Foreword
Caring Management in Health-care Institutions: Oxymoron or Pleonasm?

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

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

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

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

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

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

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

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

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

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

On this point, Mathieu Detchessahar's work on the deliberate enterprise sheds light on the...