation perspectives, we would like to explore another one, on the one hand, by defining democracy not by its functioning but as a movement and, on the other hand, by asking the question of the possibility of this movement in an ordinary environment, i.e., without extraordinary leaders or trade union struggles and without a prior transformation of the companies’ legal regime of ownership and power.
1.2. The prospect of democratisation in the ordinary environment
The first question in the debate on the possible forms of democracy, raised from the earliest days of political philosophy, is that of defining the best way to operate and therefore the constitutional formation that organises this political regime. But a second question, immediately raised and linked to the first, is that of defining the principles of this functioning. And for a certain tradition, both philosophical and political, taking one of its first formulations with Aristotle, the principles and functioning of a democratic regime are necessarily in tension and potentially in conflict. Furthermore, it is argued that these conflicts are not the signs of degeneration but are, on the contrary, the conditions for the effectiveness of democratic functioning. In this respect, for É. Balibar, who seeks to establish a genealogy of the transhistorical invariants of democracy, democratic practices are always caught up in the conflict of the relations between representation and participation, freedom and equality, institution and insurrection, with these poles being potentially reformulated by the relations between autonomy and subordination, centralisation and decentralisation, conservation and transformation. The ‘permanent tension between insurrection and institution’, between ‘freedom and equality (carries) a contradiction that must be permanently overcome […] in democratic practices’. Democracy here is not ‘a constituted regime’ (Balibar, 2016), but is ‘always under construction, essentially incomplete and always to be completed’ (Balibar, 2020). Put differently, democracy is not defined by its functioning but as the possibility of shifting, through collective activity, the relations between conflicting poles to give them new configurations. It becomes ‘the very tension between processes of de-democratisation and processes of democratisation’ (Balibar, 2018), i.e., the bringing to work, or, on the contrary, the setting aside, of contradictions that are always renewed in contact with the problems posed by life, collective action and, here, work.
This construction opens up a specific understanding of the question of work democratisation. It is no longer a question of opposing democratic functioning to non- or anti-democratic functioning and then defining the possibilities and conditions of transition from one to the other; it is a question of following the possible modalities of a democratisation of social labour relations, even within a non-democratic or authoritarian functioning, through the reformulation and displacement of the contradictions and problems at work in any professional environment. The challenge becomes to follow a democratisation movement, instead of the replacement of one system by another. Our perspective is then to understand how, in an ordinary environment, a democratisation of labour relations can allow employees to displace the framework in which social relations at work are inscribed to allow other ways to solve the problems they face. Or how, by shifting the framework upon which they can define these problems and act on their work, employees ‘re-democratise’ their labour relations.
2. Experiments in ordinary medical settings
In order to analyse the possibility of this perspective, we propose to follow certain experiments carried out in health establishments, which are exposed to all the difficulties of this professional environment, in the framework of the QLWW Social Clusters initiated by the HAS.
2.1. The QLW Social Cluster system
The Higher Authority of Health (HAS), an independent public authority, has the task of recommending good practices and measuring and improving the quality of care (the ruling aspects remain under the authority of the Regional Health Agencies). This authority has decided to link the Quality of Life at Work (QLW) to the Quality of Work, which in its jurisdiction is the quality of care. This choice is explained by its desire to avoid the ‘risk of normativity’ and improve the quality of care by supporting the development of ‘the initiative and reflexive capacities of organisations and professionals’ (Ghadi and Liaroutzos, 2015), this authority noting that ‘the normative approach is not sufficient to satisfactorily control the quality and safety of care’. Based on the text of the 2013 National Interprofessional Agreement on QLW, the HAS defines QLW as ‘the ability of employees to express themselves and act on the content of their work’, adding that ‘the keystone of QLW lies in their power to act on their work’ (HAS, ANACT, ARACT, 2017). To implement these principles in health care institutions, the HAS, in partnership with the National Agency for the Improvement of Working Conditions (ANACT) and the General Direction of Healthcare Provision (DGOS), has set up a specific mechanism, the QLW Cluster, which is intended to ‘enable experimentation with the QLW approach in real working environments’ (Ghadi, 2017). This mechanism, which provides support for the Regional Agencies for the Improvement of Working Conditions (ARACT) and a space for exchange between establishments, allows for the possibility of experimentation based on this strong conception of QLW. The evaluation of this QLW Cluster system (Kornig et al., 2019) allowed us to conduct 170 interviews in 10 of the 164 health establishments that participated in this system during the first two years.
2.2. Feedback from experiments
We will not describe here the various experiments carried out by these establishments, whether or not they have succeeded in supporting the expression and action of health professionals on the content of their work. We will follow, in part, a few examples that allow us to formulate hypotheses on the ways in which a movement to democratise social relations at work has been initiated.
2.2.1. The common problem of quality of care
The problem posed by the HAS, and instrumented by the Social Cluster mechanism, is that of ‘renewing the mechanisms of accountability, autonomy and decision-making’ (HAS, ANACT/ARACT, 2017) to develop the quality of care through QLW. But this general problem could not be, in this form, that of the management of these care establishments, as they have other problems to deal with. These managers therefore first sought to reformulate this problem considering their own organisational issues. In a private psychiatric establishment, the problem posed by the director was the establishment’s future relocation: ‘For the QLW approach,’ this director told us, ‘I asked them to draw up a set of specifications with proposals for the future organisation of the new site’. In another private gerontology establishment, the problem posed was that of communication between departments at the time of changeover. However, these problems could not be taken up in this form by the operational staff either, as they also had other problems to deal with, such as work-related problems. The first question for the operational staff was to find out what they could do with these generic problems.
In this psychiatric establishment, the response was initially instrumental: the creation of a Steering Committee (CoPil) consisting of a doctor, the deputy director, a staff representative sitting on the Working Conditions, Hygiene and Safety Committee (CHSCT), a quality manager and a nursing care coordinator, without the director being present. At first, this CoPil did not know how to tackle the problem of the relocation in the light of each department’s challenges. ‘At the beginning, in the Steering Committee, the subject was very open. Too much so. We didn’t know what to do, we caregivers, with this relocation deal!’, recalls the coordinating nurse. She decided to come to a ward at 6 a.m., when the patients wake up, to discuss the problems that the caregivers might experience.
I went by early in the morning and saw my colleagues working. It was 6 a.m. I realised straight away that there were some very complicated things… I did so because I know this job. I have been doing it for 30 years. So when I went to the Steering Committee meeting, I had all this in mind, and we took that shift as our focus.
The problem of relocation is reformulated here as a problem to organise the 6- 9 a.m. shift. However, this is the formulation of a general organisational problem, not yet a professional or work problem. Thus, when the working group made up of the CoPil members and this shift’s nurses met, the nurses found it difficult to explain their problems directly on the basis of this general organisational problem. To understand this situation, the working group decided to send the quality manager to carry out an activity survey from 6 a.m. to 9 a.m.
We realised that we needed to take stock of the practices to understand what was going on and identify dysfunctions. I had never done it before, coming at 6 a.m. to see the nurses’ work. I made an activity report in which I noted everything, minute by minute: movements, the words they said, interruptions, equipment used… Everything! No holds barred. And then, in the working group, I read out what I had observed. (Quality manager)
The reading of this report with the nurses was immediately the subject of lively discussions, with the nurses expressing their disagreement on what was done and what should and could be done. Gradually, care-related problems emerged, particularly the problem of patients having to queue to take their medication.
After a while, we came to the question of the queue. It’s a very important problem for patients… This queue in the morning is not good for anyone. That’s it! The queue is long and slow… it’s… it’s a flaw that has effects on the caregivers and the patients for the rest of the day! (Nurse)
The working group therefore identified the problem of waiting as one of the main issues to be addressed in the context of the Director’s request to produce a report to organise the site’s relocation.
At each of these stages, the actors of the psychiatric clinic translated and displaced the organisational problem they had been posed from their own working problems. The generic problems of QLW and the development of the HAS’s ‘power of expression and action on the content of work’ were successively reformulated as relocation problems, then as organisational problems of the 6-9 a.m. shift in a department, and finally as different work problems, including that of the patients’ wait. These actors collectively proceeded, spurred by the initial request of the HAS, to a succession of displacements and comparison of their particular problems. And it is along these progressive reformulations of an initial problem that a power of initiative and expression was transmitted from the HAS to the management, then from the management to the committee members, and finally to the professionals and caregivers. This transmission was not the autonomous and centralised work of the HAS, the director or the steering committee, but of a collective and progressive reformulation process. However, this transmission did not take place in all the establishments that participated in the QLW Clusters.
In the case of the gerontology centre, the problem of communication did not allow for a work of reformulation and displacement. On the contrary, it was understood as the imposition of a problem formulated by the management and addressed, without sufficient discussion, to the operational staff. As the problems defined by this management could not be reformulated and shifted by the professionals, the latter gradually withdrew from the system.
I don’t know how we came up with this report thing (in the Copil)… We didn’t pay enough attention to the problem of organising the working day. There were other priorities and our colleagues reproached us for it. [All of a sudden] they somewhat discredited us before the other departments. That’s not what they were expecting! […]. And I don’t know if I would sign up again (for the QLW groups) if they keep working on things that are not among my priorities! (Care assistant)
Without a common point of articulation or the possibility of shifting the initial problem, the collective work of reformulation and the transfer of initiative came to a halt, as the QLW mechanism was unable to support the professionals’ capacity for expression and action on the content of their work.
In this transmission, we find some of the elements analysed by the sociology of translation when it seeks to understand how actors with multiple identities can come to an agreement on the treatment of a common problem to support their action. This sociology observes that such agreement is ‘made up of a series of displacements (that can) be described as a translation leading all the actors concerned, after various metamorphoses and transformations, to pass’ (Callon, 1986) through the reformulation of a common problem. The challenge of joint action lies in a collective capacity to ‘translate, displace […] and express in one’s own language what others say and want’. But here, the common problem is not primarily that of QLW, the development of professionals’ power of initiative and action, or even the democratisation of social relations. It is first and foremost the quality of care, and more generally the quality of work. This is the common problem that constitutes the framework of successive translations, formulated from the HAS to the health personnel. The shift in the relationship between representation and participation, conception and execution, initiative and subordination, which open up a first movement of democratisation of social relations at work, is the effect of a common will, notably within the institution, to confront the problems posed by the quality of care and work.
2.2.2. Controversies about real work as a means of invention
The question posed by the HAS is not only regarding the ‘expression’ of problems but also the ‘action’ of the personnel on work and its organisation. In the psychiatric clinic, the discussions held in the working group did not focus solely on analysing the activity and identifying problems but also on developing ways of modifying the organisation of work:
We had this objective: working in the future organisation. Anticipating how we could work there. It was positive… That’s what helped us not to go off in all directions… Because there was this issue: formulating proposals for our management and the next organisation. (Nurse)
But the first methodological problem discovered by these healthcare professionals is the existence of disagreements between them over what they do and what could be done.
When the quality manager read the activity report, the discussion with the nurses became very controversial.
She read the minutes in the working group, with everything she had observed, minute by minute, and without comments. So, I wrote down my observations as she went along. And I said to myself: ‘Something doesn’t add up here’. And… we know each other well! (laughs). And at one point, it went off! It got hot! But frankly! […] And so I began saying: ‘It’s not possible to work like this!’. Others said: ‘We can’t do it other way’. I replied: ‘We can do it differently…’. […] And after a while, we asked ourselves: ‘What is so complicated?’ Point by point. That’s how we could move forward. And that’s how we made progress. (Nursing Coordinator)
These professionals discovered, or rediscovered, a process that has been well documented by the various work clinics, from psychodynamics to ergonomics: the externalisation of activity, in an object, by reformulating it for an external recipient, this ‘verbalisation that makes it possible to talk about work and to facilitate a work of externalisation in which the activity is reified, made external to the operator’ (Arnoud and Falzon, 2013). But through this exteriorisation, these agents discover that they each do differently what must or should be done, and above all, that they have a different conception of what should and could be done. The discussion shifts from the analysis of work carried out to actual work, the latter being defined, in the clinic of activity, as ‘what is not done, what we try to do without succeeding, what we would have liked to do or could have done, what we think we could do elsewhere’ (Clot, 2001). Professionals in other establishments studied, mobilised or invented other methods to displace their activity as an object of analysis and discussion. For example, the ‘photo safari’ was a device whereby a professional photographed a moment in his or her activity or a colleague’s gesture which, in his or her opinion, posed a problem or, on the contrary, illustrated a good way of doing their work. This photo was then put up for discussion, and everyone had to explain themselves with this gesture. The ‘patient’s day’ method consisted in describing collectively, through a speaker who notified all the elements, the real day of a patient assisted by several departments, professions, and professionals, each one having to explain their intervention. These different methods are ways of exploring what is done and, above all, what is not done and could be done. These professionals then discovered, through these devices, their disagreements not only on what they were doing but above all on the extent of the unrealised possibilities. And it is here that the shift from the problem analysis to inventing new ways of doing things took place, if we look at the process that took place in the psychiatric clinic.
In this clinic, although the working group members agreed on the importance of the problem of the residents’ waiting queue to take their morning medication, they disagreed on the possible ways to solve it. For some, medication should be administered in two rooms, instead of one, by two nurses, in order to reduce the waiting time. For others, it should be administered in each patient’s room, to respect their rest, privacy and, in some cases, fragility. However, each of these solutions also poses other problems. For example, in-room administration meant that residents would have to wait for the nurses before having breakfast, thus restricting their autonomy, and in double rooms the other resident would have to leave so as to respect medical confidentiality. For its part, administering in two rooms meant mobilising two nurses, thus leaving the care assistant alone in charge of the entire ward, rooms, and corridors at breakfast time. The members of the working group discovered that they disagreed on the effective solution to the problem of the patients’ wait, and that this disagreement took other forms for other issues. However, in the face of this situation, the members of the working group decided to take the word ‘experimentation’ in its literal sense: both caregivers and patients would test each of these solutions for a fortnight to determine their respective qualities.
Frankly, we had to tackle the problem because what we were doing didn’t satisfy anyone… It was obvious that waiting in the morning like that was not good, and so other things. But at the same time, there were those who said that we should do it in each room and those who said that in two rooms… We couldn’t figure it out. We were stuck. So that’s how we came up with this experimentation thing. We had to find a solution! (Nurse)
This experimentation is carried out with the residents, who then participate in its evaluation. In the end, distribution in two rooms was considered preferable. The results of this experimentation are then presented to the CoPil. The director finally decided, among other things, to modify the distribution of the future establishment to accommodate the administration of medicines in two rooms.
The members of this working group did not breach their divide by appealing to a higher authority or seeking a compromise to protect themselves from potential conflict. Instead, preserving their disagreement was the means to seek and experiment with other ways of doing things. We find here, in the framework given by the collective displacement of a common problem, the practice of controversy between equals as a means to overcome disagreements through the invention of new ways of functioning, in this case, administering medicine in two rooms and then the experimentation in situ. Facing the problems posed by the work reality, that is to say, both ‘what resists control’ (Dejours, 1995) and what is not done, opened up a creative discordance and a means of developing new ways of functioning. We can see here a movement of democratisation of the social relations at work in two respects. First, these different professionals reached a collective decision through a deliberative practice, which is the only way to reach a legitimate choice between equals in the midst of uncertainty (Manin, 1985). Moreover, it is because they opened up the plurality and contingency of possibilities, refusing to decide definitively on what they necessarily had to do, that they could make their joint deliberation. By acknowledging that they did not know, that they could not definitively know in the face of the contingency of reality, they opened up the possibility of their collective action, given that ‘contingency appears as an opening towards the activity, both haphazard and effective, of men’ (Aubenque, [1963], 1986). Then, by shifting their relationships and the relations between participation and representation, conception and execution, conservation and transformation, they initiated a democratisation movement. But what we perceive here is that the practice of deliberation and the process of democratisation were not the primary end of their action. That end was first solving the problem of quality of care posed by actual work, democratisation being then a means to such end. In other words, what was primary in this process of democratisation was the conflictual relationship with this real that resisted control, with this contingency full of unfulfilled possibilities, and the shared will to confront it. Then, in the second place, the democratisation of labour relations was achieved.
Conclusion
The democratisation of the social relations of production can be sought through the modification of power relations, the displacement of hierarchical authority, the transformation of the enterprises’ right of ownership or the conquest of power, within or beyond the enterprise, by citizen-workers. But the perspective we have sought to explore here is different. First, we defined democracy not in terms of a given political functioning but as the tension between the processes of de-democratisation and democratisation, which enable, or hamper, the participation of workers in defining the organisation and content of their work. Then, we situated this issue in the ordinary environment of health establishments, an environment which had not been the subject of prior transformations, specific demand actions, or that did not benefit from a management with singular qualities seeking to liberate its organisation.
Two observations can be made. The first is that the democratisation of social relations, understood as a process, took place within the framework opened up by assessing the common problem of the quality of care, i.e., the quality of work, and beyond the framework of QLW and democratisation. Democratisation was not an end in itself, but a means to solve this problem. The second is that this democratisation, in its effective deployment, was based on the capacity of the various actors and professionals not to breach but, on the contrary, to tackle the divide between them regarding what they were doing, as well as what they could do, to solve problems related to the quality of work. Everything seems to have happened as if the common desire to act on what posed a problem allowed deliberation, controversy, and disagreement to make their way towards the search and invention of new ways of doing things. These observations are not in contradiction with other perspectives on the democratisation of production relations. Thus, for example, even within the setting of a revised organisation, in which the powers were shared between capitalists and workers, the question of how to formulate the common problem of quality of work and the means of its translation would still arise.
But these observations pose two types of problem. First, the democratisation of the social relations of production is, in the ordinary environment, subordinated to management and supervisory staff and their will to make of real work —i.e., what is not well done and could be otherwise— a common problem. This shift of the organisations’ management towards work-related problems, as that initially carried out by the HAS and certain establishment managements, constitutes the framework that enables to start a democratisation movement. However, a principle of governance, both theoretical and practical, in contemporary organisations is precisely that ‘the rational manager not only cannot but also should not take an interest in the concrete content of his subordinates’ work’ (Favereau, 2016). Or, put differently, according to the dominant conception of efficiency, work problems and market evaluations must remain separate. For these managements based solely on the deployment of market normativity, the problem of democratisation then becomes that of the possibility and the will to produce a return to this real work which, at once, resists control and is not carried out. The idea seems to be that democratisation is only possible if there is a shared will to work together upon that unfinished and unachievable reality. And, no doubt, that requires leaders with certain qualities and wills. Moreover, if a democratisation movement stops, it runs the risk of following an opposite slope of de-democratisation, since ‘a democratisation process that does not advance regresses’ (Balibar, 2018). This is the feeling expressed by the nurses in the psychiatric clinic’s working group, looking back on their experimentation: ‘It was a very interesting experiment, but… We must continue. That’s what’s important: we mustn’t stop! Because… otherwise we’ll have the impression that we’re regressing, that we’re going back to our usual routine! It’s… Now what do we do?’. The problem may then be that of the capacity of these collectives to seize new problems to bring to life, through new objects, the conflicts between what they do and what they could do. And, ultimately, this problem of continuing the democratisation of the social relations of work is that of the evolution of the work-organising institution into becoming the guarantor of the ‘political conflict on the quality of work’, according to the expression of Y. Clot (2010). Or, in another formulation, it is the transformation of the work organisations’ conflict on the qualities of work ‘as a democratic institution’ (Balibar, 2020) in the name of the realilty that could be.
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