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

Henri Bergeron, Patrick Castel, Nicolas Lot

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## To cite this version:

Henri Bergeron, Patrick Castel, Nicolas Lot. From Close Cooperation to Its Unravelling: A Political View of the COVID Crisis Management in Hospitals. Journal of Organizational Sociology, 2025, 10.1515/joso-2023-0031. hal-05338685

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Submitted on 30 Oct 2025

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Research Article

Henri Bergeron, Patrick Castel and Nicolas LOT*

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

https://doi.org/10.1515/joso-2023-0031

Received October 9, 2023; accepted August 8, 2025

**Abstract:** In France, the first wave of the COVID-19 pandemic was marked by intense cooperation between hospitals and a high level of job satisfaction, both of which declined in subsequent waves. How can these dynamics be explained? This paper demonstrates that the collective mobilisation cannot be accounted for solely by an injection of financial resources and the strength of a shared professional ethos; it claims instead that relations of cooperation must be understood as relations of power. Drawing on a qualitative study in 14 French hospitals (139 interviews), it shows that the initial wave created conditions and mechanisms that greatly enabled cooperation, but which then waned with ensuing waves. The paper argues that cooperation is related to three types of relationships that had improved during the first wave: those between healthcare professionals, between healthcare staff and top hospital management, between healthcare professionals, patients and their families. It identifies the mechanisms behind these relationships, respectively: the suspension of competition between doctors and departments, the greater autonomy given to healthcare professionals in management decision-making, and the absence of patients' families, which enabled caregivers to reassert their professional authority. Conditions conducive to cooperation were no longer present during subsequent waves, making cooperation more difficult.

**Keywords:** cooperation; professional relationships; crisis management; power

# 1 Introduction

During COVID-19, hospitals were held up as a model. In France, as in many countries, people came out onto their balconies every evening to applaud healthcare workers,

Henri Bergeron and Patrick Castel, Sciences Po, Centre de Sociologie des Organisations (CSO), CNRS, Paris, France

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<footnote>*Corresponding author: Nicolas LOT, EDF Lab Paris-Saclay, Palaiseau, 91120, France; and Crisis Lab, Sciences Po, Paris, France, E-mail: nicolas.lot@edf.fr. https://orcid.org/0009-0002-4039-1512</footnote>
particularly during the first wave. This was due to the fact that, despite the influx of patients, hospitals did not collapse between February and June 2020, with staff managing to come together in the face of adversity and cooperate effectively (Chabrol et al. 2023). This mobilisation was also praised in several official and public reports (Pittet et al. 2021; Deroche et al. 2020). To French observers, this professional mobilisation was all the more remarkable since hospitals were already in crisis (in terms of budget, human resources, administrative factors, etc.) resulting from numerous management reforms undertaken over the course of previous years, which were already the subject of heated collective protests when the coronavirus emerged. The press placed less emphasis on the extent to which, as we shall see, professionals expressed satisfaction with their work during the first wave, which is surprising given the harsh nature of the work they had to perform. Similarly, while the press has highlighted the discontent that emerged during the second and subsequent waves, there has been little analysis of the reasons behind this change in professional experience. These two puzzles will be the focus of this article. We will address them by examining the conditions of cooperation between professionals, which have changed over time.

In the public narrative promoted by journalists, decision-makers (Hirsch 2020; Rousseau 2021), healthcare workers themselves, and some academic analysts (Gelly & Spire 2021), strength and resilience depend on two factors, which are said to have enabled this extraordinary mobilisation. Firstly, an injection of significant financial resources, following President Macron's decision to fight the coronavirus and to commit to a policy of "whatever it costs" (an expression that he used in his speech of 12 March 2020, when he announced national school closures). Secondly, the strength of the professional ethos and the sense of professional duty that emerged during this crisis, with healthcare workers having rediscovered "the meaning of care" (faced with a unique and dire situation), enabling them to reach their potential.

Numerous empirical studies conducted in France (Chabrol et al. 2023; Mininel et al. 2023; Gelly & Spire 2021; Dumez & Minvielle 2024) and in other countries (David et al. 2023; Fanelli et al. 2020; Honda et al. 2023; Zhelyazkova et al. 2023; Oliveira et al. 2021; de Graaf et al. 2021) have identified other factors that enabled hospitals to manage the COVID-19 crisis through better collective mobilisation: communication, increased coordination, and reallocation of resources. Despite the contributions of these studies, conditions of cooperation remain an enigma and appear as a mechanical consequence of formal reorganisations. Indeed, these studies do not help us to understand why professionals coped better with the crisis during the first wave than in subsequent waves. However, seminal (Perrow 1986; Friedberg 1997) and more recent work (Kellogg 2009; Hallett & Ventresca 2016; Hallett & Hawbaker 2021) in organisational sociology have shown that cooperation can never be taken for granted and does not rely only on formal (re)arrangements. Instead, conditions of cooperation must be
reconstructed by studying the interactions and exchanges of resources between actors. Notably, the analyses of how hospitals managed the COVID-19 crisis disregard the long-standing tradition of studies demonstrating that organisations are political systems in which cooperation stems from power relations based on the exchange of resources (Gouldner 1954; Crozier 1964; Crozier & Friedberg 1980; Friedberg 1997; Huising 2015). This political approach to organised action is all the more necessary for understanding cooperation during periods of crisis, given that, in general, they lead to destabilisation and the redistribution of ordinary resources and often, as with the COVID-19 crisis specifically, the injection of additional resources.

Our research, which consists of three in-depth qualitative case studies, conducted in parallel at 14 French hospitals, seeks to make a contribution to this literature by focusing on the involvement of top hospital management, heads of medical departments, doctors and nurse managers in crisis management, as well as by analysing how this mobilisation evolved over time as the crisis unfolded. We identify three types of relationship whose changing characteristics during the different waves of the crisis help to explain the collective response in hospitals to the pandemic: relationships between healthcare professionals, between healthcare staff and top hospital management, and between healthcare professionals, patients and their families. We argue that a major part of the collective mobilisation during the COVID-19 crisis and the experience of the crisis, which varies depending on the wave, should be sought empirically in the conditions of cooperation between actors and their changing nature over time. During the first wave, the national lockdown that was introduced in France and its local implementation established favourable organisational conditions for cooperation. More specifically, cooperation between healthcare professionals, and especially between doctors, was based on the suspension of competition between them. Cooperation between healthcare professionals and top hospital management was based on a rebalancing of power relations which led to a new form of governance in favour of the former. Finally, the absence of patient families enabled professionals to exercise their decision-making power in a more autonomous (monopolistic) way. These conditions were no longer present during subsequent waves, resulting in more chaotic management of the pandemic in hospitals and reduced job satisfaction among professionals.

# 2 Methods and Settings

## 2.1 Data Collection

The French healthcare system is not nationally run, by contrast with the British system for instance. Nonetheless, State institutions play a major role in health
insurance and healthcare provision. “The French healthcare system is based on compulsory social insurance funded by social contributions, co-administered by workers’ and employers’ organisations under State control and driven by highly redistributive financial transfers.” (Nay et al. 2016, 2236) It is also characterised by a diversity of hospital types: public hospitals, private not-for-profit hospitals providing a public service, and for-profit hospitals; all have been financed in the same way since 2005 through a prospective payment system. A limited number of public university hospitals (3 in the Paris region, for example) were set up to deal with emerging epidemics such as COVID-19. However, when the pandemic hit France at the end of February/beginning of March, a large number of hospitals were mobilised to deal with the influx of patients, who could not be accommodated in these referral hospitals.

We conducted three case studies. Our hospital sample was constructed so as to capture the diversity of contexts of the outbreak at the national level: hospitals that were hit first and therefore taken by surprise, hospitals that were operating as frontline facilities due to their status (namely university hospitals), and second – or even third – line hospitals, that were therefore less accustomed to managing massive flows of severe patients. The focus was on intensive care, anaesthesia and emergency departments because they were at the heart of the crisis response and were the departments most overwhelmed by the scale of the pandemic. But, as we shall see, other professionals (health and administrative) were interviewed to understand how these departments collaborated with them to help fulfil their mission (Table 1).

A grid of semi-structured interviews was designed with 4 main themes: (1) main phases of the pandemic in the hospital (timing), (2) internal organisation and re-organisation within the hospital (management of patient flows, allocation of human and material resources, health protection for professionals), (3) decision-making

<table><caption>**Table 1:** Sample of the professionals interviewed.</caption><thead><tr><th></th><th>Case study #1</th><th>Case study #2</th><th>Case study #3</th></tr></thead><tbody><tr><td>Physicians</td><td>35</td><td>15</td><td>23</td></tr><tr><td>Including</td><td></td><td></td><td></td></tr><tr><td>- Intensivists</td><td>7</td><td>3</td><td>5</td></tr><tr><td>- Anaesthetiologists</td><td>10</td><td>5</td><td>11</td></tr><tr><td>- Emergency doctors</td><td>18</td><td>2</td><td>2</td></tr><tr><td>Nursing management</td><td>19</td><td>7</td><td>2</td></tr><tr><td>Hospital management</td><td>18</td><td>4</td><td>1</td></tr><tr><td>Others</td><td>11</td><td>4</td><td>0</td></tr><tr><td><strong>Total interviews</strong></td><td><strong>83</strong></td><td><strong>30</strong></td><td><strong>26</strong></td></tr></tbody></table>
(treatments, participation in research protocols, etc.), (4) relationships with other professionals and stakeholders, both within and outside the hospital. We deliberately left ample opportunity for free discussion with the interviewees.

First, two public university hospitals in the same French city were selected to conduct an in-depth monographic analysis. The first was one of the referral hospitals in charge of managing this type of pandemic on the front lines (hospital 1, case study 1). It was first affected by the pandemic at the end of February and overwhelmed by the first weekend in March. Given the long-standing collaborative relationship between one of the present authors and this hospital, in particular with the crisis medical director (a doctor in anaesthesia), this author was able to collect all the data from the first days of the pandemic. Data was collected through non-participant observation of different units (average of 1 h per meeting): 52 crisis units, 13 working groups bringing together different medical departments, 10 working groups including surgical departments, and one working group of critical care departments. Thirty-seven interviews were also conducted during the first wave (March-May 2020). The work continued during subsequent waves: a further 11 interviews were conducted during waves 2 and 3 (October 2020-June 2021), working groups comprising medical teams (13 meetings) and surgical teams (10 meetings) were monitored; 14 interviews were carried out during the fourth wave (February–March 2022); and, finally, 21 interviews were carried out during the fifth wave (April–May 2022). All in all, eighty-three semi-structured qualitative interviews were conducted. They lasted an average of 1 h, and were recorded and fully transcribed. All interviews were conducted remotely, with the exception of 5 interviews in wave 4 and 8 in wave 5, which were conducted face-to-face.

The second hospital (hospital 2) belongs to the same public hospital group as hospital 1 and was called in at a later stage, by mid-March, when the referral hospitals were overwhelmed with patients. The semi-structured qualitative interviews took place between the third week of April 2020 and January 2021 (case study 2). Thirty interviews were conducted (25 remotely and 5 face-to-face): twenty-four during the first wave, and six during the second wave (these interviews were conducted with individuals previously questioned). A feedback session with the interviewees took place in June 2021. Each interview lasted between 40 and 120 min, with most lasting from 60 to 75 min, and all were recorded and fully transcribed.

In these two hospitals, although the anaesthesiologists, intensivists and emergency doctors were the most frequently interviewed, other professionals were also interviewed in order to reconstruct the local emergency response system.

Case study #3 was designed to capture the potential diversity of responses and consisted of a limited number of semi-structured qualitative interviews at a large number of hospitals. These interviewees worked at 12 different hospitals: 8 university hospitals, 2 community hospitals, and 2 private not-for-profit hospitals (in the
rest of this article, for reference, each hospital has been assigned a different number,
starting with 3). Geographic locations also varied so as to include areas that had been
hit to varying degrees by the pandemic, and also following different timelines: one
university hospital that was the first to manage a substantial number of patients in
February 2020 but with a relatively small subsequent wave as compared to the
national pattern, one community hospital that recorded the first death of a French
citizen and had to manage the first French cluster thereafter, 3 hospitals from an area
that was among the most hardest hit in France (the Grand-Est Region), 5 university
hospitals from the *Assistance Publique-Hôpitaux de Paris* (the largest university
hospital trust in Europe comprising a total of 39 hospitals with approximately 20,000
beds), and two private not-for-profit hospitals, including the largest in France, which
accommodated up to 90 patients in the ICU at any given time during the outbreak
peak. Twenty-six professionals were interviewed remotely between April and
September 2020. The length of the interviews ranged from 40 to 130 min, with most of
them lasting between 60 and 90 min (mean duration: 80 min), and all were recorded
and fully transcribed.

Our sample is therefore based on a wide range of hospitals and professionals
who were involved in managing the emergency situation during the first wave. This
allows us to draw reliable conclusions about the conditions that enabled hospitals to
cope and for their professionals to have a very rewarding experience and a sense of
fulfilment during this period. The depth and variety of our data for the other waves is
less significant, as we have comprehensive data for hospital 1 and, to a lesser extent,
for hospital 2, but no first-hand data for other hospitals. Nevertheless, the reports of
difficulties, and even discontent, at both hospitals corroborated press articles
describing fatigue among healthcare professionals and their public calls for new
lockdowns as stringent as the one imposed during the first wave. In addition to
feedback sessions in hospitals 1 and 2, we presented our analyses at roughly 10 other
seminars attended by professionals from various other hospitals from the end of
2020 and throughout 2021. While this does not constitute the same level of evidence as
first-hand data, the favourable reception of these analyses, particularly those con-
cerning deteriorating cooperation between actors within hospitals, has reinforced
our confidence in the validity of our explanations.

## 2.2 Data Analysis

The analysis was structured through a process of inductive analysis (Gioia et al. 2013).
The tradition of organisational sociology in which we work was first developed by
Michel Crozier and Erhard Friedberg (Crozier 1964; Crozier & Friedberg 1980;
Friedberg 1997). It gives primacy to fieldwork and is thus part of the ‘grounded
theory* (Corbin & Strauss 2008; Glaser & Strauss 1967). This perspective analyses organisations, and collective action more generally, as the result of more or less unbalanced exchanges between actors when solving problems. Our investigation was therefore guided by an understanding of the main problems encountered by actors during the crisis, the relevant resources available for resolving these problems, and by whom these resources were held. This informed the subsequent exchanges between these actors. All authors reviewed the resulting material and discussed the main themes that emerged. We systematically abstracted the grounded data into more general patterns that we could then use for theorising. More specifically, the analysis followed the framework proposed by Grodal et al. (2021), which identifies different 'moves' from data analysis to theorising. As these authors remind us, all analytical work begins with a question. Our initial one was to understand how hospital professionals had managed to withstand the first wave, when gloomy predictions of the collapse of French public hospitals were widespread. The analysis then focuses on the puzzles that emerge from the data and guide the rest of the process. In our case, the most surprising finding was the sense of professional satisfaction that they expressed, despite their fatigue and the numerous deaths they had to deal with, as well as the link they established between this satisfaction and the unprecedented level of cooperation between professionals that they were experiencing (March–April 2020).

In their methodological article, Grodal et al. (2021) describe the different categorisation methods used. Consistent with their work, our initial categorisation was very close to the data. *Four conditions* appeared to be conducive to cooperation: budgetary constraints were suspended; the administration ratified (either before or after the fact) the decisions taken by the health care teams; there was no conflict between doctors over the admission of patients (except at the very beginning of the pandemic); and the suspension of surgeries freed up time for other doctors and nurses (including anaesthesiologists and intensivists in the first instance) to concentrate on managing the crisis. Nurses expressed ambivalence about the ban on patients' families entering hospitals: on the one hand, they regretted that families were unable to see their loved ones; but, on the other, they acknowledged that they saved time and energy by not having to manage to them.

To further develop our theoretical framework, we then “merged” some of these categories (Grodal et al. 2021) and found that cooperation related to *three types of relationships* that had improved during the first wave: relationships between health professionals (and especially between doctors); relationships between health professionals and hospital management; relationships between health professionals, patients and their families. The arrival of a second deadly wave of COVID-19 allowed us to test our framework and showed that when these conditions were no longer present, cooperation became much more difficult.
We were finally able to construct what Grodal et al. (2021) have called “con-
trasting categories” by distinguishing the *mechanisms* behind the three types of
relationships that developed: relations between health professionals were improved
by the suspension of competition between doctors and between departments; re-
lations between management, nurses and doctors were improved by the greater
autonomy given to health professionals in management and clinical decision-
making; and, finally, with regard to relations between health professionals and
patients, the absence of families enabled them to reassert their professional
authority.

In order to answer our question regarding the sustainability of cooperation and
how it evolved over time, we present our results over two periods. Although the
constraints imposed by the external crisis, particularly the reasons for lockdown
(Borraz & Jacobsson 2023), experienced by the hospital changed over the two years, it
is possible to distinguish between two distinct periods.

- The first wave (March-June 2020) aimed at treating patients with COVID-19, leading to a redesign of the scope of intensive care to optimise resources. This occurred to the detriment of surgical activity, which was almost completely halted, and to the treatment of other patients.

- From the second wave onwards (October 2020-May 2021 for the second and third waves, and December 2021-March 2022 for subsequent ones) the need to balance the treatment of both COVID-19 and non-COVID-19 patients, maintain surgical activity and address staff fatigue led to increased staffing pressures.

## 2.3 Ethics

This study did not involve human patients and therefore did not require any
approval from an ethics committee according to French law. It was however
compliant with our institutional regulations and with the General Data Protection
Regulation. All participants gave electronic informed consent both a week before the
study and on the day of the interview. There was no compensation or incentive of any
kind for participating in the study. A verbal guarantee that there was no conflict of
interest was obtained from each participant. No patient-related data was shared.
Both electronic and verbal guarantees were provided to participants that their re-
sponses would be reported in an unbiased manner and that they would remain
anonymous. However, none of the participants were able to review the current
findings before submission to the journal.
## 3 Literature Review: Collective Action in Crisis Situations

Previous scholarship on crisis management, including responses to the current pandemic, emphasises the importance of cooperation. According to this literature, cooperation is primarily based on the reallocation of resources and cognitive coordination mechanisms. However, little is known about the actual conditions and mechanisms of this cooperation, i.e. the power relations that emerge when the nature of exchanges between actors is studied in detail. Recent work on cooperation during the pandemic takes little account of these mechanisms and conditions.

A large body of published research on the collective ability of hospitals in different countries to cope with the pandemic (particularly during the first wave) is now available: Japan (particularly Tokyo: Honda et al. 2023), France (Chabrol et al. 2023; Mininel et al. 2023; Gelly & Spire 2021; Dumez & Minvielle 2024), Germany (Zhelyazkova et al. 2023), Italy (Fanelli et al. 2020), Quebec (David et al. 2023), Brazil (Oliveira et al. 2021), and the Netherlands (de Graaf et al. 2021). In most cases, this research falls under the management and public health disciplines within the health services research field (see Gelly & Spire 2021; Mininel et al. 2023 for exceptions). While these studies and research projects do not use the same methodologies or deal with identical subjects, a comparative reading reveals two main types of organisational resilience measures: a) rearrangement and reallocation of resources, including human resources (e.g. reassignment of professionals to non-traditional departments); and b) mobilisation of new coordination mechanisms. Regarding the latter, Honda et al. (2023, 1) argue that the creation of task forces is necessary to carry out actions that are “absorptive, adaptive, and transformative” in the areas of hospital governance, human resources, nosocomial infection control, space and infrastructure management, and supplies management. Zhelyazkova et al. (2023) also argue that establishing a “Pandemic Board” to facilitate communication between stakeholders was crucial for “coordinating the information flow”, “handling pandemic-related enquiries from internal and external stakeholders”, and “conducting regular meetings with executive and operational-level representatives”. In contrast, Fanelli et al. (2020) note that the main difficulty of Italian hospitals was the lack of coordination mechanisms (technologies, committees, and plans), and that reallocating resources to the fight against the pandemic was insufficient to enable Italian hospitals to adapt effectively.

These perspectives overlap with a large body of research on crisis management which primarily relies on the concept of coordination (Faraj & Xiao 2006; Comfort 2007; Wolbers et al. 2018). This concept involves the use of tangible or intangible devices to organise teamwork between individuals or sub-organisational units,
direct tasks assigned to individuals or collective actors, and achieve a predetermined
purpose. The positive contribution of these devices to professional coordination has
been recognised since Star and Griesemer's (1989) work on boundary objects. These
devices, whether designs and prototypes (Bechky 2003), standards (Bigley & Roberts
2001), planning (Tillement & Gentil 2016) or information systems (Hayes & McDermott 2018), play a significant role in professional coordination. They produce information and act as systems for action. They highlight conflicts and problems, facilitate negotiation and arrangements, and organise distributed activities with minimum consultation. They act as a bridge between different worlds and support the development of the skills needed to perform tasks (Midtlyng 2024). However, these devices have limits, and the cited research often focuses on their cognitive and/or rationalistic dimensions, neglecting the political dimensions of exchanges between actors. Consequently, in these studies, cooperation is often conceived as the mechanical product of the devices, instruments, values, and norms developed to promote it; however, these are not seen as intrinsically problematic. This conception of collective action underpins much of the research on collective action in crisis situations.

Moreover, while developments in hospitals' collective capacity to cope with the
pandemic are important, they remain mainly descriptive. Although Honda et al.
(2023) emphasise the extent to which hospitals established task forces that enabled
close collaboration between managers and infection control experts, facilitated
interdepartmental coordination and communication within hospitals, and supported other adaptive and transformative responses (p. 8), the precise mechanisms
that made these coordination activities possible and effective remain unclear.
Similarly, Mininel et al. (2023, 2) argue that “collective care” is the result of interactive
processes involving the shared construction of meaning for action, the development
of mutual aid capacities, and margins for action and innovation “from below” that
are not subject to pre-established norms. Gelly and Spire (2021) add that internalising
the “standard of a job well done” and an influx of resources explain the response of
French hospital professionals. Beyond the sharing of practical norms, these studies
do not clarify the nature and content of the exchanges between actors that underpin
these cooperations. Indeed, the sharing of norms alone cannot explain why cooperation became more difficult from autumn 2020 onwards (unless we assume that
professionals lost their commitment to professional norms over the summer). In
Brazil, “absorption capacity was related to the reorganisation of services and
modification of protocols, as well as to continuing education initiatives and collaborative work” (Oliveira et al. 2021, 6). However, we have little information on either
the conditions that made this reorganisation acceptable to those involved or the
micro-foundations of this “collaborative work”.
Similarly, Chabrol et al. (2023) and Dumez and Minvielle (2024) demonstrate that local self-organisation enabled healthcare professionals to “push back the walls” of the hospital, resulting in exceptional individual mobilisation. These articles demonstrate that the response to the crisis enabled departments to be reorganised quickly to accommodate an influx of infected patients. However, despite the interest in the formal reorganisations that hospitals undertook, these articles cannot explain how and why professionals collaborated during the first period, and why their mobilisation waned from the second wave onwards (Chabrol et al. 2023). An explanation based on sensemaking, which is often used in organisational studies of crisis management, does not provide a complete answer to these questions. Building on Weick’s seminal work on the Mann Gulch fire, subsequent research has demonstrated that the difficulty actors have in making sense of critical situations can result in disasters (Weick et al. 1999; Farazmand 2007; Oliver et al. 2017). Much of this literature focuses on sensemaking processes that direct attention during collective action based on a shared concern for failure, awareness of practices, and commitment to success (Weick & Sutcliffe 2006). However, as Dosdall and Löckmann (2023) have pointed out, with a few exceptions (Maitlis 2005), this research does not focus specifically on the organisational dynamics underlying crisis management.

In short, previous work on crisis management and recent work on hospital management consider the mechanisms of cooperation only partially, neglecting their political dimension. These studies have focused on cognitive or rational mechanisms to explain coordination, paying less attention to the practical conditions of negotiation and exchange that facilitate cooperation between actors. The political dimension of organised action is lacking here. However, classic work in the sociology of organisations has emphasised that relations of cooperation and conflict should be analysed as relations of power by examining the nature of exchanges between actors in detail (Gouldner 1954; Crozier 1964; Crozier & Friedberg 1980; Friedberg 1997). More recently, other studies, mainly in healthcare contexts and outside of crisis situations, have encouraged moving beyond strict jurisdictional battle analyses to take a detailed look at the specific exchanges between professionals (doctors and non-doctors), patients, and their loved ones as part of treatment (Kellogg 2009; Eyal 2013; Numerato et al. 2012; Levay & Waks 2009; DiBenigno 2020). This approach aligns with what Anteby and his colleagues (2016) refer to as a “relating lens”, as opposed to the “doing lens” favoured by Freidson (1970) and Abbott (1988) in their theoretical models of occupations, which focused on conflict and competition between occupational groups. In contrast, “a relating lens focuses attention on understanding when and how occupational groups collaborate with other groups to perform interdependent work” (Anteby et al. 2016, 212). As we shall see, the “relating lens” and the analysis of relations of power help explain how professionals were able to
cooperate on care during the first wave of the pandemic, and how this cooperation became more complicated during the following waves.

# 4 Results

## 4.1 The First Wave and the Conditions for Unusual Cooperation Between Hospital Professionals

### 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)<fnref n="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.

<footnote n="1">1 As outlined in the methodology section, Case Study #3 includes all hospitals with a number greater than or equal to three.</footnote>
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.<fnref n="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.

<footnote n="2">2 This message was later criticised insofar as it may have dissuaded people from coming forward to be tested for other serious diseases (notably cancer and HIV) or encouraged them to put off tests that could have led to earlier detection and treatment of serious illnesses or recurrences of disease in the case of cancer.</footnote>
However, the interviews showed that COVID-19 cases were all very similar,<fnref n="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

<footnote n="3">³ In some interviews, there was even a sense of boredom expressed, due to the repetitive and homogenous nature of treatments.</footnote>
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 “orchostra 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 interpro-
fessional cooperation, as we will see in the next section. This supports our main
argument that organisational factors and structures supporting reciprocal ex-
changes, i.e. power relations, clearly facilitate collective action more than shared
normative and cognitive beliefs and goals.

## 4.2 From the Second Wave Onwards

We were struck by the contrast between job satisfaction during the first wave and the tensions and dissatisfaction observed in subsequent waves. Although the uncertainties of the first wave were reduced in subsequent waves (due to a better understanding of the disease and of the management of patients with COVID-19, an improvement in their condition, the mutation of the virus, better tools, and access to vaccination), cooperation broke down. According to sensemaking approaches, it should have improved. However, this was clearly not the case. Other things being equal, the conditions that enabled cooperation during the first phase were more or less suspended during subsequent waves. This led to tension between professionals and organisations (between departments). These conditions were not suspended uniformly over time or space: hospital 1, as a referral centre, always allowed its medical teams autonomy to organise themselves, whereas hospital 2's management team quickly took back control following the first wave. Nevertheless, our model enables us to formulate assumptions that explain the relative and variable deterioration of cooperation in hospitals after the first wave.
The conditions described in the previous section were no longer in place: financial control became an issue again; treatment other than for patients with SARS-CoV-2 could no longer be suspended; and families could no longer be excluded from hospitals. These changes negatively impacted cooperation between professionals.

### 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 anaesthetisiologists 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-19 patients 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.
# 5 Discussion and Conclusion

The literature on the management of the COVID-19 crisis by hospitals emphasises the importance of cooperation and explains that two main types of measures are necessary to maintain “organisational resilience”: the rearrangement and reallocation of resources and the implementation of new coordination mechanisms. One of our main theoretical arguments is that this literature tells us too little about the actual conditions under which this cooperation takes place and is negotiated, i.e. the exchanges that develop between different categories of professionals. In most of these studies, cooperation seems to be conceived as the mechanically produced output of devices, instruments and norms developed to promote them but is not seen as intrinsically problematic.

The same criticism can be levelled at research relating to sensemaking processes and mindfulness during crises, which focuses attention during collective action on a shared concern for failure, awareness of practices, and commitment to success. However, with a few exceptions (Maitlis 2005), the political dimensions of sensemaking remain largely unexplored, often being analysed only from a cognitive perspective. A framework of representation, a sense of situations, and the requisite knowledge are necessary for collective action, but their development is not free of disagreement or tension. Understanding these discrepancies and controversies requires shifting the focus to the underlying relationships and the contexts in which interactions occur.

The literature surrounding structural systems often gives priority to formal mechanisms. This gives the false impression that these are the most important and does not capture the full complexity of the processes leading to cooperation. However, the sociology of organisations can help us to grasp this complexity by inviting us to place power relations and the nature of exchanges at the centre of our analysis (Gouldner 1954; Crozier 1964). More recently, other studies have encouraged detailed attention to exchanges between professionals when performing activities. Building on Eyal's pioneering work (2013), our research contributes to the growing body of literature that has advocated for the adoption of a “relational lens” when examining the organisation of occupational work (Anteby et al. 2016; DiBenigno 2020). This approach contrasts with the “doing lens”, which primarily focuses on exclusion or subordination between professional groups to secure jurisdictions. A more complete explanation of organisational resilience and the durability of collective action requires a focus on the factors that explain cooperation between hospital staff. Power and cooperation are not opposites; rather, a relational perspective on power shows that cooperation is the result of more or less unbalanced reciprocal exchanges of resources.
We have therefore argued that the dynamics of local crisis management can be better explained by focusing on changes in three types of relationships: between healthcare professionals, particularly doctors; between healthcare professionals and top hospital management; and between healthcare professionals and patients' families. By examining the different patterns of these relationships, we can understand why cooperation was stronger in the first wave of the crisis than in the second or third. Relationships between doctors deteriorated when the conditions for suspending competition were no longer present. Relationships with management deteriorated when management sought to regain control over the organisation of care and expenditure, thereby destroying the established balance of hospital governance. From the second wave onwards, it became impossible to strictly control visits from patients' families. Some of these families were once again able to criticise the treatment given to their loved ones, thus challenging the medical dominance that had been temporarily established during the first wave.

We draw three theoretical conclusions from these results.

First and foremost, agreements do not simply depend on the actors' ability to communicate and mobilise additional resources to create an "organisational arrangement" adapted to the situation (Girin 2011). Rather, these are fundamentally the result of negotiations and exchanges between different categories of actors, the striking of compromises between the interests of professional groups (Strauss et al. 1963), and the establishment of a balance between managerial and professional perspectives. These exchanges and arrangements support the sharing of information, knowledge, and expertise that is not clear enough to be incorporated into devices. They facilitate the creation of social ties, the sharing of resources, and the capitalisation of relationships for a common objective. These elements support the construction of new solutions and strategies and their incorporation into hospital operating rules so that all staff can act together and cooperate in the event of a crisis. The power resources held by actors – such as control of information and its circulation, control of skills and expertise, and the ability to access the environment and enact rules (Crozier & Friedberg 1980) – promote or prevent the creation of shared solutions and the institutionalisation of new rules in the way organisations operate.

Secondly, our investigation highlights a different kind of social dimension to that underlying the dominant and canonical approaches to collective action in crisis. This literature often draws on sensemaking (Weick 1993), which is described as social in order to explain discursive practices in interactions (Maitlis & Christianson 2014), knowledge exchange (Faraj & Xiao 2006), or meaning in relation to action. However, our case offers an alternative interpretation of the social: while it is still driven by interactions, it is primarily the enduring reciprocity of (more or less imbalanced) exchanges that emerge from interactions and provide the social glue of cooperation. It is the constructs of collective action based on these power relations that ensure the
cooperation of autonomous actors in order to achieve organisational goals (Crozier & Friedberg 1980). The sense of professional satisfaction that actors experienced during the crisis should be understood as related to establishing the cooperative relationships necessary to carry out their activities.

Finally, the comparison between the various waves enables us to better understand the conditions and temporalities of cooperation in times of crisis. A time of crisis is often considered separate and distinct from the ordinary functioning of organisations and is above all seen as a parenthesis in the ordinary power relationships that actors maintain. However, we have shown that the relationships established during a crisis and the actions taken can only be understood by placing them in the context of pre-existing ordinary forms and relationships (Friedberg 1997). The successive waves brought the hospital closer and closer to a return to normal functioning, resuming (more or less) the “ordinary” relationships that were altered at the height of the crisis. This means that crisis does not entail the suspension of power relations, but rather their modification (as the distribution of resources and the type of constraints that structure relations evolve). It is then the ordinary functioning of the organisation that largely determines its capacity for collective action in an extraordinary situation. Existing interdependent or autonomous relationships, rather than the application of dedicated plans or procedures, or the mobilisation of additional resources, make cooperation possible (or, if not impossible, difficult). Our perspective enables us to understand the mechanisms that determine whether cooperation becomes sustainable or fragile over time. To achieve this, we must consider how power relations shape practices and cooperation (as well as conflicts) in times of crisis and in ordinary times.

Based on these results, we can formulate the important conclusion that the commitment and cooperation of actors who had previously cooperated only minimally is more likely to be explained by specific organisational conditions than by the sharing of a strong professional ethos and the sense of awe that the onset of the crisis may have aroused. This conclusion, based on our study of a larger volume of data collected during the first wave, nevertheless needs to be further analysed in future studies.

**Acknowledgments:** This paper benefited from discussions we had with Olivier Borraz, François Dedieu, and the entire CrisOrg project team (ANR-21-CO14-0002-01). Thanks also to Lucile Hervouët for her help. Part of this project was funded by the Simone Veil Health Sciences Department; research project ‘COVID-19’. We would like to thank Marie-Emmanuelle Chessel, Philippe Decléty, Dominique Fletcher, Hakim Harkouk, Louis Puybasset, Mathieu Raux, Thomas Similowski, Dominique Thabut and Jean-David Zeitoun, who played an important role at the beginning of this research in putting us in touch with certain colleagues.
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